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A 13 year old girl presented to us with diffuse hair loss over the scalp involving more than 50% of the scalp [] for the past 6 months. She had consulted many dermatologists in the past 6 months since the onset of her complains, but none of the treatment brought relief. Therefore, it was not only the disease entity that we needed to consider but also the financial and psychosocial impact on the patient. She had no associated hair loss over any other body site. There was no history suggestive of any associated complaints. Her nails were normal on examination. There was no history of similar complains in the family. After taking a prior informed consent, phenolisation was done over the bald patches with 88% phenol until a uniform ivory white frost appeared. Phenol was applied all over the bald patches, covering more than 50% of scalp surface; 1 ml of phenol was taken in a container and applied to the scalp by dipping a bud in phenol. We assume that out of 1 ml, some amount of phenol was left in the bud. Thus, the total application of phenol was below the safe limit. No neutralization was done. The patient did complain of burning sensation and was given 5 mg diazepam orally. She underwent 5 such sittings at an interval of 15 days each. She was also given dexamethasone pulse therapy for 4 months. Dexamethasone was given in the dose of 60 mg intravenously in 5% dextrose. She was given dexamethasone and phenolisation at an interval of 15 days. She began to show response to therapy after the 2nd sitting when vellus hair regrowth was evident diffusely all over the bald patches. After five sessions done with 88% phenolisation and 4 pulses of dexamethasone intravenous therapy, she showed marked improvement with well-marked hair growth over the patches. Phenolisation is painful and therefore she was given intravenous diazepam prior to the procedure. There were no reported side effects in the present case. |
This is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).\nIt also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.\nThe patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained of sleeping difficulties with ruminative worries about his situation. He denied any suicidal thoughts.\nThe patient was started on Remeron (mirtazapine), 15 mg at bedtime. He also engaged in weekly psychotherapy sessions. Over the next two months, the patient noted improvements in his sleeping patterns and appetite. The crying spells persisted. The patient was observed to be tearful while at the waiting area, during the psychiatric evaluation, and after his treatment appointment. His family reports that he cries every day for no apparent reason. Despite reassurances that he was not depressed, the family was convinced that his emotional state was getting worse. The patient was eventually diagnosed with pseudobulbar affect (PBA) because of his repeated outburst of involuntary crying. The crying was occurring even though there was no sad event that triggered those emotions. These episodes were persistent and had occurred in different situations or settings. He was referred to a local neurologist who confirmed the PBA. Eventually, he was managed with dextromethorphan hydrobromide and quinidine sulfate (DM/Q), 20 mg/10 mg capsules twice a day, in addition to his mirtazapine. The patient's crying spells improved significantly after the DM/Q was started. He tolerated it very well with no complaints of any side effects.\nA year later, the patient had multiple tragedies in his family. His father, with whom he was very close with, suddenly and unexpectedly died. He also had an argument with his daughter, who later refused to talk to him. He was overwhelmed with financial problems. Because of these, the patient became more depressed and the crying spells recurred. Despite his medication compliance with DM/Q and mirtazapine, he noted worsening depression and occasional suicidal thoughts. He reported symptoms of sad mood, anhedonia, fatigue, excessive sleeping with early morning awakenings, increased appetite and weight gain, psychomotor retardation, and feelings of helplessness and worthlessness. He was having thoughts of shooting himself, even though he does not own a gun. This time, he was subjectively complaining of being "down in the dumps." He was seen in the emergency room for a crisis evaluation and referred back to the mental health center. He was reevaluated and his mirtazapine was switched to Viibryd (vilazodone) because of weight gain concerns. He also attended twice a week psychotherapy sessions. A month later, with these interventions, the patient's depressive symptoms, including the crying spells, had improved. He continues to receive his DM/Q and vilazodone and weekly psychotherapy sessions with no exacerbations of any mood symptoms. |
A 62-year-old female had a low-energy fall at home, with trauma to the left hip region followed by inability to stand or walk. She was taken to a nursing home at her native place and X-rays done there, revealed an intertrochanteric fracture of neck of the left femur. There were no other skeletal injuries. The patient was a known case of hypertension, on medication for the past 7 years. She did not have any other medical comorbidity. She was not receiving any blood thinners. The patient was investigated and operated the next day by an orthopedic surgeon. The patient underwent fracture fixation using a DHS, on fracture table under spinal anesthesia. As per the information mentioned in the discharge card, intraoperative period was uneventful. The patient was transfused two units of packed red cells in post-operative period. On the 3rd post-operative day, the patient started developing discoloration of the toes and foot of the operated lower limb. Color Doppler done the following day revealed the absence of flow in popliteal, anterior tibial, and posterior tibial vessels. As there was no facility of vascular intervention where the patient was operated, it being a small nursing home at a remote place, the patient was referred to our tertiary care center. The patient came to our hospital on the 7th post-operative day. On examination, the patient had discoloration of skin over the left lower limb up to the mid-thigh with evidence of dry gangrene up to middle third leg (). Peripheral pulses were not palpable on the affected lower limb and the patient had absence of sensation over the foot and leg. Vascular surgeon was consulted; he advised a computed tomography (CT) angiography which revealed abrupt cutoff of flow in SFA (). The level of cutoff was corresponding to the level of the third cortical screw of the DHS plate. There was no significant collateral circulation. As the patient presented late with changes of gangrene already set in, the limb could not be salvaged and the patient landed up having to undergo an amputation. |
A 25-year-old Japanese female presented to our emergency department with the chief complaints of dyspnea and palpitations on exertion, starting 1 month ago. Upon arrival, physical examination revealed systolic murmur. The bedside ultrasound examination demonstrated moderate tricuspid regurgitation and possible pulmonary hypertension and the patient was hospitalized. A contrast-enhanced chest CT showed dilatation of the main PA, filled with a hypodense area with calcification adjacent to the right and left PA. The lumens of the main PA and the hilar areas of the right and left PA appeared almost obliterated by the mass; however, the mass was not attached to the pulmonary valve and did not extend into the peripheral parts of the right and left PA (Fig. ). The differential diagnosis included primary PA tumor and pulmonary thromboembolism, but we suspected it to be a PA tumor based on the radiological findings: a relatively poor contrast effect on the lesion with calcification. Lung perfusion scintigraphy revealed decreased blood flow in the whole bilateral lungs, except for the left lung upper lobe. Due to critical symptomatic obliteration of the pulmonary circulation, an emergency surgery was performed on the second day of hospitalization. Preoperative FDP D-dimer was 1.9 μg/mL, slightly higher than the normal limit (within 1 μg/mL).\nFollowing a median sternotomy and institution of cardiopulmonary bypass, deep hypothermic circulatory arrest was induced for the removal of the tumor. The longitudinal incision was made on the main PA extending into the left PA (Fig. ). A whitish shiny mass filled the lumens without any attachment to the surrounding intima, except that the tumor was attached to the intima of the left interlobar PA. The tumor was completely removed from the vessel lumen (Fig. ). Next, the longitudinal incision of the right PA behind the aorta and the superior vena cava was extended to the right interlobar PA. The neoplasm had no attachment to the intima in this area and was obliterated by the segmental branches of the right PA. The tumor was extracted and completely removed from the vessels, and the peripheral ends of the tumor demonstrated a finger-like appearance (Fig. ). After complete removal of the tumor and copious irrigations, the incisions were simply closed using 6-0 polypropylene sutures. The postoperative CT scan confirmed that no tumorous mass was left behind in the PAs.\nGross pathology showed a soft-to-hard whitish-brown tumor. Microscopically, spindle cells with marked cytological atypia proliferated with tumor osteoid formation. There were also lobular proliferations of chondroid islands composed of atypical chondroblasts (Fig. ). Based on the pathological findings as well as the results of the clinical examination that there was no possible primary tumor, it was diagnosed as a primary ISCOS of the PA.\nShe received adjuvant chemotherapy, but 5 months later, a contrast-enhanced chest CT scan showed a hyperdense lesion with calcification at the upper hilum of the right lung, indicating the recurrence of the disease. Right upper lobectomy was performed, and the resected specimen contained a neoplastic lesion with similar pathological features to the primary lesion. Intraoperatively, a pleural metastatic nodule was also found and resected, which was of the same pathological characteristics. The patient is currently being followed up in an outpatient clinic without any known complications 16 months after the initial surgery. |
The patient was a 47-year-old male police officer who sought care at a consulting office and had been the victim of a perforating firearm wound to the right infraclavicular region 7 months prior to presentation. At the time of wounding he had been treated conservatively.\nThe patient complained of exertional dyspnea and considerable edema and pain in the right arm. He had brought the results of a chest tomography conducted some weeks before which showed considerable dilatation of the right subclavian vein and the cervical veins of the right upper limb.\nPhysical examination revealed significant edema of the right upper limb, with pain on palpation and holosystolic murmur in the topography of the right pulmonary apex. Right radial, ulnar, and brachial pulses were all reduced in comparison with those of the contralateral limb.\nTwo weeks after this consultation, the patient presented at an emergency room with exacerbation of the dyspnea, symptomatic ventricular tachycardia, and frequent premature ventricular contractions and was admitted to the hospital.\nSupplementary cardiac tests were then conducted. The echocardiogram showed dilatation of the left cardiac chambers and an ejection fraction of 63%. Myocardial scintigraphy showed signs of dilated cardiomyopathy.\nAfter clinical and cardiac stabilization, the patient underwent arteriography of the right upper limb, which showed a large arteriovenous fistula between the right subclavian vessels and a pseudoaneurysm of the subclavian artery ( ).\nThe treatment chosen was endovascular repair under local anesthesia with sedation. The technique employed was via puncture of the right common femoral artery with a 7F introducer and puncture of the right brachial artery with a 5F introducer. The subclavian artery was catheterized via the brachial access and the guidewire was snared and a through-and-through system constructed via the femoral access, due to difficulty in advancing the guidewire via the subclavian artery. The injury was repaired using a 8x100 mm Fluency covered stent (Bard) ( ).\nAfter the procedure, the patient was transferred to the ward. He exhibited good postoperative recovery, with significant improvement of the pain in the right upper limb and reestablishment of symmetry of pulses with the contralateral limb. He was discharged from the hospital 2 days after the operation, on double platelet antiaggregation with acetylsalicylic acid and clopidogrel.\nHe was reassessed 15 days later in the consulting room. There was regression of the right upper limb edema, maintenance of the radial, ulnar, brachial pulses, and improvement of the dyspnea.\nA control angiotomography conducted 15 days after the follow-up visit (i.e., 30 days after the procedure) showed that the endoprosthesis was patent and there was no premature venous filling ( ).\nThe study was approved by the Research Ethics Committee at the Hospital Saúde da Mulher (HSM), Belém, PA, Brazil. |
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 22-year-old female patient who had previously been affected by bulimia nervosa, presented erosion of the maxillary teeth, which was particularly evident on the palatal side (Fig. a,b). According to the Basic Erosive Wear Examination (BEWE) (), the sum of the scores of the maxillary sextants was 19 with a risk level classified as high. In the BEWE the most severely affected surface in each sextant is recorded with a four level score and the cumulative score classified and matched to risk levels which guide the management of the condition. The sum of the scores of the mandibular sextants was 3 with a risk level classified as low. According to the anterior clinical erosive classification (ACE) (), the patient was considered ACE class IV regarding laterals and canines since the palatal dentin was largely exposed and the loss of length of the clinical crowns was more than 2 mm, while the facial enamel was still preserved. The central incisors were classified ACE class VI because of the loss of tooth vitality. In addition the patient presented generalized erosion on the maxillary premolars and molars on the cervical third of the palatal side. The erosion was extended to the occlusal surfaces of the maxillary premolars and molars but only on the palatal cusps, so that the vertical dimension of occlusion was entirely preserved by the vestibular cusps. On the other hand, the mandibular teeth presented only moderate signs of erosion especially at the level of the occlusal surface (Fig. c). The observation of minimal erosion to erosive damage of the mandibular teeth in bulimic patients has been described in previous published studies (). The patient reported that she was unhappy with the appearance of her teeth. The teeth were vital with the exception of the two maxillary central incisors, which had previously received a root-canal treatment. During the first examination, she stressed her desire to have a restoration procedure with a high aesthetic result, without the use of metal. Periodontal screening resulted in no pathological findings; the Periodontal Screening Index (PSI) was 0 in all sextants. The patient’s oral hygiene was good. She had no signs or symptoms of temporomandibular disorders. The patient insisted on having a rapid and effective aesthetic and functional result, but with a limited budget. To enable the clinician and the dental technician to study the clinical situation and to choose the most appropriate treatment option in the first clinical session, intra and extraoral photographs of the patient were taken as well as two polyvinyl siloxane impressions (Flexitime Dynamic Heavy Tray, Flexitime Correct Flow, Heraeus-Kulzer, Hanau, Germany). The occlusion of the patient and the inclination of the occlusal plane were also recorded with a facebow. During the first laboratory diagnostic step, split-cast models were obtained (VertySystem, A.GREE srl, Altavilla Vicentina, Vicenza, Italy; Elite Rock, Zhermack, Badia Polesine, Rovigo, Italy) and articulated on a semi-adjustable articulator by means of the facebow in the maximum intercuspidation position (MIP) (Artex C, AmannGirrbach, Vorarlberg, Austria; Elite Arti, Zhermack). A functional and morphological evaluation of the casts was simultaneously conducted by the clinician and technician. The aim of the technique outlined in this clinical report was to restore a compromised dentition using both direct bonded posterior composite restorations and indirect adhesive techniques for the anterior teeth (palatal and facial composite veneers). To perform the direct posterior restorations, all the teeth with the exception of the second molars were waxed up () (Nawax Compact, Yeti Dental, Engen, Germany) (Vertys Heavy Glass 72 Shore, VertySystem, A.GREE srl). A translucent silicone key (Memosil II, Heraeus-Kulzer) was fabricated reproducing the wax-up of the posterior teeth at the increased vertical dimension of occlusion (VDO) (Fig. a). The increase of the VDO was determined looking at the height of the intact vestibular cusps.\nDuring the following clinical session, the clinician loaded several times the translucent silicone key with a tooth-colored composite and positioned it in the patient’s mouth. The second maxillary molars were used as stops for the key. Therefore direct composite restorations were fabricated to restore the maxillary first molar and the two premolars (Clearfil Protect Bond and Clearfil Majesty Posterior, Kuraray Medical Inc, Tokyo, Japan). In order to keep the interproximally contact points opened polytetrafluo-roethylene film (Teflon) was used to protect the adjacent teeth. Another translucent silicon key was fabricated for the six maxilla-ry anterior teeth to prepare the mock-up (Vertys Easy Putty 70 Shore and Vertys Precision 56 Shore, VertySystem, A.GREE srl). The clinician loaded the translucent silicone key with a resin for temporary crowns (SINTODENT S.r.l., Roma, Italy). The mock-up helped the clinician to verify that the aesthetic appearance of the final restoration would have met the expectations of the patient (Fig. b). In the same appointment the anterior teeth were prepared to receive six palatal composite veneers. The interproximal contacts between the maxillary anterior teeth were slightly opened using thin diamond strips, and the incisal edges were smoothed by removing the unsupported enamel prisms. The palatal dentin was also cleaned with nonfluoridated pumice, and the most superficial layer was removed with a diamond bur. After this minimal preparation of the palatal surfaces an impression was taken (Flexitime, Heraeus-Kulzer, Hanau, Germany) in order to obtain the palatal veneers described in the Three Steps Technique by Vailati and Belser () The dentin was sealed with Optibond FL (Kerr). No provisional restorations were placed.\nFollowing a similar protocol, previously published by Vailati et al. 2012 (), after one week, the palatal veneers (Estenia C&B, Kuraray Medical Inc) were bonded, one at a time, using rubber-dam isolation (Fig. 2c,d). The palatal sealed dentin was sandblasted (Cojet, 3M ESPE; Seefeld, Germany), the surrounding enamel was etched (37% phosphoric acid), and the adhesive (Clearfil Esthetic Cement Kit, Kuraray Medical Inc) was applied but not cured (). The composite veneers were also sandblasted (Cojet), cleaned in alcohol, and several coats of silane were applied (Clearfil Esthetic Cement Kit, Kuraray Medical Inc). In the same appointment, after bonding of the palatal veneers, a conservative preparation was performed on the vestibular side of the maxillary incisors and canines (Fig. a). To deliver a light chamfer, the six facial veneers were prepared at the cervical level, following the curve of the marginal gingiva, with no need to extend the preparation to the gingival sulcus (in contrast to the crown preparation) (). After the impression (Flexitime, Heraeus-Kulzer) a provisional was fabricated using a resin for temporary crowns (SINTODENT S.r.l., Roma, Italy) with the same silicon key used for the mock-up. The laboratory step consisted in the realisation of the vestibular composite veneers for the anterior maxillary teeth (Estenia C&B, Kuraray Medical Inc). After one week, in the last clinical session the six veneers were cemented on the anterior teeth following the same procedures described for the palatal veneers (Clearfil Esthetic Cement Kit, Kuraray Medical Inc) (Fig. b). The patient came for a first follow-up visit one month later; she was satisfied with the overall treatment. The restorations were well integrated with the other teeth and the soft tissues were very healthy.\nAfterwards the patient was scheduled for a 6 month follow-up. During each control a professional air-polishing () with glycine powder was performed in order to reduce the plaque accumulation. A clinical follow-up after 4 years showed that the occlusion remained satisfactorily restored thanks to the posterior direct composite resin restorations and anterior indirect composite adhesive restorations (Fig. c,d). Lastly, with regards to the direct composite restorations, no loss, fracture, marginal discoloration or loss of marginal integrity was noted after 4 years of clinical function. |
A 54 year-old male with no significant past medical history was initially diagnosed with a cutaneous melanoma involving his left forearm in September 2012. He underwent local resection and sentinel lymph node biopsy at an outside institution with pathology showing an invasive melanoma characterized by an ulcerated Clark level V lesion with a Breslow thickness of 5.5 mm and 3 mitoses/mm2. A sentinel lymph node biopsy was positive for 1 of 1 lymph node with a 0.35 mm deposit of melanoma. A complete lymph node dissection of the left axilla was performed demonstrating no evidence of melanoma in any of 42 lymph nodes. He underwent surveillance imaging by whole body PET CT through June of 2013 with no evidence of disease recurrence.\nIn September of 2013, the patient noted development of a subcutaneous nodule in his left upper extremity. On examination, he was found to have unilateral swelling of his left lower extremity and a palpable intra-muscular mass. Fine-needle aspiration of the left upper extremity nodule was performed and pathology was consistent with melanoma. PET CT imaging performed in October of 2013 demonstrated a subcentimeter FDG avid lesion in the left upper extremity correlating with the subcutaneous nodule, as well as an intramuscular lesion in the left gastrocnemius with marked FDG uptake and a focal area of FDG uptake in the small intestine without a CT correlate.\nThe patient was referred to our melanoma clinic for further care in December of 2013. Repeat imaging with PET CT performed at that time confirmed prior FDG avid lesions involving the upper and lower extremities along with the small bowel lesion (Fig. ). Brain MRI was negative. Molecular diagnostics performed on a tissue sample identified the melanoma as BRAF and c-kit wild type. The patient elected to enroll in the CheckMate-069 randomized, double blind clinical trial evaluating combination ipilimumab and nivolumab therapy versus ipilimumab monotherapy in previously untreated patients with advanced melanoma (NCT01927419). He received his first infusion in January of 2014, returning 2 weeks later with a diffuse grade 3 skin rash, tachycardia, and reports of hot flashes (Fig. ). Laboratory analysis indicated elevated levels of free triiodothyronine at 9.68 pg/mL (normal 2.20 – 3.80 pg/mL) and free thyroxine at 4.16 ng/dL (normal 0.52 – 1.21 ng/dL) in the setting of a decreased thyroid stimulating hormone (TSH) level of 0.06 uIU/mL (normal 0.34 – 5.66 uIU/mL). Anti-microsomal antibodies were positive and his thyrotropin receptor antibody level was noted to be elevated at 4.74 IU/L (normal 0.00 – 1.75 IU/L). Autoimmune thyroiditis was diagnosed prompting treatment with prednisone and metoprolol while the rash was managed with topical steroids.\nOnce his symptoms resolved and he was tapered off systemic steroids, the second infusion was administered approximately 6 weeks later. Three weeks following his second dose of combination ipilimumab/nivolumab therapy, routine laboratory analysis indicated a grade 2 hepatotoxicity, attributed to treatment-induced autoimmune hepatitis, as well as symptoms consistent with a grade 1 colitis. Testing for CMV reactivation was not performed. He was treated with prednisone which was tapered as the transaminitis resolved. At this time the patient was found to have abnormally diminished levels of free triiodothyronine at 1.69 pg/mL and free levothyroxine at <0.25 ng/dL along with an elevated TSH at 7.50 uIU/mL. Given his hypothyroid state, his metoprolol was stopped and therapy with levothyroxine was initiated.\nRepeat imaging with PET CT in March of 2014 showed complete resolution of the left upper extremity nodule and small intestine lesions and decreased size and FDG avidity of the left gastrocnemius lesion (Fig. ). Diffuse colitis was apparent on imaging. The patient continued to report one to two loose stools a day throughout his treatment course and his symptoms were managed with loperamide in addition to the previous prednisone taper.\nIn May of 2014 the patient received his third infusion. Two weeks later, he returned to the clinic with extreme weakness, myalgias, nausea, and vomiting. His vitals showed a blood pressure of 88/54 mmHg with a pulse of 121, and his laboratory analysis revealed profound hyperglycemia with an anion gap metabolic acidosis. Due to concerns for new onset diabetic ketoacidosis with acute adrenal insufficiency, he was transferred directly to the medical intensive care unit. Intravenous fluids, insulin, and methylprednisolone were initiated. His β-hydroxybutyrate level was noted to be elevated at 0.40 mmol/L while his ACTH was found to be undetectable and his cortisol level was 3.5 μg/dL (normal 5.0 – 25.0 μg/dL). The patient’s C-peptide was <0.1 ng/mL, and he was noted to have elevated levels of anti-glutamic acid decarboxylase (anti-GAD) antibodies during his hospitalization at 0.38 nmol/L (normal ≤0.02 nmol/L). The patient was eventually transitioned from intravenous insulin to a subcutaneous regimen, steroids were tapered to hydrocortisone, and he was discharged to home after a 3-day admission. Notably, further studies on serum previously collected per study protocol showed that the patient exhibited an undetectable anti-GAD antibody titer 1 month prior to initiating treatment with combination ipilimumab/nivolumab immunotherapy.\nAs the patient had demonstrated evidence of multiple endocrinopathies, further evaluation of his pituitary function was conducted. This included a prolactin of 6.51 ng/mL (normal 2.64 – 13.13 ng/mL), LH of 3.8 mIU/mL (normal 1.4 – 7.7 mIU/mL), FSH of 17.8 mIU/mL (normal 1.3 – 19.3 mIU/mL), free thyroxine of 0.84 ng/dL (normal 0.52 – 1.21 ng/dL), testosterone of 64 ng/dL (normal > 300 ng/dL), and free testosterone of 1.9 ng/dL (normal > 9 ng/dL). A subsequent brain MRI performed with pituitary protocol was unremarkable and unchanged compared with a baseline study. An early morning Cosyntropin stimulation test was conducted in October of 2014 following a 5 month maintenance dosage of prednisone at 10 mg daily which was tapered to discontinuation over a period of 6 weeks prior to stimulation testing. Baseline testing of ACTH and cortisol remained undetectable while the cortisol level post-stimulation was inappropriately low at 1.8 microgram/dL (normal 5.0 – 25.0 microgram/dL). Together, these findings were felt to be consistent with hypophysitis.\nIn light of the multiple autoinflammatory toxicities, the patient was removed from the study and placed on surveillance comprised of a physical exam, lab assessment, and PET CT imaging every 3 months in addition to dermatologic surveillance every 6 months. Soon thereafter, it was revealed that the patient had been randomized to the combination ipilimumab and nivolumab immunotherapy regimen. His follow-up exams continued to reveal a stable 1.1 cm nodule with low-level FDG avidity within the left gastrocnemius muscle with no other evidence of disease recurrence until September of 2014 when the left gastrocnemius lesion was no longer FDG avid. As of August 2016, the patient has been without evidence of melanoma recurrence and continues on an insulin regimen with an undetectable C-peptide level. |
A 57-year-old male patient was admitted to the hospital due to acute abdominal pain and diffuse peritonitis that lasted for 3 days. Due to severe septic shock, a central venous catheter was introduced through the right jugular vein during the operation to facilitate rapid fluid resuscitation and the application of vasoactive drugs. Two days after surgery, the hemodynamics was stable. On the third day, the patient had spontaneous exhaust and got out of bed with slight movement. The vasoactive agent was discontinued on day 5. On the 7th day, patient was given a small amount of liquid diet; parenteral nutrition fluid was introduced through central venous catheter, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On day 14, the patient was able to eat normally and had to stop parenteral nutrition treatment. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest and received emergency cardiopulmonary resuscitation. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein (Figs. and ; Additional file 1 [Long axial section of the right jugular vein showing the thrombus attached to the inner wall of the vessel and drifting with the blood stream.] and Additional file 2 [A short axial view of the right jugular vein shows thrombus drifting with blood flow.]). The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle (Additional file 3 [Lower section of the xiphoid process shows decreased systolic amplitude of the right atrium and right ventricle.]), widened and fixed inferior vena cava, and no variation with respiration (Fig. ). Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased (Additional file 4 (Long axis view of the parasternal left ventricle showed that the right ventricular outflow tract widened significantly and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased.)). Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing “D” sign (Additional file 5 (Short axial section of left ventricle shows right ventricle enlargement and ventricular septum deviation of left ventricle, showing “D” sign.)). Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased (Additional file 6 (4-chamber view of apical heart showed increased right ventricular ratio and decreased contractility.)). In consideration of fatal pulmonary embolism, 1500,000 units of urokinase were immediately given trough intravenous drip. After 20 minutes, his autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later. Because the patient's condition has been in an extremely dangerous state, the pulmonary embolism was not diagnosed by computed tomography pulmonary arteriography (CTPA). |
A 17-year-old female coming from MSES who was premorbidly maintaining well came with complaints of asymmetrical repetitive flickering like movement of the right hand which started on the day of her 12th grade board exams. She was observed to have reduced sleep since 1 week before her exams and had relatively less communication with family members. On the day of her exams, by the time she got the question paper her whole of her right arm started having repetitive flickering movement vigorously, and she had to support her right arm with the left to write the exam and had come out of exam hall without completing the exam. Within a few days, the abnormal movements had progressed to her right leg. She did not attend the remaining exams. Informant said that she use to have crying spells and appear sad most of the time as she had not given the exams. The patient visited a neurologist. She was treated with promethazine and trihexyphenidyl neuroimaging was done which was found to be normal. She showed some improvement after 20 days, but she was not completely resolved, on the day before the day of admission, she developed shivering over her whole body and was admitted to the Intensive Care Unit. It was not associated with loss of consciousness, no urine or fecal incontinence, no frothing from the mouth, no tongue biting, and no up rolling of eyeball. Electroencephalogram computed tomography and magnetic resonance imaging brain were done and were found to be normal. She was referred here for further management. On repeated interview, it was found that she was an above average student in her class and that her family had too much expectation from her. She also said that her younger sister was always given more attention by her mother. Her episodes were provoked when asked to write or hold a pen with her right hand, also when she was asked to walk without assistance. She was also observed to flex her right toe while walking and during stay in the hospital she was observed to be having a sudden onset of asymmetrical repetitive jerky movements of bilateral legs. She used to report that her episodes could not be stopped by voluntary effort. General physical examination and systemic examination did not reveal any abnormality. Routine hemogram, renal function test, liver function test blood sugar, lipid profile, and thyroid function were found to be normal. Video Electroencephalogram (EEG) was done was found to be normal.\nThe patient was prescribed diazepam 4 mg per days and after 2 days it was increased to 6 mg per day, she showed gradual improvement. She was started on supportive psychotherapy sessions. There was a total of five psychotherapy sessions. On the initial days of sessions, her symptoms got aggravated during the sessions and session had to be stopped in between. After few attempts, the patient had ventilated to us how her mother gives less importance to her when compared to her younger sister who is 6 years younger to her. The patient had also said that from her toddler stage till 10th standard she was living with her paternal grandmother and father, and now she moved to a different house along with her parents. The patient was first reassured regarding the management of her symptoms. Her parents were also included in the sessions and her issues with her mother were discussed. The patient had gradually started walking without difficulty and frequency of abnormal movements had reduced. As per the suggestion of the pediatric neurologist therapeutic nerve conduction study was done. After that procedure, patient showed marked improvement and her abnormal movements had stopped. Patient was observed for few more days. Diazepam was tapered and stopped within a week and had been stable at the time of discharge. Patient came for a follow-up after 2 weeks, and she had been maintaining well. |
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 |
An 80-year-old lady with a past medical history of hypertension, chronic obstructive pulmonary disease, atrial fibrillation, heart failure, chronic kidney disease, fibromyalgia, cerebrovascular disease and a non-active pituitary mass presented to the hospital with nausea, vomiting, fatigue and poor oral intake. Further workup revealed that she had panhypopituitarism, which was being managed in the hospital. During her hospital stay, she became lethargic likely secondary to delirium with electrolyte abnormalities from her pituitary disorder and required bilevel positive airway pressure (BiPAP) support for respiration. Her respiratory status continued to deteriorate with acute respiratory failure, which prompted further workup with a CT scan of the thorax. CT thorax revealed a finding of edematous changes isolated within the right breast area with several gas foci just superficial and inferior to the right clavicle (Figure ).\nThe patient did not have any pain or discharge from the right breast. She did not have any fevers or chills during the hospital stay. Physical examination did not reveal warmth, erythema, induration or crepitus over the breast. Labs showed normal leukocyte counts during this course. The finding of air in the breast was therefore not attributed to infection. She was thoroughly evaluated for other possible causes of air in the breast based on prior case reports. She did not have any procedures over the right chest wall during the hospitalization. She did not have a central line placement, was not intubated but was placed on BiPAP for respiratory failure. She did not have a history of breast cancer and no recent mammogram, but reported that her mammograms from several years prior did not show any abnormal findings. After a thorough chart review, it was found that there was a peripheral intravenous line placement on the day prior to the CT thorax over the right upper extremity. It was attributed to being the most likely source of the edema and gas foci. The surgery team was consulted to ensure no surgical intervention was necessary. No surgical intervention was warranted given her lack of infectious symptoms and they recommended a follow-up if she noticed any changes to her breast. The patient has not had repeat imaging done since then and has not followed up for any complaints with regard to her breast. |
A 51-year-old man was admitted to the hospital with a diagnosis of a left lung nodule for 1 month. The patient reported a history of cough and hemoptysis 1 month previously, at which time a chest CT scan showed a nodule in the left lung hilum accompanied by calcification (), which was initially diagnosed as pulmonary tuberculosis; this patient then received anti-tuberculosis treatment and was discharged after improvement. To exclude the possibility of malignancy, the patient underwent a chest CT scan again, and multiple nodules partly accompanied by calcification in the left lung parenchyma, an enlarged high-density mass compared to that on the previous scan in the hilum of the left lung and pleural effusion were observed (). The contrast-enhanced CT scan and three-dimensional volume rendering image revealed that the large high-density mass in the left hilum invaded the adjacent left pulmonary artery and vein and bronchus of the upper lobe (). On bronchoscopy, the bronchus mucous membrane of the left upper lobe was swollen and congested, accompanied by mucosal protrusion and lumen stenosis (). The patient had a history of diabetes and lost 4 kg of weight in the recent 1 year. There were no other abnormalities reported by the patient in terms of medical history, and the physical examination and laboratory tests were normal. After routine antibiotic treatment for 1 week, the patient progressed and developed symptoms of chest pain and tightness, shortness of breath, and recurring orthopnea, which resulted in respiratory insufficiency. Therefore, left pneumonectomy under cardiopulmonary bypass was performed.\nIntraoperative exploration confirmed the CT findings and detected a giant and hard mass in the left lung hilum, and the tumor occluded the adjacent left pulmonary artery and vein lumen. The pathological examination showed that the tumor tissue involved the whole left lung, but there was no evidence of pleural involvement, positive bronchial margins, or local lymph node metastasis (). Immunohistochemical analyses revealed that the tumor cells were positive for vimentin and Ki67 but negative for AE1/AE3, CD34, S-100, and EMA. The final diagnosis was primary extraskeletal osteosarcoma in the left lung and pulmonary artery. The patient refused to receive chemotherapy and radiotherapy after the operation and was discharged after 1 month of symptomatic and supportive treatment. Four months after the operation, a contrast-enhanced CT scan demonstrated tumor recurrence in the left hilum and multiple metastases in the left pleura and somatic muscles, which showed high concentrations of radioactivity on 99mTc-MDP SPECT/CT examination (). Then, the patient received a course of systemic chemotherapy with epirubicin, cisplatin, and ifosfamide. Six months after the operation, a contrast-enhanced CT scan revealed enlargement of the recurred local tumor and metastases, especially the lesion at the left hilum, causing compression of the adjacent esophagus (). |
A 71-year-old female presented with several weeks of fatigue. Her pertinent medical history was significant only for a hysterectomy and oophorectomy in the 1980's for menorrhagia. A surveillance CT scan of a right lower lobe lung mass revealed a 3.6 × 2.5 cm right adnexal solid mass involving her right gonadal vein with extension into her inferior vena cava (IVC). A repeat chest CT, performed at an outside facility, reported that the mass extended up to the IVC-RA junction, with no intracardiac presence (Figure , Panel A and B). Based on the CT finding an abdominal MRI was performed where the mass appeared to propagate up to the confluence of the infrahepatic veins with unclear level of termination and based on the CT result no effort was made to study the right atrium. The patient did not have any renal, bowel or cardiac compromise at the time of presentation.\nResection of the tumor was planned via laparotomy and sternotomy with possible cardiopulmonary bypass (CPB). Intraoperative TEE was performed after induction of general anesthesia. Using a slightly modified transesophageal bicaval view a cyst was seen unexpectedly in the right atrium (RA) with a very thin wall (Figure , Panel A). The existence of the cyst was confirmed by color Doppler and a bubble study where the bubbles surrounded the cyst (Figure , Panel B and C). Both studies suggested that the cyst was separated from the atrial walls and positioned close to the intersection of the IVC. The TEE probe was advanced in the direction of the IVC, where a mass was appreciated filling up about 50% of the lumen (Figure , Panel A). Moving the probe closer to the intersection of the IVC and RA, the mass was divided into a solid and a tubular part (Figure , Panel B and C). In the RA the cyst was detected again seemingly in continuation with the tubular part of the mass and the head of the solid part was sitting at the inter-atrial septum (Figure , Panel C and Additional File ). The rest of the TEE examination was normal.\nThe tumor was removed intact via the IVC using TEE guidance without requiring CPB. After removal of the mass, the TEE showed no residual tumor and normal cardiac function (Figure , Panel D). The removed tumor divided to a cystic and solid head (Figure , Panel D). The TEE findings matched well with the tumor in the IVC and in the RA (Figure , Additional File ). The patient tolerated the surgery well. The pathological review described the mass as a low-grade endometrial stromal sarcoma (ESS) with a cyst located at the cephalad portion of the tumor. |
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. |
The patient was a 62-year-old female of African American ethnicity, with a past medical history of type 2 diabetes mellitus, chronic kidney disease secondary to diabetes, glaucoma, macrocytic anemia, chronic back pain and hypertension, who initially presented to her ophthalmologist with a small growth over her left upper eyelid. The patient had the swelling for more than four years that had gradually increased in size. She did not have it evaluated as it very occasionally caused symptoms like on and off tearing, itching, and irritation. She decided to seek medical care when she noticed some tenderness over the lesion. On initial evaluation, she was noted to have a 0.6 mm, elevated, cystic-appearing subcutaneous nodule in the central medial left upper lid margin and lash row. It was noninflamed and tender to palpation. The lesion was in close proximity to the cornea. All other eyelid and orbital functions were normal.\nThe lesion was initially thought to be a benign cyst. As it was symptomatic, it was excised and reconstruction was done. Histopathological analysis revealed positivity for carcinoma cells and suggested that it was a mucinous colloid carcinoma. As the margins were positive, a repeat excision with wider margins and reconstruction via advancement of her lateral full thickness upper lip into the central upper lid was done following a superior cantholysis of the lateral canthal tendon. The surgeons felt that there was no evidence of regional extension beyond what was excised. This was further confirmed by CT imaging of the orbits that revealed no locoregional extension or residual tumor (Figure ). Histopathological exam showed that the tumor was present within the dermis abutting the orbicularis muscle and was composed of lobules of epithelial cells floating in pools of mucin. Small ductal structures were observed within the lobules. A dual population of epithelial cells was identified with mild to moderate pleomorphism admixed with some atypical mitotic figures. Adjacent to the tumor, there were distended ductal structures with atypical proliferation of epithelial cells with a cribriform architecture and extracellular mucin. The tumor extended into the deep tissue edges, but perineural invasion was not identified. Immunohistochemical analysis revealed that the tumor was positive for tumor protein p63 (P63) and cytokeratin 7 (CK7) and negative for cytokeratin 20 (CK20), thyroid transcription factor-1 (TTF-1), and human epidermal growth factor receptor 2 (HER-2). These findings confirmed the diagnosis of PMA of the eyelid.\nGiven that an underlying occult malignancy of the gastrointestinal tract or breast may present similarly, she was evaluated extensively with CT scans of the thorax, abdomen, and soft tissues of the neck. She also had a mammogram and a colonoscopy. All the tests were unremarkable and negative for malignancy. Given the rarity of the disease, Radiation Oncology and Medical Oncology services were integrated to her care. She is being followed up in regular intervals and has not had any recurrence of her tumor thus far. |
A 37-year-old right-handed male presented to the emergency department with right wrist pain and decreased range of motion of the forearm following a friendly grappling match. On history, he was mildly intoxicated by alcohol at the time of the injury. His friend had performed an arm-bar holding the patient's right arm between his legs while pulling on the forearm with his hands. The patient tried to escape the maneuver by forcefully pulling and pronating his forearm. He immediately felt pain in his right forearm and was unable to use it afterwards. His past medical history was significant for alcohol, tobacco, and cocaine use. He was not known to be suffering any other medical conditions and had never suffered any injury to his right wrist or forearm in the past. On physical examination, the forearm was locked in supination, with no passive or active pronation elicited. There was loss of the dorsal ulnar prominence, and a palpable and tender solid mass was felt on the volar aspect of the wrist, which was presumed to be a volarly dislocated ulnar head (). The skin was intact, and the neurovascular status of the hand was normal. Radiographic examination of bilateral forearms confirmed our suspicions, displaying overlap between the radius and ulna on the anteroposterior view and volar displacement of the ulnar head relative to the distal radius on the lateral view. A CT scan was performed, completing the clinical picture by revealing impaction of the ulnar head on the distal radius ().\nAfter obtaining informed consent, closed reduction was planned under procedural sedation. The reduction was first attempted by pronating the forearm while applying a posteriorly directed force to the ulnar head. After an unsuccessful first attempt, a second attempt was performed with an assistant applying pressure on the interosseous membrane (IOM) of the forearm using the palm of both of his hands, in an effort to free the impacted ulnar head from the distal radius (). With the ulnar head now freed from the radius, the second attempt at manipulation was rewarded by an audible click and a return of the wrist's normal position and motion. On postreduction stability testing, the DRUJ was felt to be unstable at 45° of supination. This prompted the clinician to immobilize the patient in neutral rotation and 90° of flexion using an above-elbow back slab. Postreduction radiographs confirmed the success of the reduction maneuver ().\nAt the three-week clinical follow-up, the splint was removed and physical examination was repeated. The patient showed full range of motion of the wrist and elbow in flexion and extension. Compared to the contralateral forearm, there was a 10° lack of pronation and 25° lack of supination. Pain and tenderness were minimal, and no instability could be elicited. Diagnostic imaging confirmed that the reduction was maintained. The patient was discharged from the clinic with instructions for range of motion exercises and avoidance of loading activities for an additional three weeks. No additional follow-up visits were planned. |
A 22-year-old G2 P-0-0-2-0 Hispanic patient was transferred from outside hospital for evaluation and management of worsening abdominal pain and findings of bilateral cystic adnexal lesions with septations and large ascites. Her obstetric and gynecologic history was significant for two dilatation and curettage procedures for elective abortion. Her surgical history was otherwise not significant. She was currently using oral contraceptive pills and continued to be sexually active. She denied any history of sexually transmitted diseases and did not have a recent pap smear. Her medical history was remarkable for bipolar disorder and depression. Her social history was notable for her being adopted and she did not know her biologic family. She also was a smoker.\nShe had previously presented to an emergency department (ED) at an outside hospital for evaluation of right lower quadrant pain without report of fever, chills, or abnormal vaginal discharge. She had no prominent gastrointestinal or urinary symptoms. Her urine pregnancy test was negative. After workup including a pelvic ultrasound, this pain was thought to be due to a ruptured ovarian cyst and was managed with analgesic medications. She however returned to the outside ED 2 weeks later with persistent pain and on repeat pelvic ultrasound was found to have larger bilateral septated ovarian cysts measuring up to 5 cm in largest dimension with free fluid seen in pelvis. She was transferred to our hospital for additional workup and management.\nOn presentation, she reported that the pain has moved from the right lower quadrant to the left lower quadrant and was aggravated by exercise. She also reported early satiety and noticed 15 pounds of unintentional weight gain in last 2 months.\nHer examination revealed that she was afebrile and was hemodynamically stable. Her abdomen was soft but distended and tympanic in upper quadrants with mild tenderness in epigastrium on deep palpation. There was no rebound or guarding and a negative murphy's sign. A fluid wave was elicited at this examination. Pelvic exam revealed minimal yellow-white vaginal discharge, bilateral adnexal tenderness left more than right with pelvic fullness. The rectal exam was unremarkable.\nHer blood test results revealed mild anemia with a hemoglobin of 10.8 g/dL. White blood cell and platelet count were within normal limits at 6,800/microliter and 358,000/microliter, respectively. The comprehensive metabolic profile was within normal limits and there was no evidence of liver dysfunction. Serum CA 125 and inhibin analysis demonstrated increased levels at 97.1 U/mL and 35 pg/mL, respectively. Serum concentrations of the other tumor markers were within normal limits.\nChlamydia trachomatis and N. gonorrhoeae DNA probe test were performed in the ED at the time of the vaginal exam. C. trachomatis test was positive and treatment was immediately initiated with 2 grams of single dose of intravenous azithromycin during her ED visit. Her partner was also treated. Since C. trachomatis testing was positive, other serological tests were performed to rule out sexually transmitted infections (STI) such as HIV and VDRL with the patient's consent. However, all of the subsequent STI testing was negative.\nComputed tomography (CT) scan of the abdomen and pelvis had been ordered due to the ultrasound findings and revealed rim enhancing complex cystic lesions in the right and left adnexa measuring 3.5 cm and 1.4 cm, respectively, with multiple other nodules in both adnexa (). Enhancing soft tissue densities in the mesentery, peritoneal enhancement in the pelvis, a large amount of ascites, and an indeterminate 1 cm liver lesion was also appreciated on CT scan (). Differential diagnoses at this point were broad, including infectious, inflammatory, or possible malignant diseases. Chest imaging was noncontributory. Considering the CT scan findings of mesenteric disease and liver lesion, which could very well be seen in metastatic ovarian cancers, we decided to further investigate for the possibility of a malignancy.\nWorkup was initiated with a paracentesis which was diagnostic and therapeutic at this point. Peritoneal fluid appeared straw-colored, cytologic examination was negative for malignant cells, and no fungal organism or bacteria were detected with either the direct microscopic examination of the fluid, gram stain, or culture.\nGiven the limited knowledge of her family history as well as the possibility of a germ cell ovarian tumor in this age group, the patient was then counseled regarding the option of a diagnostic laparoscopy for further investigation of the findings. She consented to an exploratory laparoscopy, possible unilateral versus bilateral cystectomies, liver biopsy, and any other necessary procedures. Intraoperative findings were consistent with Fitz-Hugh-Curtis syndrome, loculated ascites, and overall severe PID (Figures and ). She ultimately underwent segment 3 liver wedge resection for 1 cm nodule, pelvic washings, omental and peritoneal biopsies, and extensive lysis of abdominopelvic adhesions. The liver lesion was a very unexpected finding even with Chlamydia trachomatis infections and the managing physicians wanted to rule out other etiologies such as a primary liver lesion versus a metastatic deposit from another site.\nPathologic examination demonstrated fibrous tissue on multiple peritoneal and pelvic nodule biopsies and the omental biopsy showed atypical lymphoid proliferation. The liver biopsy showed nonspecific reactive hepatitis.\nPeritoneal fluid flow cytometry and B- and T-cell gene rearrangement tests were also performed due to the finding of atypical lymphoid proliferation on pathology. These results all returned without significant abnormalities and the atypical lymphoid proliferation was therefore thought to be as a result of severe PID. In strong support of this diagnosis was also the ascitic fluid Chlamydia trachomatis IgG antibody titer of 1 : 1024.\nTherefore, this patient was diagnosed with a complicated PID. As she had previously been treated with IV azithromycin, she was then treated with metronidazole 500 mg twice daily and doxycycline 100 mg twice daily after receiving a single dose of ceftriaxone 250 mg intramuscularly. She had an uncomplicated postoperative course and was discharged home on postoperative day 3.\nBy postoperative day 25 she was again complaining of abdominal distension and was found to have a reaccumulation of ascites. A repeat therapeutic paracentesis was performed. She was again found to have mainly loculated ascites and as such 600 cc of serosanguineous peritoneal fluid was drained for symptomatic relief. She continued with the antibiotic therapy and received a total of 28 days of antibiotics after discharge. She was completely asymptomatic at a follow-up appointment eight months after her initial presentation. Her follow-up pelvic ultrasound showed normal appearing ovaries bilaterally and a minimal amount of pelvic free fluid. |
In 2008, a 41-year-old lady developed an ulcer on her left heel. This was excised by a general surgeon at another hospital. Pathological examination revealed a 3.8 cm, moderately differentiated SCC; the margins were involved. No further treatment was offered to the patient. A year later, in June 2009, the tumor recurred and was excised again; the margins were negative this time.\nTwo months later she was referred to our center for further management. On examination she had a small non-healing ulcer on the left heel. There were palpable LN in the popliteal and inguinal regions of the same limb. An MRI was done for the popliteal and inguinal regions (Figure ). It showed multiple inguinal LN and a 3-cm popliteal mass partially encasing the popliteal artery. A CT scan of the chest and liver did not reveal any distant metastasis. A biopsy was taken from the heel ulcer, and it confirmed the presence of residual SCC.\nA wide local excision of the tumor as well as popliteal and groin dissections were performed. The ulcer was excised with a wide margin including part of the calcaneus. The resulting defect was covered with a flap. The patient underwent popliteal dissection in the prone position. The popliteal mass and LN were removed together with the adherent segment of the popliteal artery (Figure ). A reconstruction was then undertaken with an autologous saphenous vein graft. The groin dissection was performed with the patient in supine position and it included the femoral, iliac and obturator LNs. The patient recovered well, and aside from a small seroma in the groin, she had no complications. The histopathologic examination revealed an ulcerated, moderately differentiated squamous cell carcinoma showing moderate atypia, few mitotic figures and keratin pearls (Figure ). The tumor was completely excised with negative margins. There were 3 involved popliteal LNs, one of them completely replaced by tumor, and 13 involved inguinal LNs out of the 32 removed. The tumor in the LN showed similar morphology to the primary tumor (Figure ). Because of the extensive lymphatic involvement, the patient was offered radiotherapy to the region. As expected, she developed significant lymphoedema, but remained ambulatory without assistance when she was last seen 11 months after the operation.\nThe popliteal fossa is a diamond-shaped area bound superiorly by the heads of both the Biceps Femoris and Semimembranosus muscles and inferiorly by the 2 heads of Gastrocnemius muscle (Figure ). This space is covered by the tough popliteal fascia and contains the popliteal LNs in addition to the popliteal neurovascular bundle. The neurovascular structures pass through the fossa in the middle. The LNs are contained in the fatty tissue that lies along the vessels. For adequate LN dissection, all of the fatty content should be removed. There is usually 1 LN in the subcutaneous tissue, usually in relation to the site where the small saphenous vein crosses the fascia. Making extra-fascial skin flaps ensures excision of this LN. The popliteal LNs are usually 2 to 7 in number [-].\nIn general there are 2 steps to popliteal LN dissection. The first step is adequate exposure of the diamond shaped fossa. This should include careful identification and preservation of the neurovascular structures. Once that is done, dissection of the fat pad should be performed thoroughly.\nThe patient is positioned prone with the knees slightly flexed on a pillow. The posterior approach offers the best exposure for this procedure []. The skin is incised in an S-shaped fashion, with the transverse limb over the posterior knee crease (Figure ). The cranial extension is made laterally and the caudal extension medially. It is imperative that the incision does not cross the transverse crease; doing so might lead to some contracture of the knee joint, especially if the patient is to receive postoperative radiotherapy to the region. This incision can be modified in some cases to incorporate a preceding scar of the SLN biopsy procedure; that's why the incision for a SLN biopsy should be carefully planned. Skin flaps are dissected down to the popliteal fascia. During dissection of the lower part of the flaps 2 structures are found: the small saphenous vein and the medial Sural nerve. The vein is usually ligated and divided. Preservation, however, is sometimes possible. In some cases the vein will not be encountered at this stage because it crosses the fascia at a lower level. The medial Sural nerve, which arises from the Tibial nerve, usually passes behind the vein and it should be preserved if possible. In some cases this is not possible, and this results in an area of cutaneous anesthesia on the lateral aspect of the foot and ankle.\nSubsequently, the popliteal fossa is entered by opening the popliteal fascia vertically in the midline. The first structure to appear is the Tibial nerve, which crosses vertically and disappears between the 2 heads of Gastrocnemius. Lateral to it is the Peroneal nerve, which courses laterally along the biceps femoris tendon and then turns obliquely towards the fibula. Both nerves should be retracted laterally with vessel loops to allow adequate and safe exposure of the vessels and the LNs. Dissection deep to the Tibial nerve will reveal the popliteal vein. The popliteal artery passes deep and slightly medial to the vein. It is the deepest structure in the popliteal fossa and lies on the femur and capsule of the knee joint. The LNs are contained within the fatty tissue that is found superficial, alongside and deep to the popliteal vessels. LN dissection should include, therefore, all the fatty tissue in the popliteal fossa till reaching the posterior aspect of the knee joint. It should be noted that the popliteal fossa is wider in the deeper part than in the superficial part. Adequate retraction of the Gastrocnemius muscle heads, therefore, is essential to ensure adequate exposure and dissection of all the LNs.\nAfter securing hemostasis, the fascia is approximated and the wound is closed over a negative suction drain. A knee splint or back slab is preferably applied at this stage and left in for the first few postoperative days. Postoperative Lymphoedema is expected in some patients []. The incidence of lymphoedema is expected to increase dramatically with the addition of inguinal dissection and or radiotherapy. |
Ms. S, a female aged 16 years, hailing from rural background in northern India, with lower socio-economic status, presented with recurrent spontaneous extrusion of copper wires from all of her limbs for the past 1½ years. The patient initially reported pain and development of pustules in the posterior aspect of the left hand which took a long time to heal when an X-ray revealed thin metallic wires in the muscle bulk. These wires were removed by a surgeon, but the problems recurred after a couple of days. Subsequently these wires would be removed every week or two at a clinic in a nearby town, but they would soon recur. The copper wires extracted from the patient surgically would be entrusted to the family members, who would dispose them off near home. The patient and the family members sought treatment at many places in nearby towns but there would be recurrence in a few days. The family members had also taken her to many faith healers for cessation of extrusion of these wires, who told them that she was afflicted by a powerful jinn causing the presence of the wires. Faith healers had suggested rituals which the patient did not follow meticulously. She had also received brief media attention for her symptoms, which she liked and the family members would often talk about it with pride during the interview. The patient presented to our center after she was refused surgery for extraction of wires by local surgeons, who referred her to a tertiary care center. She was admitted in the psychiatry ward for management. In past history, the family members reported that the patient had difficulty with affect regulation since childhood. She would be stubborn and inconsiderate toward younger siblings, would get angry easily, and refuse food. She would refuse to do the delegated household chores, sought attention of others and would go out of the house without informing the family members. Physical examination of the patient revealed multiple scars and wounds bilaterally, in the forearms, arm, thighs and knees. However, no scars or wounds were present in any inaccessible areas like back. On interview the patient was guarded. She appeared tidy and kempt with normal speech, had euthymic affect and no perceptual and thought abnormalities. Higher mental functions were within normal limits. She expressed displeasure on being asked about any psychological stressors and focused primarily on her physical complaints. When asked nonjudgmentally about the possible source of such wires in the body she became verbally aggressive and assumed a challenging stance toward the ward team. Engaging her into a therapeutic relationship was very difficult. She refused psychometric and personality testing and did not cooperate for the same on repeated attempts. X-rays of multiple body areas were obtained [Figures and ] and a surgery consultation was sought. The surgical team decided against operation as it was considered unnecessary with risk of further tissue scarring, and advised regular dressing of the wounds.\nThe diagnosis of factitious disorder was made due to the presentation of repeated healthcare seeking for metallic wires in the body parts. Malingering was ruled out due to absence of a definite external incentive occurring from the act. Repeat X-rays confirmed the diagnosis as no new wire formation occurred during the ward stay.\nThe patient became disappointed when surgery was refused and started requesting for discharge. When all attempts to gain confidence of the patient failed, the patient was confronted in a supportive manner in a way that redefines the patient's illness from that of a physical disease to that of psychological distress, and with the assurance that the information will not be communicated to any family member. However, the patient became aggressive, and stopped communicating altogether with the treating team. Family intervention also failed as family members vehemently declined the possibility of the patient inserting the wires herself and were quite insistent that it be due to supernatural powers. Understanding the plurality of the belief system of the family, where they believed that the causation was by “jinn” but the treatment needed was surgical, the family was also allowed to visit faith healers during hospitalisation. Ultimately a therapeutic contract was drafted between the family members, the psychiatry team and the surgical team, whereby it was agreed that all wires from one limb will be removed by surgery, and a soft bandage with tamper protection seal will be made in the same limb. If no new wires developed in the protected limb after a month, family members will come back for psychiatric treatment. Although family members initially agreed, they refused the contract subsequently fearing that the “jinn” will be angered and may cause further damage, and left the hospital against medical advice |
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 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 38-year-old white male with a history of DVT and PE nine years ago, who presented to the clinic with discoloration and pain of bilateral feet and lower extremity digits. The patient reported that his symptoms began with tingling in the toes and later numbness. A week after his initial symptoms he described the feeling of severe pain in his feet. At this time he started to notice a change in the coloration of his toes bilaterally. He described them as becoming dark purple and appearing blotchy in certain areas, with blanching on palpation. The patient stated the pain in his feet and toes was typically more severe at night. The pain became so severe that it began to interfere with his work at a construction company. He had been experiencing these issues for about a month and it has been slowly worsening over time. He has never experienced manifestations like those before. The only medication he had been taking was testosterone cypionate 250 mg 1 cc per week, which he began five to six months ago. He said he received this prescription from a men’s health clinic after voicing symptoms of low energy and loss of libido. His laboratory results revealed borderline low testosterone levels, 340 ng/dl. After further questioning, the patient admitted that this was not his first time receiving testosterone therapy. He reported that around nine years ago, he received testosterone and trenbolone (an anabolic steroid traditionally used on livestock) to increase muscle mass from a friend at his gym. At this time he was taking thrice the dosage as he was now. He stopped supplementation after five months when he was diagnosed with DVT as well as PE which led to hospitalization. The symptoms during this presentation differed significantly from those experienced during his hospitalization from DVT/PE. The blotchy and purple discoloration of his digits and feet which blanched with pressure appeared similar to palpable purpura or embolic disease.\nThe patient initially presented to his primary care physician (PCP) who started him on rivaroxaban 10 mg daily and after minimal symptomatic improvement, a rheumatological evaluation was requested, due to vasculitis concern. Workup included a 2D echocardiogram which was negative for thrombus or vegetation. Complete blood count (CBC), comprehensive metabolic panel (CMP), testosterone levels, prolactin, erythrocyte sedimentation rate (ESR), and C-reactive protein were within normal parameters. Anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), and hepatitis viral panel were negative. Ankle-brachial indices demonstrated normal results as well. The patient was clinically diagnosed with bilateral lower extremity ischemia with infarction secondary to testosterone therapy. The most likely pathogenesis behind this case is testosterone-induced hypercoagulability with ensuing dermal and epidermal vascular occlusion with infarction.\nDuring the previous admission, thromboses involved the venous system, subsequent involvement of the arterial system suggests that testosterone-induced hypercoagulability confers risk for both venous and arterial thrombosis. His treatment regimen consisted of rivaroxaban 10 mg daily, full dose aspirin (325 mg) daily, amlodipine 10 mg daily, and sildenafil 10 mg daily to prevent blood clots and improve blood flow to ischemic regions. Neuropathic pain control with gabapentin 100 mg at bedtime and pain control with tramadol 25 mg twice a day as needed. Most importantly, the patient was advised to discontinue the use of testosterone therapy. He reported improvement in symptoms within 2-3 days of beginning a full treatment regimen. |
The patient was a 47-year-old male police officer who sought care at a consulting office and had been the victim of a perforating firearm wound to the right infraclavicular region 7 months prior to presentation. At the time of wounding he had been treated conservatively.\nThe patient complained of exertional dyspnea and considerable edema and pain in the right arm. He had brought the results of a chest tomography conducted some weeks before which showed considerable dilatation of the right subclavian vein and the cervical veins of the right upper limb.\nPhysical examination revealed significant edema of the right upper limb, with pain on palpation and holosystolic murmur in the topography of the right pulmonary apex. Right radial, ulnar, and brachial pulses were all reduced in comparison with those of the contralateral limb.\nTwo weeks after this consultation, the patient presented at an emergency room with exacerbation of the dyspnea, symptomatic ventricular tachycardia, and frequent premature ventricular contractions and was admitted to the hospital.\nSupplementary cardiac tests were then conducted. The echocardiogram showed dilatation of the left cardiac chambers and an ejection fraction of 63%. Myocardial scintigraphy showed signs of dilated cardiomyopathy.\nAfter clinical and cardiac stabilization, the patient underwent arteriography of the right upper limb, which showed a large arteriovenous fistula between the right subclavian vessels and a pseudoaneurysm of the subclavian artery ( ).\nThe treatment chosen was endovascular repair under local anesthesia with sedation. The technique employed was via puncture of the right common femoral artery with a 7F introducer and puncture of the right brachial artery with a 5F introducer. The subclavian artery was catheterized via the brachial access and the guidewire was snared and a through-and-through system constructed via the femoral access, due to difficulty in advancing the guidewire via the subclavian artery. The injury was repaired using a 8x100 mm Fluency covered stent (Bard) ( ).\nAfter the procedure, the patient was transferred to the ward. He exhibited good postoperative recovery, with significant improvement of the pain in the right upper limb and reestablishment of symmetry of pulses with the contralateral limb. He was discharged from the hospital 2 days after the operation, on double platelet antiaggregation with acetylsalicylic acid and clopidogrel.\nHe was reassessed 15 days later in the consulting room. There was regression of the right upper limb edema, maintenance of the radial, ulnar, brachial pulses, and improvement of the dyspnea.\nA control angiotomography conducted 15 days after the follow-up visit (i.e., 30 days after the procedure) showed that the endoprosthesis was patent and there was no premature venous filling ( ).\nThe study was approved by the Research Ethics Committee at the Hospital Saúde da Mulher (HSM), Belém, PA, Brazil. |
A 33-year-old woman presented with a history of permanent silicone injection at the gluteal area 9 years back which was done in a beauty salon by an unlicensed person. In 2016, she underwent partial removal of the filler after a pus discharge from the right gluteal induration burst. The fluid culture was positive for Pseudomonas aeruginosa which was treated with intravenous (IV) piperacillin/tazobactam for ten days. Also, she had a history of DVT 3 times in the right proximal leg. The first was 5 years back when she was pregnant at the second trimester, and the second was 2 days after delivery. The third thrombotic event occurred after a few months of filler removal. She presented to the emergency department with marked right leg swelling and pain associated with skin thickness and erythema extended to the lower part of the abdomen. Ultrasound Doppler of the right leg confirmed right iliofemoral DVT. Abdominal CT showed retroperitoneal soft tissue density with multiple calcifications that compress the aorta and inferior vena cava. They also compress the right ureter contributing to hydronephrosis and right proximal hydroureter (). No fluid collection had been noticed. In addition, subcutaneous tissue edema and wall thickening of the lower part of the abdominal wall and gluteal area were also reported. She was managed with enoxaparin therapeutic dose and clindamycin and ciprofloxacin for the possibility of cellulitis. Meg 3 demonstrated the nonfunctioning right kidney with only 3% function. A biopsy was taken from the right gluteal area that showed diffuse subcutaneous tissue fibrosis and fat necrosis along with multiple foreign body giant cell reactions (). Fungal culture was negative. Serum IgG4 level was normal, and ANA was negative by immunofluorescence and ELISA. Skin-snip biopsy also showed dermal edema with vascular proliferation and chronic inflammatory cell infiltration, representing a reaction to the previous injected material. The retroperitoneal fibrosis was managed with oral prednisolone and methotrexate 10 mg weekly along with folic acid and vitamin D supplements, in addition to warfarin. After the hospital discharge, the right leg was progressively swollen and painful. She experienced multiple times of fluid discharge from the edematous leg over 2 months. She was readmitted as a case of complicated nostra verrucose with possible cellulitis. Venous thrombosis was excluded by Doppler US. MRI of the right leg showed extensive circumferential subcutaneous edema of the right leg and thigh and fat stranding (). It also showed multiple collections occupied the medial aspect of the thigh were the largest that measured approximarely 1.4 cm × 5.7 cm × 9.0 cm in anteroposterior, transverse, and craniocaudal transverse, respectively. Another small collection in the lateral aspect of the lower right limb was 2 × 1.6 cm. Blood culture grew Streptococcus pyogenes, and culture from the discharge fluid was positive to Acinetobacter baumannii. Intravenous piperacillin-tazobactam 4.5 g was initiated, and methotrexate was paused during hospitalization. After 3 months, she was readmitted for cellulitis and treated with IV pipracilline/tazobactam and clindamycin for 10 days. Finally, one month before writing this report, she was admitted with pyelonephritis. Since her discharge, she is off MTX and prednisolone was gradually tapered as no marked improvement was noticed. |
A 53-year-old man with transient dysarthria and left hemiparesis was admitted to our hospital. The patient had recovered from neurological deficits before being transferred to our hospital, and serological examination showed no presence of vascular risk factors. Magnetic resonance imaging (MRI) showed an UCA originating from the MCA bifurcation (7 mm in diameter) without evidence of acute cerebral infarction []. The patient was diagnosed with transient ischemic attack (TIA); subsequently, careful observation was performed because of the UCA. He had a medical history of hypertension and a familial history of SAH. Cerebral angiography was performed 1 week after the initial TIA, wherein a saccular aneurysm including the superior trunk of the M2 branch was confirmed []. Surgical treatment for the aneurysm was scheduled a few months later because of the acute state of brain ischemia. A month later, the patient was transferred again and admitted to our hospital on account of TIA recurrence. MRI showed no acute brain ischemia, but revealed that the aneurysm had expanded from 7 mm to 14 mm in diameter []. Three days after admission, the left hemiparesis and dysarthria reappeared, and MRI showed acute cerebral infarction in the area supplied by the MCA perforating artery [ and ]. In addition, parenchymal edema in the insular cortex surrounding the aneurysm was observed on a fluid-attenuated inversion recovery image []. Intimal thrombosis within the aneurysmal sac was not clearly detected on MRI. Computed tomography (CT) angiography clearly depicts rapid enlargement of the aneurysmal sac []. We considered that the direct compression to the adjacent proximal perforating artery was caused by the rapidly enlarged UCA, which led to cerebral infarction. Although the cerebral infarction was in an acute state, we considered that the rapid enlargement of the aneurysm was due to an imminent rupture. Thus, the patient was assigned to undergo surgery. Surgical clipping was performed 2 days after admission. The MCA aneurysm was exposed through the pterional approach. Because the UCA was enlarged, the intimal pressure was suspected to be high, and the perforating arteries from M1 located behind the aneurysmal sac were difficult to observe under the microscope. Initially, the proximal M1 and distal M2 trunks from the aneurysm were occluded by temporal clipping to decompress the aneurysm. However, the aneurysmal intimal pressure remained high after blocking blood flow by temporal clipping. Therefore, we decompressed and shrunk the enlarged aneurysmal sac using the suction and decompression technique.[] After adequate decompression, angioplastic clipping using multiple clips was successfully completed without obstruction of the parent artery and perforating arteries. Post application of surgical clips, intraoperative endoscopy clearly showed an association between the aneurysmal sac and the perforating artery [-]. Postoperatively, CT angiography showed no evidence of the M2 trunk obstruction and the aneurysmal neck remnant []. The patient’s mild hemiparesis improved, and recurrence of infarctions could not be verified clinically for 2 years after surgery. |
Mr. RJ was a 70 year old gentleman who presented with right knee pain. The pain in his leg had been present for many months and was progressively becoming more swollen to the point that he had difficulty ambulating. This was on the background of a past history of bilateral popliteal artery aneurysms that were ligated and bypassed surgically. Examination of his knee revealed a large knee joint effusion with considerable restriction in motion due to pain.\nRadiographs of the right knee demonstrated multiple permeative lytic lesions surrounding the distal femoral condyle and metaphyseal region, resembling a "soap-bubble" appearance. Magnetic resonance imaging (MRI) of the knee revealed numerous rounded areas that were hyperintense on T2-weighted imaging in the subcortical bone of the distal femur (Figure ). Some of the lesions exhibited a sclerotic margin and two lesions appeared to breach the cortex and extend into the soft tissues adjacent to the bone. Diffuse abnormal bone marrow signal was seen in the distal femoral diaphysis and metaphysis but not the proximal part of the femur. A large aneurysm arising from the femoral artery was evident, that extended to the popliteal artery, with MR evidence of thrombosis. Around the knee joint there was diffuse oedema and synovitis. A triple-phase bone scan of the knee was performed that showed abnormal tracer uptake in the distal right femur which was greatest in the lateral femoral condyle. The bone scan appearance was not typical for metastatic disease and there was no evidence of osteoblastic metastatic disease elsewhere. Thallium scan showed an active metabolic process occurring within the lateral femoral condyle with permeative bone lesions.\nComputer tomography (CT) guided closed biopsy of the lesion was performed. The histological examination showed fibrotic changes and was deemed non-diagnostic. Because of the bizarre clinicopathological picture, an open biopsy was performed and yielded two grams of haemorrhagic soft tissue. Histological examination showed a reactive process resembling aneurysmal bone cyst formation similar to the CT percutaneous biopsy. There was no evidence in either biopsy sample to indicate malignancy or infection.\nFollowing this, the patient continued to experience ongoing symptoms over the knee. Repeat MRI revealed progressive multiple, destructive bone lesions involving the right femur, with some haemorrhagic components in the soft tissue around the knee. It was decided that a wide en bloc resection of the distal femur and proximal tibia would be performed. A rotating hinge megaprosthesis (Global Modular Replacement system, Stryker, Howmedica) was used for reconstruction of a mobile knee joint. Histological analysis of the resected specimen showed cystic spaces which were lined by fibrous septa that contained blood vessels (Figure ). Prominent, multinucleated giant cells were seen and there were areas of haemosiderin deposition and recent haemorrhage. No other accompanying neoplastic cells were seen. Therefore, given these features, a provisional diagnosis of cystic haemorrhagic aneurysmal bone cyst was made. The patient received rehabilitative exercise postoperatively, however, the knee pain was persistent.\nTwo months after the index operation, he presented with an acute extensive and painful haemarthrosis. Angiogram of the right leg was performed and revealed extravasating collateral branches from the profunda artery around the knee joint. Exploration and ligation of the right popliteal aneurysm and evacuation of the knee joint haematoma was performed. The patient was also anaemic, however, haematological assessment showed no underlying blood malignancies that could account for this, leaving chronic blood loss the most likely clinical cause.\nThe patient continued to have unremitting limb pain, and an x-ray of the knee showed progressive osteolytic destruction over the bone-implant junction (Figure ). It was suggested that this was the result of tumour to the proximal part of the right leg. Subsequently, a hindquarter amputation was performed 5 months after the initial surgery. The macroscopic specimen was sent for expert consultation at the Mayo clinic, Rochester, MN, USA where the definitive diagnosis of angiosarcoma was made (Figure ).\nThe patient's disease progressed and he subsequently developed pulmonary and intra-abdominal metastases. Lung biopsy confirmed tumor metastasis. He died of metastatic disease and sepsis one year after initial presentation. |
A 72-year-old female was referred to our lymphedema clinic with a 26-year history of chronic acquired left lower extremity lymphedema. She had a history of lymphoma and treated with radiation therapy on right inguinal area. Interestingly, she had lymphedema in both extremities, which was more severe in the left lower extremity (International Society of Lymphology stage 3) than in the right lower extremity (International Society of Lymphology stage 2). She first noticed the signs and symptoms of lymphedema after radiation therapy. She complained of severe left lower extremity heaviness and pain, difficulty in ambulation, and recurrent cellulitis, and intermittent sepsis that required hospitalization. She underwent combination treatment including decongestive physiotherapy for years, daily manual and mechanical lymphatic drainage, and compression garments. However, the nonsurgical management of lymphedema did not significantly improve the swelling and associated symptoms.\nThe patient did not have a history of diabetes mellitus or hypertension according to the complete patient medical history. The severity of the vascularity was measured by the ankle-brachial index, partial transcutaneous partial oxygen tension, and 3-dimensional computed tomography angiography. The patient had a decreased ankle-brachial index in both extremities and the transcutaneous partial oxygen tension on the left lower extremity was 8 mm Hg. The lower extremity computed tomography angiography identified severe stenosis of the bilateral superficial femoral artery. Furthermore, a left peroneal artery in the lower extremity was completely occluded below the knee. Percutaneous transluminal angiography was recommended but the patient strongly refused. Indocyanine green (ICG) fluorescence lymphography showed severe dermal backflow in the entire extremity including the foot and no lymphatic vessels were visualized on her left lower extremity with severe lymphedema. However, magnetic resonance lymphangiography showed some functioning lymphatic vessels were identified in the lower extremity with severe lymphedema. Therefore, we planned simultaneous LVA and VLNT for the left extremity that had severe lymphedema for 26 years and we provided detailed information on the donor sites except for the contralateral groin flaps including inguinal lymph nodes due to the high risk of aggravating the contralateral lower extremity lymphedema. The patient selected supraclavicular lymph node transfer and LVA and underwent surgery. Written informed consent was obtained from the patient. |
A 4-year-old boy presented with 3 days history suggestive of duodenal obstruction. On clinical examination, the patient appeared irritable with no evidence of fever or hemodynamic instability. The abdominal examination was unremarkable except mild discomfort in epigastrium on palpation. Plain abdominal radiograph was suggestive of high small bowel obstruction. Upper gastrointestinal contrast study showed obstruction in the second and third part of the duodenum. The contrast did not pass beyond third part of the duodenum. He was managed conservatively with nasogastric (NG) aspiration, intravenous fluids, and H2 blockers. He had large amount of greenish aspirate from the NG tube every day. His routine hematologic investigations and biochemistry were normal except high serum amylase level (307 U/L). An abdominal ultrasound showed a cystic mass (8 × 9 cm) in the epigastrium in relation to the head of pancreas. Computed tomography scan of abdomen showed similar finding and a diagnosis of pseudocyst at the head region of pancreas was made. Upper gastrointestinal endoscopy showed narrowing of duodenal lumen beyond the second part due to extraluminal compression of C-loop of duodenum []. There was an area of friable mucosa with fistula on the medial wall of the second part of duodenum in the vicinity of ampulla of Vater. A diagnosis of spontaneous internal drainage of pseudocyst of head of pancreas was thought of and no further endoscopic intervention was attempted. Conservative management was continued till the next 72 h when sudden improvement in the clinical condition was observed. His NG aspirates came down and repeat endoscopy showed complete disappearance of mass effect in duodenum with an opening in the medial wall of the second part of the duodenum suggesting spontaneous duodenal fistulization of pseudocyst of pancreas []. The patient had prompt clinical recovery with resolution of symptoms. The NG tube was removed and oral feeds were resumed. He was discharged home and repeat endoscopy done after 1 month was normal. The patient is on regular follow-up for the last 2 years and is doing well. |
The patient is a 31-year-old African-American, left handed female who was recently diagnosed with hypertension. She presented with left handed clumsiness, most notably in her left index finger and thumb, she also complains of an episode of slurred speech and left sided facial numbness that lasted for about 30 minutes to 1 hour. The patient was initially seen in a local hospital nearby and was reported to have an abnormal EKG with T wave inversions in leads v2–v4 and left ventricular hypertrophy but the patient refused admission and was admitted to our institution 10 days later. Her symptoms had improved two days after the attack but she still had difficulty with fine motor task like typing. During her stay she maintained a saturation of 95-96%.\nHer neurological work-up included an MRI of the brain, which demonstrated a subacute infarct within the right precentral gyrus, involving the region of the hand knob correlating with her left hand weakness ().\nTransthoracic echocardiography revealed moderate left ventricular hypertrophy without regional wall motion abnormalities. The left atrium was mildly dilated. There was an increased mitral valve E point, ventricular septal separation; the visually estimated ejection fraction was 45–50%. There was no evidence of right to left shunting by agitated saline bubble contrast study performed in the right arm.\nHer chest radiography demonstrated abnormal soft tissue densities along the right paratracheal region extending to the right main stem bronchus and along the right cardiomediastinal margin of unclear etiology which was further evaluated with a CT scan. CT imaging demonstrated persistence of the left superior vena cava draining into the left atrium without visualization of a coronary sinus. Cardiac venous drainage is seen directly into the inferior vena cava via the great cardiac vein. Subtle high attenuation contrast extends deep into the interventricular septum. While this may be a myocardial cleft in the same setting of possible left ventricular hypertrophy, the alternate possibility of a sinusoidal VSD is raised as a potential component of Raghib Syndrome. The mass seen in the chest radiograph along the cardiomediastinal margin was correlated to be a 5.4 cm pericardial cyst, and a 1 mm right middle lobe nodule was also noted.\nFor cryptogenic stroke, the patient underwent upper and lower extremity Doppler ultrasound as well as cardiac MRI. Doppler ultrasound showed no evidence of deep vein thrombosis. Cardiac MR demonstrated concentric hypertrophic cardiomyopathy, with relative sparing of the apical chamber. Left ventricular systolic function was moderately reduced with a calculated ejection fraction of 36%. The persistent left superior vena cava drained into the left atrium resulting in a right to left shunt with a Qp/Qs = 0.694 ().\nThe patient's clinical diagnosis was Raghib syndrome with paradoxical embolization causing stroke. Although PLSVC serves as a right to left shunt, our patient during her stay has maintained oxygen saturation of above 90%. The right to left shunt caused by PLSVC is usually small and does not lead to significant oxygen desaturation. Transcatheter treatment is performed in patients with unroofed coronary sinus or an ASD and also seen in a reported case of LSVC which had a bridging with the RSVC by left brachiocephalic vein, such a treatment option was not considered in our patient as she did not have any of the above. She was discharged on aspirin, metoprolol, and a Holter monitor was placed prior to discharge. She will continue to follow up with the hospital for further evaluation 6 months later with a cardiac MRI. |
The case was a 25-year-old MG3L1ab2 woman with a history of infertility, complaining from irregular uterine bleeding and she was diagnosed with a pelvic mass in MRI. She got married 7 years ago.\nAll of her pregnancies were by induction and ovulation and the first and second pregnancies were aborted spontaneously between 6 and 8 weeks. The third pregnancy, 3 years ago, was terminated by cesarean section and resulted in the birth of a healthy baby.\nThe patient who had menorrhagia for the last 6 months was examined for irregular uterine bleeding. She also complained about occasional pains under the abdomen and in the right upper quadrant abdomen. In MRI, the retroperitoneal uterus and endometrial thickness was 5 mm, and a mass with an abnormal heterogeneous signal and heterogenic enhancement of about 95×80 mm in the anterolateral and right border of the hip with the extension to the hypogastric region was reported suggesting tumoral lesions in the right ovary or endometrium ().\nAccording to the report of the ovarian mass in MRI, the patient became a candidate for laparoscopy.\nThe laparoscopic surgery was planned in the operating room of Mehr Hospital in Mashhad on January 10, 2018. Initially, to enter the abdominal cavity, there was no possibility of passing the veress needle through abdominal wall from the umbilicus and the Palmer’s point, so the decision was made to enter the abdominal cavity through open laparoscopy. After creating a 2 cm incision in the umbilicus, and touching with finger, a solid and abnormal texture in this place was observed. Therefore, the decision was made to continue the operation by laparotomy.\nThe abdomen was opened with a midline incision and a solid mass was in the midline of the abdominal wall adhering to the rectus muscles and the fascia with 12 cm in size. First, the mass was dissected from the rectus muscles and the peritoneum below it. After complete dissection, it was observed that the mass was connected to the abdominal wall with a relatively thick bundle (2 cm) in the suprapubic region ().\nThe mass was similar to uterine fibroids in shape and consistency. After complete removal of the mass, in the examination of the abdominal wall, the visceral peritoneum was completely healthy. The visceral peritoneum was opened to check the abdominal cavity. No specific pathological findings were observed in the examination of the abdomen and pelvis. The uterus and adnexa were completely healthy and there was no evidence of adhesion, mass or ovarian cyst or uterine fibroids. So, the surgery was terminated.\nPathology report of the abdominal wall mass was leiomyoma. |
A 66-year-old, right-hand-dominant man presented with dull, throbbing pain in his middle, ring, and small fingers of his left hand, which began 2 days prior to admission. On physical examination, the affected digits were cyanotic with ulceration (Fig ). Radial and ulnar pulses were palpable. The patient's medical history was significant for smoking, coronary artery disease, and hypertension. He also reported sustaining a deep laceration of the ulnar aspect of the left wrist with a piece of glass at age 10 years. Arteriography of his upper left extremity demonstrated occlusion of the ulnar and radial arteries at the level of the wrist, with poor distal perfusion to the middle, ring, and small fingers (Fig ). Distal collateralization beyond the level of occlusion at the wrist suggested chronic ulnar artery occlusion. There was no filling of the superficial palmar arch. The patient had a normal electrocardiogram. Both the aortogram and echocardiogram showed no evidence of an embolic source. We surmised that the patient's abnormal arterial anatomy was caused by a previous ulnar artery injury with subsequent atherosclerotic disease leading to subacute digital ischemia. Given these findings, the surgical team recommended an attempt at distal revascularization of the digits to prevent further tissue loss.\nAn ulnar artery to superficial palmar arch bypass using a cephalic vein graft from the left forearm was performed. Initial dissection was carried out under tourniquet control with release prior to anastomosis. Access to the superficial arch was obtained through a palmar incision, incorporating the carpal tunnel. There were several thrombi in the ulnar artery, including one just proximal to the superficial arch and another in the distal wrist. The ulnar artery appeared to be thrombosed in the distal forearm and proximal wrist and up into the proximal hand. However, the proximal ulnar artery had pulsations and a strong Doppler signal. The distal superficial palmar arch also had a good Doppler signal, suggesting a patent artery, likely from collaterals. The distal ulnar artery was therefore used for inflow and the proximal superficial arch for outflow.\nA segment of cephalic vein was harvested from the left forearm. The ulnar artery was divided just proximal to the area of thrombosis and the superficial arch just distal to the thrombosis. These vessels exhibited pulsatile bleeding and both had grossly normal intima. The vein graft was reversed and anastomosed in an end-to-end fashion to the distal ulnar artery, using interrupted 9-0 nylon sutures with the operating microscope. The vein graft was then brought down through the carpal tunnel into the palm (Fig ). Because of a size mismatch, the palmar arch was anastomosed to a side branch on the cephalic vein graft in an end-to-end fashion. It was unknown how much perfusion would reach the small finger so the remaining distal portion of the cephalic vein was used to create a third anastomosis to the common digital artery to the ring and small fingers. Because of the size mismatch, the common digital artery was divided and anastomosed to the side of the cephalic vein graft. The distal end of the graft was then ligated. A handheld Doppler device confirmed pulsatile flow through the graft and distal to the anastomoses. Immediately, capillary refill to the ring and small fingers was brisk. An implantable Doppler probe was placed on the vein graft to monitor graft patency postoperatively.\nThe patient has since recovered uneventfully and without complication. The graft has remained patent at 18 months' follow-up and continues to have brisk capillary refill to the involved digits. His ulcerations have healed (Fig ). The finding from the patient's neurovascular and motor examination is normal. |
A 56-year-old male patient was admitted to hospital with severe chest and back pain for 10 hours. Initial diagnosis was a type B aortic dissection. Two weeks after admission, the patient still had back pain and CTA indicated that the pseudocavity was large and the true cavity was small, with poor organ perfusion. Therefore, a thoracic endovascular aortic repair (TEVAR) was performed, and the left subclavian artery opening was not closed. On the third day following surgery, the patient complained of pain in the anterior cardiac region with recurrent dizziness. A re-examination of CTA revealed a retrograde tear of the ascending aorta to form a type A dissection. The brachiocephalic trunk was torn by the dissection while the right CCA was normal. The left CCA was torn to the bifurcation and the true cavity was narrow as a result of a massive thrombosis in the distal pseudocavity (). An ascending aorta and total arch replacement was then performed under extracorporeal circulation. Due to the large number of thrombi in the pseudocavity of the left CCA, cerebral perfusion was performed with a unilateral brachiocephalic cannula when circulation was stopped. The aortic arch was cut open intraoperatively and a large number of fresh thrombi were found in the left carotid artery pseudolumen, with little blood return. The thrombus was sucked as far as possible into the suction device until there was no visible thrombus and a good blood return. The branch of the vascular prosthesis was anastomosed directly onto the dissecting wall of left CCA. During the early postoperative period, the patient was in a state of severe delirium. However, he recovered completely in approximately 48 hours, without any permanent neurological dysfunction such as hemiplegia. The aortic CTA was reviewed on the ninth postoperative day, which suggested that the left CCA was completely occluded from origin. The brachial and left subclavian arteries developed normally (). After 18 months of follow-up, CTA re-examination revealed the same situation. The patient’s main symptom was repeated severe dizziness. Reoperation on the left CCA was recommended but was rejected by the patient. |
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 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 54-year-old male with a history of progressive ankylosing spondylitis presented to our hospital with complaints of worsening bilateral leg weakness and difficulty ambulating. He also described a shooting, electric sensation that began in his lower back and radiated laterally to his hips and down his legs whenever he flexed his trunk, such as when transferring from a seated to standing position. A skiing accident occurred approximately 2 months prior to presentation during which the patient sustained a fracture dislocation of his right shoulder. Imaging at that time included X-rays of the right shoulder, in addition to imaging of the thoracic and lumbar spine. These images were unremarkable other than degenerative changes consistent with the patient's previous diagnosis of ankylosing spondylitis. Several weeks after the accident he began to experience an intermittent, sharp pain in his lower back that radiated anteriorly around his abdomen at the T10 level. He had been to both his primary care and physical medicine and rehabilitation physicians after the accident, and they had followed him up for further medical management and physical therapy.\nApproximately 2 weeks prior to admission, the patient began to experience the intermittent shock-like sensation and worsening bilateral lower extremity weakness. He described his weakness as not only a perceived loss of muscular strength but also an excessive fatigue resulting in the inability to complete physical activities that had previously been routine for him. Two days before presenting to the hospital, the patient was unable to lift himself off an exercise mat after the completion of a physical therapy appointment and required the assistance of his wife and son to help him return to his vehicle. He subsequently developed a wide-based and ataxic gait with frequent loss of balance and near falls. Pertinent negatives throughout the course of this patient's presentation include any loss of bowel or bladder function, loss of consciousness, dizziness, light-headedness, vertigo, headache, numbness, tingling, burning, or other neurological symptoms other than those already described.\nThe patient's past medical history included ankylosing spondylitis initially diagnosed at the age of 25 and hypertension treated with amlodipine. He had undergone an umbilical hernia repair in 2004. He was a previous smoker, having quit in 2007, and denied alcohol or drug abuse. Upon presenting to the EC, the patient received a preliminary laboratory workup consisting of a CMP, CK, ESR, and CBC, all of which were unremarkable other than elevated WBC of 10.2 and ESR of 31 consistent with his underlying inflammatory condition. A CT of the brain and cervical spine revealed no signs of acute infarct, hemorrhage, or fracture. Due to the nature of the patient's symptoms an MRI was ordered of the same regions and also interpreted with unremarkable results. The patient was subsequently admitted for further neurologic and orthopedic workup.\nUpon examination, the patient demonstrated hip flexor and foot dorsiflexion weakness bilaterally with vague sensory disturbances of the left and right anterior thigh, as described by the patient. An ataxic gait was also present, and the patient was unable to complete tandem gait testing due to loss of balance. Position and vibration sense, heel to shin testing, and reflexes were preserved throughout the lower extremities. Interestingly, flexion of the neck did not elicit any symptoms; however, the sudden shooting pain located in the lower back, hip, and legs presented when the patient was asked to stand from a lying position. The patient was otherwise intact neurologically. There was no focal vertebral tenderness to palpation over the cervical or thoracic spine.\nGiven the patient's clinical examination and symptoms we were most concerned with an underlying progressive pathology of the spinal cord, whether it be of neurologic, orthopedic, or multifactorial origin. We had also not ruled out metabolic, inflammatory, or infectious etiologies at that point without more extensive laboratory testing. Our differential diagnosis at the time included cervical or thoracic spondylotic myelopathy, vertebral disc herniation, thoracic vertebral fracture, spinal stenosis, transverse myelitis, chronic inflammatory demyelinating polyneuropathy, multiple sclerosis, thoracic or lumbosacral radiculopathy, pernicious anemia, malignancy, or an infectious condition such as tabes dorsalis. Our primary concern was to first investigate a potential acute spinal cord injury, so we ordered STAT cervical and thoracic MRIs to evaluate any underlying physical abnormalities that may help explain the patient's overall presentation. The T2 thoracic MRI revealed a three-column vertebral fracture at the T11-T12 level that was associated with significant edema surrounding the spinal cord and loss of vertebral body height, which had resulted in moderate spinal canal stenosis at that level (). Later that day the patient underwent an uncomplicated T10-L1 laminectomy and fusion with instrumentation to stabilize the vertebral column. Within 2 days post-op the radiating electrical sensation with spinal flexion had disappeared, and the patient was able to stand and walk without loss of coordination or balance. He was discharged several days later able to stand and walk without assistance and felt that he had regained much of his previous lower-body strength by that point. He continued to be compliant with his physical therapy regimen and reported his symptoms completely resolved by the time of his 1-month follow-up visit with the surgeon. |
This is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).\nIt also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.\nThe patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained of sleeping difficulties with ruminative worries about his situation. He denied any suicidal thoughts.\nThe patient was started on Remeron (mirtazapine), 15 mg at bedtime. He also engaged in weekly psychotherapy sessions. Over the next two months, the patient noted improvements in his sleeping patterns and appetite. The crying spells persisted. The patient was observed to be tearful while at the waiting area, during the psychiatric evaluation, and after his treatment appointment. His family reports that he cries every day for no apparent reason. Despite reassurances that he was not depressed, the family was convinced that his emotional state was getting worse. The patient was eventually diagnosed with pseudobulbar affect (PBA) because of his repeated outburst of involuntary crying. The crying was occurring even though there was no sad event that triggered those emotions. These episodes were persistent and had occurred in different situations or settings. He was referred to a local neurologist who confirmed the PBA. Eventually, he was managed with dextromethorphan hydrobromide and quinidine sulfate (DM/Q), 20 mg/10 mg capsules twice a day, in addition to his mirtazapine. The patient's crying spells improved significantly after the DM/Q was started. He tolerated it very well with no complaints of any side effects.\nA year later, the patient had multiple tragedies in his family. His father, with whom he was very close with, suddenly and unexpectedly died. He also had an argument with his daughter, who later refused to talk to him. He was overwhelmed with financial problems. Because of these, the patient became more depressed and the crying spells recurred. Despite his medication compliance with DM/Q and mirtazapine, he noted worsening depression and occasional suicidal thoughts. He reported symptoms of sad mood, anhedonia, fatigue, excessive sleeping with early morning awakenings, increased appetite and weight gain, psychomotor retardation, and feelings of helplessness and worthlessness. He was having thoughts of shooting himself, even though he does not own a gun. This time, he was subjectively complaining of being "down in the dumps." He was seen in the emergency room for a crisis evaluation and referred back to the mental health center. He was reevaluated and his mirtazapine was switched to Viibryd (vilazodone) because of weight gain concerns. He also attended twice a week psychotherapy sessions. A month later, with these interventions, the patient's depressive symptoms, including the crying spells, had improved. He continues to receive his DM/Q and vilazodone and weekly psychotherapy sessions with no exacerbations of any mood symptoms. |
A 1-year-old girl child was brought by her parents to our hospital with a complaint of swelling in the mandibular right posterior region. The mother of the child noticed the swelling since 2-3 months, which gradually increased in size. Her medical, surgical, family and social history were unremarkable. A systemic review was within normal limits and no medication had been taken for this swelling.\nIntraoral examination showed a hard swelling in the right mandibular body, which was present in the canine to molar region. The overlying mucosa was intact and of normal colour. The buccal cortical plate expansion in the region of the swelling was detected [].\nThere was no evidence of pus or blood discharge from the swelling. The radiographic examination (occlusal and lateral oblique view) showed a large well defined unilocular radiolucent lesion extending from right deciduous canine to second molar region. The borders of the lesion were well defined and corticated with thinning and expansion of the inferior border of mandible and buccal cortex. The lesion was associated with a displaced developing mandibular first molar towards inferior border of mandible while second molar was displaced posteriorly [Figures and ]. The clinical diagnosis of dentigerous cyst was made. Enucleation of the lesion was advised, but the parents refused the surgical treatment.\nAgain after 3 months the patient reported with a rapid increase in the size of the swelling. A proliferative growth was evident in the mandibular right posterior region extending from canine to molar region. Approximate size of the lesion was 3 cm × 2 cm which was soft and non-tender. Right submandibular lymphadenopathy was present. Taking into consideration the sudden rapid growth, which was proliferative a clinical suspicion of a malignant lesion, ameloblastic fibrosarcoma was considered, and an incisional biopsy was performed.\nH and E stained sections showed a tumor mass made up of epithelial and mesenchymal components of odontogenic origin. The epithelial component consisted of multiple, sharply defined strands and islands which were bordered at the periphery by a layer of tall columnar cells resembling ameloblasts. The mesenchymal component is made up of primitive connective tissue consisting of closely interwining fibrils interspersed by large connective tissue cells closely resembling those of dental papilla. The histopathological diagnosis was AF [Figures and ].\nSurgical excision of the lesion with curettage of surrounding bone was performed. The post-operative course was uneventful and the patient was discharged for further follow up. On follow up healing was uneventful and there were no signs of recurrence. |
A 56-year-old male presented to a medical emergency department with complaints of high-grade fever, altered behavior in the form of irrelevant talk, agitation, and irritability with fluctuating orientation for 2 days.\nThe patient was a known case of undifferentiated schizophrenia as per International Classification of Diseases, 10th edition since past 24 years and was on regular treatment with good compliance since the start of treatment. Initial symptoms of the patient included suspicion against family members that they will harm him, muttering and gesticulating to self, aggressive and abusive behavior, reduced sleep, and disinhibited behavior for which he was treated with electroconvulsive therapy and psychotropic medication during initial period. The patient improved in a few weeks and continued the treatment as advised by the psychiatrist. The patient had aggravation of symptoms while on medication multiple times mostly without any precipitating factors during the course of illness. Since 24 years, the patient had been prescribed various antipsychotic medications including trifluperazine, risperidone, and olanzapine in adequate doses and for adequate duration. Quetiapine was prescribed in low doses for agitation whenever required as per the response. In spite of being compliant to the treatment, the patient never improved to a premorbid level and some residual symptoms would always remain. The patient had been admitted under psychiatrist's care for three times due to aggravation of symptoms despite being compliant in the past few years before he was considered to be a case of resistant schizophrenia and prescribed tablet clozapine with normal baseline CBC and weekly counts were advised. Dose was gradually increased to reach up to 200 mg in 2 weeks along with continuation of risperidone 4 mg in divided doses. Patient showed partial improvement in symptoms after 2 weeks of treatment and improvement was increasing slowly.\nWithin 30 days of starting clozapine, the patient presented to the casualty with above symptoms suggestive of some organicity. The patient also had urinary complaints (urgency and frequency). Neuroimaging revealed no abnormality, but urine examination showed plenty of pus cells. Urine and blood culture revealed infection with Klebsiella pneumonia with signs suggestive of cystitis on ultrasonography. His serum potassium levels were low (2.57 mEq/L) with deranged kidney and liver functions. Patients' CBC revealed low hemoglobin of 7.6 g% and TLC of 400/mm3 (differential count could not be done due to low leukocyte count) with 3.47 mil/ul RBCs. His platelet count was normal (3.42 lakh/mm3). Bone marrow biopsy was suggestive of “depressed granulopoiesis and erythropoiesis with hypoplastic anemia.” Patient was negative for antinuclear antibodies and his cardiac functioning in echocardiography was within normal limits. There were no abnormalities in other blood investigations. The patient was treated in the Intensive Care Unit (ICU) with antibiotic drugs, adequate hydration, supportive treatment, and other measures. Clozapine was stopped immediately, risperidone dose was increased to 6 mg (divided doses), and aripiprazole was added in 5 mg dose that was later increased. Patients' blood investigation charting was done, and there was improving trend in blood counts. Slowly patients' hemoglobin increased to 9.4 g/dl at the end of 3 weeks. TLC found increased in subsequent testing, and at the end of 3 weeks, it was 6900/mm3 with absolute neutrophil count (ANC) 5796/mm3. RBC count increased to 4.3 mil/ul at the time of discharge. Serum potassium level became normal within few days of admission. There was no growth on urine and blood culture on repeat testing.\nWhen the patient was discharged, dose of aripiprazole was increased to 30 mg in the next few days along with risperidone 6 mg. The patient showed aggravation of symptoms within a week of stopping clozapine but again reported improvement after increasing the dose of aripiprazole. |
A 70 year-old male presented with a 4-month history of dry cough and general malaise. He had had a right arm melanoma excised 5 months previously but otherwise had no significant medical history. Clinical examination revealed a left pleural effusion confirmed by chest radiograph which subsequently drained blood-stained fluid positive for reactive mesothelial cells and lymphocytes. Cytology was negative for malignant cells. Computed tomography (CT) of his thorax and abdomen undertaken just prior to discharge from hospital revealed a left renal mass consistent with renal cell carcinoma (RCC) and multiple bilateral subpleural nodules. Renal function was normal at this stage.\nThe patient was electively re-admitted a week later for planned thoracoscopy and pleural biopsy. Biopsy confirmed the subpleural nodules to be metastatic RCC deposits. Following repeat chest drain insertion the patient collapsed some hours later and became acutely dyspnoeic with oxygen saturations of 82% on room air and a systolic blood pressure of 96 mmHg. There was no clinical evidence of lower limb deep vein thrombosis. Arterial gases confirmed type I respiratory failure and an electrocardiogram revealed a sinus tachycardia with new right bundle branch block. Subsequent CT pulmonary angiogram (CTPA) demonstrated a large saddle embolus with thrombus extending into the lobar branches of both main pulmonary arteries (Fig. ). Massive PE was diagnosed and in view of its acute setting and the patient being in extremis the origin of the PE was not sought at this stage. Moreover a team of chest physicians; oncologists and urologists concluded that with the combination of neoplastic disease; a recent biopsy and a chest drain in-situ thrombolysis would be deleterious to the patient. Intravenous heparin was commenced whilst a cardiology opinion was sought to explore the possibility of percutaneous intervention. We as a faculty had no previous experience of using percutaneous mechanical thrombectomy (PMT) for dealing with massive PE at the time. The lead cardiologist was asked to review the patient with a view to endovascular intervention by a chest physician who wanted to exhaust all the options available. The cardiologist had remembered a case in the literature where the AngioJet system had been used to treat massive PE and from this a consensus decision was reached to pursue PMT as a definitive therapy for the patient.\nWe proceeded to rheolytic thrombectomy using the AngioJet system (Possis Medical, Minneapolis, MN). Access was gained via 5-French (F) and 10F sheaths into the right femoral vein. A 4F sheath was also introduced into the right femoral artery for blood pressure monitoring. We confirmed the absence of thrombus in the inferior vena cava (IVC) angiographically before proceeding with right heart catheterisation. A 0.035-inch guidewire was placed in the right ventricle over which a 5F multipurpose-1 (MP-1) diagnostic catheter was fed. Pulmonary angiography via this catheter revealed filling defects in both pulmonary arteries (Fig. , Additional file ). A temporary pacing wire was then placed in the right ventricular apex via the 5F sheath to protect the patient from bradyarrhythmia.[] Mean pulmonary artery pressure was measured at 35 mmHg.\nThrombectomy was performed using a 6F AngioJet Xpeedior catheter directed to both main pulmonary arteries via a 9F MP-1 catheter in the right ventricle (Fig. ). This was undertaken through the 10F sheath in the right femoral vein. The AngioJet system was used for a total of 2 minutes and 10 seconds and selective pulmonary angiograms revealed significant reduction in thrombus burden from both left and right pulmonary arteries with significant restoration of blood flow (Fig. , Additional file ). A quantitative measure of perfusion improvement was not assessed due to our relative inexperience with this procedure. Clinically, however, as perfusion returned to each main vessel the patient suffered what appeared to be a pre-syncopal episode on both occasions although all observations including heart rate, blood pressure and oxygen saturations remained within the normal range. Why this occurred remains unclear. The entire process took a total of 1 hour and 35 minutes and required 90 ml of contrast. Heart rate remained within normal range throughout. Following thrombectomy the collection bag could be seen to contain a significant amount of thrombus material (Fig. ).\nBoth the temporary wire and arterial sheath were left in situ overnight and the patient remained on intravenous heparin. The chest drain was subsequently removed and the patient was off supplemental oxygen within 3 days. Ultrasound of the abdomen and pelvis on day 2 post rheolytic thrombectomy was essentially normal and showed patent IVC, hepatic, portal and renal veins. Despite this a prophylactic IVC filter was inserted in preparation for planned cyto-reductive nephrectomy in approximately six weeks and subsequent immunotherapy. Following insertion of the IVC filter the patient was warfarinised and then discharged home. |
In this work a case report of a 14 years old Caucasian boy has been described. The patient had a scooter crash without any protective head and body gear [] and referred to our attention only 4 hours after the accident.\nAs a consequence he underwent a dentoalveolar damageof both upper central incisors and vestibolarization of two crown fragments, with no fracture line clinically detectable. A horizontal root fracture was radiographically evident between the middle third and the apical third of the central upper incisors ().\nThe care plan comprised reduction, repositioning and rigid splinting of the coronal fragments. []. The initial treatment consisted in repositioning, using firm finger pressure to the coronal segments. All the maxillary elements were subsequently splinted using interproximal composite (). After 24 hours an orthodontic stainless steel arch was applied, using a photopolymeric resin after a careful assessment of the occlusal contacts (). No medication was prescribed. The splint was held 1 year long because of the presence of severe dental mobility. Despite this therapeutic solution, a correct oral hygiene was kept thanks to a professional hygiene, to a strong motivation of the patient and to the use of the dental floss (Superfloss®). Moreover, the absence of the fracture line with the oral environment prevented any bacterial penetration. Ten days later the damaged teeth did not show chromatic alterations and the thermal and electrical tests (Crio Test - Pulp Test) suggested no pulpar necrosis [].\nA follow-up was performed after 20 and 30 days, through clinical and radiographic examinations. Then the patient returned for periodic clinical and radiographic follow-up after 3 months and 1, 3 and 4 years (-). After the splint removal the mobility of both incisors was within normal limits and the patient reported no discomfort with his teeth and no pain during horizontal and vertical percussion tests. The electrical test responses of both central incisors were grade 4. The control check was performed on laterals and it was grade 2. No sign of pathology was visible on the radiograms. |
A 20-year-old man with both upper limb disabilities admitted to our hospital for mandatory health screening before military service. He had no health complaints other than the skeletal disorder involving his upper limbs. In detailed questioning, he stated that he had four fingers in his left foot. He is the last of six children born to nonconsanguineous healthy parents. All of his brothers and sisters are completely healthy. There is no family history of any kind of congenital skeletal abnormalities in the extended family. His mother was at the age of 32 when she gave birth to our patient. There is no history of any drug, smoke, alcohol, or radiation exposure during pregnancy. Our patient was born uneventfully at full-term through normal vaginal delivery. No other significant health problem is present in the history of his childhood.\nOn physical examination, all skeletal elements beyond his left elbow and right wrist, and the fifth finger of his left foot were found to be absent (). He had oligodactyly of the left foot (). Anteroposterior radiograph of the right arm depicted the absence of the hand with well-developed radius and ulna. There was a rudimentary bone of about 1 cm in the medial neighborhood of the distal ulna (). Anteroposterior radiograph of the left arm demonstrated that the proximal forearm segment participating in the elbow joint structure was small but present, while the radius and ulna distal to this point were absent (). Anteroposterior, lateral oblique, and mediolateral radiographs of the left foot revealed absence of the fifth finger and the lateral cuneiform. The second to fourth fingers were short. The number, size, and joint relations of the other bones forming the foot were normal (). Magnified anteroposterior and lateral oblique radiographs of the left foot showed that the middle phalanges of the second and third fingers were shorter than the distal phalanges, and the middle phalanx of the fourth finger was absent ().\nThe patient was then referred to the Department of Orthopedic Surgery to identify the best prosthetic fitting option and to provide a convenient training regimen. |
A 27-year-old woman with TN during 11 years in the left V2 and V3 divisions was submitted 6 years ago to microvascular decompression in the posterior fossa due to neurovascular conflict. Her symptoms disappeared for 4 years and she was resistant to standard drug therapy at the time. Percutaneous balloon rhizotomy was performed in another service. Massive bleeding during the procedure was described, and the patient presented with proptosis, eye pain, chemosis, and paralysis of extraocular movements in the left eye a few hours after the procedure, with worsening of symptoms over the following days. A brain magnetic resonance image (MRI) [] showed an oval structure of 14 × 13 × 11 mm adjacent to the left cavernous sinus. Moreover, a prominent and serpiginous tubular image in intraconal situation located caudal to the superior rectus muscle and cranially to retrobulbar segment of the optic nerve with significant hypointensity similar to that displayed in the cavernous portion of the ipsilateral ICA suggested a flow void compatible with vascular abnormality of high flow. This structure corresponded to the superior ophthalmic vein, which captured contrast and presented with ventral extraorbital insinuation and dorsal insinuation to the orbital apex through the superior orbital fissure with gradual reduction of its caliber. After 10 days, she was referred to digital subtraction angiography (DSA) of the intracranial vessels, which confirmed the diagnosis of a high flow CCF. The fistula was indirect [] because it filled the cavernous sinus retrogradely through an abnormal communication between the final segment of the posterior petrous portion of the ICA and veins draining to the sinus (vidian artery communicating with the inferolateral trunk). There was no other vascular abnormality involving the right ICA and external carotid artery bilaterally or posterior circulation []. Transarterial embolization of the fistulous orifice was performed using coils, with immediate cessation of early venous filling []. The patient showed complete regression of ocular symptoms in a period of 5 days. During a 6-month follow-up, the patient confirmed complete remission of the TN. |
A 25-year-old male reported to our department for opinion regarding a massive, asymptomatic enlargement of the right half of the face since childhood (). The asymmetry had increased with age and ceased to grow after 18 years of age. Family history was unavailable since he was an orphan. Medical examination did not reveal any other health issues. The patient had deferred treatment until now due to the lack of financial resources. Extraoral examination revealed a massive and diffuse enlargement of the right side of the face. The enlargement extended from the midline to the preauricular region, superiorly to the frontal bone and inferiorly to the inferior border of mandible. The nose and chin were deviated towards the left side of the face, with the facial midline describing a gentle arc from nasion to gnathion instead of the usual vertical straight line. The right corner of the mouth was drooped and lips were larger on the right side. The skin of the involved right side of the face was coarser than the unaffected left side. The right pinna was larger than that of the left side. There was monstrous enlargement of the soft tissue over the zygoma, the infraorbital region and the symphyseal region. The enlarged soft tissue mass on the right side of the face caused closure of the right eye, compromising the patient's vision. There appeared to be an excessive increase in size of the right side of the mandible, maxilla, zygoma, and frontal bone, as compared to the contralateral side. On palpation a nontender, soft tissue swelling over the right parietal bone was noticed. No temporomandibular joint disorder or dysfunction was detected. No discrepancy in range of mandibular motion was noted.\nIntraoral examination disclosed an obvious alveolar enlargement of the right maxillary and mandibular quadrants as compared to the left quadrants (). The surface of the gingival tissue and palate on the right side was granular in appearance. Right half of the tongue showed an obvious enlargement to the midline with polypoid excrescences representing enlargement of the fungiform papillae (). The right buccal mucosa was thickened and hung in pendulous folds (). A distinct tooth size discrepancy was observed between right and left side. Detailed coronal dimensions of the teeth were measured on the casts with vernier calipers, which revealed major variations in size between the teeth of the affected side compared to the uninvolved side. Right permanent maxillary canine, first premolar, second premolar, first molar, and second molar were larger cervicoincisally, mesiodistally, and labiolingually than those of the left side (). Similarly, right permanent mandibular lateral incisor, canine, first premolar, and second premolar were larger cervicoincisally, mesiodistally, and labiolingually than those of the left side (). The above mentioned right maxillary and mandibular teeth were considerably enlarged than their contralateral counterparts. The right permanent maxillary canine, first premolar, second premolar, first molar, and second molar demonstrated 224%, 100%, 63%, 110%, and 75% increase in volume, respectively, than their contralateral counterparts, while the right permanent mandibular lateral incisor, canine, first premolar, and second premolar demonstrated 337%, 150%, 116%, and 57.14% increase in volume, respectively, than their contralateral counterparts. The maxillary and mandibular midline was shifted to the left. A generalised crossbite was present due to a prognathic mandible (). The occlusal plane on the right side was canted downwards.\nThe panoramic radiograph showed enlarged right body of the mandible with the widening of the right inferior alveolar canal (). PA Skull showed enlargement of right half of mandible, maxilla, and zygoma (). Soft tissue enlargement was seen on the right side of the face and also encircling the symphysis.\nComputed tomographic (CT) scan of face revealed enlargement of the bony structures, including right half of maxilla, mandible, condyle, zygoma, bony walls of external auditory canal, and pterygoid bone (Figures and ). There was bony overgrowth of the glenoid fossa with irregularity of the articular surface. The right condyle was found to be irregular and flattened; however, the temporomandibular joint space was maintained. The right external auditory canal appeared stenosed due to bony overgrowth. The right frontal and parietal bones were thinned out with irregularity of inner table. The right foramen ovale, spinosum, rotundum, mental and infraorbital foramen, vidian canal, and greater and lesser palatine canals were widened as compared to those of the left side (). An intracranial lipoma in the quadrigeminal cistern of the right side was also seen (). Bony orbit on right side was deformed; however, globe, intra-, and extra-orbital structures were normal. Deformation and deviation of the nasal bone and chin were seen towards the left side due to enlargement of overlying soft tissues. Prominent vessels and few nodular serpiginous areas were seen within right parotid gland which was enlarged with heterogenous appearance (). The right submental region, submandibular region, parapharyngeal space, pterygopalatine fossa, soft palate, tongue, and floor of mouth were involved (). All the muscles of mastication and the anterior belly of diagastric on the right side were enlarged with fatty infiltration (). Soft tissues of the right half of the face were hypertrophied, which demonstrated predominantly fat HU (Hounsfield unit) value (Figures and ). A 5.4 × 4.7 cm sized soft tissue swelling was seen in right high parietal region with fat HU value suggestive of lipoma ().\nBased on clinicoradiological findings, the diagnosis of THFH was established. Multiple reconstructive procedures were advised in view of correction of the massive facial deformity. The patient, however, refused to undertake the extensive surgeries, since the enlargement was asymptomatic. |
A 64-year-old Greek male patient underwent a radical nephrectomy for a stage 2, grade 3, renal cell carcinoma in September 2001. Five years later, he presented with left hip pain and he was eventually diagnosed with biopsy proven relapsed disease. Imaging with CT scans and bone scan revealed a prominent bulky metastatic lesion extending from the acetabulum of the left iliac bone into the iliosacral joint, a metastatic lesion of the second left rib, as well as several metastatic pulmonary nodules (,). He was started on anti-angiogenetic TKI agent sorafenib and biphosphonates.\nAfter a year of treatment, in October 2007, a necrotic ulceration appeared on the left flank area, proven by CT to be an extension of the increasing metastatic left iliac focus, which measured 8 cm in maximum diameter, associated with increasing pain. The lesion was considered too large to be controlled with irradiation. The patient underwent an arterial embolization of the metastasis using a femoral artery approach (). One week later, the same mass was treated by radiofrequency ablation (RFA) (). The procedure was well tolerated overall and led to significant pain reduction (). However, the ulceration rapidly enlarged and evolved into a crater-like deficit of the skin and subcutaneous tissue 5 cm deep and of 5 cm diameter (). It was decided to be managed conservatively with frequent local wound care. Antiangiogenic treatment was suspended for a period of a month to allow for wound healing. However, during this time the pain recurred and a follow up CT showed evidence of extension of the large lesion medially towards the spinal canal; the bulk of the lesion was necrotic and a large tissue deficit was documented. The patient received external beam irradiation with symptomatic control (4750 cGy in 19 sessions) followed by initiation of sunitinib and biphosphonates. The patient continued improving, regained ambulation, and his disease elsewhere remained stable for over 16 months. His necrotic ulcer has shrunk considerably to less than 0.5 cm in diameter (,). Because of intolerance to sunitinib, after 4 months of treatment, he was switched to bevacizumab. The patient currently, as of October 2008, remains in good state of health, with slowly progressing pulmonary nodes. |
A 44-year-old Caucasian male had previously had a right hemicolectomy for a paracecal mass. He had no significant past medical history, although his father and paternal grandfather had both been diagnosed with bowel cancer over the age of 70 years. The histology had shown myoepithelioma of uncertain malignant potential, arising from the paracecal mesentery, which had partially infiltrated the large bowel wall but which showed no origin from bowel mucosa. Three years later, the patient presented with abdominal distension and lower abdominal pressure. On examination there was a palpable lower right quadrant mass. He was found to have multifocal recurrent intra-abdominal disease. Imaging revealed multiple lesions up to 8.8 cm within the mesentery and abdominal wall (), which were confirmed by biopsy on laparoscopic evaluation to be recurrent myoepithelial tumor. He was subsequently treated with 6 cycles of single agent doxorubicin with stable disease by response evaluation criteria in solid tumors for a total of 8 months. On treatment his symptoms improved. He then developed abdominal pain and imaging revealed progressive intra-abdominal disease and he was commenced on gemcitabine and docetaxel. He received 6 cycles of this combination schedule, and after 6 cycles, repeat imaging demonstrated progressive disease. His symptom of abdominal pain also worsened on this schedule. On the basis of an excellent performance status, he was offered participation in a clinical trial assessing molecular and radiological markers of response to the VEGFR tyrosine kinase inhibitor, pazopanib. He continued on the clinical trial for 7 months, but unfortunately his disease progressed. He was subsequently treated within a Phase I trial, but the first restaging scan after 6 weeks on trial showed progressive disease. His symptoms are currently well controlled and he is on active surveillance. Due to the location of the metastatic disease, no radiation has been administered as it could potentially result in toxicity.\nGrossly, the original resection specimen comprised bowel with multiple lobulated tumor masses with attached peritoneal fat. Sectioning showed firm white tumors, without hemorrhage or necrosis. Histologically, tumor masses of the primary excision specimen were centered in the mesentery (), with focal infiltration of the bowel wall. Both primary and recurrent tumors were composed of cords, trabeculae and clusters of relatively uniform cells with minimally to mildly atypical ovoid vesicular nuclei and small amounts of eosinophilic cytoplasm, within fibrous to fibromyxoid stroma. The mitotic index varied from 0-1/10 high power fields, and no necrosis was present. Immunohistochemically, there was diffuse strong expression of cytokeratin (CK) 14 (), with focal strong pancytokeratin AE1/AE3, focal, strong nuclear expression of S100 protein (), and focal expression of CK5/6, p63, smooth muscle actin (SMA) (), calponin, CD10 and D2-40. Epithelial membrane antigen (EMA), CAM5.2, CK7, CK20, CDX2, CEA, TTF-1, CD34, desmin, h-caldesmon, CD117, DOG1, HMB45 and MelanA were negative. INI1 was retained within nuclei. FISH showed no evidence of EWSR1 gene rearrangements. Multiple sections from the rest of the large bowel wall showed unremarkable mucosa, only.\nThe features in both primary and recurrent cases were of soft tissue myoepithelial tumor of mixed tumor-type morphology. |
This patient was a 43-year-old female who married 5 years ago. She had a history of infertility for 4 years. She had undergone abdominal myomectomy at age 35, during which 6 myomas were excised from her uterus, and a Cesarean section (CS) was performed at age 42. Her first pregnancy was induced by IVF with donor eggs. Placenta previa was diagnosed by sonographic examination at 23 weeks of gestation. The patient was advised to terminate her pregnancy by Cesarean section at 25 weeks of gestation because of uncontrollable genital bleeding. After evacuating the baby and placenta, a transverse fundal incision was repaired with two suture layers. The patient had no history of abnormal bleeding after CS. The present pregnancy was also induced by IVF with donor eggs. There was no mention of her uterine scar before embryo transfer at the 10th week of gestation (). The exact location of her gestational sac (GS) was determined at the first day of hospitalization at 11 weeks of gestation; her GS had implanted in the scar or the niche of a previous Cesarean delivery (). The diagnosis was based on finding a GS at the site of the Cesarean scar in the uterine cavity associated with a thin myometrium by transvaginal ultrasound. We suspected that the pregnancy was a CSP. After careful examination, radiological imaging and management options were planned. The following day, the patient complained of sudden lower abdominal pain. Observations showed a pulse of 106 beats per min and a blood pressure of 84/46 mmHg. Emergent sonography in the emergency ward showed free fluid in the cul-de-sac and pelvic fossa and no fetal heartbeat in the GS found in the abdominal cavity, near the abdominal wall. Uterine rupture was diagnosed. An emergent laparotomy was performed. Intraoperative findings revealed approximately 1300 mL blood in the abdominal cavity and between the intestinal loops. The uterus was torn at the fundus, and all gestational sac contents with the fetus had moved away from the tearing zone. Rupture was identified in the uterine fundus and cornea of the Cesarean scar (). Hysterectomy was performed, and 12 units of packed red blood cells and 8 units of frozen fresh plasma were transfused. The patient was later discharged from the hospital in good condition. |
A 52-year-old woman with bilateral accessory breast tissue attended a local breast clinic for annual mammography and ultrasonography screening, during which clustered microcalcifications were detected in ectopic breast tissue of the right axillary area. It was decided to maintain observation only with close surveillance, because the mammography findings were assessed as Breast Imaging Reporting and Data System category 3 (). After 3 months the patient was readmitted to the clinic with a palpable axillary mass. The mass was hard and fixed in the right side of axilla and an irregularly shaped axillary mass including microcalcifications, was identified on ultrasonography. A breast surgeon performed an excision biopsy of the axillary mass, and clustered microcalcifications were identified on specimen mammography (). Histologic observations revealed that the mammary ducts, within the fibrofatty stroma, were filled with and distended by a solid epithelial proliferation. The lesion measured 1.5 cm in the largest dimension. Necrosis and multifocal microcalcification were noted (), and the epithelial cells showed a moderate to high degree of nuclear atypia (). The patient was diagnosed as having high-grade ductal carcinoma in situ and was referred to our department for additional procedures.\nPreoperative evaluation via positron emission tomography and computed tomography did not reveal any metastatic lesions. The patient underwent a wide local excision of the axillary ectopic breast tissue with a safety margin around the cavity of 1 cm; sampling of sentinel lymph nodes was also performed. For the evaluation of sentinel lymph nodes, 2 mL of a blue dye (indigo carmine) was injected into the peritumoral site. The weight of the excised ectopic breast tissue was 60 g; the contained microcalcifications were identified on specimen mammography.\nIn a section of the excised specimen, a cavitary lesion was noted along with focal fat necrosis due to the excision procedure. Remnant tumor was not clearly detected on macroscopic examination, but on microscopic examination, remnant tumor measuring 0.5 cm in maximum diameter was observed around the cavity; histologic findings were similar to those for the excision biopsy. And there was no indication of metastasis to the lymph nodes among seven sentinel lymph nodes biopsied. Immunohistochemical assay showed positive and negative staining for the estrogen and progesterone receptors, respectively, and strong positive staining confirmed overexpression of the c-erbB-2 protein. Tamoxifen was administrated as adjuvant hormonal therapy. The patient continues to undergo surveillance up to 3 months after surgery, with no specific problems. |
A physically healthy woman in her 50s was admitted to the closed psychiatric ward due to suicidal thoughts. The preliminary diagnosis was an acute episode of depression due to psychosocial stressors and diagnosed with an adjustment disorder. Precipitant stressors included the hospitalization of a chronically ill partner with whom she had long had a contentious relationship.\nShe had been getting reproachful remarks from him for weeks, and he had been prescribed quetiapine because of aggressive behavior. She denied alcohol or substance abuse and admitted there had been problems in the marriage for some time.\nShe had been sleeping badly for a number of weeks. Because of the lack of effect of treatment with a benzodiazepine, and the probable association of insomnia with rumination and suicidal thoughts, a low dosage of an atypical antipsychotic medicine (quetiapine 50 mg) was prescribed, with a reasonable effect on the sleeping quality. After a week, the symptoms were attenuated enough to permit a leave of two days during the weekend, in which she was to be telephoned by the nurses of the psychiatric ward. She was considered to be in phase 2 of a structured suicide risk management taxonomy []. When the nurses could not establish contact with this patient, she was actively searched for. Her remains were found in her house, and the municipal coroner determined that unilateral pneumonia was the cause of death. The treating psychiatrist suspected suicide and contacted the coroner, but the municipal coroner did not instigate further investigation.\nThe conclusion that a healthy woman would die of one-sided pneumonia without earlier symptoms is deemed to be very unlikely. In the days following her demise, the treating physicians contacted her close relatives and together decided to request an autopsy, arranged and paid for by the psychiatric institution. During the autopsy, a lethal blood concentration of quetiapine in combination with ethanol was found. The psychiatric team and the pathologist were convinced that her demise was caused by an intentional overdose in combination with alcohol.\nThis combination probably resulted in aspiration and suffocation. However, in official statistics, the cause of death was never adjusted, and this suicide was, in our opinion, falsely registered as a natural death. |
This is a case of a 54-year-old divorced Caucasian male who has no prior psychiatric history or hospitalization. He was the lead singer of a local rock band. The patient has a 20-year history of cocaine abuse. He routinely uses cocaine prior to his stage performances. He reportedly binged on cocaine following a concert performance in a downtown bar. He snorted more cocaine than usual and immediately developed a severe headache and lower extremity numbness. He was rushed to the local emergency room, and an MRI of the brain without contrast was done. The MRI of the brain without contrast showed two small foci of increased signal intensity within the subcortical white matter of the left frontal lobe (Figure ).\nIt also showed the finding of bilateral foci of infarct involving the right side of the pons (Figure ). Both figures are consistent with an embolic phenomenon.\nThe patient has not complained of any somatic issues related to his cocaine use. The patient reported some depressive and anxiety symptoms as a result of the stroke but he remained optimistic about his recovery. He denied any vegetative depressive symptoms or suicidal ideations. He was initially seen by a nurse practitioner at the emergency room who diagnosed him with an adjustment disorder. After stabilization in the medical floor and a two-week stay at a rehabilitation program, the patient was sent home with good family support. Over the course of two weeks, the patient noted significant crying spells most of the day, nearly every day. He consistently denied that he was depressed and suicidal. His family became concerned and sent him to his primary care physician. The physician believed that he was suffering from depression because of his dramatic clinical presentation. The patient was eventually referred to the local mental health center by his primary care physician because of uncontrollable crying spells. He was not subjectively depressed but objectively tearful with a flat affect. He also complained of sleeping difficulties with ruminative worries about his situation. He denied any suicidal thoughts.\nThe patient was started on Remeron (mirtazapine), 15 mg at bedtime. He also engaged in weekly psychotherapy sessions. Over the next two months, the patient noted improvements in his sleeping patterns and appetite. The crying spells persisted. The patient was observed to be tearful while at the waiting area, during the psychiatric evaluation, and after his treatment appointment. His family reports that he cries every day for no apparent reason. Despite reassurances that he was not depressed, the family was convinced that his emotional state was getting worse. The patient was eventually diagnosed with pseudobulbar affect (PBA) because of his repeated outburst of involuntary crying. The crying was occurring even though there was no sad event that triggered those emotions. These episodes were persistent and had occurred in different situations or settings. He was referred to a local neurologist who confirmed the PBA. Eventually, he was managed with dextromethorphan hydrobromide and quinidine sulfate (DM/Q), 20 mg/10 mg capsules twice a day, in addition to his mirtazapine. The patient's crying spells improved significantly after the DM/Q was started. He tolerated it very well with no complaints of any side effects.\nA year later, the patient had multiple tragedies in his family. His father, with whom he was very close with, suddenly and unexpectedly died. He also had an argument with his daughter, who later refused to talk to him. He was overwhelmed with financial problems. Because of these, the patient became more depressed and the crying spells recurred. Despite his medication compliance with DM/Q and mirtazapine, he noted worsening depression and occasional suicidal thoughts. He reported symptoms of sad mood, anhedonia, fatigue, excessive sleeping with early morning awakenings, increased appetite and weight gain, psychomotor retardation, and feelings of helplessness and worthlessness. He was having thoughts of shooting himself, even though he does not own a gun. This time, he was subjectively complaining of being "down in the dumps." He was seen in the emergency room for a crisis evaluation and referred back to the mental health center. He was reevaluated and his mirtazapine was switched to Viibryd (vilazodone) because of weight gain concerns. He also attended twice a week psychotherapy sessions. A month later, with these interventions, the patient's depressive symptoms, including the crying spells, had improved. He continues to receive his DM/Q and vilazodone and weekly psychotherapy sessions with no exacerbations of any mood symptoms. |
A man in his 50s was admitted to the closed psychiatric ward because of suicidal thoughts and stress, due to complicated psychosocial circumstances. He started in phase 4 [–] of a structured suicide risk management taxonomy [], and after a day, this was decreased to phase 3. There were no somatic problems.\nThe patient history encompassed a major depressive and personality disorder, with several serious suicide attempts, including overdoses with pharmaceuticals, for which he had been admitted to the intensive care unit before. The cause of the present suicidal thoughts upon admission was a serious allegation from a close family member. The partner of the patient had ended the relationship due to these allegations and filed for divorce. There were also work-related problems and debts. Because of the high estimated risk of suicide, the patient stayed at the closed ward for several weeks. In addition, the tricyclic antidepressant medication (TCA) was increased. The dosage was near its maximum, resulting in therapeutic blood levels. Hereafter, the patient denied having any remaining suicidal thoughts, and after some days, in phase 2 [–] of a structured suicide risk management taxonomy [], he was discharged to a home that had been found for him with the help of social services. Two days after being discharged, the patient was found dead in his home. The municipal coroner registered a natural death by heart attack, and no autopsy was commissioned. Through a family member, treating physicians learned that during the tidying of the house, around 5 empty medication strips (containing 10 tablets each) of the tricyclic antidepressant were found. This specific medication is lethal in higher dosages, and an overdose can cause adverse cardiac effects. Because this drug has a relatively narrow therapeutic window and there was no history of cardiac problems, cardiac arrest as a result of an overdose was deemed to be a likely cause of death. Additionally, no other medication could be found in the house, even though the patient had recently filled his prescriptions at his pharmacy. Upon discharge, he had been given a prescription for 2 weeks with separate medication for 3 days. It was later learned that he had also been to the general practitioner for a prescription. Considering the patient's recent admission into a psychiatric ward due to suicidal thoughts, the previous serious suicide attempts, and the physical health of this patient, we highly suspect this case to be death by suicide. However, no further postmortem investigation took place and it was not recorded as such in official records. |
A 22-year-old male patient applied to our clinic for painless asymmetric swelling on the right side of the face for five years (). The history of the patient revealed that there are no parafunctional habits, functional and mouth opening limitation, bruxism, and trauma. And also, the masseteric region was nontender and normal in tone, and the temporomandibular joints and mandibular angulus region were not painful on palpation. The patient said that the only complaint was aesthetic and he wanted to have a more attractive facial appearance. Computed tomography, MR imagination, and panoramic radiographs were taken to make a differential diagnosis of MH. In MR examination, significant enlargement of the right masseter muscle compared to the left side was naturally detectable. There was also no pathological formation in the muscle. In CT and panoramic radiographs, reactive bone formation and significant asymmetry compared to the left side were observed in the mandibular angular region on the right side (). The patient was diagnosed with masseter hypertrophy. It was decided to apply botulinum toxin as the first step of the treatment.\nBotulinum toxin type A (Botox; Allergan Inc., Irvine, CA) was supplied as a freeze-dried powder of 100 units and was reconstituted with 2 ml of sterile saline solution, giving a concentration of 100 units. Percutaneous intramuscular injection of botulinum toxin type A was performed to the hypertrophic muscle using 2 ml syringe with 25G needle. 75 units of botulinum toxin type A was injected equally into five points at the centre of the lower third of the masseter muscle (). Determining the number of injection points is based on our clinical experience and previous satisfactory results as injections are more homogenously located in the masseter muscle. A month later, an additional 60 units of botulinum toxin were applied to the muscle at the second visit. A decrease in the size of the masseter muscle was seen after one month of the application (). Within the six months' follow-up period, severe masseter muscle atrophy occurred, but although clinically significant atrophy has occurred, the patient was not entirely satisfied with his appearance. Thus the decision to perform surgery has made with permission of the patient and his family in order to reduce the volume of the right masseter muscle and soften the couture of the patients face.\nThe patient underwent surgery involving bilateral resection of mandibular angles and unilateral resection of the masseter muscle through intraoral and extraoral submandibular approaches. Under general anaesthesia, on the right side of the patient, an intraoral incision was made supraperiostally, slightly lateral to the external oblique line, and extended mandibular first molar region. The anterior portion of the masseter muscle was exposed, and the inner belly of the muscle was removed by the method described by Beckers []. The intraoral incision was closed with absorbable sutures. Next, by using the extraoral submandibular approach on both sides, after the skin incision was made 1.5 cm below the mandibular border, the platysma muscle and the superficial layer of the deep cervical fascia were sectioned, and with taking care of the marginal mandibular branch of the facial nerve, facial vein, and facial artery, the pterygomasseteric connection was reached. The pterygomasseteric connection was cut from the bottom of the mandible to the angular region. A bone cut was made on the lateral surface of the ramus via a piezoelectric surgery device on a curve shape line connecting a point about one-third height of the posterior border of the ramus and the anterior portion of the antegonial notch. Complete separation and removal of the segment from mandible were accomplished using a periosteum retractor (Figures and ). The pterygomasseteric connection was closed with single absorbable suture, while the platysma was covered with absorbable continuous suture. Particular attention was shown to ensure that the underlying vascular structures and the mandibular nerve were not damaged during closure and the skin was closed. No drain was used in the surgery zone, and primary closure was performed. A pressure bandage and ice pack were applied for 72 hours. Antibiotic and analgesic therapy was prescribed. From MR views which were taken one year following the surgery, the decreased volume of the right masseter muscle can be seen apparently (Figures and ). The patient was followed for one year without any problems (). |
An eight-year-old boy was referred to our department due to recurrent meningitis. The parents reported the occurrence of a minor head trauma at the age of 15 months (falling from a stroller), and initiation of watery nasal discharge since then. The first episode of meningitis happened 3 months later and recurred 6 times in the next 4 years. At the age of 6 the boy was admitted to the neurosurgery department of a district hospital and, most probably because of the suspicious nasal discharge, a craniotomy was performed through a bicoronal approach to seal the assumed leakage at cribriform plate and the adjacent floor of the anterior fossa. In the 2 years following surgery the patient had no episodes of meningitis but he had had 2 attacks of meningitis in the past 6 months before being admitted to our department at a tertiary referral university hospital.\nDuring the performance of a comprehensive otologic history the patient turned out to have hearing impairment in his right ear, which the parents maintained had happened after the first episode of meningitis. He had watery nasal discharge with an undetermined source (diagnostic tests couldn’t prove the discharge was CSF). The oscopic exam was normal but an audiogram showed right ear deafness and the tympanogram was type A on both sides. The high resolution CT revealed an anomaly in the inner ear on the right side ().\nThe anomaly was most likely a mondini variant with associated defects in the lamina cribrosa and in the stapes footplate. An MRI was also completed which showed that the middle ear was partially filled with fluid and there was some collection of fluid in the paranasal sinuses ().\nSumming up our pre-operative information, we deduced that the inner ear was the culprit but the suspicious nasal discharge, temporary cessation of meningitis episodes after the craniotomy, obliterating anterior fossa floor, and fluid accumulation in the paranasal sinuses all challenged this presumption. Moreover, the small chance of simultaneous CSF otorrhea and rhinorrhea from two separate sources was another point we considered. So we decided to make the final diagnosis in the operating theatre. After inducing anesthesia we used an intrathecal dye; 20mg fluorescein diluted in 10 cc of the patient’s own CSF was injected into L3–L4 space. Initially, an endonasal endoscopy was performed. While implementing the maneuvers to increase intracranial pressure no dye was detected in the nose and in sinuses but a green-colored fluid was noticed in the nasopharynx coming out of eustachian tube orifice. Next we did an otomicroscopic examination and saw that the intact membrane had an accumulation of green fluid behind it ().\nAn exploration of the middle ear was then performed and a defect in the footplate was detected. To correct the problem we did a stepedectomy and the vestibule was obliterated with an oversized muscle plug and then covered by a facial graft. The leakage stopped and the patient was discharged within 4 days. The patient was monitored for the following 18 months during which no significant events occurred. |
A 66-year-old Caucasian male with a past medical history of mild degenerative joint disease presented to his primary physician with pain and swelling of the left knee without any history of recent injury. He did not have any history of alcohol abuse but noted history of dental abscess that was treated with root canal procedure approximately 4 months prior to the initial presentation. On physical examination, he had left knee joint effusion and about 35 ml of clear joint fluid was aspirated. Unfortunately, joint fluid was not sent for analysis or culture. Patient was diagnosed with possible degenerative arthritis with effusion and intra-articular steroid injection was given to reduce inflammation and alleviate pain. After a few days, patient presented with recurrence of left knee pain and progressive swelling in the left calf along with intermittent chills. On examination, he had left knee effusion, probable popliteal cyst along with erythema, tenderness, and induration in the calf region. Ultrasound noted a 6 × 2 × 3 cm complex fluid collection along the posteromedial aspect of left knee, suggestive of popliteal cyst with debris or hemorrhage. Magnetic resonance imaging (MRI) of his left knee confirmed the ultrasound findings and showed large radial tear through medial meniscus body, anterior cruciate ligament tear. Patient underwent left knee arthroscopy with partial medial meniscectomy, chondroplasty, and subtotal synovectomy. Intraoperatively, the joint fluid was noted to be cloudy but both aerobic and anaerobic cultures of joint fluid were negative.\nAbout 6 weeks after the arthroscopic procedure, patient developed fever with recurrence of pain and swelling in left knee while he was on vacation. He declined any surgical intervention at the time and was prescribed oral amoxicillin-clavulanate 875–125 mg twice daily. Upon his return, he was evaluated in the orthopedic surgery clinic and was noted to have a large, firm, indurated subcutaneous mass measuring about 5-6 inches in diameter in the posteromedial aspect of left knee. Magnetic resonance imaging (MRI) showed extensive soft tissue edema around the knee with multiple complex peripherally enhancing fluid collections ().\nAbout 30 ml of purulent material was aspirated with ultrasound guidance and anaerobic culture grew Actinomyces meyeri. He did not have any cough or productive sputum. Patient improved briefly with aspiration and 10-day-course of oral amoxicillin-clavulanate 875–125 mg twice daily.\nFew weeks later, he was referred to the Infectious Diseases Clinic when his symptoms recurred and was noted to have erythema, warmth, and induration involving the posterolateral aspect of his left calf, without any fluctuance, purulent drainage, or sinus tract. Ultrasound of left leg showed complex popliteal cystic fluid collection with internal debris extending into posterior lateral calf. 20 ml of purulent material was aspirated with ultrasound guidance and its analysis showed 533,000 cells per cubic millimeter; RBC 114,000 cells per cubic millimeter; 98% segmented neutrophils; 1% lymphocytes; and 1% eosinophils. Aerobic culture of aspirate was negative; anaerobic culture grew Actinomyces meyeri that was susceptible to penicillin and clindamycin. White Blood Cell count was 15.6 × 10(9)/L and CRP was elevated at 158 mg/L. Chest radiography was negative for any pulmonary infectious process. He was treated with 6 weeks of intravenous penicillin G 24 million international units every 24 hour via continuous infusion. Patient improved clinically and was transitioned to oral penicillin VK 500 mg twice daily.\nWhile on oral penicillin regimen, patient developed severe throat pain. He was noted to have inflamed left posterior tonsillar fossa, atypical abscess with suspected fistulization, suggestive of actinomycosis. He underwent incision and drainage of left peritonsillar abscess and anaerobic culture grew multiple anaerobes but Actinomyces meyeri was not isolated. He received approximately 5 weeks of intravenous ertapenem 1 g every 24 hours, a broad spectrum antibiotic to cover multiple oral anaerobes until the left peritonsillar abscess resolved and was then transitioned to oral penicillin VK 500 mg twice daily ().\nPatient completed 12 months of oral penicillin VK treatment and he has not had any recurrence of symptoms 12 months after completion of treatment. |
A 73-year-old male had a traffic accident while riding his bicycle and hit his left knee on the ground. He presented at our hospital 4 days after the accident. He could walk without crutches but could not extend his knee against gravity. We palpated a subcutaneous depression in the left knee.\nThe patient was 165.5 cm tall, weighed 63.8 kg, and had a BMI of 23.3 kg/m2. He had previously experienced a comminuted left patellar fracture and underwent a total patellectomy when he was 20 years old. After the patellectomy, he had no complaints and had a full range of movement in the left knee. The preinjury Lysholm knee score was 90 []. At 57 years of age, the patient had received mitral valve replacement for regurgitation at another hospital and had been on anticoagulant therapy since then.\nPlain radiographic examination did not show any fracture of the left knee but detected the absence of the patella and a small heterotopic calcification at the distal side of the quadriceps tendon (). Ultrasound examination showed a loose left patellar tendon compared with the contralateral side (), although it could not identify the rupture site. Magnetic resonance imaging (MRI) revealed subcutaneous edema and tendon disruption at the proximal side of the left patellar tendon, which indicated patellar tendon rupture (). We immediately immobilized the left knee with a splint and changed his anticoagulant therapy from warfarin to intravenous heparin.\nSurgery to reconstruct the ruptured left patellar tendon was performed 12 days after the accident. We made a midline incision instead of an oblique incision along the previous scar and found a complete patellar tendon rupture with both medial and lateral patellar retinaculum rupture with about a 2.0 cm gap filled with a hematoma (). These ruptures were at the proximal side of the patellar tendon. We first washed and removed the hematoma and refreshed the ruptured tendon edge with scissors. The length of remained patellar tendon was about 5 cm. We then performed end-to-end suturing with two Krackow locking stitches with #2 Hifi high-strength suture (CONMED, NY, USA) and added approximately twenty figure-of-eight sutures with #0 Hifi high-strength suture ().\nPostoperatively, the left knee was protected with a splint for 6 weeks. The patient was permitted to walk without limiting weight bearing at 1 week postoperatively. After 6 weeks, knee flexion exercise was started, but the knee was protected in extension with a knee brace during walking for another 6 weeks. At postoperative 3 months, the patient could walk without any difficulty and could almost fully flex his left knee but had an extensor lag of 20° and left quadriceps muscle atrophy. Currently (at 1 year postoperatively), the patient can extend his knee with almost no extension lag and can flex fully but has persistent quadriceps muscle atrophy. The Lysholm knee score at 1 year postoperatively is 81. The patient is satisfied with the outcome.\nWritten consent was obtained from the patient for publication of the study. |
Mr. C was a 55-year-old African-American male born in a neighboring state. He and his brothers were raised by their uncle and aunt. According to the records, his father and mother did have limited education and possibly were mentally retarded but, according to the family report, his parents never had any psychiatric admissions. Mr. C. had two brothers: one possibly had mental retardation and the other was definitively diagnosed with mental retardation and had multiple admissions to our state psychiatric hospitals. According to the records, the patient was malnourished when he was a baby. He did not learn to talk until age 7 when he was diagnosed with mental retardation. His first intelligence quotient (IQ) was 41 at age 8. At age 22, he had his first psychiatric admission due to aggressive behavior and carried the diagnosis of severe mental retardation. Since that time, he had been “institutionalized” and spent most of his time in hospitals for adults with ID with occasional admissions to psychiatric hospitals. According to the records available, he had taken different antipsychotics throughout his life since he was 15 years of age, but there was no clear description of delusions and hallucinations. The antipsychotic appears to have been prescribed to control his behavior, including inappropriate sexual behavior. He had also been tried for several months on lithium and carbamazepine, which appear to have been added to augment his antipsychotic medications in an effort to control his aggressive behavior. At 36 years of age, he was taken to an emergency room for syncope, and an abnormal value of CPK of 415 was described, but the cause could not be identified. There was no description of the behavior at that time to verify or rule out catatonia, and the abnormal CPK was not followed up. Over many years, episodes of unprovoked agitation, sometimes with violence toward others, were described; however, the description was very poor, and it was impossible to retrospectively determine if they were associated with catatonia or not. At the time of the assessment, he had resided at a hospital for adults with IDs for ten years, and his diagnoses were psychotic disorder not otherwise specified, bradycardia (with a pacemaker), and severe mental retardation. The patient had never been diagnosed with catatonia, but once some of the behaviors were identified as catatonic, the staff described these behaviors as having been intermittently present for the last ten years.\nAt the time of initial evaluation, he demonstrated catatonic symptoms such as posturing, mutism, stripping, freezing, posing, mild immobility, fixed staring, grimacing, hitting and rubbing and scratching his bottom to the point of injury, and twisting paper []. These behaviors seemed to be stereotypic in nature and did not respond to redirection. He had no other abnormal movements. He had no hallucinations or delusions. Moreover, hallucinations and delusions were not present in the year that the senior author followed Mr. C and were not described by the hospital staff who had known him for years.\nIt was determined that during the assessment and year of follow-up he met the following eight out of the twelve criteria for catatonia: stupor, mutism, negativism, posturing, mannerism, stereotypy, agitation not influenced by external stimuli, and grimacing. Other catatonic symptoms included in the KANNER scale [] that were present with catatonic worsening were refusal to eat or drink and nudism. If the DSM-5 had been available at that time, he would have met criteria for catatonia associated with a neurodevelopmental disorder. The patient had no other abnormal movements besides those associated with catatonia.\nMr. C was started on oral lorazepam, 3 mg/day, and his CPK level at that time was 992 (), but the lorazepam treatment was initially intermittent. He was followed up for one year for treatment of catatonia with lorazepam and required increasingly higher doses over the course of the year, likely secondary to developing tolerance to the medication. His behavior, CPK, and KANNER scores were monitored. During this time, he was also taking olanzapine 20–25 mg/day. Lorazepam became a standard dose of 1.5 mg/day on day 129 and then increased to 3 mg/day on day 137, to 9 mg/day on day 157, to 12 mg/day on day 199, and to 18 mg/day on day 221 (). Generally, the patient's behavior would improve for a few days to weeks after increasing his daily dose of lorazepam; however, he would quickly become tolerant of the medication and would have a relapse in symptoms. Furthermore, at times, it was difficult to determine whether his aggressive behaviors were behavioral in nature or were secondary to an underlying etiology such as catatonia.\nDespite using increasing doses of lorazepam, the catatonic behavior appeared to become partly tolerant to lorazepam. We have prior experience with patients recovering benzodiazepine response after ECT, which has been described by Petridis et al. []. Treatment with ECT was seriously considered when catatonic symptoms including ambitendency [] and a specific stereotype (see footnotes 1 and 2, ) increased at the same time that there were increases in aggressive behavior and CPK rose to the 1400s. Due to the presence of a pacemaker, ECT was excluded as a treatment option by the only available hospital providing ECT in the area. It should also be noted that, despite these high benzodiazepine doses, he did not become sedated or have any symptoms of respiratory suppression. |
An elderly lady in her late fifties, was referred to the endodontic department of a private dental clinic with her chief complain being dull tight pain on the left side of her face. She stated that she had been experiencing this sensation of pain for the past two weeks. On clinical inspection no facial discrepancy and swelling was noticed. Oral examination revealed a maxillary first molar on the left side that had an extensive amalgam filling and was extremely sensitive to percussion and palpation of the periradicular area. She mentioned previous root canal therapy of this tooth five weeks earlier. Radiography was indicated and revealed a phenomenon that was supposed to be the cause of all these discomforts (). The mesiobuccal root was perforated in many zones and the perforation sites were over obturated with gutta-percha. Surprisingly she was told that her tooth had five canals and was extra-charged for these canals.\nThe situation was discussed with the patient and extraction/implant placement was indicated. Patient had too much anxiety and refused to accept the situation stating that she could not take that due to recent complications in her personal life. She insisted on an alternative approach. Thus, she was referred to another endodontist for evaluation of possibility of intentional replantation. It was later decided to approach through trial and error; if the replantation was not successful the tooth would be extracted. On the very same session the procedure was initiated. Unfortunately, the mesial root was separated during extraction and the clinician had to extract the tooth.\nOne week later, she appeared with persisting pain on the left side of her face. This time she mentioned that this pain worsened when she became more stressful. She was not satisfied because she expected the pain would vanish after losing one tooth. As she was explaining her disapproval, it was observed that her face was blushing and she was sweating allover. The patient also mentioned pain worsening at the very same time. The clinician suggested an immediate medical visit because the manifestations seemed so irrelevant to odontogenic signs. One week later her daughter came to the dental office to inform that her mother was diagnosed with cardiac ischemia and myocardial infarction (MI) and expressed her gratitude for in time referral of her mother.\nIn summary, the primary cause of patient’s discomfort was CFP with cardiac origin (prodromal angina) not her tooth, whatever the condition of that tooth was. The in-time referral helped in saving patient’s life. |
A 54-year-old Chinese man consulted a medical doctor with the complaint of recent painful neck and right upper limb without any clear causes. He had a medical history of left traumatic humeral fracture 10 years ago that did not significantly affect his recent daily life after surgery. The patient had no recent history of head or spinal trauma and did not take any related antiplatelet or anticoagulant drugs. In addition, the patient had no exposure to any toxic substances and no significant relevant family history. A clinical diagnosis of cervical spondylosis was originally considered based on X-rays of the cervical spine, and the patient received small needle-scalpel treatment for relieving pain relief, which was administered by a rural doctor. When no obvious improvement was observed 20 days later, the patient was admitted to our hospital for further diagnosis and treatment. The patient was experiencing progressive neurologic deterioration involving both upper and lower limbs. Upon neurological evaluation, he exhibited reduced response to light touch and pinprick, with a sensory level below the angle of the mandible. He had trouble during urination and significantly decreased muscle tension. He was subsequently incapable of antigravity power in his upper limbs (the left and right muscle strength was graded as 4/5 and 2/5, respectively) and had a significant loss of motor function in both lower extremities (the muscle strength was graded as 1/5). Urgent magnetic resonance imaging (MRI) of the cervical spine demonstrated a right spinal epidural hematoma located at the posterior spinal epidural space with severe cord compression and subcutaneous soft tissue hemorrhage, extending from the C2 to C7 spinal vertebral level (). Routine laboratory investigations indicated that renal and liver functions, serum potassium and coagulation index were normal. Given his progressive symptoms and MRI results, the diagnosis of cervical extradural hematoma was finally considered. The patient had received the ventilatory and adjunctive therapy, omeprazole, mannitol, and a high dose of steroids after the diagnosis of cervical extradural hematoma. Unfortunately, the patient refused urgent surgery; thus, he continued to progressively deteriorate and later died due to respiratory failure. |
A 46-year-old male presented the emergency department with a history of a decline in his mental status and reduced level of cognition for four months. The history had to be elicited from a relative. The symptoms were associated with an unsteady gait of and urinary incontinence. He sought medical care five months prior to his presentation for weakness of the right side involving right upper and lower limbs associated with facial numbness and slurred speech. The CT brain at that time showed diffuse atrophic and small vessel changes with mild hydrocephalus (). He was suspected to have an atherosclerotic cerebrovascular accident and was treated empirically with aspirin, simvastatin and atenolol. As his condition was worsening he was brought to the Emergency Room, 5 months later. He had a progressive decline in his level of cognition, speech and gait was unable to express himself to the extent where his answers became yes or no responses. He became unable to care for himself independently. There was also significant weight loss of 20 pounds over the preceding three months without any change in appetite. He had no significant medical history. His prior medication included aspirin, atenolol, simvastatin, which was started since the presumed cerebrovascular event, associated with mild dyslipidemia and hypertension. The family history was non-contributory. However, he had a 20-pack year history of smoking but stopped one year prior, and a history of alcohol use for 25 years. There was no history of herbal, marijuana, cocaine or other illicit drug use. There were no recent ill contacts or travel, and he never received blood transfusions or tattoos. His relatives reported that he only had one sexual partner with whom he had three children and no history of prior sexual transmitted conditions.\nOn examination he was not in respiratory distress. He was anicteric, acyanotic, afebrile and his mucus membranes were pink and moist. The pupils were equal round and reactive to light. He had a Glasgow Coma Scale of 12/15 accounted by the following responses: eye=4, motor=6, verbal=2. His speech was limited to yes or no answers and was dysarthric. The blood pressure was 120/77, pulse 65, respiratory rate 20, percutaneous oxygen saturation 99%, random blood glucose 147. The mini mental state examination could not be completed. He had a reduced power of 4/5 on the right upper and lower limb, with associated past pointing and intention tremor. The patient was able to understand instructions but had severe difficulty executing them as well as expressing himself. His reflexes were +++ in S1S2, L3L4, C5C6 and T1T2 on both right and left sides. Plantars were upgoing on the right and equivocal on the left. There were involuntary jerky myoclonic movements of both upper and lower limbs, which were worse with movement. Sensory functions were intact. He had an ataxic broad based gait, and needed assistance while walking. Fundoscopy examination was normal. Other aspects of the physical examination were non-contributory.\nInitial laboratory investigations showed normal renal function, liver function, thyroid function, C-reactive protein test, coagulation profile, electrolytes, serum B12 and red cell folate, HIV, hemoglobin electrophoresis, as well as a normal connective tissue screen. Prothrombotic screening was considered unnecessary. The electrocardiogram was in normal sinus rhythm at a rate of 50 bpm. The echocardiogram was normal with an EF 70% with no aortic regurgitation or aortitis/aneurysm. Electroencephalography showed subcortical dysfunction in left frontal lobe, accompanied by cortical irritability in the same area spreading posteriorly to central and temporal regions. He had mild elevation of lowdensity lipoprotein and was normotensive during his hospital stay.\nCT brain on admission showed dilated ventricles with an Evans index of 0.523 out of proportion to the degree of cerebral atrophy and hypodensities in bifrontal lobes, which appeared to be consistent with edema and microangipathic small vessel disease ().\nMRI imaging on T1,T2,T2 FLAIR, apparent diffusion coefficient (ADC) and diffusion-weighted imaging (DWI) on admission confirmed hydrocephalus, bifrontal white matter hyperintensities, mesotempoaral atrophy and absence of infarctions or gumma ().\nLumbar puncture on presentation and 3 months later showed elevated protein and serological evidence confirming neurosyphilis, with improvement at 3 months following treatment ().\nHe was treated with aqueous crystalline penicillin G 4 million units intravenously every four hours, for 14 days. Prior to treatment he had a Barthel scale 20 and modified Rankin scale of 4. At the end of 2 weeks of treatment his Barthel scale and Rankin scale were 90 and 3 respectively. With improved verbal communication from the patient with treatment, he reported having multiple prior sexual partners, and did not use barrier contraception on all occasions. Furthermore, he recalled having an ulcer on his penis several years prior however did not seek medical care. He had no history of secondary syphilis.\nRepeat MRI at 6 months post treatment showed significant reversal of MRI findings. ( and ) |
A 37-year-old right-handed male presented to the emergency department with right wrist pain and decreased range of motion of the forearm following a friendly grappling match. On history, he was mildly intoxicated by alcohol at the time of the injury. His friend had performed an arm-bar holding the patient's right arm between his legs while pulling on the forearm with his hands. The patient tried to escape the maneuver by forcefully pulling and pronating his forearm. He immediately felt pain in his right forearm and was unable to use it afterwards. His past medical history was significant for alcohol, tobacco, and cocaine use. He was not known to be suffering any other medical conditions and had never suffered any injury to his right wrist or forearm in the past. On physical examination, the forearm was locked in supination, with no passive or active pronation elicited. There was loss of the dorsal ulnar prominence, and a palpable and tender solid mass was felt on the volar aspect of the wrist, which was presumed to be a volarly dislocated ulnar head (). The skin was intact, and the neurovascular status of the hand was normal. Radiographic examination of bilateral forearms confirmed our suspicions, displaying overlap between the radius and ulna on the anteroposterior view and volar displacement of the ulnar head relative to the distal radius on the lateral view. A CT scan was performed, completing the clinical picture by revealing impaction of the ulnar head on the distal radius ().\nAfter obtaining informed consent, closed reduction was planned under procedural sedation. The reduction was first attempted by pronating the forearm while applying a posteriorly directed force to the ulnar head. After an unsuccessful first attempt, a second attempt was performed with an assistant applying pressure on the interosseous membrane (IOM) of the forearm using the palm of both of his hands, in an effort to free the impacted ulnar head from the distal radius (). With the ulnar head now freed from the radius, the second attempt at manipulation was rewarded by an audible click and a return of the wrist's normal position and motion. On postreduction stability testing, the DRUJ was felt to be unstable at 45° of supination. This prompted the clinician to immobilize the patient in neutral rotation and 90° of flexion using an above-elbow back slab. Postreduction radiographs confirmed the success of the reduction maneuver ().\nAt the three-week clinical follow-up, the splint was removed and physical examination was repeated. The patient showed full range of motion of the wrist and elbow in flexion and extension. Compared to the contralateral forearm, there was a 10° lack of pronation and 25° lack of supination. Pain and tenderness were minimal, and no instability could be elicited. Diagnostic imaging confirmed that the reduction was maintained. The patient was discharged from the clinic with instructions for range of motion exercises and avoidance of loading activities for an additional three weeks. No additional follow-up visits were planned. |
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 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 6-year-old asian girl was referred to the Department of Pediatric Dentistry with a chief complaint of several missing teeth. The child was in good health and the health history did not reveal any systemic disease, child was born to non-consanguineous parents. Mother reported uneventful pregnancy and no significant family history. According to the mother no tooth had been lost due to trauma, extraction or exfoliation of teeth for this child. Extraoral examination revealed facial symmetry and no skeletal malocclusion. The child was examined with particular attention to hair, nail, eyes and ears, all of which appeared to be normal. No sweating abnormality was reported by the patient's mother. An intraoral examination revealed the presence of maxillary right and left primary second molars, mandibular right primary second molar, mandibular left primary canine, first and second molars. The teeth were of normal size, shape, and color. The alveolus present was very thin. There were no carious teeth and the patient has good oral hygiene. None of the teeth were mobile. Her oral range of motion was within normal limits. No temporomandibular joint sounds or masticatory muscle pain was noted. Panoramic radiograph revealed congenital absence of 14 primary teeth which included maxillary right and left central incisors, lateral incisors, canines (cuspids), and first primary molars. It also showed absence of right and left lower central incisors, lateral incisors, right canine and right first primary molar and also revealed the presence of all four first permanent molar tooth buds, lower left first and second premolar tooth buds and lower right and left second permanent molar tooth buds. Radiograph showed the beginning of calcification of cusp of lower right second premolar and probably early beginning of calcification of left mandibular second premolar (). The treatment plan included prosthesis in the form of simple acrylic partial dentures and oral health education. Maxillary and mandibular removable partial dentures were inserted with minor occlusal adjustments (). The patient and parent were shown about proper insertion, removal and maintenance of the prosthesis and instructions were given on adequate oral hygiene. Regular recalls were scheduled for 3 months to make necessary adjustments and to monitor the patient's compliance and oral hygiene. |
A 65-year old woman was hospitalized after reporting abdominal pain and faecal impaction. Blood samples were normal and a chest X-ray revealed hypoplasia of the right lung with severe thoracic scoliosis. A colonoscopy and gastrografin enema were performed with diagnosis of adenocarcinoma of the rectosigmoid junction. Pre-operative staging was performed with a CT scan that highlighted a right diaphragmatic hernia with involvement of the right kidney and subsequent migration of the right liver into the thorax. This herniation led to torsion of the caval axis and occlusion of the right and middle hepatic veins with modification of liver outflow, thus creating a right to left hepatic vein shunt passing anteriorly to the umbilical recess (Fig. ). An alteration of the retrohepatic cava vein was also demonstrated with suspected double caval system. The right lung presented absence of the inferior segment with bronchial ending without atelectasis. The patient underwent combined hernia repair and rectosigmoid resection. Intraoperative findings revealed a large right posterior diaphragmatic hernia without a sac opened in the thorax. Exclusively the left lobe remained inside the abdominal cavity with traction of the hepatic hilum under the right diaphragm with the round and falciform ligament overlying the diaphragm sustaining the liver (Fig. ). The liver was rotated in the abdominal cavity intraoperatively: this retraction revealed a ligament between the diaphragm and the liver determining compression of the inferior vena cava (Fig. ). The ligament was therefore, dissected in order to restore the vena cava’s normal diameter. Also the right kidney was reduced in the abdominal cavity and hernia repair was performed with dual mash sutured with non-absorbable separated stitches to the diaphragm. A shift of the liver outflow was seen with a natural by-pass inverting flow from the right and middle hepatic veins to a large accessory hepatic vein in the parenchymal bridge in front of the umbilical recess and then to the left hepatic vein (Fig. ). Sigmoid resection with mechanical colorectal anastomosis was performed at the same time. The postoperative course was uneventful and the patient was discharged eight days after surgery. |
A 79-year-old Chinese female accompanied by her daughter was seen at the complicated metabolic bone disorders clinic of our hospital for a second opinion on the management of her severe osteoporosis. She stated that she had been started on oral alendronate about two weeks ago, but had developed an “allergy” to it and therefore wanted an alternative medication. She had a history of left ankle fracture in 2017. Axial dual energy X-ray absorptiometry (DXA) scan of the hip and spine showed a T score of −3.8 at the left femoral neck and −3.5 at the lumbar spine. She had no other medical problems other than dyslipidemia for which she had been taking lovastatin for several years. She had been started on generic alendronate tablet 70 mg/week by the physician. She took the first dose on 12 September. On 13 September, she started to experience gum pain with food intake and noticed a small oral ulcer of approximately 1 cm on the hard palate. She dismissed it without giving it much importance. By the 19th of September, when she took the 2nd dose of alendronate, the ulcer had increased in size (). By now, the oral pain had increased, and she found it difficult to take any food that was not soft or sweet. The ulcer had increased in size and had extended to the upper gum (). She went back to the general practitioner on 21 September who diagnosed her with oral thrush and prescribed an antifungal oral gel. The ulceration by then had progressed rapidly to involve the tongue and the inside of the left side of the lip, and she could only tolerate a liquid diet. She had a fever with temperatures up to 38.5 degree Celsius that lasted for about 8 hours that subsided with oral acetaminophen tablets. She had no previous history of oral ulcers or gastric problems. No skin lesions were present. Other mucosal surfaces such as the eyes and genitalia were not affected.\nIn view of the accelerated spread of the oral ulceration, the family decided to consult a dentist who referred the patient urgently to an oral and maxillofacial surgeon on the 22nd of September (). The surgeon diagnosed her to have an “allergic” reaction secondary to alendronate and asked her to no longer take alendronate. She was prescribed oral prednisolone, antiseptic mouth rinse, and antiseptic gel with some improvement of the oral ulceration and pain. She attended the metabolic bone disorders clinic on the 25th of September. On examination in our clinic, she was found to be a well-nourished elderly lady with no evidence of systemic malaise. She complained of some pain on opening her mouth. Examination of the mouth revealed a well delineated 3 × 4 cm sloughy erosion with irregular margin affecting the hard palate and surface of the tongue with erosions at the angles of the mouth (). On palpation, induration was felt along the margins. On further questioning, the patient's daughter stated that what she had understood of the instructions given to her by the pharmacist who dispensed the medicine was specifically that the medicine should be put in the mouth to be dissolved by saliva, to sit upright for 45 minutes and then to drink water. It was not clear to us if the instructions given had been misunderstood or if incorrect instructions had been given. Given the temporal association of exposure and our knowledge of potential chemically induced mucosal erosions with bisphosphonates, we made a diagnosis of alendronate-induced mucosal ulceration most likely caused by direct prolonged contact of the oral mucosa with the chemical agent. She reported to us 2 weeks later that she had fully recovered. A photograph taken at 1-month postepisode showed normal, edentulous oral cavity (). This further confirmed our diagnosis. |
A 73-year-old female presented to her general practitioner with a complaint of difficulty with walking, and an inability to weight bear on her right side. She also complained of pelvic pain, and had noticed an abdominal mass centrally and on her right side. There was no history of vaginal bleeding, discharge or a change in bowel habits. The general practitioner suspected a possible gynaecological cause for her presentation, most likely fibroid uterus, and subsequently referred her to a gynaecologist for further work up. She also had a history of five previous hip replacement operations for severe osteoarthritis of her hip joints, three on her right and two on her left side. Her last surgery was for her 3rd right hip total arthroplasty. This last total hip replacement surgery was performed in a teaching hospital setting. There were postoperative complications, most significantly a cold right lower limb. For this she had undergone successful endovascular stenting of her right external iliac artery and was discharged home. Her current presentation was 6 months after the last surgery. Gynaecological examination revealed a firm non-tender right iliac fossa mass. Vaginal examination revealed mobile masses protruding into the pouch of Douglas. Ultrasound examination of the pelvis demonstrated extensive acoustic shadowing. A working diagnosis of possible retained swab with a granulomatous mass was entertained. Having now suspected a non-gynaecological aetiolgy for her presentation, plain film radiographs were requested.\nSupine pelvis and lateral hip radiographs (,) demonstrated superior migration of the femoral head component of the prosthesis into the right side of the pelvis as well as a dislocated acetabular component lying in the mid lower pelvis. On lateral view the dislocated acetabular component was situated in the region of the pouch of Douglas with its screws directed inferiorly.\nThe patient was transferred to a teaching orthopaedic unit where she underwent emergency surgery for removal of the intrapelvic acetabular cup. It was postulated by the surgeons that her multiple revision surgeries and osteoporotic bone state predisposed her to protruso acetabuli prosthetica. Her surgery involved a laparotomy with a transperitoneal approach. In view of the extensive destruction of the acetabular bone salvage was done using a saddle prosthesis and a total femoral replacement. This was done at a different institute and thus a follow up radiograph was not available |
An 82-year-old female patient complaining of left hip pain after a simple fall was admitted to our hospital. There was pain and tenderness in the left groin and the patient could not stand on the left leg. The patient was mobilized with a cane before the trauma and body mass index was 23.8. The radiography revealed an intertrochanteric hip fracture () and the patient was hospitalized. After preoperative preparations, it was decided to perform hip arthroplasty instead of fixation because of severe osteoporosis and the low adaptive cooperation of this low-demand patient. Bipolar hip arthroplasty was applied with a posterolateral incision under spinal anesthesia. A cemented prosthesis was applied because of insufficient stability during the operation. After the femoral stem and the bipolar head were placed, an assistant applied traction to reduce the hip. The reduction was difficult to achieve and required aggressive reduction maneuvers. Hip radiography taken in the operating room was satisfactory and the femoral stem was not high placed (). During the operation both legs were draped with elastic bandages and the knee was overlooked. After the operation when the patient was transferred to the bed, the left knee was seen to be deformed (). Knee dislocation with underlying knee osteoarthritis was detected on radiography (). The neurovascular evaluation was intact and the vascular continuity was confirmed with Doppler ultrasonography. However, the knee was grossly unstable so that it dislocated even in the cast or a knee brace. Treatment with a rotating hinged knee prosthesis was planned for the dislocated knee to be able to mobilize the patient as soon as possible. Surgery was applied 9 days after the first operation (). A hinged knee prosthesis was applied and no complications were seen postoperatively (). After the operation the patient was encouraged to comply with knee and hip strengthening and range of motion exercises. The patient was mobilized with a walker. It was subsequently learned from the family that the patient died due to cardiac arrest 7 months postoperatively. |
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. |
A 75-year-old woman with a history of good past health presented to the emergency department complaining of pain in both shoulders. She lost her balance and fell forward while she was doing the bench push-up at the park. She hit on bench with both shoulders in extension, abduction and external rotation position. She noted severe bilateral shoulder pain afterward. Physical examination revealed forehead hematoma and the squaring of bilateral shoulders was also noted. Both shoulders were irritable with a restricted range of movement in all aspects. Diagnosis of bilateral anterior shoulder dislocation without associated fracture was confirmed by imaging (). Closed reduction was performed in the emergency department under sedation, successful reduction of both shoulders was also confirmed with imaging () and then the patient was admitted to our department. The patient complained of the recurrent right shoulder pain after admission. On examination, the recurrent right shoulder anterior dislocation was suspected and confirmed with imaging. Closed reduction was performed using the Kocher’s technique under fluoroscopy. Left wrist drop was also noticed (). On detailed examination, numbness along the posterior aspect of forearm, weak triceps action and complete loss of left wrist finger extension were noted. A traction injury to the posterior cord was suspected. The nerve conduction test (NCT) and magnetic resonance imaging (MRI) showed the left brachial plexus injury together with bilateral shoulder dislocation. Both shoulders were immobilized with a shoulder immobilizer and a dynamic wrist splint was applied to the deformed wrist joint. The NCT was performed four months post-injury and the mild motor abnormality of left radial nerve was noted. MRI scans of bilateral shoulders and bilateral brachial plexus were performed six months post-injury. It showed Hill Sachs defect of the right humeral head and focal full thickness tear of the right supraspinatus tendon (). There was also a complete rupture of the left supraspinatus tendon with proximal retraction of 3.5 cm (). No significant finding was noted in the brachial plexus except perineural cysts over C8 and T1 nerve root. The patient was referred to physiotherapy and occupational therapy for rehabilitation. The shoulder immobilizers were kept for six weeks and the active-assisted mobilization was then started. Electrical stimulation of the affected muscle was performed to prevent muscle atrophy. At follow-up, 6 weeks post-injury, the patient reported an improvement in bilateral shoulder pain and no recurrent shoulder dislocation. There was also an improvement in the numbness of the left upper limb and the power of left wrist and finger extension (both reached grade 4/5). At follow- up, 4 months post-injury, the patient was able to flex both shoulders to 145 degrees and abduct them to 160 degrees. |
A 57-year-old obese female presented to the emergency department with worsening pain and infection of the right inguinal region, right thigh, and lower abdominal wall. A CT scan confirmed the likely necrotizing fasciitis, and the patient was also found to have poorly controlled diabetes mellitus and sepsis on admission. She was admitted by the Critical Care team and emergently taken to the operating room for incision and drainage, with extensive debridement of her necrotizing fasciitis. The original wound size following this debridement was 60 cm x 30 cm x 15 cm down to the muscle. Her sepsis failed to resolve, and she was, therefore, taken back to the operating room 36 hours later for further debridement down to the muscle with a long segment of visible femoral artery and sciatic nerve exposed. She was taken back to the operating room again four days later for further debridement as she was too unstable during the previous procedures for prolonged anesthesia and blood loss.\nThroughout the above-mentioned procedures, her wound was also thoroughly irrigated via pulsavac lavage. After the second debridement due to the severity of her wound, an orthopedic consult was obtained for an opinion on a hip disarticulation; they recommended proceeding with the current wound care and would proceed with disarticulation if she failed with the current therapy. Forty-eight hours following the 3rd OR debridement (Figure ), an NPWTi-d Veraflo device was placed on the wound with normal saline instillation solution with the following settings: 325 ml normal saline was instilled for a 10 minute soak every three and a half hours under -125 mmHg continuous pressure per the recommendations of the clinical panel [-] (Figure ). Use of normal saline for instillation was chosen as studies have shown that it is as effective as other topical wound cleaning solutions [-]. Similar to the use in this patient, multiple clinical trials have shown that NPWTi-D versus NPWT achieves faster wound closure and better skin perfusion when used with -125 mmHg [-].\nThe dressings were changed on a 3-4 day schedule. After four days of treatment with the NPWTi-d Veraflo, the wound showed improvement with increased granulation tissue and viable skin edges, with granulation over the exposed artery and nerve (Figure ).\nThe patient had a prolonged hospital course. Once she was off sedation and medically stable, due to the size and extent of her wound, she was taken back to the OR three days later for a dressing change, and the overall wound showed great improvement with increased granulation throughout (Figure ).\nNPWTi-d Veraflo therapy was continued with one more subsequent dressing change seven days later and then returned to NPWT -125 mmHg until discharge from the hospital to the LTAC facility. NPWT was continued with dressing changes three times weekly at the outside LTAC facility as discussed for continued therapy for expedited granulation. The patient was then readmitted 20 days later for other medical complications; the wound was evaluated and exhibited almost complete granulation over all exposed muscle, vasculature, and nerve structures--almost superficial to surrounding peri-wound skin (Figure ).\nShe was once again discharged to the LTAC facility with NPWT. The patient was then readmitted about 30 days later for VRE pneumonia and expired from this, therefore complete closure of her wound was not able to be achieved. Informed consent was waived, and no reference to the patient's identity was made at any stage during data analysis or in the report. |
A 19-year-old male patient, injured as a result of a single vehicle motorcycle accident, was accepted as a trauma transfer to our Level I trauma center for definitive evaluation and management of an open femur fracture with significant segmental bone loss (). The patient had lost control of his motorcycle while performing “wheelies” and struck a concrete highway divider. His resultant injuries included multiple minor orthopedic fractures and ligament disruptions, including a Gustilo III-B open fracture to the distal left femur. All injuries were evaluated and treated by the initial treating hospital, including external fixation stabilization and two rounds of irrigation and debridement of the open femur fracture.\nA thorough history and physical examination revealed that the young patient was in otherwise good health aside from his orthopedic injuries. Distal vascular function to the leg below the level of the open fracture was uninterrupted, and no deficit existed either in the motor or in sensory function of the distal lower extremity. New radiographs and a repeat serial irrigation and debridement upon arrival at our hospital revealed absence of the distal 17 centimeters of metadiaphyseal bone of the left femur. The distal end of the femur was fractured, including extension into the articular surface, but was retained with significant soft tissue attachments. The segment of missing bone included a modest amount of the lateral femoral trochlear articular surface.\nThe decision on how to best proceed was made after numerous and detailed discussions with both the patient and his family regarding the surgical options of primary amputation of the severely injured leg, or limb salvage. The superior short-term results of primary amputation, as well as a lack of published support for superiority of either technique at two years, were thoroughly discussed []. Despite the probability of multiple surgeries over the course of approximately the next year, the attendant risks of each surgery, and the very real possibility of enduring pain and challenging control measures, the patient opted for the limb salvage option. We then set about formulating a surgical plan to provide the best possible outcome to that end. |
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 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 73 year-old Japanese woman underwent arthroscopic surgery of the knee for a torn medial meniscus. She had a surgical history of excision of a right frontal meningioma 11 years ago. She was receiving medications for hypertension and hyperlipidemia. She had no history of trauma, headache or coagulation abnormalities.\nFrom around four years before presentation to our center, our patient started to experience right knee pain and was treated at her local hospital with intra-articular injections of hyaluronic acid and physical therapy. She was referred to our center because of deterioration of pain and a catching sensation on the medial side of her right knee joint. Examinations at presentation detected pain from the medial side to the popliteal region of her right knee joint, a restricted range of motion to -10 degree extension and 110 degree flexion and a positive McMurray test. A plain radiograph showed findings of osteoarthritis. Magnetic resonance imaging (MRI) revealed a degenerative tear of the medial meniscus. Arthroscopic surgery was scheduled and our patient was admitted.\nSpinal anesthesia was conducted by puncturing the L4-5 space with a 26-gauge spinal needle and injecting 2.3 mL of 0.5% isobaric bupivacaine. The puncture was successful on the first attempt, and the course of anesthesia was without incident. During surgery, arthroscopic examination showed wear of the articular cartilage and a degenerative tear of the medial meniscus; partial excision of the medial meniscus was conducted. Her intraoperative vital signs were normal and the surgery was completed uneventfully. The operation time was 87 minutes. At discharge from the operation room, her sensory block region was below the 10th thoracic vertebra.\nOur patient used a wheelchair one day after the operation and started physiotherapy on her third postoperative day. There were no symptoms of a postdural puncture headache, and the postoperative course was uneventful. On the fifth postoperative day, our patient started to have a headache with vomiting at 6 a.m. while defecating in the toilet. The severe headache persisted even in a supine position, and her blood pressure was 232/103 mmHg. Pentazocine was administered for the headache. Our patient appeared somnolent but showed no definitive paralytic symptoms. At 9 a.m., a computed tomographic (CT) scan was performed, which showed a subdural hematoma from her left frontal to temporal region. The greatest thickness of the hematoma was 1 cm, and a slight midline shift was observed (Figure ). MRI performed consecutively did not show an aneurysm, only the subdural hematoma. The size of the hematoma did not change on CT examinations performed six hours and 24 hours later.\nOur patient was treated conservatively with blood pressure control, administration of a hemostatic agent and bed rest. Her headache was resolved after seven days of rest. On day 12 after onset, a CT scan showed that the hematoma had reduced in volume and in density (Figure ), indicating hematoma absorption. Rehabilitation was restarted from the 13th postoperative day. A CT scan one month later showed further reduction in the volume of the hematoma (Figure ). On the 49th postoperative day, our patient had no subjective symptoms and was discharged. |
A 55-year-old female, on treatment for rheumatoid arthritis and hypothyroidism since 10 years, presented in February 2015 with scleral necrosis and pain 1 month after clear corneal cataract surgery done elsewhere. She was on systemic steroids and systemic methotrexate. The diagnosis of scleritis was concurred with at our institute and the patient continued to follow-up with her local ophthalmologist and rheumatologist. She underwent a clear corneal phacoemulsification in the right eye 3 months later, while on systemic immunosuppressives, following which she developed scleritis in the other eye with worsening of signs in the other eye. She was administered pulse methylprednisolone and cyclophosphamide twice by her treating ophthalmologist and referred to us for further management. She was on topical steroids, antibiotic, and lubricant in addition since the past 3 months.\nHer BCVA was noted to be 6/36 in the right eye and counting fingers close to face in the left eye. Clinical features were similar to that noted in the previous patient with tarsal ischemia and ulceration and skin ulceration [Figs. and ], all of which were not corroborating with the clinical diagnosis of scleritis. Her blood investigations revealed a normal erythrocyte sedimentation rate and C-reactive protein despite a worsening of the ocular condition. Clinical features were strongly suggestive of chemical injury and the patient as well as the attendants were questioned repeatedly about the instillation of anything other than the advised eye drops in the eye which was strongly refuted. The patient, however, complained of severe pain and discomfort during instillation of the antibiotic eye drop. Examination of the bottle with the antibiotic did not reveal anything amiss, though it appeared darker in color compared to the normal drop.\nWhen the content in the bottle was checked for pH using the pH strip, it turned acidic indicative of pH 1–2. The bottle was subsequently subjected to biochemical investigations that revealed the true nature of the liquid to be sulfuric acid [].\nThe patient was informed of the same; the attendants were confronted though they continued to remain in denial. The patient care was continued with tenonplasty and amniotic membrane grafting done twice for both the eyes [Fig. and ]. Only eye ointments were used postoperatively, and when patient was seen at the next follow-up 3 months later, the surface had healed with a BCVA of 6/9 in the right and 3/60 in the left eye. |
The patient was a 37-year-old woman, G2P1, with an unremarkable family history. She had been diagnosed with bronchial asthma by her family doctor at the age of 33 years. The use of steroid inhalation therapy did not appear to impact her condition []. Her previous pregnancy had resulted in an emergency cesarean delivery at 33 weeks of gestation due to severe hypertensive disorders of pregnancy (HDP) and fetal growth restriction (FGR). She became pregnant for the second time and was referred to our hospital owing to her previous birth history. Her estimated due date was confirmed from the CRL value during the first trimester. Her pregnancy was uneventful; however, she developed fever and cough at 26 weeks of gestation and was subsequently diagnosed with sinusitis due to deteriorated bronchial asthma. She was admitted to the hospital under the care of the respiratory team and was administered ceftriaxone. However, despite administration of antibiotics, the wet cough associated with asthma persisted. She suffered from pneumonia at 28 weeks of gestation, and atelectasis was detected in the left lower lobe using a chest radiograph. Although her symptoms began to improve, bronchoscopy was performed at 34 weeks of gestation due to recurrent pneumonia. Bronchoscopy showed a tumor with a smooth surface measuring approximately 1.5 cm in the left main lung bronchus. The tumor obstructed nearly 100% of the trachea () []. Further enlargement of the mass would have led to complete tracheal obstruction, suggesting a risk of sudden left lung atelectasis and maternal hypoxia; therefore, early medical intervention was necessary. Additionally, her blood pressure was elevated at 32 weeks of gestation and fetal growth was restricted at -2.0 SD of normal fetal growth, so that she was diagnosed with preeclampsia (PE-EO). Following counseling with the patient, her family, and respiratory medicine doctors, a bronchoscopic tumor resection was planned following the delivery of the baby. A cesarean section was performed at 34 weeks of gestation due to previous cesarean delivery. She delivered a female infant weighing 1322 g, with Apgar score of 8 and 9 points at 1 minute and 9 points at 5 minutes, respectively. The pH of umbilical artery blood gas was 7.321. A chest CT taken after delivery revealed a bronchial tumor in the left main bronchus without invasion to surrounding organs (), and the patient underwent rigid endoscopic bronchial tumor resection 7 days after the cesarean section () []. The histological type could not be identified at this point, and left lung atelectasis developed due to postoperative inflammatory changes. CT examination 4 weeks after the endoscopic resection confirmed relapse of bronchial tumor. Owing to obstruction by the recurrent bronchial tumor and to rule out the possibility of malignancy, left main lung bronchial resection and bronchoplasty were performed 6 weeks after the endoscopic resection. The pathological diagnosis of the resected specimen was a low-grade mucoepidermoid carcinoma (). No postoperative adjuvant treatment was needed, and her postoperative course was uneventful. There was no recurrence evident 18 months later. |
A 68-year-old male presented to our hospital with complaints of weight loss, fatigue and a progressively increasing mass over the left mandibular area for the past three months. On examination, the mandibular mass was firm, with no overlying skin changes or discharge. His past medical history included type two diabetes mellitus and chronic pancreatitis diagnosed eight months ago on computed tomography (CT) of the abdomen and pelvis from an outside institution. The CT also reported a 1.4 cm mass in the left kidney. Since his renal function tests were normal and there were no systemic complaints, no further investigations were ordered. Three months later the patient noticed bilateral swelling in armpits which were identified as bilateral axillary lymphadenopathy. Fine needle aspiration cytology of the left axillary lymph node revealed chronic lymphadenitis. Consequently, the patient was prescribed antibiotics. As the axillary lymphadenopathy persisted and the patient noticed new onset cervical lymphadenopathy, an otorhinolaryngology consultation was sought and CT of the neck was performed. The CT revealed bilateral cervical lymphadenopathy and small lytic lesions in the scapula, humerus, upper ribs and cervical vertebrae. This raised the suspicion of bone marrow involvement with a differential diagnosis of a lymphoma, multiple myeloma or metastatic disease. The patient's laboratory investigations on presentation are shown in Table .\nA serum immunofixation electrophoresis was ordered which revealed normal levels of serum immunoglobulins G, A, and M, decreasing the likelihood of multiple myeloma. Tissue biopsy of the mandibular lesion exhibited a tumor comprised of nests of polygonal cells with abundant and clear cytoplasm. The nuclei were round to oval and hyperchromatic. A tissue biopsy from a lesion in the left rib revealed predominantly necrotic tissue with one fragment showing a tumor. The tumor comprised of atypical, ovoid cells with hyperchromatic nuclei and eosinophilic to clear cytoplasm. An admixed lymphocytic infiltrate was also seen. Figure shows the tissue biopsy of the mandibular lesion.\nA bone marrow biopsy was performed to rule out bone marrow involvement. Bone marrow trephine revealed a hypercellular marrow showing infiltration by non-hematopoietic tissue, composed of tubular structures lined by large cells with abundant and clear cytoplasm. Figure shows the bone marrow trephine biopsy.\nThe infiltrate was positive for cytokeratin AE1/AE3 and CD10 immunostains. CD10 is an immunostain that is found positive in proximal convoluted tubules. Figure shows a section of the bone marrow showing positivity for CD10.\nThis confirmed the presence of metastatic renal carcinoma, likely clear cell RCC in the bone marrow. The patient was referred to the oncology clinic for further workup to identify the primary neoplasm. |
A 15 years old girl came to our hospital with a complaint of pain and swelling over her left hand with history of fall. She also complained of occasional pain over lower third and inner aspect of her forearm. While we were managing the patient for hand injury we took x-ray of hand with wrist and forearm suggesting of fracture of fifth metacarpal. X ray also showed findings of expansile lytic lesion with multiple septas in diaphyseal region of left ulna. Examination of forearm revealed a mild diffuse swelling over the lower third and inner aspect of her left forearm. The overlying skin was normal. No signs of inflammation were visible. On palpation, there was tenderness over the swelling. The swelling was soft in consistency with a feeling of ‘egg shell crackling’. Movement at all the joints was full in range and was painless. There was no neurovascular deficit. Clinically diagnosis came out to be either Aneurysmal bone cyst or Simple bone cyst. We decided to take FNAC. The report of FNAC was suggestive of Giant cell tumor. For confirmation of diagnosis, we took open incisional biopsy which came out to be giant cell tumor. Diagnosis of giant cell tumor was confirmed as we sent specimen at two different histo-pathology laboratory, both suggestive of GCT. Then after proper counseling of patient and relatives, we decided to excise whole tumor and reconstruct it with a fibular graft. We expose entire tumor with standard ulna surgical approach. We had removed tumor with 1 cm clinically normal looking bone both side. We had also sent intra operative frozen section for safe margin. Report came as negative. The bone gap after excision of tumor in ulna was about 8 cm. We took cortical bone graft from ipsilateral fibula of respective size. We took cancellous bone graft from ipsilateral proximal tibia. Implantation of fibula at recipient site after appropriate freshening of margins, fixation of fibula in between the two ends of ulna with intramedullary ulna nail from proximal to distal. Then we put cancellous bone graft at both ends which were taken from ipsilateral proximal tibia & then closure was done in layers. The tumor was reddish brown, ovoid in shape and soft in consistency. Frozen section was done to know the extent. It extended from the diaphyseal area of the distal ulna to the distal third. It was removed cleanly. After doing Histology examination diagnosis of giant cell tumor was confirmed. After discharge, first 6 month patient was followed every 2 monthly. After six month, next visit every 6 monthly up to 2 years. Complete fibula incorporation at the end of one year. Next follow ups were uneventful. |
An 83-year-old woman suffered from nausea and posterior headache with a history of hypertension, peripheral artery disease, and hemodialysis for 16 years. An emergent magnetic resonance imaging revealed a small infarction in the right cerebellum, and the cardiologist pointed out blood pressure difference between the right upper arm (88/55 mmHg) and the right lower leg (152/76 mmHg). Contrast-enhanced computed tomography (CT) was performed on suspicion of aortic dissection and revealed that the intimal flap was recognized in the distal ascending aorta through the aortic arch but was not found in the mid-ascending aorta (). She was diagnosed as type A aortic dissection with an atypical form and was transferred to our hospital for further treatment. On arrival, she was fully alert, and her hemodynamic state was stable. The CT also revealed an extravasation of contrast medium to the posterior wall of the proximal ascending aorta () with a slight pericardial effusion. At the emergency room, she complained of chest oppression, and her vital status rapidly deteriorated. A repeat transthoracic echocardiography revealed an increasing effusion in the pericardial cavity. She was immediately transferred to the operating room under a diagnosis of rupture of the aortic dissection. A profuse amount of pericardial effusion was bloody, but the ascending aorta was not bluish. After pericardial effusion evacuation and clot removal, excess bleeding was not found. Because the ascending aorta seemed unruptured, we started core cooling through the ascending aorta to bicaval bypass. When we divided the posterior wall of the ascending aorta, fresh bleeding came out. We hurried a cooling under compression around the posterior wall of the ascending aorta, and circulatory arrest was induced at the tympanic temperature of 25°C. A retrograde cerebral perfusion through the superior vena cava was immediately started. The ascending aorta was opened, and we found a circumferential detachment of the intima at 2 cm below the brachiocephalic artery. The intimal flap was intussuscepted distally to the aortic arch. A vertical tear reached down to 2 cm above the sino-tubular junction in the posterior wall of the ascending aorta, and the top of the vertical tear was sought to be the rupture site (). The inverted intima was retrieved from the aortic arch to the ascending aorta. The false lumen of the distal side extended to the arch vessel and that of the proximal edge was almost thrombosed and limited around the vertical tear. As no more tear was found distally, and the aortic valve and the coronary ostium were intact, replacement of the ascending aorta was performed using 30-mm woven polyester graft (J-Graft, Japan Lifeline, Tokyo, Japan). Reinforcement of the anastomosis site was done in the proximal and distal side with BioGlue (CryoLife Inc., Kennesaw, GA, USA) and external Teflon felt strip. The cardiopulmonary bypass was weaned uneventfully. The time of the operation, cardiopulmonary bypass, and circulatory arrest were 352, 202, and 43 min, respectively. The patient was extubated on the second operative day without any neurological deficit. On the third operative day, a metabolic acidosis progressed in spite of a continuous renal replacement therapy. The rate of water removal was 70 ml/h for 50 ml/h intake, and water balance still remained at >4,700 ml. An emergent contrast-enhanced CT revealed a global mesenteric ischemia, although no residual dissection was found and the celiac and superior mesenteric artery were patent (). Her family denied a surgical intervention as a further treatment. Although she was treated with a continuous infusion of alprostadil alfadex (0.005 µg/kg/min), she expired on the fourth operative day. Her family denied an autopsy. Histologic examination of the aortic wall taken during the operation showed cystic median necrosis. |
A 37-year-old right-handed male presented to the emergency department with right wrist pain and decreased range of motion of the forearm following a friendly grappling match. On history, he was mildly intoxicated by alcohol at the time of the injury. His friend had performed an arm-bar holding the patient's right arm between his legs while pulling on the forearm with his hands. The patient tried to escape the maneuver by forcefully pulling and pronating his forearm. He immediately felt pain in his right forearm and was unable to use it afterwards. His past medical history was significant for alcohol, tobacco, and cocaine use. He was not known to be suffering any other medical conditions and had never suffered any injury to his right wrist or forearm in the past. On physical examination, the forearm was locked in supination, with no passive or active pronation elicited. There was loss of the dorsal ulnar prominence, and a palpable and tender solid mass was felt on the volar aspect of the wrist, which was presumed to be a volarly dislocated ulnar head (). The skin was intact, and the neurovascular status of the hand was normal. Radiographic examination of bilateral forearms confirmed our suspicions, displaying overlap between the radius and ulna on the anteroposterior view and volar displacement of the ulnar head relative to the distal radius on the lateral view. A CT scan was performed, completing the clinical picture by revealing impaction of the ulnar head on the distal radius ().\nAfter obtaining informed consent, closed reduction was planned under procedural sedation. The reduction was first attempted by pronating the forearm while applying a posteriorly directed force to the ulnar head. After an unsuccessful first attempt, a second attempt was performed with an assistant applying pressure on the interosseous membrane (IOM) of the forearm using the palm of both of his hands, in an effort to free the impacted ulnar head from the distal radius (). With the ulnar head now freed from the radius, the second attempt at manipulation was rewarded by an audible click and a return of the wrist's normal position and motion. On postreduction stability testing, the DRUJ was felt to be unstable at 45° of supination. This prompted the clinician to immobilize the patient in neutral rotation and 90° of flexion using an above-elbow back slab. Postreduction radiographs confirmed the success of the reduction maneuver ().\nAt the three-week clinical follow-up, the splint was removed and physical examination was repeated. The patient showed full range of motion of the wrist and elbow in flexion and extension. Compared to the contralateral forearm, there was a 10° lack of pronation and 25° lack of supination. Pain and tenderness were minimal, and no instability could be elicited. Diagnostic imaging confirmed that the reduction was maintained. The patient was discharged from the clinic with instructions for range of motion exercises and avoidance of loading activities for an additional three weeks. No additional follow-up visits were planned. |
A 22 year old pregnant lady in the third trimester came to the emergency with absent fetal heart sounds in the third trimester in a government general hospital. Absent fetal heart sounds, meconium stained liquor and non progressive labour were the basis for considering the patient for emergency caesarean. The prognosis of the patient and the baby were explained clearly to the patient attendants. The patient in addition had severe post burn scarring due to burns in childhood and it extended from the chest region to the abdomen and perineal region with supra-clitoral hooding deformity. The left breast nipple-areolar complex was partially buried. Realizing the severity of contracture of the lower abdomen and perineum with distorted anatomy, the umbilicus lying very close to the mons region, the obstetrician realized the possible need for a plastic surgeon to reconstruct the huge defect once an incision for the caesarean section would be given which would not have been easy to close primarily.\nA combined multi-speciality expertise was involved including a plastic surgeon, an obstetrician and a pediatricianand an anaesthetiest. The patient was given spinal anaesthesia after optimizing her for surgery. An inverted t- shaped skin incision was planned in the lower abdomen region horizontally extending as far as the contracture and vertically extending as low as possible just stopping short of the clitoris when normal tissue was encountered and then the incision was converted to an inverted y-shape along both the sides of the remnant labias []. The rest of the caesarean section was completed in the usual way and a full born female baby weighing 2.75 kg was delivered. The baby was shifted to NICU for further observation. The anterior abdominal wall was closed in the usual way after delivering the placenta and the repaing the uterus. The mons pad of fat was found displaced and was recontoured to give the mound its normal shape. The skin defect extending from the lower abdomen to the upper thighs and anterior perineum [] was resurfaced with skin grafts harvested from the thighs [Figure and ]. After infiltration of local anaesthetic, the left side nipple was everted along with the release of the gland tissue with skin graft cover as far as possible. But owing to the chronicity of the burns, the left breast had not attained the larche and hence she could lactate from the right breast only which seemed sufficient for the baby. She did not develop any breast engorgement on the left side however. The total operative time was 4 hours from the time of incision which included 20 minutes for the delivery of the baby. She received 3 units of packed red blood cells and 4 units of fresh frozen plasma in the peri-operative period. Custom made splintage that extended from the abdomen to the thighs was provided for her for maintaining the thighs in the extended and abducted position. The baby was eventually handed over to the mother after sufficient monitoring. |
A 70-year-old lady with history of long standing multinodular goiter presented with progressive rapid enlargement of a midline thyroid nodule for 3 months which was associated with dyspnea and dry cough.\nDuring examination there was multinodular goiter with a hard and fixed mass in the midline of the neck, the mass was moving with swallowing, the voice was normal and the patient was sent for vocal cords evaluation by flexible laryngoscopy, which showed no evidence vocal cord paralysis. Other parts of the general examination were unremarkable.\nThe complete blood count was normal, and the thyroid function test was also normal.\nFNA was performed and confirmed malignant cells mixed with inflammatory cells.\nPreoperative echocardiography showed good cardiac function and preoperative workup including CXR showed no evidence of any lung lesion during the first operation.\nDuring surgery there was a hard and fixed mass arising from the isthmus of the thyroid gland with multinodular thyroid enlargement, the mass was about 7 × 7 cm and was locally invading the larynx and the carotid sheath, complete excision was not possible because of unclear anatomical plans, debulking surgery was done and the sample was sent for the histopathology. A suction drain was placed in the neck at the site of resection which was removed after 3 days.\nThe final histopathological result was consistent with mixture of thyroid nodules and moderately differentiated squamous cell carcinoma. , , , .\n6 months after surgery the patient presented with progression of the mass at the same site, which was hard and fixed, associated with multiple enlarged hard cervical lymph nodes at both sides of the neck. The patient was sent for CT-scan which showed an evidence of an ill-defined heterogeneous mass at the site of surgery and left lobe of thyroid, the mass was invading the esophagus and the trachea with enlarged multiple bilateral cervical lymph nodes. There was evidence of 2 possible metastatic nodules in the upper lobe of right lung. The patient was sent for post-operative radiotherapy. |
A 56-year-old man was admitted for acute right hemiparesis and a mild speech disturbance (3 on the modified Rankin Scale). He was well before admission without a history of hypertension, diabetes mellitus or hypercholesterolemia. On admission, the MRI scan revealed watershed and a small cortical ischemic infarction at the left cerebral hemisphere with diffusion abnormality on the diffusion weighted image (DWI, ) and a decreased apparent diffusion coefficient (ADC). MR angiography () revealed severe stenosis at the left proximal ICA.\nThree days after admission, digital subtraction angiography (DSA) was performed to plan for CAS. The DSA showed complete occlusion of the left proximal ICA without forward flow to the distal ICA from the point of occlusion, moderate to severe stenosis at the left proximal external carotid artery and atherosclerotic plaque with ulcer at the distal common carotid artery (). The delayed phase of the left common carotid angiography () showed retrograde filling of contrast media from the supraclinoid ICA to the cervical ICA distal to the occlusion. The left arteries of the anterior circulation were seen from the prominent transdural collateral vascular supply of the distal external carotid artery (ECA) branches via the transopthalmic route, and from the right anterior cerebral artery via the anterior communicating artery. There was no evidence of aggravation of the patient's neurologic status as compared with his neurologic status at the time of admission. We did not attempt to recanalize the occluded ICA because the patient already had acute ischemic infarction and he showed no neurological aggravation. He was medicated with only aspirin (300 mg/day) and clopidogrel (75 mg/day). The patient's neurologic status then slightly improved.\nA follow-up DSA () was performed four weeks after ictus for attempting to insert a stent into the severely stenotic proximal ECA and ulcerated CCA, and the DSA revealed spontaneous recanalization of the left proximal ICA with a tight stenosis and forward flow. The patient was stable at that time. For prevention of repeated occlusion of the ICA and ischemic infarction, CAS was performed under local anesthesia without sedation. The blood pressure, pulse and oxygen saturation were continuously monitored throughout the procedure, and the neurologic assessment was performed by a neurosurgeon. Systemic anticoagulation was performed via the intravenous administration of a bolus of heparin (5,000 U).\nPre-stenting balloon angioplasty was performed by using a 3 mm diameter balloon (Maveric, Boston Scientific, Galway, Ireland). A self-expandable Carotid Wallstent (Boston Scientific, Natick, MA, 8 mm in diameter and 3.1 cm in length) was deployed from the left proximal ICA to the distal common carotid artery. After the stent insertion, post-stenting balloon angioplasty was performed due to the residual stenosis by using a 6 mm diameter balloon (Ultrasoft-SV, Boston Scientific, Natick, MA). We could not use the distal protection device during the procedure because the diameter of the distal cervical ICA was less than 2.5 mm. No neurophysiological changes were identified during or after the procedure. Angiography after CAS showed good deployment of the stent (), and there were no findings of intracranial vascular abnormality.\nThere was no evidence of periprocedural hypertension. After the procedure, the patient was closely monitored in the intensive care unit for 24 hours and hydration was done under strict blood pressure control (under 120/80 mmHg). Four days after procedure, the patient was discharged without any complication. During one year follow-up, there has been no neurologic complication (Modified Rankin Scale 0-1). There was no significant recurred stenosis on the follow-up Doppler ultrasound that was done one year after the CAS (). |
The patient was a 78-year-old man who had alcoholic liver cirrhosis (Child-Pugh grade A) and radical laparoscopic proximal gastrectomy for gastric cancer. On routine upper gastrointestinal endoscopy, a 15-mm gastric cancer in the remnant stomach was discovered after 3 years. We performed endoscopic submucosal dissection at the first therapy. However, the vertical margin was positive in a pathological result. Contrast-enhanced computed tomography (CT) showed no metastasis in other organs.\nWe performed total gastrectomy with Roux-Y reconstruction and D1 lymph node dissection with laparotomy. Operative findings showed an atrophic liver with liver cirrhosis. When we performed blunt dissection around the gastroesophageal junction, the left pleura was damaged because of severe adhesion around the gastroesophageal junction after laparoscopic proximal gastrectomy. As a result, the left chest cavity was connected through the abdominal cavity. Moreover, we knew that the previous anastomotic site was located in the posterior mediastinum by preoperative diagnosis. Therefore, we dissected the crus of the diaphragm for pulling out the anastomotic site and the esophagus. We did not repair the pleural defect because the orifice of the hernia was small and it was difficult to confirm a defect of the pleura. Two days after the operation, the patient was suspected of having an intrathoracic hernia by chest X-rays (fig. ). CT showed incarceration of the transverse colon and Roux limb in the left thoracic space (fig. ). We diagnosed intrathoracic hernia and emergently performed repair of the hernia. Operative findings showed that the Roux limb and transverse colon were incarcerated in the thoracic cavity (fig. ). Additionally, the esophageal hiatus was not covered because of atrophy of the left lateral segment by liver cirrhosis. The incarcerated intestine was placed back into the abdominal cavity. There was no ischemic change. After replacement, the orifice of the hernia was found as a defect between the Roux-Y limb and the left crus of the diaphragm (fig. ). The orifice of the hernia was closed by suturing the crus of the diaphragm to the ligament of the jejunum and omentum. Unfortunately, he was complicated by anastomotic leakage and pyothorax on the left side on the 4th postoperative day after the emergency operation. We performed multimodal treatment and he was finally discharged on the 76th postoperative day after the second operation. |
A 68-year-old male presented to our hospital with complaints of weight loss, fatigue and a progressively increasing mass over the left mandibular area for the past three months. On examination, the mandibular mass was firm, with no overlying skin changes or discharge. His past medical history included type two diabetes mellitus and chronic pancreatitis diagnosed eight months ago on computed tomography (CT) of the abdomen and pelvis from an outside institution. The CT also reported a 1.4 cm mass in the left kidney. Since his renal function tests were normal and there were no systemic complaints, no further investigations were ordered. Three months later the patient noticed bilateral swelling in armpits which were identified as bilateral axillary lymphadenopathy. Fine needle aspiration cytology of the left axillary lymph node revealed chronic lymphadenitis. Consequently, the patient was prescribed antibiotics. As the axillary lymphadenopathy persisted and the patient noticed new onset cervical lymphadenopathy, an otorhinolaryngology consultation was sought and CT of the neck was performed. The CT revealed bilateral cervical lymphadenopathy and small lytic lesions in the scapula, humerus, upper ribs and cervical vertebrae. This raised the suspicion of bone marrow involvement with a differential diagnosis of a lymphoma, multiple myeloma or metastatic disease. The patient's laboratory investigations on presentation are shown in Table .\nA serum immunofixation electrophoresis was ordered which revealed normal levels of serum immunoglobulins G, A, and M, decreasing the likelihood of multiple myeloma. Tissue biopsy of the mandibular lesion exhibited a tumor comprised of nests of polygonal cells with abundant and clear cytoplasm. The nuclei were round to oval and hyperchromatic. A tissue biopsy from a lesion in the left rib revealed predominantly necrotic tissue with one fragment showing a tumor. The tumor comprised of atypical, ovoid cells with hyperchromatic nuclei and eosinophilic to clear cytoplasm. An admixed lymphocytic infiltrate was also seen. Figure shows the tissue biopsy of the mandibular lesion.\nA bone marrow biopsy was performed to rule out bone marrow involvement. Bone marrow trephine revealed a hypercellular marrow showing infiltration by non-hematopoietic tissue, composed of tubular structures lined by large cells with abundant and clear cytoplasm. Figure shows the bone marrow trephine biopsy.\nThe infiltrate was positive for cytokeratin AE1/AE3 and CD10 immunostains. CD10 is an immunostain that is found positive in proximal convoluted tubules. Figure shows a section of the bone marrow showing positivity for CD10.\nThis confirmed the presence of metastatic renal carcinoma, likely clear cell RCC in the bone marrow. The patient was referred to the oncology clinic for further workup to identify the primary neoplasm. |
Our case reporting followed CARE recommendations (). A 49-year-old woman had sporadic episodes of rotational vertigo 12 years ago and abdominal pain 10 years ago. Ultrasonography and magnetic resonance imaging (MRI) of the abdomen revealed the presence of pancreatic cysts that did not show significant growth in imaging tests. Seven years ago, a computed tomography scan (CT) of the abdomen showed a solid mass in the lower pole of the right kidney. The patient was then submitted to right partial nephrectomy, and pathological examination revealed the presence of CCR. There was no need for adjuvant treatment. In the same year, the patient complained of altered visual acuity and a CT scan of the skull and orbit was made. The results show thickening with tortuosity of the left optic nerve, with a small area of nodular enhancement, with an extension about 0.8 × 0.5 × 0.4 cm. The right optic nerve had a conserved aspect. These results were considered suggestive of the presence of HB in the optic nerve of the left eye (). MRI of the head showed a gadolinium-enhancing well-circumscribed mass on the left optic nerve in the orbital (). The mother of the patient died at age 63 from an advanced kidney tumor, and her father is alive and healthy at age 80. The patient has one child, currently 27 years old, who has a recurrent headache complaint but refuses to undergo the investigation for VHLS, and a healthy, symptom-free, five-year-old grandson. The patient has five brothers and two sisters. One sister underwent partial nephrectomy due to carcinoma in the right kidney without the need for adjuvant treatment, another sister was operated on by HB from the CNS and had pancreatic cysts, and one brother had two HBs removed that were located in the brain and spine. A nephew of the patient at age 12 was diagnosed with HB from the CNS and died 4 years later due to complications of brain tumor that did not come to be removed. Another niece was diagnosed at age 21 of cerebral HB, and 6 months ago the tumor had resected. The family pedigree of the proband is shown in . To date, the patient has no manifestation of PCC, is under urological and endocrinological follow-up, and is submitted to abdominal CT every year and to orbit and CNS MRI every two years. In the control examinations, the patient maintains images of pancreatic and renal cysts () without images of renal tumor recurrence or metastases. The right optic nerve is intact, and there are no CNS lesions in the MRI of the brain. She has only a slight decreased of the visual acuity in the left eye due to the optic nerve HB and does ophthalmologic follow up each 2 years. |
Our patient is a 70-year-old Caucasian male who presented to the Orthopedic Hand Clinic for the evaluation of his right dominant elbow. He was building a deer hunting blind when the platform fell and landed on the posterior aspect of his right arm. He noted immediate pain, swelling, and ecchymosis about the elbow at the time of the injury. He also complained of a painful popping sensation whenever he ranged the elbow and an inability to extend, with pain and weakness any time he attempted elbow extension. At the time of our first encounter with him, he was approximately 8 weeks out from the date of injury. His only significant medical history was osteoarthritis in his hands and a former smoker, quitting in 2010 after smoking for 30 years. He had no history of pain or trauma at the site before the injury and denied any history of exogenous corticosteroid use.\nOn physical examination, he was found to have tenderness to palpation just proximal to his olecranon (). He also had pain with range of motion of the elbow and he was unable to maintain active elbow extension against gravity or resistance. His passive range of motion was intact with no blocks to motion and functional arc of 0–140°with full pronation and supination. He was neurovascularly intact distally at the hand with no other pertinent findings on examination of the upper extremity.\nElbow radiographs reviewed at his initial visit revealed a small osseous fragment approximately 5 cm proximal to the tip of the olecranon (). No other fractures, dislocations, or other bony abnormalities were appreciated.\nOur patient’s history, clinical examination, and radiographic findings were strongly indicative of a ruptured triceps tendon. He was to obtain advanced imaging studies and follow-up was scheduled to discuss magnetic resonance imaging (MRI) findings. The MRI confirmed our clinical suspicion by showing a complete tear of the triceps tendon with hematoma at its insertion site and retraction of the tendon approximately 3 cm proximally. Based on the degree of tear and functional impairment, it was determined that his injury would best be managed by surgical repair/reattachment of the triceps tendon to which he was amenable. |
A 77-year-old man with hypertension and hyperlipidemia underwent an outpatient nuclear stress test which demonstrated a reversible inferior wall defect. He subsequently underwent cardiac catheterization diagnosing severe multivessel atherosclerotic disease. A referral was placed to a cardio-thoracic surgeon for coronary artery bypass graft (CABG) surgery. A chest CT scan obtained during pre-CABG evaluation demonstrated a mild ascending aortic root dilation measuring 4.1 x 4 cm, without any evidence of dissection. The patient subsequently underwent CABG without any intra-procedural or immediate post-procedural complications. He was discharged home in a hemodynamically stable condition on the fifth postoperative day.\nThree weeks later, the patient presented to the emergency department complaining of a productive cough, nausea, vomiting, and fever. Based on physical examination, laboratory and imaging studies, he was diagnosed with sepsis secondary to pneumonia. A CT chest performed during initial evaluation for pneumonia in the ER redemonstrated the ascending thoracic aortic root dilation, as well as a new 3.9 cm long segment of dissection of the ascending thoracic aorta, originating 3 cm distal to the aortic root (Figures , ). The dissection did not involve recently grafted vessels. The new dissection was felt to be iatrogenic secondary to the recent CABG surgery. Treatment options along with their benefits and risks were discussed in detail with the patient. Medical management of the new dissection was agreed upon between the patient and the team of multidisciplinary physicians. This was a deviation from standard practice, albeit the most pragmatic approach, and this was communicated to the patient clearly.\nThe patient was started on metoprolol and losartan, with a blood pressure goal of less than 130 mmHg systolic. The patient remained hemodynamically stable throughout this hospitalization. A repeat CT scan was performed nine days after presentation, which demonstrated an unchanged type A dissection. The patient’s sepsis secondary to pneumonia was managed successfully with IV ceftriaxone and vancomycin. On day 12 of hospitalization, the patient experienced hypoxia and difficulty breathing. He was diagnosed with a thrombosis in the left greater saphenous vein, as well as subsegmental pulmonary embolism. It was determined he was not a candidate for catheter-directed pharmaco-mechanical thrombolysis by the pulmonary/critical care team. He was managed with heparin infusion thereafter. On day 17, he was discharged with Lovenox subcutaneous, and an order for a follow-up CT scan chest in one month to evaluate for any worsening of the aortic dissection. He was advised to continue losartan 25 mg once a day and metoprolol 100 mg BID with close follow-up with a cardiologist and cardiothoracic surgeon on an outpatient basis. Subsequent follow-up CT chest angiography at one month, four months, and 12 months did not demonstrate the progression of the ascending aortic dissection. |
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 44-year-old man, who had a medical history of panic disorder, visited another hospital due to dyspnea on mild exertion. Computed tomography was performed and revealed a coronary anomaly (). The patient was then transferred to our hospital for further evaluation and treatment. A coronary angiography showed a single coronary artery originating from the right coronary ostium. A single coronary artery bifurcated into the right coronary artery and left main coronary artery. The left main coronary artery coursed between the main pulmonary artery and aorta before bifurcating into the left descending artery and circumflex artery. We thought that panic symptoms or dyspnea on exertion might be a sign of myocardial ischemia due to compression of the left main coronary artery by the pulmonary artery and aorta. We decided that surgical treatment was the best option due to the high risk of sudden death associated with a coronary anomaly.\nUnder general anesthesia, median sternotomy was performed. We dissected the left main coronary artery between the aorta and the main pulmonary artery on the beating heart. The proximal left main coronary artery was bifurcated from a single coronary artery that originated from the right coronary sinus. Under cardiopulmonary bypass, cardioplegic solution was infused, and aortic cross clamp was performed. Transverse aortotomy was then performed. Only one coronary ostium was observed in the right coronary sinus, and a single coronary artery originated from the ostium. We dissected the left main coronary to allow separation from the aortic wall. A 5-mm arteriotomy was made to the left main coronary artery at the site in which the left coronary ostium should have been located. Neo-ostium formation was performed with a 5-mm puncher in the left coronary sinus. Anastomosis between the neo-ostium and the left main coronary arteriotomy site was performed using a 7-0 Prolene continuous running suture (). The aortic cross clamping time was 88 minutes, and total cardiopulmonary bypass time was 117 minutes.\nThe patient was discharged on the 11th postoperative day without any complications. Follow-up computed tomographic angiography before discharge showed good patency of the neo-ostium in the left coronary sinus without stenosis at the anastomosis site (). A treadmill test in the outpatient department after 3 months was negative. The patient remained asymptomatic without any complications or events for 15 months after the surgery. |
A 46-year-old male who was previously healthy visited our hospital due to increasing chest discomfort and dyspnea on effort over the previous 3 months. At the time when the patient visited the hospital, skin lesions with brown pigmentation, moderate thoracic vertebral deformity, and a decrease in lung sounds in the right upper lung zone were noted on his physical examinations. In his first simple chest X-ray, a well defined huge mass of the right upper lung field was detected. In the chest computed tomography, there was a cyst with a density similar to cerebral spinal fluid that was connected to the intervertebral foramen between the third and fourth thoracic vertebrae. Furthermore, the cyst that had a high signal in the MRI T2 image did not have any connection with the spine ().\nThis case had compression symptoms due to the thoracic meningocele, so we decided to do a surgical resection. After the induction of general anesthesia, the patient was positioned in the left supine position. In order to decompress the thoracic meningocele, we performed a lumbar puncture and cerebrospinal fluid (CSF) drainage. After a thoracotomy, we removed the pleural adhesions and dissected from the dura mater surrounding the thoracic meningocele including the parietal pleura to the space nearby the intervertebral foramen by extrapleural dissection. After removing the meningocele, we sutured the remaining dura mater with nonabsorbable 5-0 Prolene performing microsurgery (NC4, Kalzeiss, X20) through the intervertebral foramen. Finishing anastomosis, we filled the thoracic cavity with normal saline. Under the state of intrathoracic positive pressure, we confirmed the absence of CSF leakage. We then augmented the anastomosis site with parietal pleura and surrounding mediastinal tissues (). To identify the rupture of the suture site, we placed an intrathoracic drainage tube near the suture site and sutured the thoracotomy site. We prevented an abrupt CSF pressure elevation by keeping a constant pressure level of the suture site by controling the amount drainage from the CSF drainage tube after the surgery. The patient was extubated immediately after the operation, stayed in the intensive care unit (ICU) without any problems and was transferred to a general ward the next day. We removed the chest tube on the seventh postoperative day after confirming that there were no complications such as suture site rupture or CSF leakage by chest computed tomography (). After the surgery, the patient did not suffer from chest discomfort or dyspnea anymore. He was discharged from the hospital on the four-teenth postoperative day and is now receiving regular outpatient follow-up care. He is doing well, and other than pain on the surgery site, he is without any complications such as the recurrence of thoracic meningocele or rupture of the suture site at one year follow-up. |
A 38-year-old Hispanic female with a past medical history of Hodgkin lymphoma during childhood treated with both chemotherapy and radiation to the chest, and pacemaker placement 3 years ago due to third degree AV block thought to be secondary to radiation therapy presented with a 1-week history of headaches, dizziness, and dysarthria. She did not present any other neurological signs or symptoms, and physical examination was otherwise normal. A CT of the brain without contrast was performed in the ER, showing a questionable mass in the superior aspect of the cerebellum at midline, measuring approximately 2.8 cm × 4.3 cm in AP by transverse dimension with surrounding vasogenic edema and mild prominence of the temporal horns without a midline shift []. Since the patient had an absolute indication for the magnetic resonance imaging (MRI) scan to guide surgery and further treatment options, she required complete removal of her pacing system, which included both the pacemaker and the leads implanted. The patient was evaluated by a cardiologist and was found to be fully pacer dependent. The patient underwent removal of pacemaker, laser lead extraction of the atrial pacing lead and ventricular pacing lead, and implantation of MRI compatible leads and pacemaker [MRI compatible pacer system; ]. In addition, the patient underwent an extensive oncological workup with no primary cancer found that could explain the etiology of the mass.\nAfter workup was completed, the patient was taken to surgery with the goal of biopsy with or without gross-total resection. A sitting position infratentorial supracerebellar approach with a suboccipital craniotomy for resection of the mass was performed. Stereotactic navigation was used to confirm the location of the tumor. After the intraoperative pathology report confirmed that it was not lymphoma but, in fact, a spindle cell tumor, gross-total resection was achieved [], and an external ventricular drain was left open at 10 cm of water above the ear. The pathology reported MPNSTs, grade 3/3, associated with abundant hemorrhage. Immunohistochemistry revealed tumor cells that focally express S100, CD34, and desmin. The patient's postoperative course was uneventful and was discharged postoperative on day nine. |
A 7-year-old boy was seen in the pediatric ear surgery clinic for evaluation of an unusual 2-year history of burning sensation and pain of his external ears. More specifically, there was a history of an intermittent sudden onset of burning sensation and erythema of both of his ears, lasting about 20 minutes. The patient reported experiencing approximately 7 of these episodes per day, which required immediate ice pack application to the ears to attain symptomatic relief.\nThere was no history of reported hearing difficulties or other otologic complaints. He did report one episode of an ear infection, which was treated with antibiotics in the past and this seemed to settle his external ear symptoms momentarily, but he shortly redeveloped the episodic burning of his ears.\nPast medical history included being born one month premature and being the smaller fraternal twin. There were no issues at birth, and he has never required a prolonged hospital stay. He had no known drug allergies and there was no family history of any skin disorders.\nExamination revealed mild redness of the ears bilaterally, with no evidence of chondritis, cellulitis, or swelling (). The ear exam was completely normal otherwise showing normal tympanic membranes with no evidence of any middle ear fluids. The external auditory canal was also normal. The rest of the head and neck exam, including examination of the cranial nerves and neurologic screen, was unremarkable.\nFollowing the initial consultation, a diagnosis was not provided, and a referral was made to the pediatric dermatology clinic to investigate further and to assess for any potential cutaneous causes. After this referral, a diagnosis of erythromelalgia of the ears was made. Suggestions were made to try topical agents such as pramocaine hydrochloride or pramoxine to help the burning sensation, given their anesthetic or menthol components. Blood work, including inflammatory markers, was within normal limits. Cholesterol and liver enzymes were also normal.\nThe episodes gradually started to occur on a less frequent basis and the severity was also reduced. At his 16-month follow-up visit, the episodes had resolved. |
A 37-year-old woman who visited our hospital presented with a 3-month history of abdominal pain and bilateral leg edema. She underwent a physical examination and a large palpable abdominal mass was discovered in the middle and lower abdomen. In other hospitals, she had undergone her first operation for pelvic tumor 10 years earlier and another operation for local relapse of the tumor six years earlier. The postoperative diagnosis was unknown because the previous medical records were unavailable. According to the statement of the patient, she had her uterus and bilateral ovaries removed in the second operation because the recurrent tumor had invaded them.\nA computed tomographic (CT) examination of the chest, abdomen, and pelvis was performed before and after the administration of intravenous contrast material. Sagittal and coronal reformatted images were produced. The results demonstrated a bulky intra- and extraperitoneal mass. The mass caused a portion of the loop of the small bowel to deviate superiorly, encase the ureters and colon, and invade the inferior vena cava (). On unenhanced images, the mass was hypo-attenuated in relation to the surrounding muscular tissue (). The mass displayed heterogeneous moderate enhancement following contrast material administration (). The contrast-enhanced images depicted dilation of the inferior vena cava. A continuous tubular filling defect projected within the lumen of the inferior vena cava and extended superiorly to the level of the right atrium (). The tubular filling defect within the lumen of the inferior vena cava had a visualized transverse diameter of 3.5 cm. There were intensely enhancing nodules within the dilated inferior vena cava and enhancing collateral vessels around the aorta during contrast-enhanced arterial and late phases (). Contrast-enhanced thoracic CT showed multiple heterogeneously enhancing nodules and masses of different sizes in both lungs. The largest one measured 4.2 × 3.1 cm and was located in the left lower lobe ().\nSurgery was performed for palliative purposes to relieve the patient's symptoms. A combined operation to remove the intravascular and abdominal lesions was planned by the cardiosurgery and general surgery departments. Resection of the intracardiac and intravascular lesion through a sternotomy under total circulatory arrest and hypothermia was successfully performed, but the giant bulky intra- and extraperitoneal mass was excised incompletely because the tumor had encased the ureters, urinary bladder and colon. Histological examination of the specimen revealed a hypocellular mesenchymal lesion characterized by spindled and stellate cells with an ill-defined cytoplasm, loosely scattered in a myxoid stroma without evidence of nuclear atypia and mitosis. The lesion showed numerous, thin-to-thick wall vessels of different sizes (). Immunohistochemical studies showed strong staining for desmin, estrogen receptors, and progesterone receptors. Staining for actin, CD34 and smooth muscle actin was intermediate, and staining for S-100 protein was negative. Based on the morphological and immunohistochemical findings as well as the patient's medical history, the diagnosis of recurrent aggressive angiomyxoma was made. Histologic examination of a specimen from a CT-guided, core needle punch biopsy of one of the pulmonary lesions showed the same histologic pattern as the abdominal mass, confirming the metastatic spread of the primary tumor. |
A 59-year-old woman had a palpable mass in the right midabdomen during routine physical examination by her primary care physician. Other than abdominal pain, she had no signs or symptoms of urogenital disorders, such as hematuria or irritative voiding symptoms. She had no prior history of renal disease or trauma. Family history included a brother who underwent nephrectomy for RCC at age 62.\nAn abdominopelvic computed tomography (CT) scan revealed a large, solid, right renal mass (14x13x12 cm) and several hypoenhancing liver lesions suspicious for metastases. CT also identified a focal, slightly lucent lesion with sclerotic rim in the T10 vertebral body which was felt to represent a small hemangioma of bone or metastatic lesion, but a subsequent bone scan was negative. CT thorax revealed no metastases. There was significant enhancement of the solid components of the tumor and finger-like extensions of absent enhancement throughout the renal mass consistent with areas of necrosis or acute inflammation (). The mass arose from the mid and upper pole of the right kidney and extended superiorly displacing the right lobe of the liver and inferior vena cava (IVC) anteriorly, making the liver palpable (). The liver, in fact, extended down to her right iliac crest and below her umbilicus on both sides of her abdomen (). There was no evidence of tumor thrombus in the right renal vein or IVC. A diagnosis of likely malignancy with potential liver metastases was made and she was scheduled with interventional radiology for biopsy for pathologic confirmation.\nCT scan revealed multiple indeterminate lesions on her liver, the largest of which was 12x10 mm. She was referred for percutaneous biopsy of the kidney and liver lesions for tissue pathology and staging. As well-defined liver lesions were identified, the interventional radiologist performed liver mass biopsy only based on the perceived additional risk of biopsy of the hypervascular renal tumor. Pathology revealed liver parenchyma with fatty deposits, negative for malignancy. Given the negative liver biopsies and normal bone scan, an open radical nephrectomy with right retroperitoneal lymph node dissection was performed for suspected localized RCC using a subcostal incision. With a fixed retractor for the bowel and manual retraction of the liver, exposure of the renal hilum was quite good. No blood transfusion was necessary (estimated blood loss = 100 ml) and the patient was discharged home on postoperative day four without complication. According to final pathologic analysis, including a panel of immunochemical stains which excluded RCC and metanephric adenoma, the diagnosis was renal oncocytoma (). Preoperative glomerular filtration rate (GFR) was 101 ml/min/1.73m2 and new baseline GFR was 58 ml/min/1.73m2. The liver and bone lesions identified prior to surgery have been stable and no local or distant metastases have been seen now nearly four years postoperatively. |
A 47-year-old healthy man consulted a local hospital with complaints of unsteadiness and dizziness. Despite magnetic resonance imaging (MRI) revealing a cystic lesion in the third ventricle, he presented with no neurological abnormalities and his symptoms disappeared shortly. One year later, he was referred to the hospital again with complaints of headache. MRI revealed unilateral obstructive hydrocephalus with enlargement of the cyst, which occluded the foramen of Monro and protruded into the left lateral ventricle []. He was referred to our hospital for the surgery of cyst fenestration, and his headache resolved spontaneously. Endoscopic biopsy of the cyst wall was scheduled for the relief of headache and histological confirmation was obtained one month later. Upon admission for operation, MRI revealed that the cyst drew back in the third ventricle, and the shape of the ventricles turned out to be symmetrical. However, the ventricles still remained enlarged []. The sequential MRI findings demonstrated that the cyst at the third ventricle was flexible in its location and induced noncommunicative hydrocephalus with different obstructive points. He complained of different types of headaches, and finally we decided to perform endoscopic surgery to eliminate the symptom and normalize CSF flow in the ventricles.\nThe patient underwent endoscopic cyst fenestration at the third ventricle via the left lateral ventricle with a fiberscope (VEF-V, Olympus, Japan). The cystic lesion occupied the enlarged foramen of Monro []. There was a slight gap around the cyst wall at the foramen of Monro and the cyst wall, and some granular tissue could be found through the cyst wall. The cyst wall was connected to the choroid plexus behind the foramen of Monro []. Most of the cyst wall could be easily removed using endoscopic forceps, but the small part of the cyst wall was tightly adhered to the choroid plexus and was left untouched []. Finally, near-total resection was achieved to recover the physiological CSF flow through the foramen of Monro [].\nUpon pathological examination of the surgical specimen, cuboidal epithelia lined with connective tissue were found in papillary patterns with some calcification and no malignant appearances []. Immunoreactivity for epithelial membrane antigen and glial fibrillary acidic protein were positive in cuboidal epithelia, and these findings are consistent with CPCs.\nThe postoperative course was excellent, and his symptoms disappeared completely. MRI revealed the ventricles were reduced in size compared to preoperatively []. The patient was discharged on postoperative day 10 without any complications. He presented no complications for 6 months postoperatively. |
A 72- year old male patient attended the department of oral pathology for evaluation of a painless gingival growth in the premolar region of the right mandible. This lesion has been growing over the last year. The patient referred the excision of a similar lesion 6 years before which was diagnosed as ameloblastoma, but unfortunately, he did not have the previous documentation. His past medical history also included the diagnosis of diabetes mellitus that was on regular control. The examination revealed an oval-shaped exophytic mass of 1×1 cm in the lingual gingiva of the right mandible at the first and second premolar region. The surface was pebbly, with a sessile base and firm on palpation. No local enlarged lymph nodes were identified ().\nThe Orthopantomography (OPG) showed no evidence of bone involvement. The initial working diagnosis was pyogenic granuloma though the suspicion of recurrence of ameloblastoma was not ruled out ().\nAn incisional biopsy was done, considering the previous history of ameloblastoma and upon the microscopic examination, the diagnosis of pseudo epitheliomatous hyperplasia was made (). However, complete excision was performed because the initial diagnosis was not convincing. The analysis of excisional biopsy showed numerous proliferating odontogenic epithelial islands spreading throughout the moderately dense connective tissue stroma. The odontogenic epithelial islands were mainly of follicular pattern with peripheral hyperchromatic palisaded columnar cells resembling ameloblasts. The center of the follicle disclosed stellate reticulum like cells. In some of the odontogenic epithelial islands, the central cells underwent squamous metaplasia with keratin formation.\nThe overlying stratified squamous epithelium was proliferative and was found to be in close association with the odontogenic epithelial islands in few areas. A moderate amount of chronic inflammation was depicted in the subepithelial zone. No inductive effect was noticed around the odontogenic epithelial islands. The histopathological diagnosis of the peripheral ameloblastoma-acanthomatous variant was made (, , and ). The immunohistochemical study was carried out with CK 19, and positive expression was found (). No recurrence was evidenced during the first two-month follow up. Considering the recurrent nature of the lesion, a regular follow up every six months was scheduled. |
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 25-year-old man with no significant medical history presented with a rectal foreign body. According to the patient, it was PUF. He used to insert many different kinds of materials, but this was the first time that he could not retrieve it himself. Digital rectal palpation revealed a hard mass with a smooth surface in the anal canal. Laboratory findings and physical examinations were almost normal. A plain radiograph in upright and supine positions showed an increase of colorectal gas without bowel distension, but, unfortunately, an abnormal shadow that looked like a foreign body was not detected. The gas distribution in the rectum and left colon on both upright and supine positions was strangely almost equal (Figures and ). On initial CT images for detecting the exact location of the foreign body and adverse abdominal events, perforation and intra-abdominal bleeding were not detected. Moreover, the foreign body itself and its exact location were not depicted contrary to our expectations (). An endoscopy showed a yellowish mass with a sharply demarcated margin 7 cm from the anal ring, perhaps the lower edge of the foreign body. A physician promptly tried to retrieve it using alligator forceps, but the foreign body was fixed, brittle, easily crushed, and the strategy was not successful. Precise reevaluation of CT images taken with the air attenuation display setting revealed abnormal reticular strands from the distal transverse colon to the rectum, probably corresponding to the foreign body created by PUF (Figures and ). We decided that it was impossible and dangerous to retrieve it per anus because it occupied a long segment on the left side of the transverse colon; therefore, operative removal was selected. The foreign body was removed through the incision in the sigmoid colon. The foreign body was composed of PUF and corresponded to the gas trapped on the left side of the colon on the plain radiograph (). However, the PUF was brittle material and was easily crushed into many pieces by colonic peristalsis. Unexpectedly, it was distributed to the proximal portion of the colon, and we needed 4 other operations to remove the PUF completely. |
A 53 year old Caucasian female with a past medical history of right eye choroidal melanoma presented with a one year history of erythema and induration of the skin at the junction of the inferior aspect of the right nipple profile and surrounding areolar skin (Fig. ). The patient had subsequently been treated with the application of topical steroids and topical antibiotics to the right nipple profile and surrounding areolar skin for the duration of approximately 5 months, and showed no clinical improvement. No palpable intraparenchymal breast masses were detected on clinical breast examination within either breast. A bilateral digital mammogram performed approximately seven months before presentation was within normal limits. Dermatoscopic findings revealed increased red serpiginous and annular structures most prominent at the 6 o’clock position of the right nipple profile (Fig. ).\nAn initial 3 mm punch biopsy of the skin at the junction of the inferior aspect of the right nipple profile and surrounding areolar skin was obtained by a dermatologist and histopathologic evaluation was reported to show subareolar sclerosing duct hyperplasia without abnormalities of the skin. Subsequently, one month later, a larger 6 mm punch biopsy was performed by a breast surgical oncologist to the same region of the right breast and histopathologic evaluation was reported to show adenosis and associated usual type ductal hyperplasia, consistent with subareolar duct papillomatosis. No atypia or malignancy was identified within either of the two sequential skin punch biopsy specimens. Repeat diagnostic digital mammography was performed on the patient during her evaluation by the breast surgical oncologist, and showed stable, benign-appearing right breast calcifications, and no suspicious mammographic findings within the right subareolar region or elsewhere within the right breast.\nThe patient was subsequently taken to the operating room (Fig. ), and elected to undergo a right central breast resection, consisting of surgical excision of the right nipple profile, adjacent surrounding areolar skin, and superficial underlying breast and subcutaneous tissues (Fig. -). The patient elected to simply have primary skin closure of her right breast surgical incision site, and without any attempt at cosmetic reconstruction of a right “neo-nipple” (Fig. ).\nHistopathologic evaluation by a breast-specific pathologist of hematoxylin and eosin stained sections from the right central breast resection specimen revealed a well-circumscribed, compact proliferation of tubular glands within the nipple stroma and nipple skin dermis (Fig. ). The lesion appeared centered in the reticular dermis, with focal extension into the papillary dermis. The overlying epidermis showed acanthosis, but was not directly involved by the lesion itself. Epidermal ulceration was not identified. At medium power, an adenosis pattern with proliferation of benign tubular glands was seen (Fig. ). At high power, several glands showed usual type ductal hyperplasia and apocrine metaplasia (Fig. and ). A medium power hematoxylin and eosin stained section (Fig. ) and the corresponding immunohistochemical stained sections (Fig. , and ) are shown collectively in Fig. . Immunohistochemical stains for p63 (antibody BC4A4, BioCare Medical Inc., Concord, CA; Dilution 1:300 HIER, Bond Epitope Retrieval solution 1, Bond Autostainer) and smooth muscle myosin heavy chain (antibody SMMS-1, Dako, Carpinteria, CA; Dilution 1:350 HIER, Bond Epitope Retrieval solution 1, Bond Autostainer) confirmed the presence of myoepithelial cells surrounding the glands (Fig. and ). CK5 (antibody XM26, Novocastra, Buffalo Grove, IL; Dilution 1:150 HIER, Bond Epitope Retrieval solution 2, Bond Autostainer) showed a mosaic pattern of reactivity in foci of usual type ductal hyperplasia (Fig. ). Therefore, a final pathologic diagnosis of NA was given. There was no histologic evidence of atypia or malignancy identified within the submitted specimen at the time of histopathologic evaluation.\nThe patient has continued regularly scheduled follow-up with her dermatologist and her surgical oncologist. At the current time, some 31 months after her definitive surgical therapy to her right breast, the patient remains without any evidence of any recurrent process within her right breast. |
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