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A 33-year-old female patient reported to the department of oral medicine and radiology with a chief complain of multiple ulceration in the oral cavity for 1 month. On asking she gave history of similar kind of ulcerations 3 years back but did not take any treatment during that period and that healed by itself. Past medical history was not contributory. On general examinations, all the vital signs were within normal limits. On extraoral examination, face was bilaterally symmetrical with no TMJ disorder. On intraoral examination there were diffuse ulcerations seen on the right and left buccal mucosa [], [] and on the ventral surface of the tongue [] on the left side. Size of each ulcer was around 1 * 2 cm approximately, shape roughly linear, surface covered by yellowish slough surrounded by erythematous halo. Margins well defined. Blisters were seen on the right and left corners of the lower lip []. Other intra oral findings included missing with 36, stain and calculus present. Routine laboratory investigation included complete hemogram with SGOT and SGPT were advised. Treatment advised were tablet Livozit 70 mg at a dose of twice daily for 7 days, local application of hexigel three times daily for 7 days and local application of Tess buccal paste four times daily for 3 days followed by three times daily for 2 days, and then two times daily for the next 2 days. Patient was recalled after 1 week. After 1 week, patient reported with the blood investigation reports wherein all the values were within normal limits. Patient got complete relief pain and ulcerations. On examination it was observed that there were no ulcers seen on the right and left buccal mucosa [Figure and ], and on ventral surface of tongue []. There were also no blisters observed on the lower lip []. Patient was advised to take tablet livozit 70 mg at a dose of two times daily for 7 days. Patient recalled after 7 days. Patient came for second recall visit after 7 days and patient got 100% relief. There were no evidence of any ulcer on the buccal mucosa [Figure and ], and on the ventral surface of tongue [] and no blister were visible on the lower lip [].
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.
M., a 43-year-old male, arrived at a private psychotherapist requesting help to improve his parenting capacities with his 5 years old daughter. His main goal was to demonstrate that he was a good father and to obtain the daughter's custody having a chronically unresolved conflict with the child's mother. M. lived with the mother of his daughter for one year and because of their high conflict they decided to not marry. He recounts that he didn't want children but that after his daughter's birth he became very involved in her caretaking. M. reported that the child's mother didn't want him to care their daughter and he was deeply convinced that the child's mother only wanted money from him. He described his daughter as difficult to manage and having severe behavioral and emotional problems such as concentration difficulties, impulsivity and nervousness. M. appeared highly distressed by the quality of his relationship with his daughter, but responsibility for all his daughter's difficulties were attributed exclusively to her mother or to specific intrinsic characteristics of the child. He showed low empathy and awareness of his child's needs and low reflective capacity regarding his own internal processes.\nWhen M. started treatment, the situation was characterized by high levels of parental conflict for child custody as he and the child's mother each had an attorney and the level of antagonism and aggressiveness between the parents was increasing. The request to improve his parenting capacities seemed to be moved mainly by the conflict with the child's mother. M. seemed more motivated by the desire for revenge against the mother than to find new ways to connect with his daughter. The COS-P program was offered within the context of individual therapy with the aim of helping him shift his focus from parental conflict and management of the child's behavior to the improvement of the quality of his caregiving relationship with his child. Supporting his parenting capacities and self-reflection would help him recognize and respond more directly to his child's needs.
A 3.3 kg full term African American female infant was delivered at a community hospital by cesarean section secondary to fetal bradycardia and suspected macrosomia to 37 years old G8P5 mother. The pregnancy was complicated by gestational diabetes mellitus and pregnancy-induced hypertension. Apgars were 8 and 9 at 1 and 5 minutes respectively. No neck mass was reported on prenatal ultrasound. The lack of maternal fetal medicine specialists at the community hospital might explain the quality of prenatal ultrasound. In the well baby nursery at the community hospital a right neck mass was noted. Due to history of spitting on regular infant formula, soy-based formula was started, but without improvement. She was transferred to the Regional Neonatal Center for further evaluation and management of the neck mass.\nThe baby was on room air for 1 week when she developed stridor. The neck mass had increased in size and a Pediatric ENT consult was obtained. An MRI demonstrated "a cystic lesion in the nasopharynx and right neck which inferiorly followed the course of the right carotid artery probably consistent with cystic hygroma" [fig. ]. The mass continued to increase in size so a follow-up MRI and MRA were done. MRI showed increase in size of right posterior retropharyngeal to right neck cystic mass measuring 4.1 cm and displacing the trachea and oropharynx to the left and the right carotid artery posteriorly and laterally [fig. ]. MRA showed the right common carotid artery displaced posteriorly and laterally without definite hemodynamic stenosis. But it is possible that neurovascular and respiratory structures of the neck were compressed during labor to cause fetal bradycardia. Carotid duplex ultrasound was recommended, which was severely limited due to displacement of vessels, presence of the mass and small size of the neck. To reduce fluid build up in the neck mass, the patient was started on 0.1 mg/kg of dexamethasone every 6 hours after the first MRI. She was later intubated for stridor and concern of potential airway obstruction. A team of pediatric otolaryngologists and pediatric surgeons was assembled to address the mass. The otolaryngologist decided to approach the mass via a cervical incision. Imaging studies demonstrated that the mass extended inferiorly to the aortic arch and a sternostomy had been planned. Intraoperatively the mass was found to be limited to the neck, so a sternostomy was not necessary. A hemithyroidectomy was required when the cystic hygroma was found to be inseparable from the right half of the thyroid. Dexamethasone was tapered over 2 weeks. She was observed for 24 hrs after the steroid taper. Endocrinology was consulted after the hemithyroidectomy. Initial thyroid function tests were normal except for mildly elevated T4 [13.9 μg/dL]. PTH was also normal [50.8 pg/L]. Genetics was consulted and chromosomal analysis showed 46 XX. The patient was noticed postoperatively to have a weakness of the right lower lip, consistent with neuropraxia involving the marginal mandibular branch of the facial nerve. This deficit is expected to correct with time.
Clinical findings: A 24-year-old lady presented with gradually enlarging painful mass in the inner aspect of the upper thigh for the last 3 months, the patient noticed the mass accidentally during bathing. The mas was painless at the beginning but became painful with attacks of low grade fever mainly at the night. The patient had non-relevant past medical and past surgical histories.\nDuring examination, the patient has normal general examination and examination of the mass showed a tender mass about 810 cm in the medial aspect of the right upper thigh with multiple enlarged ipsilateral inguinal lymph nodes.\nThe family history was negative for chronic illnesses. There was no history of chronic drug administration and the psychosocial history was negative.\nDiagnostic assessment: The white blood cells were elevated with raised inflammatory markers. MRI of the thigh showed a mixed signal intensity lesion located in the medial aspect of the right upper thigh and measured about 65100 mm, the mass was related to the muscle compartment and appeared to be associated with the superficial femoral artery, there was no any associated bone abnormality and the lesion had multiple internal septations giving the possibility of either necrotic mass, cold abscess, or tumor. , .\nTherapeutic Intervention: During exploration the lesion appeared to be an infected hydatid cyst of the muscle compartments of the medial aspect of the thigh, evacuation of the cavity was done with removal of the hydatid cyst, the cavity of the cyst was washed with chlorhexidine, low pressure suction drain was put in the cavity which was removed after 3 days. .\nThe operation was done by 3 specialist surgeons who were specialized in the field of the vascular and general surgery.\nThe patient then was reevaluated to exclude hydatid cysts in other parts of the body by chest X-ray and abdominal ultrasound which showed no evidence of cysts in the chest and the abdomen.\nThe patient was discharged on the next day and she received anthelminthic medications for 3 months.
Our patient is a 15-year-old girl born in Sweden after 40 weeks gestation as the third of four siblings from Assyrian consanguineous parents originating from Iraq. Contact with the national health system was sparse until the age of 5 years, when she presented with sensorineural hearing impairment and developmental delay. After application of bilateral hearing aids her development accelerated in all domains. In retrospect her parents reported frequent loss of balance as a toddler. Our patient was referred from her school physician to a child neurologist at the age of 7 years and 8 months due to her toe-walking gait. Except for her Achilles tendons being tight, almost spastic, no other neurological abnormality was noted. Brain imaging at the age of 8 years showed a central lesion in the mesencephalon, from the nucleus ruber dorsocaudally down to the cerebellar peduncles. A magnetic resonance imaging (MRI) scan of her spine was normal. After physiotherapy and orthoses her gait improved, but her motor skills were still abnormal for her age. At the age of 12 years she showed bilateral muscle weakness on her peroneal muscles with absence of peripheral reflexes. Neurography and electromyography showed sensorimotor polyneuropathy and chronic neurogenic changes in her leg muscles. An MRI scan of the brain was repeated showing the same lesion as described at the age of 8 years (Fig. ). At the age of 13 she presented cognitive delay, impaired gross and fine motor skills, and tremor. At this point, a neurometabolic disease was considered. At the age of 14 she presented learning difficulties and obvious generalized muscle weakness. Her fingers are extremely flexible, her feet are in plan valgus position and she has problems with her balance. At the age of 15 she shows no signs of puberty. Growth is also delayed with a skeletal age of 10.7 at chronological age of 14. Hormonal tests have shown nonfunctioning ovaries. She has no retinal changes and normal optic nerves. One of the younger sisters presents some learning difficulties.\nBlood metabolites were analyzed twice when our patient was 13 years (Table ). Her plasma levels of C26:0 were moderately increased resulting in an increased C26:0/C22:0 ratio. The C24:0/C22:0 ratio was borderline normal. Her phytanic and pristanic acid levels were significantly increased at both sampling occasions. Her erythrocyte plasmalogen levels were normal. Because of the abnormal VLCFA and phytanic and pristanic acid levels further peroxisomal studies in fibroblasts were performed. Remarkably, her VLCFAs and DHAPAT activity in cultured fibroblasts were normal (Table ).\nImmunofluorescence microscopy analysis using antibodies raised against catalase, a peroxisomal matrix protein, did show abnormal peroxisomal staining but not in all cells. When cultured at 37 °C most cells revealed a normal peroxisomal staining, but in some cells a markedly reduced number of peroxisomes was observed. Culturing patient fibroblasts at 40 °C for 2 weeks resulted in a complete absence of peroxisomal staining with catalase immunofluorescence microscopy analysis, indicating the lack of import-competent peroxisomes at this elevated temperature (Fig. ). These results showed that our patient suffered from a Zellweger spectrum defect.\nMutation analysis was performed by using a custom-made next generation sequencing (NGS) gene panel (SureSelectQXT, Agilent Technologies, Santa Clara, CA, USA). The panel targets coding exons of 21 genes described to be involved in peroxisomal disorders including the 13 PEX genes (+/- 25 bases, according to RefSeq database and assembly Feb. 2009 (GRCh37/hg19)). Variants of interest were filtered according to allele frequency, exonic/splice site location and autosomal recessive or X-linked pattern of inheritance. NGS analysis identified only one variant of potential clinical significance, namely a homozygous mutation (c.530 T > G (p.Leu177Arg) (NM_153818.1)) in the PEX10 gene. This variant is not present in HGMD® Professional database (Biobase, Qiagen®, Redwood City, CA, USA) or ClinVar [], but has a very low allele frequency in the normal population according to 1000 genome database [], is classified as probably damaging by PolyPhen and deleterious by SIFT and affects a highly conserved amino acid. The result was verified by Sanger sequencing and targeted sequencing on the parents showed the expected segregation pattern (Fig. ). To confirm the PEX10 defect in the patient we performed complementation studies at 40 °C by co-transfection of wild-type PEX10 and PTS1 (peroxisome targeting sequence 1)-tagged green fluorescent protein (eGFP-SKL) in the patient’s fibroblasts. Three days after transfection there was restoration of PTS-1 protein import, confirming that PEX10 is responsible for the peroxisomal dysfunction in our patient (data not shown).
A 36-year-old woman was admitted to our surgical department with abdominal pain associated with episodes of nausea and vomiting over the last couple of months. She denied any history of fever, while she reported a weight loss of around 6 kilos over the same period. She also mentioned that she had undergone a cesarean section in a private clinic 6 months ago. There were no significant findings from the clinical examination of the abdomen. Before having been reviewed by our team, the patient consulted two different general practitioners. The first one set the diagnosis of viral gastroenteritis, while the second advised her to have a computed tomography (CT) scan of her abdomen. The scan was carried out on outpatient basis and revealed a longitudinal, high-density mass inside the intestinal lumen (Figures and ), which was reported as a “calcified parasite.”\nSubsequently, the patient was transferred to our unit. As an inpatient, she had further imaging studies: an abdominal sonography that was normal and a plain abdominal radiograph which revealed a high-density mass in the left iliac fossa mimicking a retained radiopaque body ().\nBlood tests were within normal values. The case was discussed with the patient and her family and a decision was made for the patient to have an explorative laparotomy. Intraoperative findings included dilatation of the small intestine, secondary to obstruction, material in the lumen of an ileal loop, and an ileosigmoid fistula. A small bowel resection en bloc with the affected part of the sigmoid () and a loop sigmoidostomy were carried out. The small intestine was dissected and a 20 × 25 cm sponge was found in its lumen (Figures and ). The histological findings are consistent with acute and chronic inflammation and fibrosis of pericolic fat. Liponecrosis is also confirmed, with the presence of histiocytes and multinucleated giant cell producing foreign material phagocytosis.\nThe patient had an uneventful recovery and was subsequently discharged on the eighth postoperative day. Two months later the patient had a successful restoration of the bowel continuity following a minimally invasive closure of the loop sigmoidostomy.
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 50-year-old female presented to the emergency department with sudden onset pain and numbness in both lower limbs for 2 hours with no obvious predisposing cause, after which her lower limbs suffered continuous pain and numbness, especially on the left side. In the emergency department the doctor in charge diagnosed the patient as cerebral infarction. A further inquiry about the patient's medical history found the patient had a history of rheumatic heart disease for 10 years, and she was diagnosed with paroxysmal atrial fibrillation 10 days ago. Unfortunately, suggested treatment was refused by the patient. The patient was conscious and a physical examination revealed that she was well nourished with normal vital signs. Her heart rate was 100 per minute with arrhythmia. Her skin felt cool on both lower limbs, and there was no palpable pulse on the dorsalis pedis artery. Sensation was diminished but her tendon reflexes were normal in all extremities, and the muscle strength was classified V. The emergency computed tomography (CT) scan demonstrated thrombosis in the lower part of the abdominal aorta, bilateral iliac artery and left femoral artery. The artery was stenosed with incomplete or complete obstruction (Fig. ).\nWe diagnosed the patient with abdominal aortic saddle embolism type II. Endovascular treatment was planned and the plan was approved by her family members and signed informed consent. The patient was transferred to the interventional radiology department for emergency surgery. Left femoral artery puncture catheterization was performed and a 0.35 inch guidewire was passed into the stenosed part of the abdominal aorta. Digital subtraction angiography (DSA) was performed by a pigtail catheter (Fig. A). Then, thrombus aspiration was performed by a 8F guiding catheter. Since the thrombus could not be completely aspirated, the patient was given thrombolytic therapy with urokinase 40,000 units per hour, which was continuously injected by a micro pump through a thrombolysis catheter in the aorta. After 12 hours, the DSA showed no significant improvement in the stenosed aorta (Fig. B), so we continued the thrombolytic therapy. After 36 hours, we repeated the DSA and found that the major part of the thrombus had resolved (Fig. C). However, the left wall of the abdominal aorta and left common iliac artery proximal ends had mural thrombus which we assumed was stale thrombus. So we performed balloon dilatation in the left common iliac artery to expand the lumen. The stenosis in the left common iliac artery decreased after the operation.\nSince the residual thrombus was in the left common iliac artery, it was difficult to aspirate from the right femoral artery catheter. So we planned a thrombus aspiration through the left femoral artery and found that the thrombus had flowed into the right femoral artery. While performing DSA in the catheter, we ensured that the pedicle of the thrombus was in the left wall of the abdominal aorta (Fig. D). Thrombus aspiration was performed by an 8F guiding catheter through the left femoral artery, and the head of the guiding catheter was positioned at the pedicle of the thrombus. We aspirated a large volume of white thrombus and mixed thrombus (Fig. ). After the operation, DSA showed no thrombus in the abdominal aorta and the common iliac artery (Fig. E), but the lower extremities DSA showed that the left peroneal artery was occluded (Fig. F). We suspected that the thrombus was shedding from the upper artery and stopped thrombolysis therapy to decrease the risk of bleeding. The collateral circulation had already formed. The skin temperature of the left extremity recovered and the pain disappeared after 1 day. CTA examination showed no stenosis or thrombus in the abdominal aorta and iliac artery after 1 month (Fig. ).
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 78-year-old male was brought to our department with the complaint of painful, progressive, and nonhealing ulcerated lesion of the tongue for 2 months. He did not give any history of fever, night sweats, cough, decreased appetite, or significant weight loss. There was no history of change in voice or choking. He did not give history of traumatic episode preceding the development of that wound. He denied any history of similar lesions in the past. He was a known case of hypertension taking antihypertensive medications. Besides having hypertension he denied history of other systemic illnesses including pulmonary tuberculosis. He admitted to smoking and drinking alcohol occasionally. The rest of his medical and surgical history was unremarkable. His past dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a local hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics but the lesion did not subside so he was referred to our hospital for the further management.\nOn general examination he was thin built with general conditions being fair, while, on examination of oral cavity, there was an indurated ulcer measuring 1.0 cm × 0.5 cm on the left lateral border of tongue on the anterior two-third part of tongue (). It was tender with irregular border. It did not bleed on touch. The remaining part of the tongue was normal in texture and color. Mobility of tongue was normal. It was not deviated to either side on protrusion. He had poor orodental hygiene along with sharp tooth adjacent to the ulcerated lesion although the multiple teeth were absent. There were no palpable cervical lymph nodes and no similar ulcers in any other body parts.\nProvisional diagnosis of traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth could not be ruled out based on the physical examination alone. As we thought it could be due to chronic trauma by the sharp looking teeth although he was unaware of any traumatic episode. Dental consultation was done as the patient had poor oral hygiene along with loss of multiple teeth and the remaining teeth having sharp edges. Dentist did the coronoplasty of adjacent sharp cusp, and since the ulcer presented for more than two months they took incisional biopsy containing ulcerated lesion along with the normal looking margin being taken under local anesthesia and the specimen was sent for histopathological examination (HPE). The patient was also given oral antiseptic gel for local application and given an appointment for oral prophylaxis. Patient then presented to Department of Otorhinolaryngology with the HPE report. Microscopically the lesion revealed the stratified squamous epithelium with granulomatous inflammation containing Langhans type giant cells, epithelioid cells, and foci of caseous necrosis, strongly suggestive of tuberculosis ().\nChest X-ray did not reveal any evidence of active or old Koch's infection. Sputum for acid fast bacillus (AFB) of three early morning samples was negative on Ziehl Neelsen stain. Complete blood count was within normal limit. His erythrocyte sedimentation rate (ESR) value was 20 mm/hr. Serum biochemistry and renal function tests were within normal limits. Serological investigation for human immune deficiency virus (HIV) was negative. Mantoux test was not performed as the histopathological findings were strongly suggestive of tuberculosis. An enquiry was made in the family whether they had any symptoms of pulmonary tuberculosis or any other chronic illnesses. No one in the family had any form of TB in the past. They denied symptoms such as chronic cough, night sweats, loss of appetite, or significant weight loss. They were all vaccinated with BCG as per the expanded programme on immunization (EPI) schedule of Nepal. In the absence of any symptoms no further investigations were ordered for them. Mantoux test was not done as well. Because every child gets BCG vaccination at birth in our country, that can yield positive Mantoux result because of the vaccination. As the sputum for AFB was negative in the patient the chance of spread is minimum to others.\nThe patient was referred to directly observed treatment, short course (DOTS) clinic after having histopathological diagnosis of TB. He was then started on antitubercular therapy (ATT). The ulcer gradually started fading once drug therapy was started (ATT). The patient felt symptomatically better after the start of ATT; and the tuberculous ulcer healed completely by the 2 months of ATT containing Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol (). The patient was then advised to continue ATT containing Isoniazid and Rifampicin for another 4 months. At the end of total 6 month's ATT course there was no evidence of residual ulcer at the primary site. We emphasized oral hygiene maintenance and advised the patient to follow up at dental outpatient department. As the patient came from a remote place in the hilly region of central Nepal, he did not seek any dental consultation as he was told that he had TB.
A 58-year-old woman presented in the ER of the urology clinic complaining of intermittent gross hematuria during the last four days and a mild flank pain during the last hour. The patient also mentioned that the hematuria was deteriorating only during defecating. Arterial hypertension was her only concomitant medical condition. The first sample of urine that we obtained was macroscopically normal with positive dipstick for blood in the urine. Her blood pressure in the ER room was 130/80 mmHg and the heart rate 75/min. The first blood examination showed a 38% hematocrit with 12 hemoglobin and normal urea and creatinine. The ultrasound of the kidneys and the bladder showed a solid formation in the upper pole of the right kidney with peripheral blood flow, while in the bladder, solid mobile formations were present as in blood clots. The second sample of urine that we obtained had macroscopically intense hematuria, and we inserted a three-way catheter performing at first manual washouts with normal saline of the bladder clearing the blood clots and adjusting an irrigating normal saline finally. While waiting for the computed tomography to be performed, the patient had clear urine without blood, and we stopped the irrigation fluid in order to examine if the urine remained cleared without the washouts. The urine remained clear, but after a cough episode, instantly the urine became intense bloody and the patient became hemodynamically unstable, while the blood pressure reduced steadily from 130/80 to 60/50 mmHg, the heart rate increased from 75/min to 140/min, and the pulse was detectable only in a central artery. The hematocrit reduced also steadily from 38% to 33% and till 18%. The patient was driven urgently in the operation room, and since a definite diagnosis was not made, both a surgeon urologist and a vascular surgeon participated in the operation. An exploratory laparotomy was performed with a midline incision in the search of a possible aortic aneurysm. Finally, a large ruptured intraparechymal aneurysm of the right renal artery was detected and a radical nephrectomy was performed (Figures , , and ). The first two postoperative days the patient was admitted to the intensive unit of our hospital and then to the urology clinic from which she was discharged 8 days later.
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.
An 83-year-old man with redness and edema in the left lower limb presented to our Dermatology Department and was diagnosed with cellulitis. Antibiotic administration failed to show any improvement, and the patient was referred to the Department of Vascular Surgery. His past medical history included psoriasis, ringworm in the extremities, thrombocytosis, and heart failure. Physical examination revealed obvious swelling of the left limb with local heat and pigmentation on the ankle. The patient did not have high body temperature or elevated inflammatory response. Color-flow Doppler ultrasonography revealed arterialized waveforms in dilated superficial veins, with increased PSV and high-velocity turbulent flow, especially in the pigmented area (). CT showed early contrast filling in the dilated superficial veins during the arterial phase, with no nidus in either limb ( and ). The left limb showed greater contrast filling of the veins in the arterial phase. No deep venous thrombosis or evidence of varices was observed. The refractory edema in the left limb was diagnosed as stasis dermatitis secondary to multiple AVFs. Compression therapy using elastic stockings did not reduce the symptoms. Erosive lesions and a large amount of effusion were present on the patients’ left lower limb (). We planned ligation of the incompetent perforator veins that were draining the arterial blood flow via the AVFs and increasing the superficial venous pressure, causing the edema. We first determined the locations of all perforators in the left limb using CT and then examined the function of the perforator valves using ultrasonography. Thirteen incompetent perforator veins associated with 10–15 mm wounds were ligated under local anesthesia. The patient’s symptoms improved postoperatively (). His right limb showed the same symptoms as his left limb. Examination revealed the same disease course, and ligation of eight perforator veins led to improvement in his condition. Seven months following this, follow-up CT revealed lesser contrast effects and a reduced size of the superficial veins. Echocardiography showed no right heart overload, and chronic heart failure was not exacerbated. No recurrence was observed during 15 months of follow-up.
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 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.
Kathy (this is a representative composite case that does not reflect any single patient) was a 67-year-old woman who suffered an out-of-hospital cardiac arrest. She received 5 min of cardiopulmonary resuscitation and defibrillation by emergency medical services at the scene before the return of spontaneous circulation. In the hospital, she was diagnosed with an ST-elevation myocardial infarction and underwent thrombolysis, followed by 24 hours of induced therapeutic hypothermia, a treatment intended to reduce the risk of brain injury after cardiac arrest. Unfortunately, Kathy sustained severe anoxic brain injury and remained comatose after restoration of normal body temperature.\nAdditional tests were done to help determine her neurological prognosis. These tests showed mixed results. On the one hand, an MRI scan showed no structural abnormality, and somatosensory evoked potentials were bilaterally present with normal latency and amplitude. While the bilateral absence of the N20 somatosensory evoked potentials response indicates a poor prognosis, its presence does not predict neurological outcome. On the other hand, Kathy displayed persistent seizure activity on her electroencephalogram, which is associated with increased mortality following cardiac arrest.\nThe neurocritical care team met with Kathy’s husband and son and explained that they were uncertain about her likely outcome and needed more time and information to develop a clearer picture of Kathy’s prognosis. The care team was aware of an ongoing research study at the hospital involving functional MRI for which Kathy was eligible. The study involved recording brain responses to stimuli and comparing patient responses with eventual outcome to determine if functional MRI could be a useful prognostic test for future patients. Functional MRI shows promise as a candidate prognostication method in patients with acute brain injury.\nThere are ethical issues associated with enrolling patients like Kathy in functional MRI studies in the intensive care unit. In particular, given that Kathy herself cannot provide informed consent, how should patient autonomy be protected and consent be obtained? Are there potential obstacles to proxy decision making in this context? Our ethical analysis stems from reflection on a research study that is currently under way at the Lawson Health Research Institute. Written informed consent was obtained from proxy decision makers in all cases. In this article, we identify four ethical issues associated with obtaining informed consent in Kathy’s case. After describing each issue, we propose potential solutions which would make Kathy’s participation in the functional MRI study compatible with her rights and interests.
A 56-year-old man with no background medical history or past ophthalmic history was referred by his general practitioner for a left nasal pterygium. The lesion had been causing ocular irritation and had initially been reviewed by an ophthalmologist 10 years earlier. Since that time, the patient reported that the lesion had slowly grown and his irritation had worsened. On examination, best-corrected visual acuity was 20/20 bilaterally and anterior and posterior segment examinations were unremarkable apart from a left conjunctival lesion. This pearly white lesion was situated on the nasal limbus of the left eye and was circular in shape with a 4 mm diameter. It was easily mobilized and appeared to be free of any deeper scleral invasion. Overall, the lesion had an appearance in keeping with an ocular surface squamous neoplasm and wide local excision of the lesion, and reconstruction with a superior autoconjunctival graft was recommended with adjunctive mitomycin C. This uncomplicated procedure was undertaken 3 weeks later.\nHistopathology of the operative specimen reported a possible low-grade mucoepidermoid carcinoma, and the specimen was referred to an ophthalmic pathologist who confirmed the diagnosis of low-grade conjunctival mucoepidermoid carcinoma 2 weeks later. Initial hematoxylin and eosin stains were followed by periodic acid-Schiff diastase stains, which confirmed the mucinous components of the lesion ( and ). The specimen showed conjunctival and limbal tissue that was infiltrated with carcinoma at the limbus. It was composed of islands of well differentiated epithelial cells showing both squamous and glandular differentiation with the glandular lumina containing inspissated mucoid material (). No immunohistochemical testing could be conducted on the specimen. A course of 0.04% mitomycin C was prescribed four times a day for 1 week, followed by only ocular lubricants for 1 week, followed then by another week of mitomycin C four times a day.\nOn review 2 months after excision, there was no sign of ocular recurrence, and the patient had no ocular symptoms and was systemically well apart from some anxiety related to the possibility of distant spread of the tumor. A subsequent computed tomography scan of the head, neck, chest, abdomen, and pelvis ruled out any signs of regional or distant metastasis. On review 10 months after excision, the patient reported no ocular irritation or other ocular symptoms, had no signs of recurrence of the lesion or lymphadenopathy, and was otherwise systemically well.
A 29-year old female diagnosed with SLE for 4 years complicated with grade II lupus nephritis presented with status epilepticus. She denied a history of fever on admission, but was treated with cyclophosphamide 1 month prior for an episode of cerebral lupus. She had noticed a papule over the left deltoid region which progressed to an ulcer over 1 week. Fever was noted following several days of hospital admission and the ulcer site became painful. She had worked in paddy fields several months prior to the admission when she was in good health. However, she could not recall any precipitating injury at the affected site during working. She is a mother of two and both pregnancies were uncomplicated. She denied history of alcohol abuse or smoking.\nOn examination she was emaciated and had a GCS score of 15/15 following recovery of status epilepticus. There was no obvious lymphadenopathy. At presentation, the size of the ulcer was about a 3 cm lesion and it gradually developed in to an ulcer with a necrotic center with surrounding erythema. A tentative diagnosis of pyoderma gangrenosum was made with the appearance of the ulcer (Figure ). It gradually advanced into the underlying muscle over 3 weeks of onset despite the antibiotic treatment. Examination of the cardiovascular, respiratory systems, and the abdomen was normal.\nHer full blood count, blood picture, and other supportive investigations showed evidence of microangiopathic hemolytic anaemia, which was suggestive of thrombotic thrombocytopenic purpura which resolved following plasmapheresis. Her ESR was persistently normal. Renal functions were stable during hospital stay, so were the liver profile. Chest radiography revealed evidence of bilateral mild pleural effusions and echocardiography revealed a thin rim of pericardial effusion and good cardiac function. MRI, MRA brain showed evidence of Posterior Reversible Encephalopathy Syndrome. Repeat imaging showed resolved changes.\nA punch biopsy of the skin was done from the lesion and sent for fungal studies and histopathological studies. The direct microscopy examination revealed wide and irregular ribbon-like nonseptate hyphae with right-angle branching suggestive for Mucormycete fungi. Culture was done on Sabouraud dextrose agar with chloramphenicol (at 26°C and 37°C) yielded a white aerial mold, which covered the entire surface of the agar and came up to the lid of the culture bottles after 4 days of incubation (Figure ).\nThe lactophenol cotton blue mount of the growth revealed broad, nonseptate hyaline sterile hyphae. The slide culture test has been attempted with the hope of sporulation, however it was not successful. They only resulted in broad, nonseptate hyaline sterile hyphae without spores. Then the isolate was subcultured on to potato dextrose agar (PDA) and Rose Bengal (RB) agar for induction of sporulation. However, they yielded only sterile mycelia.\nThe isolate was inoculated on nutritionally deficient medium, tap water agar and incubated for 14 days at 37°C. It provided a hazy view of flask shaped sporangium with rhizoids in lactophenol cotton blue mount. Then floating agar method was used and it yielded characteristic flask-shaped sporangium in short sporangeophore with rhizoids after 10 days of incubation (Figure ).The sporangia had a long neck and the apex of the neck closed with a mucilaginous plug. The sporangiospores were cylindrical, with rounded ends. Those morphological features were suggestive for S. vasiformis and the isolate was identified as S. vasiformis.\nThe histopathology of the punch biopsy of the skin also reveled broad aseptate hyphae suggestive of Mucormycetes group of fungi.\nBased on the histopathological evidence of broad aseptate hyphae, suggestive of Mucormycete fungi, the patient was started on IV amphotericin B deoxycholate. Repeated surgical debridement was done and samples were sent for fungal studies. However, local application of antifungals was not included in the management. Her second tissue biopsy, which was taken during debridement after 5 days of IV amphotericin B also had similar direct microscopy findings and yielded S. vasiformis. However third tissue sample which was obtained after 10 days after IV amphotericine B deoxycholate became negative for fungal studies. Following the confirmation of sterile cultures from the subcutaneous biopsies, superficial skin grafting was done which was completely accepted from the wound site. She was treated with intravenous conventional amphotericin B for 28 days and she was asymptomatic when she was discharged from the ward.
A 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 54-year-old female patient presented with a complaint of pain in the right lower back tooth region since 6–9 months. Pain was continuous, dull aching type localized to the right lower jaw region. It increased on chewing food, talking and decreased slightly on taking medication. She gave a history of pain 4 years ago which was sharp, intermittent, and localized in the same region. It increased on chewing food and reduced on massaging the area on the right side of the lower jaw and gradually with time. Hence, she underwent extraction of all the posterior teeth on the right side of the jaw which gave her no relief from the pain. Visiting another dentist, with the same complaints, she was diagnosed with trigeminal neuralgia and medications were prescribed. Even after one year of medication, she did not find relief from the pain. That is when visiting another dentist was decided around 3 years ago. The mental nerve block resulted in pain reduction; hence, she was advised to undergo mental nerve avulsion, which she underwent under local anesthesia.\nAfter the surgery, there was complete reduction in pain, but after 2 months of the procedure, she developed dull aching, burning type of pain in the same region. Hence, she visited our institution with the complaint of pain in the right mandibular premolar region. The patient had no contributing medical or dental history. On general physical examination, no abnormalities were detected and all the vital signs were within normal limits. The TMJ evaluation revealed no abnormalities. On extraoral palpation, paresthesia was detected in the lower lip on the right side and a part of the chin and the lower part of the cheek on the right side. On intraoral examination, a fibrosed scar was seen in the region of the right mandibular premolar on the alveolar mucosa about 2-3 mm above the buccal vestibule, measuring about 0.5 cm in diameter. The scar was firm and tender on palpation; it could be pinched off from the underlying bone (). The general periodontal status of the patient was poor along with generalized enamel hypoplasia secondary to enamel fluorosis.\nTaking into consideration the complaint and the presenting symptoms, arriving at a diagnosis was a challenge, as the features were atypical of trigeminal neuralgic pain and no lesion was evident except for the scar which was caused due to the previous surgical intervention. Therefore, provisionally, it was diagnosed as neuropathic pain on the right mental region of the jaw. Traumatic neuroma and infected and retained root stumps in the right premolar region were considered in differential diagnosis, taking into consideration the previous surgical intervention in terms of mental nerve avulsion and extraction of the teeth. As in both cases, the patient may present with continuous type of pain localized to the area of origin. To assess the condition of the mandibular canal and the premolar region of the jaw radiologic examination was essential. Interestingly, on intraoral periapical radiograph, a radiopaque material was detected in the right premolar region well within the substance of the mandible, in the region of the mental foramen on the right side (). The same was confirmed on the OPG which revealed the foreign material and the outline of the mental foramen which was not clearly made out on the right side (). The importance of radiologic evaluation is quite evident in helping us to arrive at a final diagnosis of foreign body neuralgia in the right mental foramen.\nSurgical intervention was planned to explore the right mental foramen under local anesthesia () and the foreign material was retrieved, which consisted of silver points, gutta-percha points and restorative material (). Postsurgical radiograph reveals enlarged mental foramen and complete absence of the radiopaque material (). The surgical site was sutured and the patient was advised to take an analgesic for the day if required and to stop all the other medication. During her first week of the postsurgical recall for suture removal, healing of the surgical site was satisfactory. She was reviewed after three months which revealed completely healed surgical site () and more importantly the patient was free of pain and continues to be on periodic follow up.
A 52 year old lady was referred for admission because of increasing severity in depressive symptoms. She had fleeting suicidal thoughts and expressed a belief that a former co-patient was sitting on her brain interfering with her daily activities. She reported a turbulent life history. She was born and raised in a remote community; her childhood remained uneventful and carefree. She completed high school and then took some courses in a trade school. After completing the courses, she started working as a health care support worker for few years, took a break and then resumed after she got married in 1985. Her spouse was quite abusive and subjected her to domestic violence. She remained extremely unhappy with her marital life. She finally got separated from her husband. She has two sons, ages 25 and 20 who live in a different area. Her younger son met an accident and lost his eye sight but is functional and working. The accident and subsequent events were quite stressful for her. She stopped working in the mid of 2011 as her depression and suicidal ideation became disabling. She did not report any substance abuse, legal issues or allergies but had ‘high cholesterol’ problem. She was admitted three times during the year 2011 before this admission. In terms of family history, her mother had committed suicide and sister suffered from depression. She herself had previous history of suicidal attempt. Her current admission was also precipitated following an overdose. Her depression accompanied by delusion of being overpowered was not responding to the previous treatment regime. Upon referral, there was a suggestion for a trial of Electroconvulsive Therapy (ECT). Following admission, her mental status examination revealed severe depression with fleeting suicidal thoughts, delusion of a former male co-patient overpowering her brain with limited insight into her problem. She was initially given a diagnosis of Major depressive disorder with psychotic features.\nThis diagnosis was based on DSM IV criteria for major depressive disorder. All her blood work and MRI were normal in findings. By definition in terms of phenomenology, delusion is a belief, held with extraordinary conviction, unshakeable, with incomparable subjective certainty and in contrast to person’s socio-cultural background. The patient in this case report stated that a person is overpowering her brain “sitting on my brain”, expressed firm belief of its reality and was unshakeable despite arguments presented against this belief. She was on Mirtazapine45 mg, Clonazepam 0.5 mg twice per day and Quetiapine800 mg per day without any beneficial effect before being referred for admission. Her treatment was reviewed by the multidisciplinary team. The dosage of Mirtazapine was maximised to 60 mg HS, Quetiapine was discontinued and Risperidone was introduced at 1 mg dose. Over the next two weeks, the dosage of Risperidone was titrated up to 4 mg. The patient showed very good response to this combination, her mood improved tremendously, delusions became shaky, gained adequate insight into her problem and dismissed the brain-occupation by the fellow patient as absurd and obsessional. She stated that “The occupation of my brain could be just my thought, it may not be real but it is quite undesirable”. This falls well into the quality of an obsession which is troubling thought, being recognized as once own, cannot get rid of a content of consciousness, realization of it being senseless and persisting without cause. The consideration for ECT was dropped, she was given off unit privileges and overnight passes. A family meeting was arranged in which it was expressed by the family members that she was doing quite well and they were pleased with the improvement.\nThe current case, presented with major depression with the firm belief that her brain was possessed by a man. She was considered to be suffering from Major depression with psychosis. With change of antipsychotic medication, the intensity of symptoms became less severe; she gained insight into her problem and started to believe that her thought was irrational. The journey appeared to be from delusion to obsession. This is in light with the above conclusions made in the study []. The same author had examined seven cases with features of OCD with psychosis and six of those responded well to addition of antipsychotic or antidepressants with good effect. ECT treatment was deferred in the current case in order to observe the symptoms and effect of prescribed medications. There was no strong evidence available for efficacy of ECT in obsessional disorder. However, one uncontrolled case series reported considerable improvement in such cases year after the treatment although improvement was correlated with improved depression scores []. In the current case, the patient was observed for improvement on the changed antipsychotic medication. A study [] describes co-morbid OCD with schizophrenia. In this, they mention that OCD was associated with more severe depressive symptoms, social dysfunction and worse premorbid functioning. There remains a significant degree of uncertainty and complexity surrounding the issue of distinguishing between delusion and obsessive thought. []\nSome authours feel that these symptoms are distinct entities and are distinguishable on the basis of the level of insight a patient displays. []\nApparently, this is a simple case but the intriguing factor was related to the phenomenology. Initially she remained firm about her belief giving a clinical impression of ‘delusion’ fulfilling all criteria of the same. With initiation of changed treatment she gave the picture of an obsession. With multiple interviews, it remained inconclusive whether the initial picture was of delusion or obsession. The case came under debate based on the issue of phenomenology whether the interview approach was inappropriate or the understanding of phenomenology was inadequate. Addition or change of antipsychotic medication can address both issues making the matter more complex. For training residents and clerks, the terms for psychopathology become more pertinent when it is clinically applied. In major depression with psychotic features or depression that is refractory to antidepressant medication, addition of antipsychotics may prove effective. This has been demonstrated in studies. []\nIn a study, it was concluded that antidepressant-antipsychotic cotreatment was superior to monotherapy with either drug class in the acute treatment of psychotic depression. []\nThe medical literature does not clearly mention the need for antidepressants in presence of pure psychotic features. In Obsessive-Compulsive Disorder (OCD), Quetiapine augmentation to SSRI’s was suggested to be beneficial in patients with treatment resistant OCD. [] Hence, it is obvious that though (selective serotonin reuptake inhibitor)SSRI is the medication of choice in OCD, addition of an antipsychotic may prove beneficial.\nA lesson was however learnt that addition/change of antipsychotic medication may affect mood related disorder, obsession and/or psychosis. This dilemma prompted us to write a case report for the general interest of readers. Though such type of presentations are frequently reported in academic literature, it gives repeated updates about this sort of clinical dilemmas and provide insight into the management issues.
A 33-year-old male patient had developed a 0.5 × 0.5 cm pyogenic papule in the left cervical area one month prior to presentation. At that time, the patient had been evaluated at a community hospital where the lesion was diagnosed as cellulitis and was given topical steroid and IV antibiotic treatment for two weeks without appropriate response. In the subsequent two weeks leading up to presentation at our hospital, the lesion continued to grow in size while the patient began to experience consistent fever and chills.\nInitial physical examination revealed a painful 9×4 cm ulcerative lesion in the left cervical area (). The patient reported a history of chemical burn on the left chin 13 years earlier and three scar revision procedures had been performed for keloid. The patient had been receiving local steroid injection therapy up until three years before the development of ulcer.\nUpon admission, debridement and bacterial culture tests were performed to exclude the potential for necrotizing fasciitis. Histopathologic examinations were conducted to assess the possibility of malignant neoplasms. The white blood cell (WBC) count increased to 17.56 × 103, and the patient continued to experience febrile episodes (39℃-40℃) two to three times a day. Findings characteristic of a widely spreading ulcer were observed. No microorganisms were identified in the wound culture. The histology of wound sample demonstrated papillary proliferation on keratinized squamous epithelium with significant chronic inflammation. The possibility of malignant neoplasms could not be excluded, although no stromal invasion or cellular an aplasia was observed ().\nIn cooperation with the pathology department, additional debridement was performed 8 days after admission. No necrotic findings were observed in the platysma fascia intraoperatively, and no cancer cells could be identified in the marginal ulcer area in frozen sections. Despite the consistent fever and increases in WBC count, bacteria were not observed in the ulcer or blood culture. Acute inflammation was confirmed based on the clinical manifestations of a progressive skin ulcer with a reddish violet margin and on tissue samples. Accordingly, PG was suspected over the possibility of malignant neoplasms (). Intravenous dexamethasone (10 mg/day) was administered, and the ulcer margin did not extend thereafter. The febrile episodes discontinued, and blood WBC count stabilized (6.83 × 103). After five days, IV dexamethasone was replaced with oral prednisolone (10 mg/day) for two weeks. The lesion stabilized approximately 15 days after starting the prednisolone regimen (). The defective area was reconstructed using a meshed split-thickness skin graft. A satisfactory outcome was confirmed two months after surgery ().\nPG is a rare, progressive, ulcerative skin disease that was first reported in 1908 by Louis Broc. It is not clearly understood, but may be associated with a defective immune system. About 40%-50% of cases are accompanied by rheumatoid arthritis or inflammatory bowel diseases such as ulcerative colitis or Crohn's disease []. The inflammatory skin disorder usually develops in the anterior surface of lower extremities, but can develop in any area of the body including the head, cervical, abdominal and inguinal regions []. Typical PG usually develops rapidly with associated pain, whereas atypical PG usually develops in the head, cervical region, and superficial upper extremities with hematic abscesses []. The diagnosis of PG is made usually based on past medical history and clinical manifestations of the lesion, after other possible diagnoses have been excluded. Many patients report a past history of skin injury. The lesion appears as small papules, erythema nodosum, or a red plate, and progresses to hematic abscesses and necrotic lesions. Histological tests show nonspecific findings of extensive neutrophil invasion and proliferation in the surrounding blood vessels and tissues. Epithelial necrosis is also observed in PG []. The differential diagnosis for PG should include malignant neoplasms and necrotizing fasciitis.\nNecrotizing fasciitis develops due to fulminant infection of fat cells, blood vessels, and nerves of the superficial fascia and subcutaneous tissues, leading to eventual skin necrosis. Since the fatality rate of necrotizing fasciitis is high, early surgical treatments and use of antibiotic agents are required [].\nImmunosuppressive agents such as steroids and cyclosporine are considered as first-line therapy for PG. Surgical removal of the necrotic tissues is contraindicated, as it may further induce immune reaction and promote ulcer to enlarge. Davis et al. [] reported a successful case of necrotic tissue debridement and skin grafting followed by hyperbaric oxygen therapy. The authors hypothesized that hyperbaric oxygen therapy prevented the lack of arterial blood supply and consequent delay in wound healing, which is caused by the perivascular inflammation. However, surgical treatment for PG remains controversial. High fever and progressive ulceration with severe pain may indicate the need for earlier surgical debridement. However, the lesion continuously expanded in our patient. Only one week after admission, the patient was diagnosed with PG when the work up returned negatively for both necrotizing fasciitis and malignancy.\nPG is a nonspecific disease with low prevalence as well as a diagnosis of exclusion in the differential company of necrotizing fasciitis. Furthermore, plastic surgical reconstruction of the lesion is challenging due to its rapid progression. Therefore, early diagnosis is important to prevent further acceleration of wound margin. As it was with the patient reported here, clinical suspicion for PG maybe low in patients with unexplainable ulcer without any history suggestive of an underlying systematic inflammatory disorder such as Crohn's disease or rheumatoid arthritis. Plastic surgeons should include PG in the differential diagnosis of idiopathic ulcers, and satisfactory outcomes may be expected using steroids and immunosuppressive agents in the early stages of disease.
A 54-year-old male patient was diagnosed with Barrett oesophageal carcinoma (pT1 M0 N0 R0). In the same month the oesophagus was resected with gastric pull-up operation in a university clinic which kept medical attendance over the whole time.\n5 years after the operation hoarseness appeared being interpreted as paralysis of the recurrent nerve, although this was surprisingly at all times not thought to be related to the basic disease by the university hospital. (From the author’s point of view the hoarseness can be interpreted as first sign of a recurrence of the tumor.)\n6 years and 2 months after the operation swallowing disorders started to occur. 6 years and 4 months after the operation a recurrence of the tumor at the anastomosis was diagnosed and treated during the following 3 months with a combined chemoradiotherapy.\n7 years and 4 months after the operation a second local stenosing recurrence of the tumor at the anastomosis was diagnosed and subsequently treated for 4 months with chemotherapy. Repeated ballon dilatations of the oesophagus were carried out in order to treat pronounced swallowing disorders. 7 years and 7 months after the operation, an implanted oesophageal stent was not tolerated (local pain) and had to be removed within a week. A second attempt to position an oesophageal stent led to a respiratory arrest and a revival situation. Percutaneous endoscopic gastrostomy (PEG) was performed to position a jejunal PEG tube for feeding, bypassing the swallow disturbances. A diagnostic swallow of contrast material induced a choking response resulting in an atypical aspiration pneumonia.\n7 years and 9 months after the operation local tumor masses and destruction (with e.g. erosion of the seventh cervical vertebra body, already found earlier) and suspicion of lung metastases (later confirmed) were present with no ability to orally drink or eat (full feeding by jejunal PEG tube): quality of life was poor, as saliva and mucus were very viscous (pulling filaments) and could not be swallowed and had to be spat out throughout the day and night resulting in short periods of sleep (awaking from the necessity to spit out). In total (taking into account several aspects including clinical observation of swallowing acts and the increase of amount of saliva spat out within a short time span) the situation was interpreted by the author, in contrast to the university hospital, more as a problem related to a feeling of choking (with food or fluid) in the sense of a functional dysphagia rather than as a swallowing disorder from a structural stenosis.\nAt that time, following advices by the author, acetylcysteine (2 times 200 mg per day, given via the PEG tube) and irradiation with water-filtered infrared-A (wIRA) – a special form of heat radiation (Figure 1 ) [], [], [] – of the ventral part of the neck and the thorax were added to the therapy (manufacturer of the wIRA radiator: Hydrosun, Müllheim, Germany, radiator type Hydrosun 750 FS). Within 1 day with acetylcysteine saliva and mucus became less viscous. Within 2 days with wIRA (one day with 4 to 5 hours with irradiation with wIRA at home; Figure 2 ), salivation decreased markedly and the patient’s quality of life clearly improved: For the first time the patient slept without interruption and without the need for sleep-inducing medication. After five days with wIRA the patient could eat his first soft dumpling although drinking of fluids was still not possible. After 2½ weeks with wIRA the patient could eat his first minced schnitzel (escalope). The ability to swallow concentrated/incrassated fluids, more in the sense of an eating than a drinking, was regained.\nFollowing the commencement of wIRA (with typically approximately 90–150 minutes irradiation with wIRA per day) the patient had 8 months with good quality of life with only small amounts of liquid saliva and mucus and without the necessity to spit out. During these 8 months the patient was able to sleep during the night. Some weeks after the commencement of wIRA, following consideration by the author, some additional aspects were optimized: As the patient combined oral nutrition intake with PEG tube feeding, a different PEG nutrition was chosen which induces much less viscous saliva. In addition, therapeutic training from a speech therapist having a special education in swallowing disorders was started and performed regularly.\nUnfortunately the basic disease progressed – in spite of additional chemotherapy – and the patient died 8 years and 5 months after the operation (8½ months after starting with wIRA).
The patient, a 76-year-old woman with both multiple myeloma (MM) and myelodysplastic syndrome (MDS), was seen in the haematological outpatient clinic for a planned blood transfusion. The patient had no history of GI disease apart from minor GI bleedings, and no implants or history of alloplastic surgery. The most recent surgery the patient had undergone was an operation for a rotator cuff lesion 7 years previously. Six days earlier she had received two red blood cell transfusions and one transfusion of pooled platelets. The patient was diagnosed with light-chain MM 7 years ago. During the following years she received several lines of treatment with alkylating chemotherapy, glucocorticoids, immunomodulatory drugs and radiation therapy. Two years ago, she developed transfusion-dependent anaemia and thrombocytopenia and a new bone marrow biopsy and cytogenetic karyotyping revealed therapy-related MDS. Treatment with 5-azacytidine and recombinant erythropoietin or thrombopoietin was ineffective. Subsequently the patient was put on supportive treatment with oral 12.5 mg prednisolone daily and supportive transfusion therapy. She was in partial remission for her MM at the time of infection. Due to severe thrombocytopenia and prednisolone treatment the patient had had several prior episodes with minor GI bleedings before the time of the infection. The patient had also previously been examined for infections several times before the time of infection. Sixteen days before the positive blood culture with was drawn, the patient was discharged from the hospital after an admission because of suspected tonsillitis. Blood cultures were negative, and the patient was found to be negative for influenza virus A and B and respiratory syncytial virus. No other microbiological tests were performed. The patient was treated empirically with intravenous piperacillin/tazobactam and was discharged with oral penicillin and pivmecillinam. Two months before the present case story the patient had diarrhoea and tested positive for toxin and was treated with oral vancomycin for 2 weeks. Blood cultures drawn at that time were negative. Three months earlier the patient was treated empirically with oral amoxicillin/clavulanic acid because of an increased C-reactive protein (CRP) level of 79 mg l−1. No microbiological tests were performed at that time. The microbiological record of the patient contained no other prior positive results and contained two negative sets of blood cultures obtained respectively 10 and 12 months before the time of infection.\nAt admission, blood tests revealed an increase in CRP to 127 mg l−1 from 74 mg l−1 measured 6 days earlier. The CRP value had been elevated (>10 mg l−1) for 4 months. In this patient, as in many other patients with MDS, increased CRP levels are a paraneoplastic phenomenon. Her total leucocyte count at the time was 1.5×109 cells l−1 and, as usual, she was severely thrombocytopenic, with fewer than 3×109 platelets l−1. She had no complaints, and in particular no abdominal complaints. She had a normal physical examination, was afebrile with normal vital signs, and there was no evidence of current bleeding. Her medications were oral treatment with 12.5 mg prednisolone once daily and prophylactic tranexamic acid to minimize bleeding episodes.\nBlood cultures were drawn, and the patient started antibiotic treatment with oral administration of ciprofloxacin 500 mg twice daily and amoxicillin/clavulanic acid 500/125 mg three times daily. She was discharged to an early follow-up appointment. She was contacted and admitted to hospital the following day when the blood cultures revealed Gram-positive cocci. The patient was still asymptomatic and afebrile. Ciprofloxacin and amoxicillin/clavulanic acid were discontinued, and she started continuous intravenous treatment with 14 g/24 h of piperacillin/tazobactam and one dose of 1 g vancomycin. Three days after admission, oral metronidazole 500 mg three times daily was added. Five days after admission, piperacillin/tazobactam was changed to oral penicillin 1 million international units (IU) three times daily based on the results of antibiotic susceptibility testing, and the patient was discharged the following day in her usual condition with oral treatment with penicillin and metronidazole for another 4 days. The patient was on antibiotic treatment for 11 days in total.\nOne set of blood cultures was performed, consisting of one aerobic and one anaerobic bottle (BD BACTEC, Becton Dickinson, Franklin Lakes, NJ, USA). The anaerobic bottle was positive at day 2, and a Gram stain showed Gram-positive cocci in chain form. A second set of blood cultures was obtained 1 day after the first set, and thus after the initiation of antibiotic therapy, and no bacteria were found. Two weeks after this event, another set of blood cultures was obtained, again without growth of pathogens.\nThe blood was prepared for analysis by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) by collecting 1 ml blood in a tube (Eppendorf, Hamburg, Germany) containing 200 µl 7 % saponin lysis buffer (Sigma Aldrich, St Louis, MI, USA).\nThe sample was vortexed for 15 s, incubated at room temperature for 5 min and centrifuged for 1 min at 13.000 r.p.m. The supernatant was removed, the pellet was resuspended in 1 ml 0.85 % NaCl water and vortexed. The sample was centrifuged for 1 min at 13.000 r.p.m again and the supernatant was removed. The pellet was smeared on a target plate, and 1 µl of 70 % formic acid (Honeywell Fluka, Charlotte, NC, USA) was added. The plate was left to dry, and 1 µl of HCAA matrix solution (Bruker, Billerica, MA, USA) was added. Further identification was achieved on a Microflex LT mass spectrometer (Bruker, Billerica MA, USA). The generated spectrum was analysed using IVD MALDI Biotyper (version 3.4) and Bruker Taxonomy/Compass Library (version 7) software. MALDI-TOF MS identified the pathogen as with a score of 1.78. The following three suggestions on the list of pathogens based on MALDI-TOF MS were also , but with lower scores.\nThe antibiotic susceptibility was tested for penicillin, meropenem, tetracycline, metronidazole and clindamycin by agar disc diffusion according to our laboratory’s standard procedure for Gram-positive bacteria. A suspension of the isolate with a concentration of 0.5 McFarland was plated on 7 % defibrinated horse blood agar plates (SSI Diagnostica A/S, Hillerød, Denmark). Antibiotic discs (Rosco Diagnostica A/S, Taastrup, Denmark) were added onto the plate, and were gently pressed down to the agar with sterile forceps. The plates were incubated for 24–48 h. The sizes of the zones were assessed using the European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoint system (version 8.0, 2018) for Gram-positive anaerobic bacteria. The non-species-related breakpoints were used when there were no breakpoints for Gram-positive anaerobes. The bacterium was susceptible to all of the tested antibiotics, and no resistance was observed. No E-test rendering minimum inhibitory concentration (MIC) values was performed. See for a comparison of the susceptibility between this case and previous cases.
A 63 year old male patient presented with a large 8 × 8 cm ulcerated and suppurating tumour of the scalp (Fig. ). The patient had suffered from an electrical burn at the age of 5 with delayed and incomplete healing of the wound and subsequent baldness in the healed area. The wound had never been completely healed and ulcerated again 8 weeks before admission to the hospital. The patient, a professor of philosophy, wore a turban for decades to hide the chronic wound. Due to personal neglect and the circumstance that he had been living on his own for many years, without any relatives or a partner kept him from seeing a doctor. The disease only received medical attention when he suddenly experienced a complete aphasia during lectures.\nClinically there was a palpable mass adherent to the skull. Nuclear magnetic resonance and computed tomography imaging revealed a tumour with infiltration of the cranium and the brain (Fig. ). Radical resection of the tumour including the cranium, as well as dura mater and the affected parts of the frontal cortex was performed. The dural defect was closed with an autologous fascia lata patch from the right thigh, and as recipient vessels, the superficial temporal artery and vein were dissected. A radial forearm flap with a 10 × 10 cm skin paddle was harvested with an adequately long vascular pedicle. Radial artery and vein were anastomosed end-to-end to the superficial temporal vessels above the zygomatic arch. The donor site was covered with a split thickness skin graft from the thigh (Fig. ). Histology of the specimen revealed a squamous cell carcinoma and free resectional margins. Postoperative healing was uneventful and the patient regained his speech immediately after the operation (Fig. ). Six weeks later, the patient was referred to our unit again with multiple satellite nodules around the radial forearm free flap (Fig. ). Incision biopsy revealed recurrence of squamous cell carcinoma. In a second operation, radical excision of the scalp with wide margins was performed, requiring sufficient soft tissue coverage. The skin and soft tissue of the radial forearm flap was completely resected, but the proximal part of the radial vessels which were in sufficient distance from the tumour were preserved. Thus radial artery and vein served as recipient vessels for a latissimus dorsi free flap. After the second operation postoperative healing was uneventful again, and the patient recovered well initially for the first three weeks (Fig. and ). Postoperatively, radiation therapy with single focus dose of 14 Gray was administered and one cycle of combined chemotherapy was conducted with cisplatin 180 mg i.v. on day 1 and 5-fluorouracil 1800 mg i.v. on days 1–5 continuously. However despite these efforts, six weeks after the second resection the patient again developed multiple recurrent metastatic lesions around the latissimus dorsi flap, and cerebral symptoms. Clinically, the general condition of the patient dramatically worsened and he died within two more weeks.
A 72-year-old male presented to the clinic with generalized abdominal pain for 4 months that was constant and dull. Patient had a history of intermittent GI bleeding for about 6 years with no known source of bleeding despite having a workup at different hospitals. Past history includes hypertension, benign prostatic hyperplasia, gastritis, and anemia. Patient had undergone colonoscopy and esophagogastroduodenoscopy about four months ago that showed no abnormalities. He subsequently underwent a computed tomography scan of abdomen that showed a lobulated mass like structure originating from a bowel anastomosis. However, the patient did not give a history of any abdominal surgery, nor did he have any scars on his abdomen to indicate any previous abdominal surgery. On reviewing the CT scan, there was a linear calcification inside the mass, which seemed to arise from the small bowel or its mesentery without evidence of bowel obstruction , .\nDue to the findings on CT scan, a diagnostic laparoscopy was planned with biopsy/resection of the mass. During diagnostic laparoscopy, there was hemoperitoneum in the pelvis and Morrison's pouch. On examination of the small bowel, the mass was located in the distal small bowel with omentum and loops of small bowel densely adhering to and covering the mass . Diagnostic laparoscopy was converted to a mini laparotomy due to size and complexity of the mass []. On exploration and removal of the superficial adhesions with small bowel loops, the omentum, small bowel mesentery, appendix, and another segment of small bowel about 1.5 feet from ileocecal junction were densely adhered to the solid mass with a defect in the capsule of the mass, that seemed to be the source of bleeding that had caused the hemoperitoneum . An intraoperative frozen section of the mass showed spindle cells that indicated GIST. The pseudocapsule of the mass was adhered to the serosa of the small bowel and appendix , . Therefore, the patient underwent partial omentectomy, resection of segment of small bowel with the adhered pseudocapsule and appendectomy. This was done to ensure excision of the tumor with adequate margins. There were no enlarged mesenteric lymph nodes, liver masses, omental or peritoneal nodules. Patient's postoperative course was uneventful, and he was discharged home on post-operative day four after tolerating a regular diet and having bowel function. Patient was seen in the clinic and was noted to have good healing of the incision.\nHistopathological examination of mass showed a gastrointestinal stromal tumor measuring 9.5 × 9 × 8 cm . Mitoses were 10 per 50 high power fields. There was no lymphovascular infiltration or metastasis noted. Immunohistochemically, the tumor cells were positive for Ckit (CD117) Dog1, Vimentin and negative for CD34, Desmin, Chromogranin, and S100. According to TMN staging, the pathological stage of the excised tumor is PT3 Nx Mn/a, stage IIIB. These findings indicate a high risk of recurrence at both the one year and five-year mark [,]. Small bowel attached to the mass showed a 1mm area of tumor, appendix was negative for tumor. The margins of small bowel and appendix were free of tumor. The tumor is high risk due to pathological staging (Stage IIIB), rupture of pseudocapsule leading to hemoperitoneum and involvement of adjacent segments of small bowel. Patient would be receiving adjuvant imatinib mesylate therapy, a selective tyrosine kinase inhibitor and would be under close surveillance for recurrence [].
A 55-year-old man presented to the emergency room complaining of lower back pain. He had a one-week history of pain in the left hip associated with difficulty in walking. He reported acute pain from the onset that progressed within a few days. The initial trauma to the left hip occurred ten years prior and caused AVN of both hips. He received native medical treatment at that time and was deferred for surgery. No other comorbidities or radiographic evidence of previous trauma was obtained during the visit.\nThe patient reported successful mobilization and discharge following therapy after the initial trauma, and since then, he had resumed daily activities. At approximately ten months following the initial injury, he returned to a local emergency department with vague complaints of lower back pain. After an unremarkable workup, he was prescribed analgesics and discharged.\nAt the presentation to our emergency department, his back pain was progressively increasing, and motor deficits in the lower limbs accompanied the acute onset of worsening pain. The patient appeared moderately built and nourished. The physical examination revealed apparent shortening of the left hip and pain during a range of movements. Distal pulses were found in both lower limbs.\nA lumbosacral spinal radiograph (lateral view) revealed loss of normal lumbar curvature and collapse of multiple vertebral bodies accompanied by a reduction in vertebral body height. Degenerative changes in the left hip joint along with a reduction in the left acetabular femoral joint space were also observed on the X-ray (Figure ).\nA lateral radiograph of the lumbosacral spine showed compression wedge fractures at the L1, L2, L3, and L4 levels (Figure ). Computed tomography of the spine revealed the collapse of multiple vertebrae and a marked reduction in the vertebral body height accompanied by a linear intraosseous cleft in the L2 intervertebral disc (Figure ).\nAn extensive workup was done to exclude malignancy and infection. Magnetic resonance imaging revealed fluid clefts below the superior endplates of the D12 and L2 intervertebral discs (Figures -).\nCoronal images of the hip joints obtained using magnetic resonance short-TI inversion recovery revealed hyperintensities in both femoral heads. More severity was noticed on the left side hip, with collapsed left femoral head and an increased acetabular femoral joint space. The findings were suggestive of grade III AVN on the left side and grade I AVN on the right side (Figure ).\nKyphoplasty was advised, but the patient did not consent. Therefore, the nonsurgical treatment was bed rest, wearing a brace, lumbar traction, analgesics, and medication to prevent osteoporosis.
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 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 28-year-old man with no noticeable past medical history was hospitalized for widespread abdominal pain and vomiting at our emergency surgical unit. Three weeks before he had been involved in a motor vehicle accident and was admitted with a diagnosis of blunt thoracic and abdominal trauma; the treatment was conservative, and the patient was discharged after 7 days from hospitalization without need for blood transfusion. Our examination revealed moderate abdominal distention with pronounced tenderness in the lower quadrants, and blood examination showed only mild leucocytosis. An abdominal X-ray showed soft bowel distension with air–fluid levels. A computed tomography (CT) scan was then performed, which showed some calcifications within the mesentery root (), gastric dilatation, distension with multiple air–fluid levels of the small bowel. In the right iliac fossa, there was an ileal loop with frankly thickened walls and signs of parietal suffering at a full-to-empty passage. Free fluid was sparsely evident in all the recesses of the abdominal cavity.\nMoreover, several apparently hyperplastic-reactive nodes were present along the mesentery root. Calcifications were not present at a previous CT scan performed in another hospital after the trauma hospitalization. After informed consent the patient was prepared for surgery, and initially a laparoscopic approach was hypothesized but not allowed due to a severe desaturation episode during the intubation. During the exploratory laparotomy, we identified a bulky and hardened mass of the small bowel arising within the mesenteric root and retracting the visceral peritoneum, with a frank malignant appearance. Consequently, a wide resection of the involved intestinal tract with the relevant mesenteric root was performed. Another similar small thickened nodule was removed from the peritoneum of the left iliac fossa. The postoperative course was regular, and the patient was discharged after 5 days in complete wellness and restored bowel functions. A 10% formalin solution was used to fix surgical samples for the routine histological examination. Final pathology report described thickened intestinal wall, due to diffuse oedema and areas of proliferating fibroblasts, mainly localized within the mesentery. Fibroblasts were arranged in thin bundles within a myxoid stroma with a lymphoid plasma cell and eosinophils background component. Atypia was unremarkable. The mesentery of the resected intestinal tract was almost entirely occupied by areas of bone-like metaplasia with naïve bone islands and deposition of calcium. These findings were consistent with the diagnosis of HMO (intra-abdominal myositis ossificans). Histological findings are shown in .
A 93-year-old woman was emergently transferred to the department of obstetrics and gynecology at our hospital with acute abdomen that began that morning. She had a history of hypertension and diabetes mellitus, both treated with medication. The patient needed assistance with activities of daily living because of left hemiplegia due to cerebral infarction 1 year earlier. On arrival at the hospital, her vital signs were stable. Laboratory investigations revealed leukocytosis of 11,900 × 10\n6/L and elevated levels of CRP at 19.55 mg/dL. Urgent CT revealed a fluid collection and free air in an extremely dilated uterine cavity, although only a small amount of ascites was observed in the pelvic cavity (). The patient complained of abnormal purulent vaginal discharge, which lead to a diagnosis of severe pyometra. Transcervical drainage was performed with release of 180 mL of purulent uterine discharge. With administration of FMOX to treat of endometritis and pelvic peritonitis, the amount of vaginal discharge decreased but the fluid collection in the abdominal cavity increased gradually and CRP levels increased to 38.75 mg/dL. Three days after admission, repeat CT revealed a large increase in the amount of the fluid collection in the pelvic cavity and upper abdomen, up to the level of the liver, as well as a collapsed uterine cavity (). Treatment for progressive generalized peritonitis was considered. We selected laparoscopic irrigation and drainage, as minimally invasive interventions, in consideration of her advanced age, poor performance status (PS 4)and possibility of vaginal drainage. Laparoscopic surgery with 2 ports was performed 4 days after admission. Massive purulent ascites and inflammatory adhesions were observed in the entire abdominal cavity (). After extensive suction of the purulent material and irrigation, we found a small scar with serosal spotting on the anterior wall of uterine body, which was attributed to SPP (). The leakage of purulent uterine discharge into the abdominal cavity might have occurred through this site of perforation. Uterine contractions might have led to scarring by the time of laparoscopic surgery. Hysterectomy or suturing of myometrium was not performed because no bleeding or leakage of purulent discharge from the scar was observed intraoperatively, and transcervical drainage was possible. After placing a drain in the pouch of Douglas (), bleeding occurred from the surface of liver where adhesiolysis was performed. Hemostasis was accomplished through a small incision in the upper abdomen. The operative time was 2 hours and 40 minutes. Intraoperative blood loss was 914 mL. Most of the operative time and blood loss were related to hemostatic control of bleeding from the surface of the liver. Culture of the peritoneal pus grew E. coli, ESBL.Postoperatively, peritonitis decreased with intensive care, including transabdominal and transcervical drainage with administration of MEPM and CLDM, which were selected based on bacterial culture results from the purulent material. The patient’s general condition improved;she was discharged from the hospital, on POD 35.
A 17-year-old female presented with acute right sided abdominal pain that had been progressively getting worse for the previous 3 days. Her past medical history was significant for Müllerian agenesis and lack of a uterus. Her past surgical history was significant for small bowel atresia and resection of a portion of her small bowel during infancy. Physical examination revealed tenderness to palpation in the right lower quadrant and the periumbilical region. Laboratory tests were significant for leukocytosis with a left shift and an elevation of C-reactive protein.\nCT scan of the abdomen and pelvis demonstrated a heterogeneous structure measuring 3.8 × 2.2 × 2.6 cm (transverse × anteroposterior × craniocaudal) inferior to the right hepatic lobe and posterolateral to the ascending colon with blood supply from a branch arising off the right renal artery and a draining vessel into the inferior vena cava (). A low density cystic component was seen inferiorly within the mass. There was a small amount of surrounding free fluid and fat stranding. The uterus was absent and both ovaries were present in the pelvis. Ultrasound exam () of the right upper quadrant revealed a heterogeneous mass with no internal blood flow and confirmed the arterial and venous connections noted on the CT scan. MRI exam of the abdomen () showed a mass with intermediate to low signal intensity on T1 and a low signal intensity on T2 with a cystic component inferiorly. Extensive surrounding edema and rim enhancement were also present.\nThe patient underwent laparoscopic surgery for a presumptive diagnosis of a possible torsed supernumerary ovary or acute appendicitis with perforation. The resected gross specimen consisted predominantly of yellow lobulated adipose tissue and a portion of hemorrhagic tubulocystic structure. Microscopic examination demonstrated mature adipose tissue and abundant hemorrhagic tissues (). The wall of the cystic structure was lined by cuboidal epithelium (). Immunohistochemistry for PAX-8 and smooth muscle actin (SMA) showed the presence of Müllerian type epithelium and smooth muscle within the cyst (Figures and ). The hemorrhagic soft tissue showed no evidence of follicles. The histopathological diagnosis was consistent with Müllerian derived remnant cyst with extensive hemorrhage.
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 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 43-year-old woman visited a general clinic with a painless tumor of the right anterior knee region and underwent excision of the tumor under local anesthesia. The pathological diagnosis was spindle cell sarcoma, and the lesion recurred locally. She was referred to our hospital 2 months after the initial excision.\nPhysical examination of the right anterior knee region revealed the transverse excision scar and tumor at the medial side of the tibial tuberosity. The tumor was elastic and soft, and movable, and its longitudinal diameter was 3 cm. Diffuse swelling was seen around the tumor. The range of motion of the knee joint was normal. Plain radiographs showed no abnormality. Magnetic resonance imaging (MRI) showed a well-margined mass adjacent to the patellar tendon and that a part of the tumor crept under the patellar tendon. The tumor showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Fat suppression T2-weighted images showed a high signal intensity area around the tumor, suggesting edema (). The swelling of the surrounding tissue was severe. Thus, if additional wide resection with the safety surgical margin including this edema area were to be established, the extent of skin and subcutaneous tissue excision was expected to be considerable. Therefore, preoperative radiation (total dose 25 Gy) was performed in order to reduce the surgical margin. MRI after preoperative radiotherapy showed the reduction of the tumor size (reduction rate 34%), and the extent of high signal intensity around the tumor was reduced on fat suppression T2-weighted images (). We established a 3 cm skin margin from the edema area, and performed wide resection of the tissues surrounding the tumor, including almost the full length of the patellar tendon (the patellar tendon was resected transversely 1 cm from the inferior pole of the patella), the infrapatellar fat pad, and the tibial tuberosity.\nA 4 × 10 cm portion of the fascia lata attached to iliac bone was harvested. The surgical technique adopted was similar to that described in Campbell's operative orthopaedics (). The bone trough in the tibia was made with an oscillating saw about 4 cm distal to the joint line. Contouring of the corticocancellous iliac bone was performed to fit the tibial bony trough, and the bony portion was fixed with two 4.5 mm absorbable cortical screws. The fascia lata portion was fashioned into three branches, with the central third consisting of half of the width. This central branch was 8–9 mm in diameter. A Kirschner wire was passed through the central part of the patella to make a tunnel. An 8–9 mm reamer was passed over the Kirschner wire. A whipstitch was made with a non-absorbable suture in the central branch, and this central branch was passed through the tunnel, exiting through a slit in the quadriceps tendon. Multiple interrupted non-absorbable sutures were placed through the graft in the soft tissue of the inferior pole of patella and at the edges of the quadriceps tendon (). The appropriate graft length and tension were determined as follows. The position of the inferior pole of the patella was situated at the upper portion of the intercondylar notch at 45 degrees knee flexion. A lateral view radiograph of the knee joint was obtained to confirm the height of the patella compared with the opposite side. Patellar tracking was checked carefully. The medial and lateral branches of the graft to the medial and lateral retinaculum were tagged, respectively, using non-absorbable sutures. The skin defect was covered by the bilateral head of the gastrocnemius flap and a split-thickness skin graft. The pathological diagnosis of low-grade myofibroblastic sarcoma was made.\nPostoperative swelling in the lower leg was severe, and peroneal nerve palsy developed, but improved 3 months after operation. The patient was initially treated with a splint for 3 weeks with the knee in full extension. Continuous passive motion was initiated to move the knee between 0 and 30 degrees, and this range was gradually increased. At the same time, isometric quadriceps strengthening exercise was begun. After 4 weeks postoperatively, weight-bearing to tolerance with crutches was allowed until sufficient motion and strength allowed for unassisted ambulation. Physical examination at 3 years postoperatively showed active knee motion of 0 to 110 degrees. She was able to raise her leg with an extension lag of 5 degrees (). The functional result according to the Musculoskeletal Tumor Society (MSTS) scoring system () was 97%; pain, function, emotional acceptance, supports, and walking were 5 points, respectively, and gait was 4 points. Radiographs showed that the grafted bone was united well to the tibial bone, and the grafted fascia was confirmed as a dark band on T1- and T2-weighted images (). There was no evidence of systemic or local recurrence and the donor site was clinically unaffected.
Our patient is a-64-year old Chinese female with knee pain of more than 10 years and limited activity for 7 years. The purpose of admission is to perform the right knee replacement to relieve pain and restore joint function. The patient suffered from chronic suppurative arthritis and chronic osteomyelitis caused by the right hip injury about 50 years ago, and she is currently suffering from right hip ankylosis. Eight years ago, she was treated with reduction and internal fixation of lumbar spondylolisthesis. The patient can walk independently without help, but is limited to 100 m due to knee pain. Many of her basic life activities cannot be completed, including wearing socks.\nPhysical examination: Right hip has sinus closure scar and hip joint fused in 15° of abduction, 15° of flexion, and 20° of external rotation and ipsilateral knee joint fused in 20° of flexion. There was tenderness in the medial joint space of the right knee and a sense of friction during activity. The patella grinding test was positive and patella lateral movement was less than 0.5 cm. Right knee range of motion was within 20° to 90° and friction fremitus was felt in the activity. Her right lower limb is 2 cm shorter than the left leg.\nPreoperative radiographs: Her preoperative radiographs are as follows. Figure shows the presence of right hip joint fusion. Figure shows preoperative knee abnormality. Both her knees were severely degraded, and a large number of bone hyperplasia can be seen in the right medial knee.\nMethods (surgical technique): Knee arthroplasty with ipsilateral hip fusion faces difficulty in exposing the knee joint in the traditional supine position. In the supine position, the patient's hip joint is fixed at 15° of flexion, while the ipsilateral knee has a maximum flexion of only about 30° (Fig. ). We took a special position: when the patient was placed on the operating table, the knee joint was just at the boundary between the tail plate and the back plate of the operating table, and the tail plate was removed to suspend the right leg at the end of the operating table. At the same time, in order to avoid interference with the operation, the lower limbs of the opposite side are placed at the lithotomy position. We took a surgical position similar to the lithotomy position to allow easy exposure of the knee during surgery (this position allows her right knee to flex 90° throughout the procedure) (Fig. ). Figure shows this position allows the knee joint to achieve its maximum flexion in the operation. Artificial knee joint prosthesis was implanted and postoperative X-ray showed that the joint prosthesis was firmly fixed (Fig. ). As rehabilitation plays an important role in functional recovery after total knee arthroplasty,[ the patients was include in a rehabilitation plan focusing on range of motion of the knee after surgery.\nOutcomes and follow-up: The total follow-up period was 6 months. The patient was in good condition after surgery, and can walk with the help of ambulation aid on the 2nd postoperative day. Two weeks postoperatively, her right knee range of motion was at 0° to 90° (Fig. ). At 3 months post-operative, her right knee range of motion was at 0° to 100°, and she walked well without ambulation aid.
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
This is a 27-year-old white previously healthy male with no past medical history and no risk factors for cardiovascular conditions who presented to the medicine critical care unit via interfacility transfer after an episode of chest pain with syncope while exercising and was hypotensive. He stated he had been experiencing some chest discomfort for several days with exercise intolerance and cold sweats.\nUpon arrival, the patient was alert and in no acute distress with a heart rate of 112 and irregular and blood pressure of 112/77. His oxygen saturation was 94% on two liters of oxygen via nasal cannula. He had an obvious palpable pulsus paradoxus. All of his laboratory values were within normal limits with the exception of a mildly elevated creatinine.\nUpon initial presentation, the patient received a therapeutic dose of enoxaparin for a presumptive diagnosis of pulmonary embolism. Following the drug's administration, further diagnostic workup included a chest X-ray which demonstrated cardiomegaly (), an echocardiogram which demonstrated a pericardial effusion with tamponade and a computed tomography scan also demonstrating the pericardial effusion ().\nCardiothoracic surgery was consulted for pericardial drainage and possible biopsy. He was scheduled for a pericardial window the next morning since he had been anticoagulated on arrival and was hemodynamically stable after IV fluid administration. Intraoperatively, the patient was found to have a bloody pericardial effusion. The pericardial window did not allow adequate exposure to determine the source of the persistent bleeding. At this point we proceeded with a median sternotomy. Exposure of the heart revealed a large right atrial lobulated, bleeding mass. The pulmonary artery and aorta also had plaque-like lesions. Intraoperative frozen pathologic analysis suggested some type of high-grade angiosarcoma. We removed these lesions as well as performed an extensive node dissection to include pretracheal and right paratracheal lymph nodes. A decision was made to excise all gross disease, which involved the entire lateral wall of the right atrium, to best control the bleeding and prevent a recurrent effusion. The patient was placed on cardiopulmonary bypass. The mass was then resected to the right atrial and right ventricle junction next to the right coronary artery and including the sinoatrial node. We then used a bovine pericardial graft to reconstruct the atrium and placed two temporary right ventricular pacing wires ().\nThe patient was extubated the following morning and managed with intravenous pain medication as well as pulmonary toilet. He did well and both mediastinal drains and right pleural drain were removed. He never required ventricular pacing and his final pathology was poorly differentiated angiosarcoma involving right atrial resection margin, virtually all of the lymph nodes, and the plaque-like lesions on the aorta and pulmonary artery. He was discharged to home with family with outpatient followup with medical oncology.
Our patient was a 63-year-old Japanese man who had a history of operative treatment for right inguinal hernia during early childhood, although the type of procedure was unknown. Relapse subsequently occurred, and at the age of 56 years, he received a diagnosis of a recurrent right inguinal hernia, for which the Kugel method was performed. Six years later, he visited a local physician with the chief complaint of lower abdominal pain. Computed tomography (CT) showed thickening of his bladder and cecal wall; mesh infection was suspected and he was referred to our department.\nMild tenderness was apparent in his lower abdomen at presentation. Hematologic findings revealed that although his white blood cell count was normal, his C-reactive protein was slightly increased to 1.44 mg/dl. His urine analysis was positive for occult blood and bacterial contamination, and enteric bacteria were detected in urine cultures. An abdominal CT showed a poorly defined mass in contact with the cecal wall in the right inguinal region; the mass was also in contact with his bladder wall (Fig. ). When lower gastrointestinal endoscopy was performed, a Kugel patch that had migrated into his intestinal tract was confirmed in the cecum wall on the side opposite to the Bauhin valve (Fig. ).\nBecause we suspected that the fistula formation in his intestinal tract and bladder was due to the mesh, we scheduled a mesh removal procedure, but our patient felt left testicular pain 2 days before surgery, and an ultrasound examination revealed swelling of the left epididymis. Therefore, we diagnosed epididymitis. We thought that a mesh-related urinary tract infection was the cause of the epididymitis and performed surgical removal of the mesh.\nFollowing laparotomy with a midline abdominal incision in which intraperitoneal observation was performed, the cecum was found to be firmly adhered near the right internal inguinal ring. There was no mesh exposure in his abdominal cavity, but when the adhesion was separated, we confirmed the presence of mesh migrating into his intestinal tract and piercing the cecal wall from the preperitoneal space. The inner side of the mesh was in contact with his bladder wall. We performed ileocecal resection to extract the mesh, and the mesh, including bladder wall, was finally excised by partial resection (Fig. ). Partial cystectomy usually involves the insertion of a urethral catheter to reduce pressure; however, as the cause of epididymitis was chronic urinary infection, there were concerns that the insertion of a urethral catheter could prolong urethritis. Hence, a temporary cystostomy was established. In addition, 2 g/day cefmetazole sodium was administered to treat epididymitis from the day before until 1 week after surgery.\nIn the excised specimen, the mesh had penetrated the cecal wall and was exposed in the intestinal tract (Fig. ). On histological examination, a trace of mesh was found in the fibrotic area around the urinary bladder. The mesh did not penetrate into the muscularis propria; however, an inflammatory fistula was found between the trace of mesh and the lumen of the urinary bladder (Fig. ). Postoperative wound infection occurred, but subsequently improved with drainage. The cystostomy was closed on postoperative day 11. After confirming the disappearance of the abscess cavity, our patient was discharged on postoperative day 38.
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 22-year-old female with a past medical history of cerebral palsy and prior spinal fusion for scoliotic deformity with Harrington rod constructs from T1 to pelvis presented to the office with baclofen withdrawal symptoms secondary to a nonfunctional intrathecal baclofen catheter as diagnosed on pump interrogation. She also had signs concerning for an infection of her lumbar catheter site at the incision. She had an intrathecal baclofen pump initially placed for medically refractory spasticity and had undergone three prior revisions. Although tentatively scheduled to undergo a baclofen pump revision with an associated 5–7-h surgery that involved drilling through the Harrington rods to replace the intrathecal catheter, the patient went into moderate to severe baclofen withdrawal, prompting her to present to the emergency department with symptoms of worsening spasticity, tachycardia, and tachypnea with altered mental status. She was intubated and placed on a propofol drip for autonomic dysfunction syndrome and baclofen withdrawal.\nGiven her history of multiple pump failures and the added complexity of pump revision through a fusion mass, her small body mass, likely lumbar incision infection and autonomic instability, it was decided, she was risky candidate to go through a long surgery for a new lumbar catheter replacement, as detailed above. Oral baclofen was provided, but due to the high dose required by the patient, it was insufficient. Given the limitations of her anatomy and the infection concern, as well as the failure of oral baclofen to control her potentially lethal baclofen withdrawal, it was decided to proceed with placement of the catheter into the prepontine space in an effort to reduce the risk of it failing.\nThe patient was placed supine with her head turned to the left on a horseshoe head holder. An endoscopic third ventriculostomy (ETV) entry point was planned using the Stealth neuronavigation station. We used a C-shaped skin incision followed by an oval burr hole craniotomy with an acorn drill bit. The old baclofen pump was removed from the abdominal subfascial pocket and a new Medtronic Ascenda 8781 proximal catheter was tunneled from inferiorly to superiorly from the abdomen to this cranial incision.\nThe dura was opened with bipolar cautery and an 11-blade scalpel, using further electrocautery to cauterize the dura and the pia. On a single pass, we placed the 16-gauge sheath with the aid of neuronavigation to enter the right lateral ventricle. We then passed the MINOP Neuroendoscopy System into the right lateral ventricle through the sheath.\nThe endoscope was navigated into the third ventricle and an ETV was performed with forceps through the port [ and ]. A second pial opening was created slightly anterior to our initial pial opening and the distal baclofen pump catheter was then inserted into this opening and was advanced parallel to the MINOP. We visualized the entry into the right lateral ventricle. Using the endoscopic forceps and movement of the MINOP, we were able to guide the baclofen catheter into the third ventricle and then advanced it into the prepontine cistern under direct visualization [ and ].\nWe removed the MINOP making sure not to back out the catheter and removed the sheath. The intraventricular catheter was cut and measured to the appropriate length and the straight connector was used to connect the proximal and intracranial portions of the catheter. A dog-bone plate and screws were placed on the skull and a 2–0 silk tie secured the straight connector and the catheters. We filled a new 40 cc pump sterilely with 500 mcg/mL of intrathecal baclofen and it was programed to start at 100.1 mcg/day (compared to her preoperative dose of 998.9 mcg/day. The incisions were irrigated thoroughly with antibiotic irrigation and closed. The patient was then taken back to the intensive care unit intubated.\nPlacement in the prepontine cistern was confirmed by a postoperative computed tomography head. By the time, the dose was increased to 200 mcg/day, the patient was extubated, as she no longer showed signs of autonomic dysfunction and the spasticity in her upper extremities was significantly reduced.\nBy postoperative day 5, the patient was at a dose of 400.28 mcg/day and was discharged home with minimal upper and lower extremity spasticity (modified Ashworth scores of 1 in uppers and 3 in lowers compared to 4 throughout preoperatively).
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 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 47-year-old Caucasian male with a past medical history of schizophrenia, alcohol and drug abuse presented to an outside facility with symptoms of recurrent emesis and epigastric pain. Abdominal CT scan and chest X-ray in the emergency room revealed right pneumothorax and a chest tube was placed. Soon after, the patients went into septic shock and required vasopressors, IV antibiotics and mechanical ventilation.\nEsophagogastroscopy was deferred because of his instability. His blood cultures were positive for staphylococcus hominis. The following day a transesophageal echocardiogram to rule out valve endocarditis was negative. The patient appeared to improve on antibiotics but two days later his condition worsened again, and he was transferred to our facility. Upon arrival it was noted that there was copious thick mucinous output from the chest tube. A gastrografin study of the esophagus confirmed a sizable perforation at the lower esophagus (fig. A, ). Because of the appearance of a large esophageal defect with extensive pleural contamination, we did not consider stenting [–]. The patient was stabilized and taken to the operating room. A right posterolateral thoracotomy was done through the seventh intercostal space. The pleural space contained copious amounts of purulent fluid and gastric content which exuded from an exceptionally large esophageal defect in the lower third of the esophagus. The defect initially appeared to measure 5 × 3 cm in diameter, however after debridement of its necrotic edges it measured 9 × 4 cm (fig. A, ). Faced with the large defect, sepsis and delayed treatment, we entertained the idea of performing an esophageal exclusion surgery, however because of concern with his behavioral difficulties and the potential lack of compliance, we decided that a one stage attempt for definitive esophageal repair would be best for him. Because of his compromised status, we felt that he would not tolerate an esophagectomy and that an attempt to patch the large defect was justifiable. After careful debridement of the edges of the defect a bovine pericardial vascular patch (Edwards Lifesciences, model 4700, Irvine, Ca.) was tailored to the defect with an extra 2 cm around its edges and sewn using a running 3/0 prolene suture to the esophageal edges and surrounding mediastinal tissue for extra support. To further protect the pericardial patch repair, the greater omentum was mobilized using a separate upper midline abdominal incision, pulled through the esophageal hiatus and sewn using interrupted 3/0 Vicryl sutures to the tissues surrounding the pericardial patch repair (fig. C, ).\nGastrostomy and distal jejunostomy tubes were placed, and 2 nasogastric tubes were positioned proximal and distal to the esophageal repair. Two, size 32 chest tubes, were placed. Five days following his surgery and because of a worsening oxygen requirement, a chest CT was performed that showed an increasing right pleural effusion for which the patient underwent a redo thoracotomy and lung decortication.\nThe patient was removed from the ventilator 3 days after and continued to improve thereafter. An esophageal gastrografin study performed on day 24 showed no leak (fig. C). His nasogastric tubes were removed, and he was started on clear liquids. He was discharged to a rehabilitation facility 28 days postoperatively. At 6 weeks follow up he was fully recovered and was eating a modified esophagectomy diet. His gastrostomy and jejunostomy tubes were removed. At 8 months follow up he was eating a normal diet with no difficulty and no complications with an esophageal barium study showing rapid non-obstructed flow of diet to the stomach and an endoscopic view of the pericardial patch (figs. D and A, B).
A 16-year-old male patient was diagnosed with MPS II in infancy. Five years prior to presentation, when he was 11 years old, tracheostomy was performed to treat an airway obstruction caused by laryngeal stenosis secondary to his primary mucopolysaccharide storage disease. His tracheostomy hole gradually narrowed along with his physical growth, and granulation tissue developed around the tracheostomy hole. One week prior to presentation, at the age of 16 years, he was admitted to another hospital on an emergency basis for major dyspnea. He was diagnosed with tracheostenosis due to granulation at the tracheostomy site and treated with ventilation upon admission. Slight deviation of the position of the tracheal tube obstructed his airway. His previous doctor determined that it was difficult to continue treatment at their institute because no chest surgeon was available. Therefore, the patient presented to our institute by ambulance while undergoing ventilation therapy. We performed a computed tomography scan, which showed obstruction of the airway. The distance from the tip of the tracheal tube to the carina was about 2 cm because the tracheal tube was kept on the distal side of the granulation. Moreover, the patient had pneumonia of the right upper lobe due to the airway obstruction. We performed a bronchoscopic examination through the nasal cavity in the operating room under general anesthesia with the tracheal tube in place because of the risk of suffocation (). However, obtaining a peripheral view of the airway was difficult because of macroglossia, swelling of the tonsils, and MPS II-induced tracheomalacia. An image of the patient's airway is shown in . We also considered stent placement and laser treatment for airway management but selected the construction of a mediastinal tracheostoma. The mediastinal tracheostoma was created with extracorporeal membrane oxygenation. First, we created a U-shaped flap. The manubrium, clavicle heads, and first and second ventral ribs were resected to facilitate the approach to the anterior mediastinal space. We observed the mediastinum, which exhibited severe adhesion. Second, the innominate vein and artery were sectioned for safe exposure. We exposed the trachea on the head side of the innominate artery and vein. A Metzenbaum scissors was used to cut the trachea at the minimum required length for construction of the mediastinal tracheostoma. After we confirmed that no granuloma was present in the tracheal lumen on the peripheral side (), we intubated the trachea on the surgical field side. Third, we marked the mediastinal tracheal hole on the U-shaped flap. To maintain blood flow, the skin incision for the mediastinal tracheal hole was cut using a sharp scalpel and Metzenbaum scissors, without an electrotome (Figures and ). The skin and trachea were closed with 4-0 polypropylene interrupted sutures. Mediastinal tracheostomy was performed with an inlay thymus graft between the innominate vein and trachea (). The postoperative course was uneventful, and the patient was weaned from the ventilator on postoperative day 19. He was discharged at 1.5 months postoperatively. Although he was referred to another institution for respiratory failure associated with his primary disease 6 months postoperatively, his airway management was successful for 1.5 years postoperatively ().
A 49 years old male patient presented to the hospital with the complaint of difficulty in mastication and facial disfigurement for the past three years owing to carcinoma left buccal mucosa for which he underwent composite resection of mandible and reconstructed with Pectoralis major myocutaneous flap following preoperative chemotherapy and radiotherapy. On clinical examination, there was deviation of remaining mandible towards the resected site and also downward rotation of mandible. It was noted that intermaxillary fixation was not done at the time of surgery. The mandibular defect was classified as Cantor and Curtis type III[]. Since it was resected till the midline the deviation and downward rotation of mandible was more due to loss of muscular support. The mouth opening was 35 mm. Intra oral examination revealed generalized attrition, supraeruption and partially edentulous mandible. Patient was able to bring remaining mandible to centric occlusion with guidance and he was not able to achieve this position consistently. Since mouth opening was normal compared to previous case, an acrylic GF on maxilla was planned as interim prosthesis.\nImpression, cast, interocclusal record and articulation were made following the same procedure as in case report 1. Palatal GF prosthesis was planned for this case considering the stability of prosthesis, esthetics, occlusion and downward rotation of mandible. The guide flange extended till the lingual sulcus on the nondefect side. The prosthesis was tried in patient mouth. The inclination of the guide flange was adjusted until it guided the mandible to centric occlusion (Figure ). But as both maxillary and mandibular teeth were attrited, functional cusps were worn out. The mandibular teeth glided beyond centric occlusion. To prevent this and to train the patient in centric occlusion, the acrylic resin was extended on the palatal cusps of maxillary teeth. A functionally generated path was recorded and an occlusal table was fabricated accordingly so as to stabilize the occlusion. The occlusal table was also extended on the maxillary teeth of defect side to prevent supraeruption as there were no opposing teeth (Figures and ). The patient was recalled after a month for review.
47-year-old male presented to the cardiology out-patient department (OPD) with shortness of breath and chest discomfort on exertion since one week. Chest discomfort was related to exertion and relieved by rest. He has hypertension and hypertriglyceridemia controlled well on oral Amlodipine and Fenofibrate since one year. He does not smoke, drink alcohol, or use any recreational drugs. The patient gives past history of cutaneous sarcoidosis which was diagnosed by biopsy of the lesion one year back. He was evaluated for systemic sarcoidosis and was found to have hilar lymph nodes by computed axial tomography of chest and was advised for a follow-up CT after 6 months. The follow-up CT scan showed improvement and the patient was asymptomatic. Corticosteroids were not started at that time as the patient was concerned about the side effects of steroids on longterm. Hence he was advised for regular follow up. Three months after this evaluation, he presented to our OPD with the present symptoms. Physical examination did not show cutaneous lesions, his pulse was regular at 62 beats per minute and the blood pressure was normal. Cardiovascular examination revealed normal S1 and S2 with no gallop, murmurs, or rub.\nAt the time of presentation his electrocardiography (ECG) revealed sinus rhythm with a rate of 62 per minute with prolonged PR interval and right bundle branch block (RBBB) (). Cardiac enzymes were normal. He has undergone echocardiography and treadmill exercise test for the evaluation of his chest discomfort. His echocardiography showed normal left and right ventricular function without any regional wall motion abnormalities. His stress test showed poor chronotropic response and rate dependent 2 : 1 atrioventricular (AV) block occurring during the exercise test (). Exercise was terminated at 3.5 METS due to severe fatigue and second degree AV block in ECG. The ECG reverted to sinus rhythm in the recovery phase. He was taken up for a coronary angiography next day which showed normal coronaries. He was discharged from the hospital after coronary angiography but he presented 3 days later to the ER with recurrent episodes of syncope. His ECG showed complete heart block (CHB) (), with low ventricular rate and wide QRS complex. Chest X-ray does not show any hilar lymphadenopathy but showed cardiomegaly and pulmonary venous congestion ().\nHe has undergone urgent temporary pacemaker implantation. This was followed by permanent pacemaker implantation with Victory XL DDDR pacemaker (St. Jude Medical). He made an uneventful recovery. He remained asymptomatic afterwards. A workup for the autoimmune profile was normal, serum calcium was 8.6 mg/dL, and the serum angiotensin converting enzyme level was elevated. Pacemaker interrogation showed he is fully dependent on pacemaker at 2 weeks after discharge. He remained symptom-free following the procedure. He was evaluated by an internist and a dermatologist after the surgical wound was healed. Based on the clinical presentation and available reports he was started on immunosuppressive therapy with steroids. Presently his ECG shows sinus rhythm with RBBB and pacemaker on demand mode. He is doing well one year after the procedure.
Herein, we present the case of a 61-year-old Caucasian male patient, with no medical comorbidities or prior surgical history, who was referred as suspected acute appendicitis by his general practitioner to our surgical admissions team. His clinical symptoms comprised of an approximately 10-day history of pain in the right iliac fossa without alteration of his bowel habits, rectal bleeding or substantial involuntary weight loss. On admission, clinical examination revealed the presence of localized tenderness in the right iliac fossa, with absence of diffuse peritonism. In addition, a discrete mass was focally palpable in the right iliac fossa, with rectal examination being unremarkable. Baseline blood tests on admission revealed normal white cell and hemoglobin values and essentially normal biochemistry apart from a mild elevation of C-reactive protein (CRP) (40 mg/dL; reference level 0 - 11 mg/dL). The patient underwent a CT scan of his abdomen and pelvis for further diagnostic assessment. The latter detected the presence of a 17 cm fluid collection in the right iliac fossa, with another 5 cm collection located in the pelvis (, ). Overall, the radiological features were suggestive of an appendiceal abscess and hence the patient was scheduled for a diagnostic laparoscopy with explanation of a greater likelihood of conversion to an open procedure due to the extent of the collections.\nUpon entry into the peritoneal cavity, a large gelatinous mass was seen in the right iliac fossa, with nodular deposits in the right parietal peritoneal surface and further gelatinous cystic deposits in the pelvis. No further deposits were seen elsewhere during thorough laparoscopic assessment. The preliminary diagnosis of a locally advanced, mucinous colonic/appendiceal tumor with peritoneal metastatic disease was made and after consultation with a second senior colorectal surgeon, the decision was to convert to a midline laparotomy and proceed with right hemicolectomy and maximal tumor debulking. Apart from the right hemicolectomy (enabling en block removal of the right iliac fossa mass), we were able to achieve a complete cytoreduction with performance of infracolic omentectomy, right parietal and pelvic peritonectomy. The patient was transferred to the High Dependency Unit as per routine post emergency laparotomy protocol in our institution and had an uneventful post-operative recovery. He was discharged on the 10th post-operative day and he was further investigated on outpatient basis with a colonoscopy (normal), completion staging CT thorax (no metastases).\nInterestingly, the histology was consistent with primary peritoneal benign multicystic mesothelioma, as immuno-histochemistry essays were positive for cytokeratin MNF116, calretinin and negative for CD31 (-). The above-mentioned features characterized the right iliac fossa multicystic mass, as well as the deposits on the right parietal and pelvic peritoneum and a macroscopically visible cystic deposit on the resected infracolic part of the greater omentum. Taking into account the rarity of the histological findings, the patient’s case was discussed in our institution’s colorectal multidisciplinary team (MDT) meeting and subsequently it was discussed further in our regional mesothelioma MDT, as well as in the supra-regional peritoneal specialist MDT meeting. The consensus was to evaluate the patient with annual CT scan of his thorax-abdomen-pelvis, as well as tumor markers on periodical basis. The patient was reviewed 6 months after the operation in the outpatient clinic and was updated about the further surveillance pathway.
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 doctor-led air ambulance team attended an 86-year-old Caucasian male following attempted suicide by an abdominal stab wound. On assessment he was fully conscious, lying in a pool of blood, with a respiratory rate of 35, heart rate of 100, and systolic blood pressure of 60 mmHg. A chronically infected exposed vascular graft had been almost completely divided (left axillofemoral prosthetic graft, ). His legs were cold, pale, and mottled. Blood clot had formed at the site of injury, but following fluid resuscitation, the increase in blood pressure resulted in further bleeding controlled by placement of a proximal Spencer Wells clamp. Being a case of controlled rather than uncontrolled haemorrhage, hypotensive resuscitation was not practiced (for review see []).\nHistory revealed that the patient was housebound due to severe lower limb claudication. He refused hospitalisation as he believed medical intervention would require limb amputation.\nA decision to transfer the patient to hospital was made on the basis of his immediately life-threatening condition in the setting of a lack of capacity to consent to or refuse treatment. This decision was made as although the patient clearly was able to communicate refusal of transfer, this seemed to be based on an assumption that consenting to hospitalisation would inevitably lead to further operation including limb amputation. This was despite repeated attempts by ambulance crew members to reassure him that transfer would be provided to allow for better assessment of his condition, adequate resuscitation, and analgesia and only then would further management be considered and discussed with him. He had no next of kin to discuss this with, and his general practitioner was unknown to us. 1 mg boluses of midazolam were used to sedate and alleviate anxiety during transfer and fluid resuscitation continued into hospital. Assessment by vascular, anaesthetic, and intensive care consultants concluded that the patient was very unlikely to survive surgery. This, along with the patient's prior expressed wishes for no treatment, guided the decision to make no further attempts at resuscitation but rather to maintain his comfort. He passed away within three hours.\nWe subsequently discovered that the left axillofemoral graft replaced an infected right axillofemoral graft which itself replaced an infected abdominal aortic aneurysm repair, complicated by aortoduodenal fistulae. Due to advancing age and frailty, the infected left axillofemoral graft was treated conservatively for 8 years. He had been independent until shortly before his attempt at suicide when he had become housebound.
A 38-year-old gentleman was referred to our unit following debridement, plate fixation and pedicled gastrocnemius flap and split-thickness skin graft of a degloved open femur fracture on the right. He was referred three weeks post-initial injury. The patient initially presented to an out of region major trauma centre with a crush injury to his right thigh from a heavy goods vehicle. He was taken to theatre on the same day for exploration of the degloving injury where the femoral nerve and artery were both intact. The fracture was temporarily fixed with T-Plates. This was followed by a further debridement of the thigh two days later. On day four post-injury, the patient had an open reduction and plate fixation of a distal femur fracture with soft tissue coverage of a medial knee defect using a pedicled gastrocnemius flap and split skin graft.\nOn arrival, there was a large area of skin necrosis that extended from the proximal thigh and along the anteromedial border and lateral border of the femur, with an underlying deep soft tissue infection (). A healed, grafted gastrocnemius flap covered the medial aspect of the knee. A mature scar was visible on the lateral right thigh from a previous free tissue transfer for chronic osteomyelitis of the ipsilateral tibia five years prior to his current injury.\nRadiological imaging showed extensive comminution of the distal femur with malalignment of the posterior aspect of the femur and angulation of the fracture fragment (). Locules of gas were noted in the anterior compartment of the thigh with some subcutaneous oedema.\nRevision surgery was undertaken involving removal of all primary metalwork and radical excision of the distal femur and soft tissues, leaving a defect on the anteromedial aspect of the distal femur that extended from the proximal to the distal thigh. Bone fragments, soft tissue and pus specimens were sent for culture and sensitivity. Excision of the full thickness eschar resulted in a soft tissue defect on the anteromedial aspect of the distal femur that extended from the proximal to the distal thigh. Acute shortening and plate fixation of the femur through the pre-existing wound was carried out for fracture stabilisation, with a resultant 8 × 6 cm area of bone and exposed metalwork remaining.\nLocal soft tissue reconstructive options for this patient were limited, as the medial head of gastrocnemius had been harvested for soft tissue coverage of a medial knee defect at the time of the primary surgery. A free tissue ALT flap from the ipsilateral limb had been used to resurface the distal tibia in treatment for a previous osteomyelitis. Alternative free tissue transfer options were considered; however, concern was raised about a suitable donor pedicle with adequate length to allow for primary anastomosis. Intraoperatively it was felt that the distal pedicle of the sartorius muscle was large enough to support a muscle flap, and therefore, the decision was made to utilise the distal portion of the ipsilateral sartorius muscle based within the wound bed to cover the exposed metalwork and bone. Access to the muscle was made through the existing wound that was extended both proximally and distally to allow full access to the muscle at its proximal and distal insertion. A Doppler probe was used to identify the vascular pedicle. Suitability of the distal pedicle was assessed by vascular clamping, with Ackland clamps, of all other pedicles prior to transposition and inset. The muscle was then transposed and inserted. No evidence of vessel kinking was seen. Clamps were left on for 15 minutes, and the flap assessed by checking bleeding, contractility and colour. The remaining soft tissue was covered with a split-thickness skin graft harvested from the contralateral limb ().\nMicrobiology specimens showed growth of methicillin-resistant staph aureus and vancomycin–resistant enterococcus and acinetobacter radioresistens. On microbiology advice, the patient was treated with a 3-week course of intravenous meropenem and linezolid. This was followed by 3 weeks of oral co-trimoxazole. The patient had an uncomplicated post-operative recovery and wound review on day seven post-surgery showed 100% graft take (). The patient remained non-weight bearing for 12 weeks, and repeat X-rays at this time showed evidence of callus formation. The patient continues to be reviewed in the combined outpatient clinic until the bony union is achieved.
A 74-year-old Caucasian male originally presented to the headache clinic with 1-year history of right sided headache affecting the frontotemporooccipital region. It was daily persistent headache with a pain intensity of 4/10. The nature of pain varied between dull ache with short lived shooting in the right retroorbital area once or twice a week with occasional photophobia. There was no nausea or visual dysfunction. Postural changes or valsalva did not aggravate the headache. The headache failed to settle with analgesics. There was a previous history of migraine in his teens which varied in frequency and severity. The last episode of migraine was experienced 10 years ago. There was a positive family history of migraine with both mother and sister undergoing treatment presently. The patient had significant medical history of ischemic heart disease, diabetes mellitus, and COPD.\nThere was no clinical abnormality on routine head and neck examination. Detailed neurological examination failed to reveal any abnormality.\nThe differential diagnosis included hemicrania continua or chronic migraine. A trial of indomethacin with a starting dose of 25 mg was given and the dose was titrated slowly upward weekly depending on his tolerability and his INR. A non-contrast CT scan of the brain was carried out to rule out intracranial pathology.\nDuring the follow-up visits the headache had migrated to the rest of cranium. The CT scan showed age related cerebral atrophy with no intracranial abnormality (). Patient was reassured that no serious intracranial abnormality was identified and was treated with a diagnosis of migraine. The response to the standard prophylactic and therapeutic treatment for migraine was suboptimal and variable.\nSix months later, the patient presented with new symptoms of right sided odynophagia and dysphagia which were confirmed to be due to the advanced oropharyngeal carcinoma with cervical metastasis. A staging contrast enhanced CT scan of head, neck, and chest was performed which also identified a 4 cm enhancing mass in the right middle cranial fossa in keeping with a sphenoidal ridge meningioma (). There was mild surrounding edema but no midline shift was noted. The case was discussed in the multidisciplinary meeting and it was concluded that brain metastasis from the oropharyngeal cancer was unlikely. The patient underwent surgery with postoperative radiotherapy for his oropharyngeal cancer. Because of the serious comorbidity, surgical resection of meningioma was considered too risky and inadvisable. The patient will remain under serial radiological (MRI scan) surveillance for his meningioma. The headache is thought to be secondary to meningioma and pain is managed with standard analgesics.
A 64-year-old woman presented with left ptosis and facial palsy that occurred after she sustained a left forehead abrasion () due to a vehicle accident twelve days before her presentation to our hospital. History taking showed that ptosis occurred at nine days after the injury and left facial palsy () at twelve days after the injury without other particular symptoms. Upon her transfer to our hospital from her local hospital, initial assessment showed that her awareness and vital signs were normal. To identify other possible causal diseases or pathological findings, necessary tests such as blood test, urine test, cerebrospinal fluid (CSF) examination, chest radiography, brain computed tomography, and brain magnetic resonance imaging were performed but revealed no abnormal findings. She had no history of tetanus vaccination or tetanus infection. At fifteen days after the injury, trismus (so severe that she could not open her mouth 5 mm or more) and dysphagia occurred, and on the next day, dyspnea and catochus occurred, symptoms aggravated so badly that endotracheal intubation was performed. As cephalic tetanus was suspected, metronidazole for inhibition of active infection and midazolam for control of muscular spasm were administered. However, tetanus immunoglobulin was not administered because it was considered that it was too late to neutralize the toxin. To assess dysphagia at six weeks after the injury, videofluoroscopic swallow study was performed, and penetration and aspiration were detected (). After two weeks of rehabilitation for dysphagia, reassessment did not show penetration or aspiration (). At eleven weeks after the injury, electrodiagnostic study was performed to assess the left facial palsy. Nerve conduction study of the seventh cranial nerve showed normal compound muscle action potential, and needle electromyography of the craniocervical muscles showed no abnormal spontaneous activity. Blink reflex study, which was recorded on the orbicularis oculi muscle by stimulating the supraorbital nerve, showed no abnormal findings. Since then, symptoms improved and thus the patient was discharged after comprehensive rehabilitation such as electrical stimulation therapy for ptosis and facial palsy and swallowing rehabilitation for dysphasia.
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 31-year-old primigravida was referred for prenatal assessment at 37-weeks gestation due to concerns for hydrops fetalis. Her antenatal history was unremarkable. Fetal echocardiography [] demonstrated a 16 × 19 mm intracardiac right atrial mass without hemodynamic compromise. The great vessels were normally related, cardiac chamber dimensions were normal and there was no pericardial effusion or evidence of fetal hydrops. After counseling, the family decided to deliver at a tertiary care center. Labor was induced at 38 weeks and delivery was complicated by prolonged rupture of membranes. The newborn was 3015 grams with Apgar scores of nine and nine at one and five minutes, respectively. He was transferred to the neonatal intensive care unit where routine neonatal care was instituted.\nPreoperative cardiac imaging included a transthoracic echocardiogram [] and MRI []. There was a 19 × 14 × 14 mm-right atrial tumor with a broad base of attachment arising from the inferiomedial wall of the right atrium interposed between the inferior vena cava and tricuspid valve. There was otherwise normal intracardiac anatomy without shunting and no evidence of pericardial effusion. The patient remained hemodynamically stable and was taken for elective resection on day six of life.\nA median sternotomy was performed and cardiopulmonary bypass was initiated with ascending aortic and bicaval cannulation, followed by aortic cross-clamp and cardioplegic arrest. Once the right atrium was opened and there was conformation that the tumor did not invade the left atrium, a left atrial vent was placed via the right superior pulmonary vein. The tumor was located between the coronary sinus, inferior vena cava, and foramen ovale with a portion attached to the right atrial free wall just above the inferior vena cava []. The 2 × 2 cm tumor [] was sharply resected removing a portion of the right atrial wall and staying clear of the coronary sinus. The resected right atrium was replaced with autologous pericardium. Intra-operative transophageal echocardiography demonstrated a competent tricuspid valve and unrestricted flow in the right atrium. The patient was in sinus rhythm, weaned off cardiopulmonary bypass and extubated within 12 hours. The pathologic examination was consistent with a cellular capillary hemangioma with focal calcifications. The tumor was strongly immunoreactive for anti-CD34 and actin.
A 17-year-old male sustained high-voltage electrical injury to his left forearm due to contact with a live wire hanging from a generator van. He also sustained a laceration over the site of contact of the wire while untangling the wire. He gave no history of head injury or fall. No entry or exit wound was found. On exploration of the forearm laceration, soft tissue structures were normal. A distal third minimally displaced radius fracture was noted and fixed by percutaneous nailing. No other proximal fractures were found. The patient complained of loss of shoulder abduction, elbow flexion and extension and inability to extend his wrist and use his fingers, suggestive of a brachial plexopathy. Conservative management with rest to the affected shoulder and arm was instituted and patient followed up at 1 month. No corticosteroids were given. Physiotherapy was initiated and an electromyography was done which was suggestive of axonal degeneration involving median, axillary, musculocutaneous and radial nerves. Serial electromyography was performed at 8 weeks which reported no axonal regeneration. However, the patient had started regaining partial shoulder abduction, ulnar deviation of wrist and finger flexion at approximately 4 months after injury. He was posted for brachial plexus exploration at 6 months as his elbow flexion did not recover. On exploration, there was extensive damage with multiple thickened lobulations to long sections of median, musculocutaneous and radial nerves extending from their origins at the cords up to mid arm []. Rest of the plexus exploration was unremarkable []. No perineural fibrosis was noted. The surrounding tissue was surprisingly well preserved. Histopathology of the affected nerve segments showed fibrous tissue.\nLong Sural nerve cable grafts were harvested. A single 13 cm long nerve graft was placed between anterior division of C7 root and radial nerve at the cranial end of sternal head of pectoralis major []. Lateral cord to musculocutaneous and median nerve reconstruction was performed using 12 and 26 cm single long nerve grafts, respectively [].\nAfter post-operative immobilisation for 4 weeks, gradual physiotherapy was initiated. The patient was followed up with clinical examination regularly. At 8 months after surgery, the patient has MRC grade 3+ elbow flexion and 2+ elbow extension and 3+ ulnar finger flexion with almost no recovery of median supplied muscles. At 1-year follow-up, there is MRC grade 3+ power in pronator of the wrist and MRC grade 3 power of the finger flexors except the index finger. Extension at wrist and fingers is absent for which wrist fusion and tendon transfer are planned.
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 47-year-old lady presented to us with heaviness on the left side of the face since two months and loosening of the left 2nd molar tooth of recent onset. She had also noticed a foul smelling purulent nasal discharge from the left nostril since the past week. Her past history records revealed that she had undergone Caldwell-Luc surgery on the left side way back in the year 1984 for the removal of unilateral extensive polypoid disease. The family and personal history were not significant.\nHer general physical examination appeared normal without any obvious deformities or abnormalities. Oral cavity examination revealed the presence of a mobile upper 2nd molar tooth on the left side along with the presence of purulent discharge beside the teeth suggestive of an oroantral fistula. Posterior pharyngeal wall showed the presence of a thick postnasal drip. Her nasal cavity and paranasal sinus examination were essentially normal but for a mid-level deviation in the septum and tenderness elicited on the skin overlying the left maxillary sinus. All of her other systems seemed to be normal clinically. So with a diagnosis of recurrent maxillary sinusitis and an oroantral fistula in mind, we proceeded with plain computed tomography scan of the osteomeatal complex and the paranasal sinus, which showed opacification of bilateral maxillary sinus and amorphous area of bone density in the left maxillary sinus suggestive of osteoma (). Keeping the clinical picture in mind, we also thought of a primary malignancy of the maxillary sinus. Prior to any operative intervention, a thorough diagnostic nasal endoscopy was performed which revealed thick purulent discharge in the middle meatus (Figures and ). All the hematological and biochemical investigations were within normal range.\nIn order to alleviate the symptoms and reach upon a definitive diagnosis, we planned an endoscopic sinus surgery. A wide antrostomy was performed which revealed a brownish looking hard gritty mass surrounded by pus and polypoid mucosa (). Upon probing, the mass was freely mobile with no attachment to the antral wall. Since it was difficult to remove the antrolith endoscopically via the antrostomy, a repeat Caldwell-Luc procedure was done, and calculi measuring 2 × 1 cm was removed and sent for histopathology (Figures and ). An Endoscopic sinus surgery was performed on the other side. The patient was started on intravenous cefuroxime, and the patient recovered in the postoperative period uneventfully.\nCulture and sensitivity of the pus from the left maxillary sinus revealed growth of klebsiella spp.resistant to ampicillin and sensitive to most of the other parenteral antibiotics. The reporting on the intraoperative specimen turned out be a diagnosis of exclusion, since the possibilities of osteoma, malignancy, rhinoscleroma, and fungal concretions were ruled out after suitable decalcification procedures and Periodic acid-Schiff staining techniques. We were thus left a freely lying calcareous mass which was irregular in shape and not attached to any wall of the maxillary sinus, and thus logically we concluded it to be a sinolith/rhinolith in the left maxillary sinus, rephrased as an antrolith. This was confirmed by the effective decalcification of the mass which left behind only the organic matter.
A 14-year old male soccer player was referred to our orthopedic tertiary care referral facility as a result of failure to respond to non-operative management. He first experienced pain on the medial side two years prior that was noted after sports activities although no clear injury was identified. The knee was intermittently painful and with time these symptoms progressively worsened despite several attempts at non-operative management to include anti-inflammatories and physical therapy. The symptoms limited the ability of the patient to participate in sports. Physical examination revealed no effusion, complete range of motion, and no signs of meniscal pathology. There was no tenderness to palpation of the medial or lateral joint line, a negative McMurray, and a normal ligamentous examination. There was no pain with hyperextension, and the only positive examination finding was mild pain on hyperflexion. Radiographs were normal. Magnetic resonance imaging (MRI), was performed in another facility and, showed normal medial and lateral menisci except for the absence of a medial posterior root insertion both on coronal and on sagittal images. There was no evidence of meniscal extrusion or a meniscal ghost sign (Fig. ). On sagittal magnetic resonance images, the presence of thin low-signal band was identified just anterior to the ACL (Fig. ). Diagnostic arthroscopy was performed secondary to failure of nonoperative management and revealed a white rounded band that was noted to extend from the anterior horn of the medial meniscus to the intercondylar notch adjacent to the femoral insertion of the ACL (Fig. A). This band was clearly a distinct structure from the ACL with probing. Next careful examination of medial compartment revealed that the meniscus did not have evidence of tearing or degenerative changes and appeared to be floating into the medial compartment without the typical anterior bony attachment. The posterior horn showed absence of any firm bony attachment as well. Some fibers were detected below the anterior aspect of posterior cruciate running towards the lateral compartment (Fig. B). No chondral pathology was detected. Because of absence of meniscal lesions or other intrarticular abnormalities, we elected close observation rather than surgical intervention. The patient made rapid recovery after diagnostic arthroscopy and returned to his soccer activity after 2 months without any pain, discomfort, or limitation of activity. At 4-year follow-up, he had no symptoms or abnormal findings and he was still playing soccer at a youth competitive level. On the follow-up MRI there no meniscal or chondral lesions and no significative change of the appearance of the meniscal roots from the index MRI.
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 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 21-year-old female reported to the department of oral and maxillofacial surgery with complaint of a painless swelling in the mandible and posterior maxilla bilaterally [Figures –], left lateral wall of the nose and left knee joint for the past three years, which was growing slowly; swelling started in the mandible first then in maxilla and later in lateral wall of the nose and knee joint. Clinical examination and CT scan showed a diffused swelling in the mandible measuring 6 × 7 cm and diffused swelling in the posterior maxilla at the tuberosity region; on the right side it measures 4 × 2 cm and 2 × 2 cm on the left side, and lateral wall of the nose measures 1 × 2 cm and left knee measures 10 × 6 cm [Figures –]. Skin over the swelling was normal and pinchable, mouth opening was normal, teeth involved were mobile.\nCT scan was evident for a large non-homogenously enhancing mixed density lesion. An incisional biopsy showed numerous osteoclastic giant cells with fibroblastic proliferation and areas of hemorrhage were seen with no evidence of malignancy. The histopathological features were suggestive of reparative giant cell granuloma. Routine blood investigation like HB, BT, CT, ESR, total WBC count, platelet count, and biochemical examination like thyroid profile, serum calcium, parathormone levels, FBS, and urine examination for deposits and albumin was done. The blood and urine investigation showed normal values except for the hemoglobin, which was below normal value and wide increased in the parathormone levels []. Two units of pre-surgical blood transfusion and one unit of transfusion postoperatively were given to maintain the hemoglobin levels. Surgery was performed under general anesthesia; the mandibular tumor site was approached extraorally through bilateral submandibular incision along with chin sparing lip split technique. The mandibular mass was removed by segmental mandibulectomy, and bilateral maxillary mass was approached through the mandibular resected site and posterior maxillectomy done bilaterally till the clear pterygoid plates were seen and lateral nasal lesion was approached intra orally [Figures and ]. Reconstruction plate was used to maintain the contour of the mandible []; primary closure was achieved in the mandible [] and lateral wall of the nose, but posterior maxilla was left to heal by secondary intention. The resected specimen was sent for histopathological examination; the histopathological slide with eosin and hematoxylin section with 40× magnification diagnosed as Brown tumor []. The case was further referred to endocrinologist for further management of hyperparathyroidism and was reviewed for three years, which showed no signs of recurrence.
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 37-year-old man, a BITS Pilani graduate, was highly placed with a very heavy salary. He observed 11 years ago that his secondary sexual characters such as facial hair and voice were changing, for which he consulted a doctor without informing his parents. He was found to have low levels of testosterone and was treated with hormone replacement. However, no specific attempt was made to investigate the cause of his hypogonadism. At this point of time, his employers put him in a lower scale of work for unknown reason as the patient was living alone in a single room apartment. His parents thought that it could be due to depression as he was put in a lower cadre job. At this time, he was not communicating either with parents or friends but was continuously drawing. He drew excellent pictures of gods drawn in perfect accuracy with what he saw in books. They were symmetrical and very artistic [Figures -]. Some were colored and some black and white. They contained only gods and famous people. Later, he was found to be clumsy in movement and his artistic talents declined slowly over the next 1 year. At this point, about 5 years after the onset of his hormonal dysfunction, his boss called the parents and informed them that he needs care. He was put in lower cadre job as he was slow in his job and made errors and failed to carry out the targets. Later, they had observed that he was walking with lot of dancing movements and found to suffer from frequent respiratory problems. At this point, his parents suddenly realized that their son is indeed ill and met several doctors and finally 9 years after his illness came to us. At that time, we found him with marfanoid body proportions, generalized choreiform movements and features of severe apathy and executive function impairment, dorsolateral prefrontal involvement, medial temporal involvement in the form of recent memory problems. He was investigated for Huntington's disease, mitochondrial disorders, cerebral autosomal-dominant arteriopathy with subcortical infarcts, and leukoencephalopathy, immune-mediated disorders including complete vasculitic workup, voltage-gated potassium channel, N-methyl-d-aspartate, glutamate decarboxylase antibody, and complete neurometabolic workup, all were negative. His MRI showed leukoencephalopathy and atrophy []. Angiotensin converting enzyme levels were high, and therefore, the possibility of neurosarcoidosis was considered and the patient put on steroids and followed with azathioprine and symptomatic drugs. His choreiform movements improved very well. His cognitive deterioration got arrested. However, in spite of adequate precautions, he developed osteoporosis and fracture of right femoral neck which needed two surgeries. His primary illness remains stable.
A 43-year-old woman, with a history of splenectomy after traumatic rupture at the age of 7, was referred to our surgical department for plastic reconstruction of a postoperational scar at the left abdominal wall. Preoperative laboratory values were within normal limits. At surgery, we accidentally discovered two subcutaneous nodules that appeared to be immobile and firmly embedded in the subcutaneous fat tissue, whereas the underlying abdominal fascia and muscles appeared intact. The two dark red lesions measured 2.7 cm and 1.7 cm, respectively, and had a hard consistency, resembling with splenic tissue. Biopsy specimens were acquired from both lesions and the histological examination confirmed the presence of splenic tissue with white and red pulp, and no evidence of malignancy (). The connective tissue also appeared to contain blood vessels adjacent to splenic red pulp (). The red pulp consisted of a complex network of venous sinuses and cords of Billroth, which contain most of the splenic macrophages. The sinuses were lined by a particular type of endothelial cells (known as littoral cells) and had a discontinuous wall, which allows traffic of blood cells between cords and sinuses (). The above histological assay reveals that the splenic tissue performed normal splenic function, with absence of Howell-Jolly and Heinz bodies, siderocytes or other abnormal red blood cells. The architecture of the splenic tissue was well developed with nodules of splenic tissue separated by the connective tissue of the capsule (). The location of the ectopic splenic tissue strongly favored of the diagnosis of splenosis rather than accessory spleen, a significant clinical dilemma.\nIt is known that the diagnostic method of choice, before surgery and histological confirmation, is nuclear scintigraphy, a heat-damaged red blood cell scan []. As we incidentally discovered the nodules, we did not have the opportunity to perform such an examination, so, we only performed a postoperative ultrasound examination, to examine for more nodules in other regions of the abdominal or thoracic cavity. The ultrasound revealed no other mass. The nodules were not further excised, as no further work up is necessary, once splenosis is confirmed, unless the patient is symptomatic.
An 82-year-old man incidentally presented with a protruded shadow adjacent to the aortic knob in chest radiography during an assessment of the renal dysfunction. Computed tomographic scanning revealed a fusiform-type aneurysm with a diameter of 56 mm in the distal aortic arch. Aneurysmal change extended to the aortic arch around the origin of ARSA and the left subclavian artery. The patient was found to also have a common carotid trunk and an ARSA independently originating from the back of the aortic arch distal to the left subclavian artery. This artery passed behind the esophagus and trachea and connected the axillary artery through the right side of the thoracic vertebra (). Bilateral vertebral arteries ordinarily arose from the superior aspect of the central subclavian arteries. We applied the open repair but not the endovascular repair and decided to perform total arch replacement in combination with frozen elephant trunk and reconstruction of bilateral axillary arteries via the extraanatomical bypass. The occlusion of proximal ARSA was planned just at the right side of the thoracic vertebra in the right pleural approach to avoid troublesome procedures in the deep mediastinum.\nSimultaneous preparation for bilateral axillary artery accesses was performed, and a standard median sternotomy was then made. Two pieces of 9 mm vascular grafts (J graft, Lifeline, Tokyo, Japan) were sutured to the bilateral axillary arteries respectively in an end-to-side fashion, and cardiopulmonary bypass was initiated with perfusion via these arteries and atrial drainage with a two-staged cannula. The right pleura was opened during the temporary cessation of mechanical ventilation. The ARSA was easily identified just at the right side of the thoracic vertebra and encircled with a vascular elastic band following the division of the parietal pleura (). After systemic cooling, the systemic circulatory arrest followed by aortic opening was then performed with a rectal temperature of 22.9°C. Antegrade selective cerebral perfusion was started through vascular grafts connected to the bilateral axillary arteries and perfusion catheters directly cannulated into each right and left common carotid artery. The ARSA was occluded using a surgical clip (Hem-o-lok, Teleflex, Tokyo, Japan) along the previously placed elastic band through the pleural approach. The left subclavian artery was ligated at the beginning. The aorta was transected between the common carotid trunk and the left subclavian artery, and a 29 mm stented graft (Frozenix, Lifeline, Tokyo, Japan) was inserted. Its stump was anastomosed to a 26 mm four-branched graft (J graft, Lifeline, Tokyo, Japan). The systemic circulation was resumed with a 9 mm side branch of the four-branched graft, and the common carotid trunk was anastomosed to the first 11 mm side branch. After the grafts connected to the axillary arteries were passed into the mediastinal space, bilateral axillary arteries were reconstructed via the extraanatomical bypass using second and third 9 mm side branches of the arch graft. The cardiopulmonary bypass was terminated after sufficient rewarming.\nThe mechanical ventilator support was 16 h, and thereafter, the patient experienced an uneventful postoperative course. Postoperative computed tomographic findings showed good reconstruction of the aortic arch and successful bloodstream to the bilateral carotid and subclavian arteries ().
A 52-year old male patient was admitted to the Department of Rehabilitation Medicine at our hospital with a complaint of severe sudden back pain and a radiating pain in the right lower extremity, which had gradually developed for 2 months prior to the visit. His medical history revealed that he had partial gastrectomy because of a gastric adenocarcinoma that was diagnosed about 3 years ago, and he was being treated with oral medication for his type 2 diabetes, which was diagnosed about 1 month ago. He had no medical history of diseases including hypertension, tuberculosis or hepatitis. He also had no recent history of overseas travels or eating raw meat, and there was no evidence of specific family history. The patient worked as a farmer and also raised cows.\nFrom the physical and neurological examination conducted at the time of his admittance, the patient was found to be normal in the manual muscle power test and the deep tendon reflex of upper and lower extremities on both sides. However, in the sensory test, hypesthesia was found in the L5 dermatome in the right lower extremity. The lumbar range of motion was slightly limited due to the pain in the left lateral flexion, rotation, and the ends of the extension. In the L4 and L5 spinous process, tender points were found, and the degree of pain was found to be 9 out of 10 on the visual analogue scale pain score.\nLaboratory findings on the peripheral blood test () showed a raised erythrocyte sedimentation rate (ESR) of 56 mm/hr, and C-reactive protein (CRP) was raised to 1.2 mg/dl. However, no abnormality was observed in other biochemical tests and there were negative findings in the blood culture.\nNormal findings were observed in the needle electromyography test, nerve conduction study and sensory evoked potential test (), and lumbosacral spine plain radiographs, whole body bone scan, and lumbosacral spine MRI were also conducted. Lumbosacral spine plain radiographs () showed an erosive change of the anterior portion of L4 and L5. Whole body bone scan with 99 mTc dicarboxypropane diphosphonate (DPD) () showed an increased radioisotope uptake in L5. Lumbosacral spine MRI () showed low-signal intensity in L4, L5 and S1 vertebral body from the T1 weighted image with contrast enhanced and heterogenous high-signal intensity in T2 weighted image. Also, endplate injury in the anterior portion of L4 and L5 vertebral body and contrast enhanced in nearby soft tissues were observed, indicating the possibility for infectious spondylitis, and L3-4, L4-5 herniation of intervertebral disc findings were observed.\nA medical consultation with the Infection Internal Medicine department using CT guided aspiration biopsy, tuberculosis bacillus culture test, molecular genetic testing of tuberculosis bacillus, blood culture test, and brucella antibody test were conducted. The titer of brucella antibody was measured as 1 : 320 and the patient was diagnosed with brucellar spondylitis. He was transferred to the infection internal medicine department and SDR combination therapy mixed with streptomycin, doxycycline and rifampin was injected intravenously 1g daily for 15 days. Following that, 100 mg of it was administered twice a day for 45 days orally, followed by the dosage of 15 mg/kg (600-900 mg/day) being administered once a day orally for 45 days. The follow-up observation reported improved symptoms and back pain.
A 35-year-old young adult male presented to our department with pain over lower one-third of the right arm. Detail history taking revealed that the patient was a chronic smoker and alcoholic who sustained a compound fracture of the right shaft humerus 1 year back for which he underwent interlocking nailing at some private center. He further told us that the operating surgeon did iliac crest bone grafting 6 months after the initial surgery when no signs of union were evident. However, in spite of that, no signs of union were seen and he had persistent pain at fracture site when he used to perform household activities. He again went to the operating surgeon who referred the patient to our center. We got the anteroposterior and lateral X-rays done which revealed atrophic non-union at fracture site with one locking hole proximally and one distally (). The nail seemed to be of appropriate diameter well seated in the medullary canal and removal of nail would have caused more damage to the rotator cuff. The patient was in a lot of mental trauma after the failed previous two surgeries, so he was counseled properly, and the decision was made to apply a locking compression plate (LCP) with nail in situ with iliac crest autogenous bone grafting. The patient being a chronic smoker and alcoholic was told that both smoking and alcohol cessations were mandatory before any definitive procedure and he agreed to that. After the preanesthetic checkup clearance, the patient was taken up in the theater; fracture site was opened posteriorly using triceps-splitting approach. As expected, there was rotational instability at the fracture site and no signs of callus formation were seen. The fracture margins were freshened till bleeding bone was visualized, fibrous tissue cleared, and locking compression with two monocortical holes on each side was applied along with bone graft harvested from iliac crest. Immediate post-operative anteroposterior and lateral radiograph were obtained ( and ). After the stitches were removed and wound healed satisfactory, the patient was given shoulder spica to further ensure immobilization (). Shoulder spica was removed after 1 month and aggressive physiotherapy was started. Follow- up at the end of 6 months showed solid union at fracture site () and excellent range of motion ( and ).
A 72-year-old male with a history of hyperlipidemia and Type 2 diabetes mellitus presented to the emergency department of the Community General Hospital (CGH) with generalized malaise and some difficulty with reading for one week. The malaise was first noted by the patient and he had consulted his primary care provider (PCP). The PCP had ordered his blood test including complete blood count, random blood sugar, basic metabolic panel, and thyroid stimulating hormone. The PCP discharged him after excluding any serious illness. However, the patient continued to feel the generalized malaise and a reading difficulty and thought that he needed glasses.\nWithin two weeks, the patient noticed that he was not able to do daily activities as before. His wife noticed that he has some extent of confusion and delayed response. She also noticed that the patient was not as active as before. She convinced the patient to visit the emergency department at CGH where he underwent CTA and MRI of the brain with and without contrast. The MRI in Figure revealed an acute infarction of the left occipital lobe with the involvement of the splenium of the corpus callosum and posterior thalamus.\nAfter these findings, the patient was transferred to Upstate University Hospital for a higher level of care. On the day of admission, he was alert and oriented. The optic discs were normal. He was noted to have right-sided homonymous hemianopia in both eyes. Both the pupils were equal, round, and reactive to light. His extraocular eye movements were full with no nystagmus. He was found to have an inability to read written words and phrases even though his ability to write was found to be intact. The rest of his neurological examination including language, sensory, and motor functions were intact. A magnetic resonance imaging of the brain performed on the prior day had revealed an acute infarction of the left occipital lobe extending into the splenium of the corpus callosum and posterior thalamus. The cerebral angiogram revealed an acute infarct in the territory of the left posterior cerebral artery and an incidental finding of high grade left internal carotid artery stenosis.\nHe was admitted into neurology inpatient service to find out the cause of the stroke and for treatment by standard stroke protocol. The hospital course was uncomplicated and was not accompanied by any new findings. His symptoms of generalized malaise improved but the right homonymous hemianopia remained unchanged. Meanwhile, all the workup for revealing an etiology of the stroke came negative including transthoracic as well as a transesophageal echocardiogram. The patient was discharged and put on telemetry for continuous monitoring of any paroxysms of atrial fibrillation.
A 61-year-old female reported to the department of oral and maxillofacial surgery with a swelling in the left posterior part of the palate for 2 years. The swelling was nonpainful, gradually increasing in size, and firm in consistency, with few areas of superficial ulceration. It was extending from tooth 24 to 28 with no mobility of associated teeth. The swelling was approximately 5 cm × 3 cm and partially crossing the midline []. On palpation, the margins of the swelling did not seem to be fixed to the underlying bone rather it appeared to be attached to the palate by a peduncle. The undersurface of the swelling bled upon palpation. Mucosa covering cheek, tongue, and floor of the mouth appeared to be healthy and no gingival hyperplasia was observed in the areas where teeth were present, though they were periodontally compromised. Generalized gingival recession was present along with multiple root stumps in upper and lower jaws. The patient lost multiple teeth due to her ignorance and access to tooth-saving modalities.\nFamily history did not reveal any significant finding. Her past medical history revealed that the patient was hypertensive for the last 15 years and was under medication (amlodipine 5 mg, once daily). Hematological investigations were noncontributory to the diagnosis. Radiological examination showed no remarkable bone loss in the palate but significant bone loss due to chronic periodontitis in the areas, where teeth were present.\nA provisional diagnosis of pyogenic granuloma or pleomorphic adenoma was made on the basis of clinical and radiological findings.\nAn incisional biopsy was done in the department of oral surgery and biopsied tissue was sent to the department of oral pathology for histopathological examination. The tissue submitted showed overlying stratified squamous epithelium with abundant collagen bundles in the connective tissue stroma. The whole architecture of the underlying connective tissue was obliterated by haphazardly arranged collagen bundles in the stroma. No salivary gland was identified and not many blood vessels or endothelial proliferation were seen []. The biopsied tissue appeared to be taken very superficially from the lesion, and a request of repeat biopsy was made to the operator.\nAfter a week, repeat biopsy was performed at a different site of the swelling and again the tissue was sent to us for confirmatory diagnosis. Histopathological findings were similar to the initial one, but the only difference this time was the presence of few atypical cells in the deeper connective tissue of the biopsied material []. An impression of again not reaching into the deep-seated pathology was made.\nAgain, a humble request of repeat biopsy was made, and this time, the surgeon did an excisional biopsy under general anesthesia. To our surprise, it came out to be low-grade mucoepidermoid carcinoma. The tissue showed areas of cystic degeneration, atypical mucous cells, and pooling of mucin into these cystic spaces. Tumor cells showed hyperchromatism and enlarged nucleoli. Few islands of epidermoid cells were also seen []. The excised tumor appeared to be well cradled by the proliferative collagen mass all around the tumor cells. Another very important finding which the operating surgeon gave every time while conducting biopsy was the excessive bleeding and uncontrolled high blood pressure during biopsy procedures. This finding along with the drug history of the patient was absent in the requisition form every time and we could not correlate collagen hyperplasia with drug use. And finally, when we kept all pieces of jigsaw puzzle together, the picture came out to be low-grade malignancy in the cradle of amlodipine-induced unilateral atypical palatal hyperplasia.
An 11-year-old elite level male tennis player presented for evaluation of acute right knee pain after jumping and landing on his feet during a tennis tournament. The patient was accompanied to clinic by his father, who reported immediate pain, swelling, and locking of his knee after landing. He was unable to continue participation or bear weight on the affected leg. The patient denied any history consistent with patellar subluxation or dislocation. At the time the patient was the number two ranked tennis player in the United States for his age, and had traveled across the country to compete against players from all over the world. He was otherwise healthy and had no significant past medical, surgical, or relevant family history. He was a very active competitive athlete in the seventh grade.\nThe patient was first evaluated at an outside facility, where MRI demonstrated a large chondral defect sitting in the femoral notch. He subsequently was referred to a pediatric orthopedist who placed him in a knee immobilizer, recommended not to bear weight on the affected side, and referred the patient to see us in the orthopedic sports medicine clinic. The patient was 5 feet 1 inch tall, and weighed 44.6 kg at the time of examination. On physical exam, his right knee demonstrated a mild effusion. Range of motion testing was deferred to avoid further cartilage damage; however, the patient was comfortably resting at approximately 90° of flexion and reported being able to bear weight on the right leg. He was neurovascularly intact. Examination of the contralateral knee was within normal limits, with range of motion negative 3–135°.\nRadiographs obtained were normal without fracture or dislocation ( and ). MRI demonstrated a 22 × 20-mm chondral defect originating from the lateral femoral condyle that was now sitting in the femoral notch ( and ). Likewise, the lateral femoral condyle showed a full thickness defect with no evidence of injury to the subchondral bone (). There was no evidence of injury to the patellar cartilage or medial soft tissue restraints to suggest acute patellar dislocation. A lengthy discussion was had with the patient and father regarding the significance of this injury and need for surgical fixation to maximize both short and long term functional status of his knee. Consent for surgery was obtained and scheduled for 6 days after initial consultation. We stressed the importance of maintaining a non-weight bearing status to his right lower extremity in the interim to minimize risk of further damage to this loose cartilage fragment.\nThe patient was taken to surgery. An exam under anesthesia was then conducted. He was stable to varus and valgus stress and could achieve full extension. Flexion was not tested to protect his loose fragment within the knee. A diagnostic arthroscopy then took place. He was found to have no cartilage damage to the undersurface of the patella. No loose bodies were noted in the suprapatellar pouch, medial or lateral gutters. He had full-thickness cartilage loss of almost the entire upper lateral femoral condyle ( and ). It did have full shoulders around the edges, where the cartilage was lost. It was greater than 2 × 2 cm. No cartilage damage was found to the rest of the lateral femoral condyle or the lateral tibial plateau. No cartilage damage to the medial femoral condyle or medial tibial plateau was appreciated. The medial and lateral menisci were intact without tears. Moving to the notch, the ACL and PCL were intact. The entire cartilage fragment was in one piece and sitting in the notch ( and ). Next, curettes were used to scrape away the calcified layer over the exposed bone from the donor site of the cartilage on the lateral femoral condyle. The cartilage piece was then reduced and held in place with k-wires (). Fixation was achieved with three absorbable Biotrak Helical Nails© (Acumed, LLC, Hillsboro, Oregon, USA) in a triangular fashion to the underlying subchondral bone (). The piece was then probed and found to be stable. Temporary fixation pins were removed, and the knee was ranged through a full arc of motion. The patella was observed to track well over the fixed piece. He was placed in a knee brace locked in extension immediately postoperatively.\nThe patient was discharged from the hospital the same day with crutches and strict non-weight bearing status, using the brace during ambulation. The patient returned to clinic 2 weeks postoperatively where sutures were removed, and a continuous passive motion device was given to help improve his knee range of motion. He was given no restrictions to knee range of motion. At 6 weeks postoperatively the patient was allowed to begin bearing weight on his right leg with the brace locked in extension using crutches. Formal physical therapy was initiated at this time. At 8 weeks postoperatively the patient was allowed to walk with his brace unlocked with the assistance of crutches. At 10 weeks postoperatively he began walking in his brace without crutches. At 3 months postoperatively the patient reported beginning to hit tennis balls with his feet flat on the ground without pivoting on his right leg. At 4 months postoperatively the patient had weaned out of his brace and continued to hit tennis balls from a stationary position. He was allowed to slowly increase his activities at this time starting with a light jog and subsequently cleared to return to full activities at 6 months postoperatively.\nBy 7 months postoperatively the patient had played in two tennis tournaments, winning the second tournament. The patient was seen again 10 months out from his surgery and had recently returned from playing a clay court tournament in France. His right knee range of motion was −3° to 140° and symmetric to the contralateral side. He had full quadriceps and hamstrings strength and complained of no pain or swelling. The patient returned to competitive sports; however, several months later he began complaining of some posterior right knee pain as well as intermittent swelling. MRI was obtained, now a year and a half out from the initial surgery, which showed a posterior medial meniscus tear with maintained reduction and apparent incorporation of the previously fixed chondral fragment ( and ). He subsequently underwent repeat right knee arthroscopy and medial meniscus repair. At the time of arthroscopy (1 year, 9 months from the index procedure), the site of chondral fixation was found to have excellent incorporation with a nearly anatomic articular surface ( and ). He rehabbed appropriately and recovered well from this injury. At final follow-up (2 years, 7 months) the patient had no pain, ranked in the top five nationally for his age, and continued to compete at an international level.
The patient is a 43-year-old woman who presented with a large pelvic mass and was admitted to Shandong Cancer Hospital and Institute in June 2006. Her only complaint was lower abdominal pain. Pertinent past medical and surgical history include: benign hypertension for 2 years, prior cesarean delivery, prior hysterectomy, and inferior vena cava filter placement approximately three years prior for history of venous thrombus.\nThe patient reported undergoing a total hysterectomy and bilateral ovarian cystectomies for uterine fibroids 3 years prior to this presentation at a local hospital. Pathologic review of this specimen shows uterine IVL based on the Immunohistochemical staining profile and <5 mitotic figures per 10 high-power fields. Additionally, in April 2006, three months prior to her current presentation, the patient was diagnosed with a pelvic mass with complaints of lower abdominal pain and underwent a resection of an ovarian cyst and right salpingectomy. The histopathological assessment of the specimen was an ovarian endometriosis cyst and right hydrosalpinx.\nAt the time of presentation, gynecologic bimanual exam revealed a palpable mass in the right pelvis, measuring approximately 10 cm × 10 cm × 8 cm. It was firm and non-tender to palpation. The mass appeared to invade the rectovaginal space and extend beyond the pelvis into the abdomen.\nContrast-enhanced computed tomography (Fig. ) of the abdomen and pelvis demonstrated a large soft tissue mass with partial cystic degeneration, measuring 25 cm × 13.5 cm × 7 cm. The mass was noted to be surrounding the right external and internal iliac veins, right common iliac vein and distal IVC. It was in close proximity to the right common iliac artery and abdominal aorta up to the level of the right kidney. Doppler ultrasound showed that tumors blood supply was likely originating from the iliac artery.\nBased on the physical exam and radiological findings, combined with the medical history, a preliminary diagnosis of intravascular leiomyoma was made with extension into the right iliac vein and IVC. The recommended treatment was surgical resection. The patient was counseled that surgery would include en bloc resection of the mass with vascular grafting of the distal IVC and common iliac vessels as needed.\nSurgery was performed under general anesthesia on July 5, 2006. Upon abdominal entry, two large masses were noted in the right retroperitoneum. One mass was abdominal and measured approximately 20 cm × l8 cm × 10 cm. This mass encased the distal IVC,the right common iliac vein and right external and internal iliac veins. It was closely adherent to the right internal iliac artery. The other mass measured approximately 10 cm × 10 cm × 8 cm and was adherent to the bladder wall, pelvic floor, and right iliac veins. Upon further exploration, the two masses were connected as a single tumor in a dumb-bell shape. The right external and internal iliac veins, right common iliac vein and IVC were completely occluded by the tumor. The right internal iliac and common iliac arteries were dissected off the tumor. The right internal iliac vein was ligated distal to the tumor. The tumor was dissected off the pelvic sidewall. Next the distal IVC and right external iliac vein were ligated. Finally, the left common iliac vein was ligated to free all venous attachments from the tumor and obtain a surgical margin. The tumor had a predominant blood supply from a single pedicle which was divided and the tumor removed en bloc. The en bloc resection included the distal IVC with proximal left common iliac vein, entire right common iliac vein, and proximal portion of the right internal and external iliac veins. An 8 mm expanded polytetrafluoroethylene vascular graft (by Bard Medical) was placed to reconnect the distal IVC to the left common iliac vein with 4-0 Prolene suture to restore venous return to the left lower extremity and pelvis. Given that the patient had developed significant collateral flow with no right extremity edema or venous stasis, the right iliac veins were not reconstructed. Removal of the tumor was challenging with an estimated intraoperative blood loss of 5.0 L. In total the patient was transfused 32 units of packed red blood cells and 2.0 L of plasma. Postoperatively the patient was closely observed for distal pulses, evidence of edema, and lower extremity compartment syndrome.\nPostoperative pathology confirmed this mass to be an intravenous leiomyoma arising from the right internal iliac vein (Fig. ). Immunohistochemistry shows the endothelial cells to be positive for CD31, CD34, Vimentin and smooth muscle actin. The cells stain negative for cytokeratin with low expression of p53 protein and high expression of progesterone receptor and Bcl-2.\nThe patient was managed postoperatively on anticoagulation and given nutritional support with intravenous nutrition until able to tolerate oral intake. She ultimately recovered from the operation and was discharged in a stable condition on postoperative day 20.\nEight months following her surgical resection, the patient represented complaining of an enlarging abdomen and frequent urination. She was readmitted to hospital in March 2007. Clinical examination revealed a mass measuring approximately 6 cm × 6 cm in the left pelvis. CT examination revealed a soft tissue mass close to the previously resected tumor involving the right internal iliac vessels, measuring 3.5 cm × 4 cm × 4 cm. A separate mass was also seen posterior to the bladder on the left, measuring 3 cm × 5 cm × 6.5 cm (Fig. ). This was felt to represent a pelvic recurrence of IVL. The patient was deemed to not be an operative candidate given deconditioning from the prior surgery. Three-dimensional conformal radiation therapy was performed for tumor control. External beam radiation was planned using an ADAC Treatment Planning System, delivered with 15MV X-ray from a Varian 21EX (Palo Alto, CA) and designed from CT scans. External irradiation was 2.0 Gy daily fraction, 4 fractions per week, the total dose of radiation was 4500 cGy.\nFollowing radiation therapy, the patient was followed closely. A subsequent CT scan in October 2010 demonstrated a pelvic mass on the right of the bladder and rectum. It was again felt to be surrounding the distal IVC and iliac blood vessels. The largest cross-sectional area was 4.0 cm × 2.0 cm (Fig. ). This lesion was not further treated, but followed with serial imaging and resolved. At most recent follow-up 8 years after radiation therapy in July 2015 the patient remains without evidence of recurrence on physical examination and CT images (Fig. ).
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 six-year-old girl was referred for a facial trauma to the UOC of Odontostomatology at University Hospital of Parma (Italy). The patient presented with a minor skin lesion in the chin area, only requiring a superficial medication (). She was affected by a mild pain and limitation in mouth opening (), without any problems in general health condition.\nAn orthopantomography was taken as the first diagnostic imaging and the fracture line was clearly identified, running outside the capsular area and involving the condylar neck at the edge between the neck and the mandibular ramus. Despite the largely affected area, the vertical dimension and the occlusion were preserved and the cranial piece of the fracture was not widely dislocated from the caudal one, probably due to the integrity of the periosteal layer ().\nAs a treatment solution, the orthodontist, together with the maxillofacial surgeon, decided to avoid the ORIF approach in favor of a modified CRT sequence.\nThe caudal fragment ensures insertion for the masseter and temporalis muscle, while the cranial fragment ensures insertion for the lateral pterygoid muscle. In this condition, early intense mobilization, as prescribed in the classic CRT, may cause further displacement of the cranial fragment [–]. Accordingly, a modified CRT sequence was performed, consisting in a delayed treatment with full functional exercises regimen, in order to allow the fibrous callus formation.\nInterestingly, the functional therapy was not adopted to permit regeneration of condylar head and bone remodeling, but to maintain the functional integrity of the joint during the growth.\nWe first prescribed a week of functional minimal activity, soft diet, and FANS when needed for pain control. At the end of the first week, it was decided to start a modified CRT sequence for another week. Such sequence consists in the same functional exercises as in the classic CRT, but performed in a mild way. The patient was advised to move the mandible slowly, to avoid any pain, and to not try to improve the magnitude of the movement. After this phase promoting osseous union, the classic functional therapy was prescribed, including both full exercises and functional removable appliance ().\nThe functional appliance maintained the mandible in a therapeutic position in protrusion and contralateral deviation and was prescribed by night. The series of functional exercises was suggested for 15 minutes, four times a day. The prescribed functional exercises were (A) maximum mouth opening, (B) maximum protrusive movement, and (C) maximum right and left lateral movements. The extension of these exercises was prescribed to the limit of the pain, maintaining the movement symmetry and trying to improve the range day by day. The modified CRT sequence was carried on for six months with good results in terms of jaw mobility () and a radiographic control was performed. In the new orthopantomography, the two fragments appeared perfectly jointed and the fracture line was no more visible ().\nThe removable functional appliance was then interrupted and the functional exercises were continued for a further period of six months ().
A 36-year-old-male with no significant medical history was brought into the emergency department by ambulance after being involved in a motor vehicle accident. He stated that he had experienced sudden onset of left sided numbness and weakness while driving, and lost control of the car. On admission, he was alert and oriented but had a mild expressive aphasia. His vital signs were stable. Heart sounds were regular with no murmur. The chest x-ray showed no signs of intrathoracic injury. The initial head CT scan was negative. No carotid stenosis was found by ultrasound. Transthoracic echocardiography showed left atrial mass and subsequently performed transesophageal echocardiography confirmed a large pedunculated mass in the left atrium protruding into the left ventricle though the mitral valve (Fig. ). There was no mitral valve regurgitation. He was admitted to the intensive care unit for monitoring. Cardiothoracic surgical consultation was obtained.\nA repeat head CT obtained 24 hours later showed a large acute infarct in the right middle cerebral artery distribution with diffuse surrounding edema (Fig. ). There was a small lesion highly suggestive of hemorrhage within the infarcted area. The risk of hemorrhagic transformation of the stroke was considered to be high with heparinization for cardiopulmonary bypass, which is necessary for removal of myoxma, so surgery was postponed until the risk of neurological complication during open heart surgery become relatively low. Over the next 2 weeks in the hospital, he had persistent left sided hemiplegia; however, he did not develop any additional neurological events. He was discharged to a rehabilitation facility and electively scheduled for resection of the left atrial mass 4 weeks after the embolic stroke, when the risk of a catastrophic neurologic event from anticoagulation was considered to be reduced.\nThrough a midline sternotomy, the left atrial mass was approached via the groove of Sondergaard, after the patient received 300 units per kg of heparin for cardiopulmonary bypass. A left atrial tumor arising from the atrial septum was successfully resected (Fig. ). The defect of the septum was repaired with an ePTFE patch. After resection of the left atrial tumor, intraoperative transesophageal echocardiography disclosed severe mitral regurgitation (Fig. ). Cardiopulmonary bypass was reestablished, and the mitral valve was examined. The mitral valve was found to be moderately thickened with a dilated annulus. There was a large central regurgitant jet through poorly coapted mitral leaflets. The subvalvular apparatus appeared to be normal. Mitral annuloplasty was performed with a complete ring (Carbomedics 28 mm complete ring). With this ring annuloplasty, excellent coaptation of the mitral leaflet was achieved and there was no residual mitral regurgitation. The patient was weaned off cardiopulmonary bypass without difficulty. His postoperative recovery was uneventful. He was discharged to skilled nursing facility on postoperative day 10. Pathological review of the specimen confirmed cardiac myxoma.
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 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 24 year old woman presented in her 6th month of her first pregnancy with light headedness and dizziness at rest and imbalance during walking of 2 weeks duration. Her pregnancy has been thus far uncomplicated. Prior to her pregnancy she had been in good health with no medical history or cardiac problems. She was very active, working full time, swimming, and playing softball. On her review of system, the patient reported that her heart rate had always been slow even after strenuous physical activity but denied ever seeing a cardiologist or having an electrocardiogram (ECG). Her family history was negative for any cardiac or connective tissue disorders.\nUpon presentation, her ECG demonstrated second degree Mobitz type 1 atrioventricular (AV) block with intermittent complete heart block and a ventricular rate of 32 beats per minute. She underwent an echocardiogram which ruled out the presence of any structural cardiac abnormalities. Lyme titers were negative. A presumptive diagnosis of congenital high grade AV block was made.\nBecause she was minimally symptomatic, no further testing was done. She went on to deliver a health baby boy and presented again about 3 months later with chest discomfort, lightheadedness and dizziness but no syncope. Her ECG at that time showed complete heart block with narrow QRS AV nodal escape rhythm at a rate of 30 beats per minute (). In view of her symptoms and significant bradycardia, a dual-chamber pacemaker was implanted endovascularly. The patient was discharged from the hospital feeling significantly improved.\nThree days later, she presented again with pleuritic chest pain. Her pacemaker was interrogated and found to be functioning normally with no extracardiac skeletal muscle stimulation at high outputs in both the atrial and ventricular channels. In the electrophysiology laboratory, the pacing leads were inspected under fluoroscopy and were both found to be within the cardiac silhouette. An echocardiogram showed no pericardial effusion but revealed a hypokinetic left ventricular distal septum, anterior wall, and apex with an ejection fraction of 45-50 %. As the chest discomfort continued, a CT angiography of her coronary arteries was performed which showed no disease, but revealed a possible microperforation of the right ventricular lead. The patient was taken back to the electrophysiology laboratory where her right ventricular lead was repositioned in the high interventricular septum. Within 24 hours of the procedure, the patient's symptoms of pleuritic chest pain resolved. Serial echocardiograms up to 6 months after her pacemaker implantation, showed persistence of the area of septal, apical, and anterior hypokinesis with mild decrease in systolic function.
A 24-year-old male was referred to our clinic for a lump located at the volar side of the left wrist and a lump located in his left palm and numbness at his 3rd and 4th fingers. In his history he was aware of the masses for 2 years but the numbness was only present for the last 3 months. Lumps were diagnosed as ganglias in another clinic. In physical examination a 2 × 2 cm lump at the volar side of the wrist (zone 5) and 0.5 × 0.5 cm lump at the level of palmar crisis were detected. Numbness was spotted on the ulnar side of the 3rd finger and on the radial side of the 4th finger. The lumps were nontender with no radiating pain. A positive Tinel sign at the wrist and palm and a Phalen sign were spotted. There was no objective motor deficit. There was no family history of neurofibromatosis and no associated clinical features. USG revealed a 12 × 14 mm mass at the volar side of the wrist and 4 × 5 mm mass in the palm which both were in close relation with flexor tendons and had no blood supplies. MRI revealed a 11 × 9 mm mass located in flexor tendons which has intermediate signal on T1-weighted images and hyperintense signal on T2-fat weighted images (). Also a second 6 mm diameter mass in the palm with the same properties was detected (). The masses were both encapsulated with remarkable borders.\nTotal excision was performed for both lesions. The mass at the wrist was originated from the median nerve () and the mass in the palm was originated from the common digital nerve of the 3rd and the 4th fingers (). Microsurgical techniques were used to resect the 15 × 15 mm mass from the median nerve. The palm was opened with a separate incision and a smaller mass with a 6 mm diameter was also removed from the common digital nerve. The masses were encapsulated and removed totally. Histopathological examination of the masses revealed typical features of schwannoma. At the 6th-month followup the patient was symptom-free except slight paresthesia of the 3rd and the 4th fingers. There were no motor deficit or pain and no recurrence of the lumps.
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 90-year-old female was admitted to our hospital as a case of pneumonia associated with decreased level of consciousness; Glasgow Coma Scale (GCS) was 9/15 which deteriorated days later to 5/15. Along the course of her admission, the patient was admitted in the ICU and later shifted to high dependency unit (HDU) where she remained under close observation. There, she became vitally unstable, and had an episode of apnea and asystole for which cardiopulmonary resuscitation (CPR) was started immediately as per ACLS guidelines. Right internal jugular catheter was inserted using the conventional landmark technique but subsequent aspiration revealed bright color of blood and arterial blood gas (ABG) analysis was suggestive of arterial blood. A STAT dose of clexane 40 mg was administered to prevent risk of thrombosis and catheter was left in situ until confirmation of the site of entry.\nBedside carotid ultrasound assessment was not conclusive as the catheter was not seen in the carotid artery. CT angiography (CTA) confirmed the entry of the catheter in the right VA, extending caudally into the subclavian and further into the brachiocephalic trunk, arch of aorta and further up to the descending aorta. In addition, the left VA appeared hypoplastic with nonfilling of the artery beyond the V4 segment representing posterior inferior cerebellar artery continuation (Figures -).\nThe risks and benefits of both surgical and endovascular intervention were discussed. In view of the patient’s general condition and recent episode of resuscitation, surgical intervention carried the highest risk of complications. With the involvement of the dominant VA the possibility of stroke was also higher with surgical approach. Considering these factors endovascular management was chosen as the preferable treatment option in this case, both by the vascular and interventional radiology team.\nFollowing general anesthesia and sterile preparation of the right groin, access was achieved into the right femoral artery and 5 Fr sheath was placed. Some 5000 IU of heparin was injected through the femoral sheath to prevent thrombotic complications. Some 5 Fr vertebral catheter was used for cannulation of right VA. Angiographic images were acquired in multiple projections. Iatrogenic injury of the right VA was known from the previous CT scan. A 0.035’’ safety Glidewire (Terumo Medical Corporation, Tokyo, Japan) was placed through the central line. The catheter was partially pulled over the wire and angiogram performed, which confirmed and localized the site of active extravasation from the entry site of CVC into the V1 (preforaminal) segment of VA (Figure ). Good flow of contrast was noted beyond the site of extravasation with complete opacification of the basilar artery and posterior circulation.\nThe 5 Fr sheath was then replaced with a Neuron Max 0.88 Soft tip 6 Fr long sheath (Penumbra, Inc., Alameda, CA, USA) and access achieved into the right brachiocephalic trunk. A Navien 0.72 intermediate catheter was placed via the Neuron Max and positioned at the ostium of the VA.\nA 0.014 balance middle weight wire (Abbott Vascular, CA, USA) access was then achieved into the VA beyond the site of extravasation. A balloon expandable Bentley stent graft (Bentley InnoMed GmbH, Hechingen, Germany) measuring 5 mm in diameter and 1.8 cm in length was positioned at the site of arterial injury (Figure ). Central line was removed at this point of time and the graft deployed. Angiogram performed following graft placement showed good vessel wall reconstruction with complete exclusion of extravasation (Figure ). As per the hospital's departmental protocol, femoral sheaths are removed by the end of the procedure before the patient is shifted out of the catheterization lab, provided the diameter is not bigger than 9 Fr. If greater than 9 Fr a ProGlide closure device is used for hemostasis. In this case, vascular sheath was removed and hemostasis secured using manual compression. No immediate postprocedural complications were noted.
The authors report a case of a 50-year-old patient with multiple trauma due to direct impact in car crash.\nHe presented with multiple costal fractures from 9th to 12th ribs, a diaphragm rupture with lung contusion and moderate left hemothorax. He also presented with abdominal contusion and stable fracture of the right pubic ramus without urinary disorder.\nThe hemodynamic status was stable. Thoracoabdominal CT scan then laparotomy confirmed the diagnosis of 12 cm diaphragmatic rupture at the left side admitting a stomacal hernia. A section of the mesenteric root and an injury of the spleen capsule without active bleeding were observed. The diaphragmatic injury was sutured after fixation of the mesenteric lesion and stomacal reposition. A 32 Fr chest tube was placed through the left 5th intercostal space for drainage. Postoperative period was eventless in this conscious patient. After 48 hours in the Intensive Care Unit, the chest tube was removed, but 3 days later X-ray showed a recurrence of the hemothorax. A new tube drainage was decided. A 32 Fr chest tube was placed through the 3rd intercostal space in the anterior axillary line. The early production was 2300 mL of blood while the patient experienced a cardiovascular collapse. The tube was immediately clamped. The drop of the hemoglobin level to 4 g/dL indicated a transfusion of 2 blood bags iso rhesus (1800 mL). The patient benefited from central venous catheter placement, arterial catheter placement, and orotracheal intubation. The CT scan showed an injury of the trunk of pulmonary artery due to the chest tube (); the tip of the tube was located inside the lumen of the right pulmonary artery next to the posterior wall of the ascending aorta. This patient with stable hemodynamic status was admitted in such condition in our facility. Surgical exploration was decided with sternotomy access. A complete median sternotomy permitted to see a lateral wound of the trunk of pulmonary arteries, and the tube was touchable over the right pulmonary artery wall (), without lesion of the posterior wall of the ascending aorta. He also had left pleural lesion and massive hemothorax without lung lesion.\nA normothermic partial cardiopulmonary bypass was settled for assistance with an aortic cannula and 2 venous cannulas. After half of the theoretical patient's cardiac flow (2.1 liters) pumped, the pulmonary artery was exposed with a tissue placed under the left ventricle next to the posterior pericardium wall. After drainage of the heart, the pulmonary artery trunk was explored as well the right pulmonary artery and the posterior wall of the ascending aorta, without discovering any other injuries. The defect was closed using a polypropylene stitch and Teflon-reinforced mattress sutures. After complete hemostasis, the cardiopulmonary bypass was stopped. The sternum was closed after irrigation of the pericardium and placement of 3 tubes for drainage (one tube in the left pleural). Postoperative period was free of events in the Intensive Care Unit, and the patient was discharged after tubes removal. On the seventh postoperative day a CT scan showed normal pulmonary artery with its wall being in good shape. Repeated CT scans at 1 month and 3 months remained normal.
A 27-year-old man presented in March 2012 with pain in his right hip and right wrist of two-month duration. Physical examination revealed no restriction in range of motion to either joint, but localized tenderness was present in the right medial thigh and the dorsoradial region of the right wrist.\nEighteen years prior, the patient was treated for osteosarcoma of the proximal tibia with chemotherapy and with resection and reconstruction using allograft. The followup included regular clinical and radiographic examination. Treatment was considered successful after ten years without recurrence.\nThree years prior, the patient has a lytic lesion of the right proximal humerus () and open biopsy, it was determined to be a giant cell tumor. The lesion was curetted and the cavity was filled with bone graft (). Two months later, a biopsy of a swelling of the distal phalanx of the right 5th finger was diagnosed as a giant cell tumor by our Histology Department. Amputation of the distal phalanx was performed. The patient fell two months later after the phalanx amputation resulting in a pathologic fracture of the right proximal humerus (). Treatment included curettage of the right proximal humerus and filling the cavity with bone cement (). Histological examination confirmed the diagnosis of synchronous multicentric giant cell tumor of bone. Whole-body technetium bone scan showed no further lesions. Follow-up, semiannual, clinical, and radiographic examinations revealed no signs of local recurrence.\nRadiographic examination of the patient revealed lesions in both painful areas. Plain radiograph of the pelvis () revealed a typical 3 cm lytic lesion involving the right proximal medial femur and a 4 cm lytic lesion involving the left ileum. MRI of the pelvis () showed the extension of the lesions with soft tissue involvement of the right thigh and of the left gluteal region.\nPlain radiograph and CT of the right wrist () revealed a 4 cm lytic lesion involving the epiphyseal subchondral region of the distal radius but without cortical breach.\nFurther radiographic examinations were performed to rule out the presence of other lesions or metastasis. The whole-body technetium bone scan revealed an additional increased uptake in the left distal tibia. The plain radiograph () and the CT (Figures and ) of the left ankle joint showed a further 2 cm lytic lesion of the subchondral region of the distal dorsolateral tibia. CT of the thorax and abdomen confirmed the absence of metastasis.\nTo rule out hyperparathyroidism acid and alkaline phosphatase and serum calcium were within normal range. Serum parathyroid hormone level was also normal.\nAll lesions were removed using powered burrs and were chemically cauterized with phenol solution. The resulting bone cavities were filled with bone cement. Prophylactic bone stabilization was performed in all areas where lesions were removed. A dynamic hip screw was used to stabilize the right hip; a plate was used to fix both the left posterior iliac crest () and the right distal radius; a single screw was adequate to fix the left distal tibia. The postoperative course was uneventful with full weight bearing was possible within two weeks.\nHistological examination of all lesions revealed the typical findings of a giant cell tumor of a bone (). The tissue was composed of large osteoclasts and uniform mononuclear cells with ovoid nuclei. The giant cells contained 50 to 100 nuclei. The nuclei of the stromal cells were similar to the nuclei of the osteoclasts having a so-called open chromatin pattern with indistinct nucleoli. The cytoplasms were ill-defined with very few intercellular collagen, broad sinus, and retraction artefacts. Mitotic figures were very rare.\nRadiation therapy was recommended for the two pelvic lesions, by our multidisciplinary tumor board, because of soft tissue involvement.\nInformed consent was taken from the patient prior to operation for the procedures as well as using his clinical data in this case report.
An 11-year-old male patient reported with his parents with the complaint of swelling on the right side of face for the past 3 months. The patient was apparently asymptomatic 3 months back. A small swelling appeared on the right side of his face, which slowly progressed in size; however, there was no associated discomfort.\nBorn of a nonconsanguineous marriage, with no associated history of drug, alcohol, or tobacco intake by mother during pregnancy. At birth, a deformed pinna and a linear scar on the cheek on the right side of the face were noticed. However, age milestones were achieved normally and the child is performing well in studies at school. Parents gave a history of a reconstructive procedure for the right external ear being performed at 8 years of age.\nThe patient appeared to be of normal height and weight for his age, with a medium built and stature. No associated anomalies of limbs were present. Facial examination revealed a deformed pinna of the right side and a unilateral facial scar on the right cheek as shown in . There was also swelling of the face on the malar region on the right side approximately 5 × 5 cm extending from the ala of the nose on the right side to a perpendicular dropped from the outer canthus mediolaterally and from the infraorbital rim to border of the upper supero-inferiorly as shown in . Crepitus was elicited upon palpation of the maxillary vestibule. A straw colored aspirate was obtained as shown in . A histochemical analysis of the aspirate was done, which revealed a protein content of 9.8 g%. An incisional biopsy was performed which was suggestive of a cystic lesion. The tissue was stained with a routine hematoxylin and eosin stain. The stained section showed the presence of an epithelial lined cystic cavity and connective tissue. The cystic epithelium was nonkeratinized in nature. It resembled reduced enamel epithelium and was 2-3 cells in thickness with the absence of rete peg formation. There were occasional areas of chronic inflammatory cells in the connective tissue and in these areas the lining epithelium was thickened.\nA diagnosis of a dentigerous cyst was made based upon the histological features. A paranasal sinus (PNS) view skull and a noncontrast computed tomography (NCCT) of the PNS was obtained as shown in . A routine hemogram was done and all the values obtained were within normal limits. The NCCT was suggestive of a cystic cavity wholly enclosing the maxillary antrum on the right side, with the maxillary right canine being pushed up to the level of the junction of the infraorbital rim and lateral nasal wall.\nThe patient was taken up for enucleation of the cystic lesion under general anesthesia via an intraoral crevicular incision to raise a triangular flap.\nThe exposure of the anterolateral wall of the right maxilla revealed a breach in continuity; the same was widened to gain access to the cystic lesion as shown in . The cyst was enucleated in totality with the associated tooth that is, right maxillary canine as shown in Figures -. The maxillary right first premolar was also enucleated due to its close proximity to the lesion. Complete removal of the lesion was ensured and the surgical wound closed.\nThe patient exhibited satisfactory postoperative recovery and has been placed on a bi-monthly follow-up for the past 6 months, as shown in .
A female patient in her 30s was referred to our institution with a complaint of persistent cough. Chest radiography revealed a mass in the right middle lung field (). Noncontrast CT showed a mass approximately 8 centimeters in diameter with relatively smooth margins in the right lung segment 6 (). A malignant lung tumor was suspected and fluorodeoxyglucose-positron emission tomography (FDG-PET/CT) was done. FDG accumulation was seen in the lung mass (standardized uptake value max. 3.6) as well as in the mediastinum suggesting a malignant lung tumor with mediastinal lymph node metastasis (). Bronchoscopy revealed a tumorous lesion obstructing right B6 (). Biopsy of this lesion showed proliferation of spindle cells raising suspicion of sarcoma or spindle cell carcinoma.\nNext, contrast-enhanced CT was done, and it showed that the mediastinal lesion pointed out on FDG-PET/CT was actually a continuous extension of the lung mass into the right main pulmonary artery. A skip lesion was also suspected in the periphery of the pulmonary artery trunk ().\nLung ventilation-perfusion scan showed that the right lung was not perfused although sufficiently ventilated. On echocardiography, heart wall motion was intact and no signs of right heart failure were seen.\nCollectively, a sarcomatous lung tumor with extension into the right pulmonary artery trunk or PAS with extension into the right lung was suspected. The patient underwent surgical resection of the tumor under cardiopulmonary bypass through a median sternotomy. The existence and localization of the skip lesion was first confirmed by transthoracic and transesophageal echocardiography. Venous cannulas were placed in the right atrium and the femoral vein, and an arterial cannula was placed onto the femoral artery, and surgery was carried out with the heart beating. The left pulmonary artery was carefully dissected so as not to perturb the skip lesion and was clamped just proximal to the origin of left A3. Although the tumor filled the inside of the right pulmonary artery, its wall appeared to be intact from outside. Then the main pulmonary artery was incised just above the pulmonary valve and opened distally to expose the tumor. To remove all lesions, proximal portion of the left pulmonary artery together with the pulmonary artery trunk was resected. The left pulmonary artery was reconstructed with a 20 mm Gore-Tex vascular graft and the patient was separated from cardiopulmonary bypass. Following that, right pneumonectomy and total resection of the tumor were completed. Time on bypass was 2 hours and 11 minutes. Duration of operation was 9 hours and 9 minutes.\nGrossly, the tumor seemed to arise in the large vessel of the pulmonary circulation and invade into the adjacent pulmonary parenchyma, especially in the S6 region (Figures and ). The tumor was diagnosed as intimal sarcoma and its histological findings, proliferation of atypical spindle or polygonal cells with high mitotic activity, were also compatible with the diagnosis (). The lesions were completely removed macroscopically. Further resection, particularly the distal portion of the left main pulmonary artery, was not considered to be feasible. However, the surgical margin of the left pulmonary artery was microscopically positive for tumor cells (). The patient was followed up without further treatment.\nTwelve months after surgery, recurrence in the right ventricular outflow tract was detected. Irradiation and proton therapy were done. The recurrence is without progression 2 months after detection.
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.
Our patient was a 60-year-old woman who had undergone bilateral MG II (Zimmer) total knee arthroplasty for rheumatoid arthritis of the knee (Larsen grade IV) in our department 16 years earlier (). She had no other relevant medical history. Body weight was 45.8 kg, height 158 cm, and body mass index 18.3 kg/m2. Weight and height were approximately the same as when the primary surgery was performed. After the initial procedure, she had been followed up every 3 months for 16 years and follow-up plain radiographs were regularly checked once a year. Nine years after the initial arthroplasty, she underwent surgery and chemotherapy for endometrial cancer; this treatment was successful and she experienced no recurrence or metastasis.\nA follow-up plain radiograph taken 15 years after arthroplasty revealed a deterioration of the varus malalignment of the tibia (). However, the patient had no complaints about the left knee at this point, and we considered the problem was related to polyethylene wear. However, 16 years after arthroplasty, she presented to our department with a 3-month history of severe pain in the left knee. Clinically, she walked with a limp and a varus thrust. Examination of the left knee indicated joint effusion and tenderness along the medial joint line with localized warmth. There was a well-healed anterior skin incision over the left knee with no evidence of skin infection. Active and passive motions of the knee caused pain in the medial part of the knee. Plain radiographs taken at this time showed further distortion of the tibial component of the left knee with obvious fracture of the tibial baseplate and osteolysis under the broken component (). She had not consulted us about the problem immediately because she had been undergoing conservative treatment for Graves's disease for 3 months. At the time of presentation, rheumatoid arthritis and Graves' disease were well controlled and all other laboratory values were in the normal range.\nThe patient underwent revision knee arthroplasty on the left side via the previous skin incision. Perioperatively, we observed severe metallosis within the knee joint (). The polyethylene insert was obviously worn and broken at the posteromedial site (). After the broken polyethylene insert was removed, a coronal fracture was found at the posteromedial portion of the tibial component and there was subsidence of the posterior metal tray fragment (). When the four screws were removed, we noted a cutting fracture of the screw inserted in the screw hole of the fractured tray. The remaining part of the screw could not be observed and we decided not to remove the remaining small screw fragment because it was embedded in bone and was unlikely to cause clinical complications. On extraction of the broken tibial metal tray, the medial aspect of the tibia showed cavitation of the cancellous bone under the medial weight-bearing surface. All metal and debris were removed and the revision prosthesis (LCCK, Zimmer-Biomet) was implanted. Medial augmentation was required to correct the bony deficiency (). There were no postoperative complications, and the patient was ambulating with full weight-bearing on postoperative day 2. Significant pain relief and functional improvement was achieved based on early follow-up examinations (4 months). Remarkably, the MG II prosthesis on the right side was properly aligned, surviving for 17 years after primary surgery ().\nGross observation of the retrieved broken tibial baseplate revealed that the fracture line extended in a coronal direction from the medial corner to the posterior cruciate ligament (PCL) recess (). There was no evidence of bone ingrowth at the undersurface of the posterior fragment of the tibial tray, although bone ingrowth was noted under the tray anterior to the fracture line (). The broken surface was complex, instead of showing regular fracture waves. A focal stair-step pattern could be observed on gross examination at the medial corner of the PCL recess, and scanning electron micrography showed fatigue striations at this point (). This observation supported the possible development of a fracture line that had started at the medial corner of the PCL recess []. The retrieved polyethylene insert revealed that the heavily worn medial site corresponded to the posteromedial breakage area of the tibial baseplate (). The retrieved portion of the fractured screw demonstrated the severe load that had been exerted on the posterior fractured baseplate ().
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 54-year-old female patient reported to the multispecialty private dental clinic (Latur, India) with the chief complaint of diffuse swelling in the right maxillary anterior region. Patient was not aware of such growth until 8 months back when she noticed a small slowly growing bead-like nodular enlargement of the gums that gradually progressed to the present size covering almost the entire front teeth. Her past medical history revealed that the patient was hypertensive for last 2 years and was under medication (amlodipine 10 mg, once daily).\nThe lesion was asymptomatic, but the patient complained it to be severely interfering with mastication, speech, and oral hygiene practice resulting in functional and aesthetic problem. On intraoral examination, the lesion was a well-circumscribed exophytic sessile spherical mass of 1.5 inches diameter with color same as that of the surrounding oral mucosa with the scattered erythema []. The lesion was extended from distal surface of upper right canine to distal surface of upper left central incisor crossing the midline. It was non-tender and firm on palpation. All teeth involved in lesion were mobile and pathologically migrated. AIGO was also present in dentate area of lower arch. Poor oral hygiene status of the patient was assessed from the presence of local irritating factors contributing to the mild inflammatory component of the gingival enlargement.\nComplete hemogram showed all blood counts to be within the normal limits. Urine examination was normal. Intraoral periapical radiograph and orthopantomogram in the region of AIGO showed generalized advanced horizontal bone loss around all teeth resulting in pathologic migration\nThe lesion was biopsied under local anesthesia. Maxillary teeth involved in lesion were extracted. The area was sutured and the specimen submitted for histopathological examination. As the extraction of all the remaining teeth with poor prognosis was planned substitution of amlodipine was not considered. Planned extraction of remaining mandibular teeth was carried out in subsequent appointment. Following healing period of 2 months complete denture prosthesis was given to the patient.\nHistopathological examination using hematoxylin and eosin stain, revealed proliferative parakeratinized stratified squamous epithelium, connective tissue with sheets of plasma cells intermixed with scattered small lymphocytes. The plasma cells were fairly uniform in appearance with scattered nucleoli present. Occasional dutcher bodies were seen overlying the plasma cell nuclei. The inflammatory infiltrate also contained varying numbers of neutrophils, lymphocytes and macrophages. Nuclear atypia was not seen [].\nImmunohistochemical study of the biopsy material revealed the polyclonal plasma cell infiltrate uniformly positive for CD138, a marker for plasmacytoid cells [] and kappa light chain [] and weak expression was noted for the lambda light chain. Absence of findings from common tetrad of multiple myeloma (CRAB: C = Calcium (elevated), R = Renal failure, A = Anemia, B = Bone lesions) ruled out its possibility.\nOn the basis of clinicohistopathologic examination and immunohistochemistry, a confirmative diagnosis of plasma cell granuloma was made. Healing was uneventful and the patient is presently under follow-up since 5 months. There has been no evidence of recurrence [].
A 20 year-old male patient was referred to the maxillofacial surgery department with chief complaint of a rapidly growing swelling in the left upper back tooth region associated with pain. The patient had been noticing the swelling over a period of 2 weeks.\nClinical examination revealed an expansile swelling in the maxillary tuberosity region measuring 5 cm × 3 cm []. The swelling was tender on palpation and smooth in texture. Patient had parasthesia and pain in the involved areas. Facial asymmetry was evident. However, mouth opening was normal. Clinically, there was no regional lymph node involvement. No other relevant family and medical history could be elicited. Patient was advised an orthopantamogram and a cone beam computed tomography (CBCT) scan. A typical sun ray appearance was seen in the CBCT. The tumor was found to involve the entire maxillary sinus and superiorly extending onto the inferior orbital rim. Posterior extension was seen up to the pterygoid plates and medial extension to the lateral wall of the nose [].\nAn incisional biopsy was confirmatory of osteosarcoma. A Weber Fergusson incision was planned for access to the tumor. Adequate access was obtained and resection of the tumor with at least 1 cm clearance was done at all the margins, and the specimen sent for histopathologic examination. Because of the extensive defect and considering the psychological status of the patient, reconstruction of the defect was planned. An anterolateral thigh flap was harvested and used for reconstruction, which also created a lining for the oral cavity []. Patient was on Ryle's tube feeding for 3 weeks. Postoperative healing was uneventful. Histopathologic report confirmed the diagnosis of osteosarcoma which was of the chondroblastic variety. The anterior, posterior, and lateral margins were found to be free of tumor. The superior, inferior, and medial margins shows tumor involvement, and hence, as per the medical oncologist's opinion, postoperative radiotherapy was started. Anterior and lateral portal radiation in combination with chemotherapy was done. Patient has been reviewed for the past 1 year and no evidence of recurrence has been noticed in clinical and radiographic evaluation [Figures and ].
A 59-year-old woman presented with both knee pain and contracture of the left knee, which resulted in functional disability. She was not able to walk without 2 crutches preoperatively. Four years before presentation, she fell from a second-floor balcony due to epileptic attack and sustained open fracture of both knees. She was transported to the emergency room and underwent open reduction and internal fixation of both femurs. These fractures were healed without infection; however, there remained malunions in both femurs. Progressive pain in both knees leading to limping and stiffness developed gradually. She was referred to our hospital for surgery. Radiographs showed advanced degenerative arthritis of both knees, extra-articular deformity after supracondylar fracture and retained hardware (). The magnitude of angular deformity of the right femur was rather small (); however, there was a large cavity filled with fibrous tissue and partial defect of the anterior cortex in the distal femur (Figures , , , and ). On the other hand, the distal segment of the left femur was displaced laterally and posteriorly, and the overlap at the fracture site resulted in leg length discrepancy ().\nFirstly, we performed right TKA because her right knee pain was more severe compared to her left knee. To avoid refracture due to partial defect of the anterior femoral cortex, we decided to place the femoral component without removing the hardware using navigation system. Preoperative planning confirmed that hardware was not likely to interfere with the femoral component.\nAfter removal of the Herbert screws, distal femoral cut was performed perpendicular to the mechanical axis in the coronal plane and 3° flexion to the mechanical axis in the sagittal plane using navigation system. Cancerous bone chips made from resected bones were grafted into the cavity after clearing up the fibrous tissue.\nSix months later, she underwent left TKA. Preoperative radiographs showed not only bone union but also loose screws, so we determined to remove the hardware. Laterally and posteriorly shifted distal femur prevented the use of the traditional intramedullary guide. Therefore, we used navigation system again. Distal femur was resected at a right angle to the mechanical axis in coronal plane and 3° flexion to the mechanical axis in the sagittal plane.\nPostoperative radiographs demonstrated good positioning of the components and restored mechanical axis (Figures , , and ). Mechanical axis of the lower limb improved from 9° varus to 2° varus for the right knee and from 13° varus to 0° for the left knee.\nRange of motion improved from 5°–90° to 0°–95° for right knee and from 10°–30° to 0°–75° for left knee. Knee score improved from 31 to 84 for the right knee and from 25 to 80 for the left knee. The function score improved from 20 to 70 at the latest follow-up. Soft tissue balance was well coordinated. No complication was seen postoperatively.
The patient was a 46-year-old male with type 2 diabetes on oral hypoglycemic agents for 4 years. His blood sugar control was not satisfactory because of poor compliance and the HbA1C was 10.65% checked one month ago. He sustained left lower leg swelling with ulcers and repeated cellulitis for 1-2 years. During this period he was treated at the outpatient department with both oral antibiotics and wound care. In recent months the number of ulcers increased markedly with more serum-like drainage. On physical examination, his left leg had multiple ulcerative, hyperkeratotic lesions with thick, fibrotic, hyperpigmented skin discoloration ().\nThese lesions were unilateral occurance and the involved area was about 600 cm2 from the pretibial region to the posterior aspect of leg. Significant greater circumferential distance of left lower leg was also noted with 6 cm and 10 cm longer than right lower leg in the calf and ankle level respectively. We arranged operation for the patient under the impression of unilateral lymphedema, left lower limb and diabetic foot ulcers with repeated cellulitis. Skin malignancy was suspected due to the rapid progression of these lesions. First, multiple skin biopsy was done to rule out skin malignancy and fortunately the pathology was ulcer with acute necrotizing inflammation. Second, the peripheral arterial disease was excluded by computed tomography angiography. Then, half of affected skin and subcutaneous tissue was excised deep to fascia level and covered with split-thickness skin graft ().\nThe same procedure toward the other half lesions was completed a week later. There was no immediate post-operative complication such as blood loss requiring transfusion, failure taking of skin graft or wound infection. Combination therapy with antibiotics use and hyperbaric oxygen was also prescribed. The patient was discharged seven days after operation and compression garment was applied continuously after wound healing. In one-year follow-up, no recurrent infection occurred and the patient was satisfied with the cosmetic results (). The difference of circumferential distance between two legs decreased to 2 cm and 1 cm in the calf and ankle level respectively.
Chest radiography was performed for a 7-year-old girl with persistent cough and fever who was unresponsive to oral antibiotics and showed loss of volume of left lung sustained by almost total atelectasis. The patient was then admitted to the pediatric ward to begin intravenous antibiotic therapy. Serological tests for\nChlamydia pneumoniae\n,\nMycoplasma pneumoniae\n, and QuantiFERON test for tuberculosis were negative. A computed tomography (CT) scan showed an extended mass that occupied the entire upper lobe with axial dimensions of 70 × 47 mm and assumed discreet enhancement in all the study phases. The bronchi for the upper lobe were no longer patent with endobronchial projection affecting the middle third of the main left bronchus. The mass caused posterior dislocation of the pulmonary arterial vascular axis and inferior dislocation of the superior pulmonary vein. Based on the radiological reports, the patient was referred to our pediatric surgery unit. To better define the characteristics of the lesion, a magnetic resonance imaging was performed. The pictures confirmed the presence of an expansive pulmonary lesion with a probable origin from the upper left lobe with transverse diameters of 57 × 45 mm and longitudinal extension of 85 mm. The lesion infiltrated the pulmonary hilum and invaded the bronchial structures up to the left main bronchus ∼2 cm from the carina. It appeared adherent to the common trunk of the pulmonary artery and to the pericardium at the level of the left atrium and ventricle with infiltration of the superior pulmonary vein. The mass appeared to be surrounded by a thin rim of consolidated lung parenchyma; therefore, it does not seem to infiltrate the thoracic wall (\n). For a complete diagnostic work-up, positron emission tomography–CT was performed; the findings showed softened uptake of the tracer at the voluminous expansive formation that tended to accentuate along the margins. Echocardiography revealed a 7-mm ostium secundum atrial defect with left to right shunt and deformity of the left ventricular cavity, with preserved systolic function. The deformity was attributable to the mass. All the tumor markers were negative. After multidisciplinary evaluation, ultrasonography-guided transthoracic core needle biopsy (22 Gauge) and bronchoscopic biopsies were performed to establish the diagnosis. Histopathologic examinations revealed the presence of medium–small-sized cells neoplasia, ovoid and plasmacytoid, with eosinophilic cytoplasm, lacking of evident cytological atypia with solid growth or in large nests alternating with myxoid and dense collagenous stroma. Immunohistochemical reactivity was positive for cytokeratine (CK) AE1AE3, p63, epithelial membrane antigen (EMA), S100, β-catenin, SOX10, and terminal deoxynucleotidyl transferase (TDT). The morphological and immunophenotypic data were more suggestive of myoepithelioma. However, the immunocytochemical expression of TdT did not exclude the possibility of thymic neoplasm. Fluorescence in situ hybridization analysis showed the absence of translocation of\nFUS\ngene in 16p11,\nEWS\ngene in 22q12, and\nSS18\ngene in 18q11.2. The case was discussed among pediatric surgeons, oncologists, and radiologists who concluded that the nature of the cancer was not sensitive to neoadjuvant treatment, thus indicating elective radical surgery.\nAfter the performance of sternotomy and opening of the pleura bilaterally, the left thoracic mass was revealed. The mass infiltrated the entire left lung and was attached to and infiltrated the pericardium, the left pulmonary artery and veins, as well as the left bronchus. We proceeded to release the left lower lobe by making selective distal ligation of the pulmonary arterial and venous vessels and of the left lobar bronchus. The lobectomy was completed with a mechanical stapler. The lower lobe appeared infiltrated by the mass at the level of the fissure. After resecting the lingular lobe, it was necessary to proceed under extracorporeal circulation to isolate the left pulmonary artery and veins. We isolated the pulmonary artery trunk as well as tied and dissected the Botallo's duct and the left branch of the pulmonary artery. The two left pulmonary veins and the main left bronchus were dissected and sutured. The mass was isolated from the remaining pericardium, from the vagus nerve, and from the phrenic nerve. Once the left pneumonectomy was completed and hemostasis was achieved, the interatrial defect was surgically closed, and a temporary pacemaker was implanted. A thoracic expander of 11 × 6 cm was applied and filled with 100 mL of saline solution. The expander reservoir connector was placed outside of the chest wall, and the reservoir was placed in a subcutaneous pocket. A left thoracic drain was placed dorsal to the expander. The postoperative course was uneventful. The temporary pacemaker was removed after 5 days, and the drain was removed after 8 days. The expander was gradually filled up to 200 mL with saline in three different infusions over 3 weeks (\n). The patient was discharged on postoperative day 18. Histopathological analysis confirmed the presence of primary myoepithelial carcinoma of the lung (PMC-L) that infiltrated the bronchial wall up to the mucosa, the peribronchial fibroadipose tissue with vascular perineural–neural invasion, the pulmonary parenchyma, the visceral pleura, the pericardium, and a peribronchial lymph node with embolic metastasis. In view of the rarity of this neoplasm, the TREP group (“Rare Tumors in Pediatric Age”) means rare tumors in pediatric age group was consulted to set up a plan for the follow-up care. The patient was then subjected to radiotherapy with rapid arc technique on the left thoracic wall in 34 diaphragmatic thickening fractions, 61.2 Gy in total. At the 14-month follow-up, the patient was alive and was breathing normally without oxygen support. Neither recurrence of PMC-L nor metastasis occurred, and no chest deformities were observed.
A 37 year old man was referred to our emergency department by his general practitioner with a three day history of muffled hearing and tinnitus of the right ear. Symptoms were sudden onset, with no associated pain, dizziness or otorrhea and no past history of hearing problems or medical illness. Family history was negative and physical examination was normal. Otologic examination revealed normal tympanic membranes bilaterally, with no evidence of cerumen or middle ear effusion. Tuning fork examination showed positive Rinne test bilaterally but with lateralization of Weber test to the left side, indicating right ear sensorineural hearing loss. Audiometric analysis confirmed sensorineural hearing loss across all frequencies of about 70-db in the right ear. Tympanometric analysis showed normal middle ear pressure and tympanic membrane compliance on both sides with no evidence of middle ear effusion. Ear canal volume was normal indicating intact tympanic membranes bilaterally. Routine lab work including complete blood count, erythrocyte sedimentation rate, random glucose, urea, and electrolytes were all within normal limits. Magnetic resonance imaging of brain and internal auditory canal were also normal.\nClinical diagnosis of idiopathic sudden sensorineural hearing loss of the right ear was made and the patient began a one week prednisone therapy of 60 mg daily to be tapered with a dose of 10 mg reduction every two days over the next ten days. The patient was followed for three months with repeat hearing assessment every two to four weeks. Unfortunately his hearing in the affected ear showed no significant improvement. He did not require a hearing aid since he had adequate hearing in the unaffected ear.\nThe clinical question is; “in patients with idiopathic sudden sensorineural hearing loss does the use of systemic corticosteroid therapy improve the chances of hearing recovery?”\nTo answer the question; Medline was searched using the following strategies:\nStrategy 1: the literature was searched using the keywords “sudden hearing loss, sudden deafness, idiopathic sudden deafness, idiopathic sensorineural deafness, sudden sensorineural or sudden nerve deafness, idiopathic sudden sensorineural hearing loss, or idiopathic sudden nerve deafness. ”\nStrategy 2: the literature was again searched using the words “corticosteroid(s), steroid, steroids, glucocorticoid, or glucocorticoids.”\nThe combinations of strategy one and two identified 358 papers. We attempted to identify papers using a high level of evidence and large sample size, excluding papers using direct injection of steroid into the middle ear via the tympanic membrane, a practice not widely used. We found five key papers which directly answered the question 1–5. Only two of them were prospective trials [, ].\nThe first compared the use of steroid or carbogen therapy against placebo in treating sudden sensorineural hearing loss [] in a prospective double-blind study. The authors enrolled 41 patients with unexplained sudden sensorineural hearing loss who had no diabetes, previous ear conditions, or abnormal auditory physical findings. The outcome was measured through serial audiometric analysis of hearing levels at day six, with further follow-up assessment done at 90 days. The study showed no difference between early steroid or carbogen therapy.\nThe second prospective study compared steroids to placebo []. It showed that steroids had a statistically significant effect on the recovery of moderate degree hearing loss.\nA Japanese retrospective, non-randomized, controlled study using chart review to assess the effectiveness of corticosteroids in treating sudden onset sensorineural hearing loss at lower frequencies reported improvement on audiogram in the corticosteroid treated group which was not statistically significant (P = 0.84) [].\nAnother retrospective study of patients with sudden sensorineural hearing loss was reported4. A group of 301 patients who received no treatment over a period of six years were compared with 302 patients who had intravenous blood thinning drugs and glucocorticoid therapy. Their objective criteria were hearing improvement evaluated by audiometric assessment. Results showed hearing recovery in both groups, however the group who received glucocorticoid treatment showed statistically significant hearing recovery at low and medium frequency range (P < 0.05).\nAnother non-randomized, retrospective review of patients who presented with sudden sensorineural hearing loss of unknown cause over a ten year period was reported5. It compared hearing outcomes of patients who received steroid therapy to those who received no steroid therapy. The key findings were in patients with severe sensorineural hearing loss. It was found that steroid therapy significantly improved hearing recovery compared to those who received no steroid therapy (P < 0.01). The above effect was not found in patients with milder forms of hearing loss. Idiopathic sensorineural hearing loss mainly affects low frequencies, which is the normal speech frequency.
A 20-year-old woman presented in January 2013 with an inflammatory left-side cervical swelling. She had been in a good general condition and only experienced an excision of a left-side cervical cyst 6 years before with an initial diagnosis of a fourth branchial arch anomaly. The follow-up did not show any recurrence or inflammatory process during the last 6 years. The clinical examination showed a left-side inflammatory and painful cervical swelling without evidence of external skin fistula or spontaneous discharge of pus. She had no dyspnea or dysphagia. The ENT examination did not show any pathological signs in the oropharynx, hypopharynx, or larynx. The biological findings showed an acute inflammatory syndrome with leukocytosis and elevated CRP. A cervical CT-scan showed a multilobulated liquid formation in the left lateral cervical region, measuring 29 × 15 × 55 mm, in contact with the left thyroid lobule, as well as the presence of a fistula tract between the thyroid lobule and the pyriform sinus on the left side (Figures and ).\nA surgical drainage of the abscess was done, followed by an antibiotic treatment of amoxicillin-clavulanic acid with a dose of 1 gr three times per day for 14 days ().\nThe 2-month postoperative follow-up showed good healing of the cervical wound without any signs of recurrence. An MRI was done 3 months after the surgery and showed a diffuse inflammation in the left cervical region without abscess formation and a fistula tract at the level of the hypopharynx on the left side ().\nA complete surgical treatment including the resection of the fistula tract and left thyroid lobule combined with endoscopic control of the fistula in the left pyriform sinus was proposed to the patient; unfortunately, she refused the surgery at that time. Five months later, she presented a recurrence of a cervical abscess on the left side. A cervical CT-scan showed an abscess with a fistula on the left side of the neck (). A second surgical drainage was done, followed by an antibiotic therapy for a period of 14 days.\nA complete surgical treatment was performed 2 months later. The intraoperative endoscopy showed a fistula orifice in the apex of the left piriform sinus. An endoscopic cauterization of the fistula in the left piriform sinus was done (Figures and ). A left-side cervicotomy was performed with a complete excision of the fistula tract, left thyroid lobule, and all the inflammatory tissues with multiples lymph nodes (: fistula's tracts between the left thyroid nodule and the pharynx). The surgery was followed by an antibiotic treatment. The postoperative follow-up showed a good healing of the wound, no symptoms of thyroid gland dysfunctions or any other complications.
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 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 48-year-old man presented with a tender swelling in his right lower extremity of 3 months' duration. Physical examination revealed a visually obvious 8 × 9 cm pulsatile mass on the lateral margin of the popliteal fossa. The distal extremity was stiff and tender to palpation. There was no previous history of trauma or surgical intervention. Lower extremity Doppler ultrasonography showed an 8 × 9 × 10-cm solid heterogeneous mass in the lateral popliteal fossa. Magnetic resonance imagining (MRI) demonstrated a large mass that closely approximated the muscular structures and surrounding connective tissue (). The lesion was felt to represent a vascular mass.\nIntraoperatively, the patient was placed in the supine position under epidural anesthesia. The lesion was adherent to surrounding tissues including muscle and nerve. It originated from the muscular fascia of the deep muscle within the popliteal fossa. The lesion itself was large, gray-white, fibrotic, and irregular. Its appearance was not typical of a vascular lesion. No infiltration of the surrounding large vessels was identified, but the tumor invested nerves in the popliteal fossa. As this mass was thought to be suspicious for malignancy, enbloc dissection of the tumor was then carried out, including dissection of its attachments to the deep popliteal region, accomplished with the assistance of orthopedic and neurological surgeons. Total excision was attempted, but was unsuccessful as a tumor segment 0.5 × 0.5 cm in diameter which heavily infiltrated the tibial nerve could not be excised. Macroscopic surgical margins were free from all aspects of the tumor mass (). Postoperatively, pathologic examination demonstrated widespread proliferation of spindle-shaped cells and collagen fibers. There were rare mitoses, but no signs of atypia were seen (arrow). Microscopic tumor margins were negative, and there was no evidence of malignant change ().\nThe patient's early postoperative course was uneventful. The patient refused any subsequent radiotherapy or chemotherapy, and he was discharged on the 9th postoperative day. Eighteen months later, he is free from disease without evidence of local recurrence or distant metastasis.
We had a 65-year-old male who came for the treatment of his patella fracture and deformity of knee. His knee society score was 70 for the left knee and 78 for the right knee. It was known that he was having multiple comorbidities such as hypertension and coronary artery disease. There was a history of percutaneous transluminal coronary angioplasty 1 year back. He had a history of fall from two wheelers 1 month back, and he sustains injury to his left knee. The patient was having pain, swelling, but he had not taken any treatment for it. Patient neglected the injury and was able to walk with the support of walking aid. On examination, the patient was having bilateral knee Varus 20°9 () and fixed flexion deformity of 30°. Active straight leg raising was not possible on the left side. Range of movement of left knee was possible from 30 to 90°. Radiographs revealed a transverse fracture of the patella with Grade 4 osteoarthritic changes on the left side and arthritic changes on right knee also (). Other findings of blood investigations were normal. We decided to go for single-stage procedure with fixation of patella fracture and TKR. Anterior midline incision was taken, and medial parapatellar arthrotomy was done. On extensor side the retinaculum was found intact intraoperatively, so we first proceed with TKR. Calcified medial meniscus was excised, and posteromedial tibial defect was taken care with downsizing of the tibia. After through irrigation with normal saline and debridement of soft tissue from articular side of patella fracture, the fracture ends were approximated. Reduction held with patella pointed reduction clamps and two parallel K wires. An 18 G SS wire was used for tension band wiring of patella. The extens or retinaculum was reinforced with absorbable sutures ( and ). The incision was closed in layers without a suction drain. Post-operative radiographs showed an acceptable reduction of the fracture and an acceptable TKR. In postoperative period patient was allowed early knee mobilization up to 90°, and full weight bearing was allowed with the help of walking aid. At the end of 3 months patient achieved range of motion 5-110° and his knee society score improved to 90. The patella fracture united completely without any complication ()

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