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We present the case of a 69-year-old male patient who was brought to the outpatient clinic by his daughter as he developed gait disturbances, memory impairment, and urinary incontinence with gradual worsening over the past six months. He reported having a history of falls because of his unbalanced gait. The patient started to have difficulty with findings words and had problems with concentration. There was no history of headache, muscle weakness, hallucination, or changes of personality. The past medical history of the patient was remarkable for long-standing hypertension, diabetes mellitus, and dyslipidemia. His surgical history is remarkable for inguinal hernia repair and appendectomy. The patient is retired and lives with his daughter.\nOn physical examination, the vital signs were within the normal limits. The neurological examination revealed decreased attention span and impaired concentration. However, the patient had normal fluency and normal naming of objects. The muscle tone, power, and coordination were normal in both the upper and lower limbs. Gait examination showed normal posture and speed but was wide-based. Cranial nerves examination was normal. Initial laboratory findings were within the normal limits (Table ). The Mini-Mental State Examination revealed mild cognitive impairment with a score of 27 out of 30. The patient underwent magnetic resonance imaging of the brain which demonstrated enlarged ventricles, widening of the Sylvian fissure, and narrow sulci at the vertex (Figure ). The clinical and radiological findings were suggestive of the diagnosis of normal pressure hydrocephalus. Subsequently, the patient underwent a lumbar puncture which revealed a normal opening pressure with normal cerebrospinal fluid analysis. The patient underwent a ventriculoperitoneal shunt for the management of the normal pressure hydrocephalus. One year after the placement of the shunt, the patient demonstrated a marked improvement in his gait and resolution of urinary incontinence.\nThree years after the placement of the shunt, the patient was brought to the emergency department with an expanding right-sided subcutaneous abdominal mass. The mass was soft and has a smooth surface with normal overlying skin. Ultrasound examination of the abdominal wall revealed a well-defined anechoic with fluid density measuring approximately 7 x 5 x 6 cm. The differential diagnosis for this mass was an abscess, lymphocyte, seroma, and cerebrospinal fluid. A computed tomography scan of the abdomen showed the subcutaneous mass superficial to the right rectus muscle and was containing the coiled distal end of the shunt (Figure ). Such findings were consistent with a subcutaneous cerebrospinal fluid pseudocyst. The mass was aspirated and the fluid analysis was in keeping with the cerebrospinal fluid characteristics. The fluid culture revealed no bacterial growth. The ventriculoperitoneal shunt was replaced with a minimally invasive technique.
A 67-year-old man presented to our ENT department with complaints of shortness of breath and dysphonia that had been ongoing for 2 months. This patient was referred to the ENT outpatient department with a growing tumor on the right side of the larynx. Histology of a biopsy sample verified a benign tumor. Because the biological behavior of the tumor was described as aggressive growth, a new biopsy was performed. The sample was analyzed, and histology showed a suspicious fibrosarcoma. He had not been smoking and denied alcohol consumption. Respiration was difficult.\nA laryngeal examination revealed an exophytic mass in the right vocal cord and anterior commissure. The mobility of the right vocal cord was maintained, and there was a tumor of approximately 12 mm × 15 mm × 17 mm arising from the commissure and ventral part of the vocal cord.\nDirect microlaryngoscopy was performed under general anesthesia with a representative biopsy taken from the lesion. The result of the histopathological examination was myofibroblastic sarcoma of the larynx. The laryngoscopy showed the tumor of the vocal cord, the mobility of the right vocal fold was with reduced excursion of the vocal cord by the tumor mass, but the mobility was more than 2 mm in the lateromedial direction. The vocal cord on the left had complete function.\nGiven the respiratory distress, an urgent tracheostomy with general anesthesia was performed.\nCT scans showed the transglottic location of the tumor mass being 40 mm × 22 mm × 16 mm into the base of the epiglottic cartilage. No infiltration to the cartilage was evident. No lymph nodes were described, as the largest lymph node was not over 5 mm. See .\nWe performed a total laryngectomy. The tumor in the larynx was completely obstructed by the laryngeal lumen. Revision of the lymph nodes on both sides was performed, and no evidence of enlargement was detected. A histopathological diagnosis of myofibroblastic sarcoma of the larynx (MFS / LGMS) was performed.\nThe next step involved beam therapy because the tumor margin was near the surgical board of the sample. The dose was 66 Grays. The patient is still alive, and no evidence of recurrence of the tumor or persistence of the disease had been detected to date.
A 20-year-old-male presented to the emergency department with a history of penetrating injury to the penis by a needle on the same day. The needle was reported to have accidentally pierced the external genitalia at the penoscrotal junction when the penis was erect. There was no history of hematuria. Upon physical examination, the patient was anxious and his vital signs were normal. The caudal end of the needle was just palpable at the penoscrotal junction on local examination.\nThe results of urinalysis and complete blood examination reports were normal. An X-ray of the pelvis () showed the needle within the pelvis. Ultrasound examination of the abdomen including the genitalia showed a 6-cm needle piercing the prostate from the root of the penis up to the bladder neck. Because the needle was palpable at the penoscrotal junction and the caudal end of the needle was below the urogenital diaphragm (), an urgent surgical exploration with incision over the palpable end of the needle under fluoroscopic guidance was done. This exploration showed the tip of the caudal end of the needle to be inside the corpus cavernosum at the root of the penis (). The needle was manipulated by holding the caudal end at the penoscrotal junction, which showed that the tip of the needle was in and around the bladder neck by piercing the prostate gland. Endoscopic manipulation was not done in this case. The needle was removed intact through exploration of the bulbous cavernosa (). A pressure dressing was applied to the penis and the patients post operative voiding was normal. When the patient was queried about the possibility of self-insertion because accidental injury would be unlikely to push the needle completely through the external genitalia, the patient was too ashamed to admit the cause and was discharged after 2 days. Later, the patient admitted the motive behind the insertion of the needle as sexual gratification. The surgical wound healed well and mild penile edema was noted in the immediate postoperative period. The edema was reduced by a pressure dressing and no complications such as erectile dysfunction or plaque formation occurred during the 1-year follow up after needle removal.
A five-year-old boy was presented to our clinic with refractory pain in the low back and left extremity for approximately one year. There was no history of precedent trauma or underlying disease. The parents declared that they repeatedly observed the patient awaken from sleep due to pain although it was not severe enough to hinder his play with peers. Within a year, the pain did not get much worse or better. The mother quoted that she was sometimes obliged to use ibuprofen to relieve the pain, and it was completely effective.\nOn physical examination, the child suffered from antalgic gait. His pain was mainly located around the lower back of the trunk and left lower limb and aggravated by coughing. He was not able to flex his lumbar spine. The range of motion of the left hip and knee joints was normal, but straight leg rising was severely limited. There was a mild tenderness without any swelling on the lumbosacral area. Deep tendon reflexes were completely intact, yet, the strength of the left big toe extensor was grade 2, according to the medical research council scale for muscle strength []. The boy did not complain of any remarkable associated paresthesia in his extremities.\nThere were no significant abnormalities in the laboratory studies. Due to the sciatalgic presentation, magnetic resonance imaging scan was undertaken. However, intervertebral discs and vertebral bodies had normal signal intensity and shape, and this modality did not help much. The first radiographs were reported as normal. On closer examination of recent radiographs, it was found that the left pedicle of the fifth lumbar vertebra has probably lost its normal elliptical hollow shape (). There was no evidence of spinal deformity as well.\nBecause we suspected a bony lesion, technetium-99m bone scan was requested. It showed an increased uptake in this area; ultimately, computerized tomography exactly localized the location of the lesion ().\nWith the initial diagnosis of a benign latent lesion (probably osteoid osteoma, acute on chronic unilateral spondylolysis, or some kind of infection such as Brodie's abscess), surgical resection was discussed and offered to the parents and the boy himself. They accepted and his father assigned the informed consent. Early after surgery, the pain completely disappeared and he was ambulated and discharged one and two days later, respectively. Histologic examination revealed characteristic nidus (contained immature osteoid with osteoblastic rimming)and reactive bone in the region of the sclerotic border compatible with osteoid osteoma. At the 3 year follow-up postoperatively, the patient did not have any significant problem and is able to perform all his daily activities, although he complains of occasional trivial low back pain.
A 12 year old boy presented with a 2 month history of recurrent epistaxis to the emergency department for his fourth episode. The first episode had occurred 2 months back and was treated by local pressure and a haemostatic drug. The second episode occurred 2 weeks later and was treated similarly. A week later, the patient had another bout of nose bleed, heavier this time, which had to be treated with an anterior nasal pack, and silver nitrate cauterization of the wound later on. The current episode was from the same site and needed nasal packing again.\nOn all occasions there was no history of an apparent physical trauma to the nose, nor were there any symptoms to suggest an upper respiratory infection or allergic rhinitis. There was no bleeding from any other site in the body. The patient was not using any medicines. The patient was not suffering from any diagnosed medical condition. There was no family history of a similar illness.\nOn arrival the patient was awake, alert and fully oriented. He was bleeding moderately from left nostril. On physical examination his vital signs were stable. ENT examination showed active bleeding from left anterior nares. Rest of physical examination was normal. All through the examination, the child acted fussy and had difficulty remaining focused on a given task. He continuously rocked and fidgeted in the examination chair. Even frequent reprimanding couldn't discipline the child. This prompted the attending resident to seek a psychiatric consultation.\nA detailed evaluation revealed a child who had no problems in preschool. In kindergarten, he seemed to learn alphabets and numbers normally. The parents had noticed that he seemed more disorganized and inattentive than his older brother was at the same age. They often had to repeat instructions, and he left tasks half-finished. In primary school the patient had mild difficulty with mathematics, and the teacher use to be concerned about his not listening much of the time. The patients' school work was inconsistent and he often failed to finish his assignments. The parents also admitted a frequent nose picking behavior of the patient, which they couldn't correct with even punitive methods.\nWhen the patient was seen in the child and adolescent psychiatry department, he appeared as an attractive teenager who looked his stated age and was of average build but he showed grossly conspicuous behaviour. During interview he constantly shifted position, folded arms behind his head or leaned over the table in front of him and at times fiddled with his nose. He also got out of his seat frequently, played with buttons on clothes and couldn't sit still. His attitude was over familiar, pushy, demanding and lacking distance. He showed difficulty in sustaining attention and concentration which was elicited in writing and reading task given to him in interview. He was oriented in time, place and person. Intelligence was normal\nA diagnosis of Attention Deficit/Hyperactivity Disorder, hyperactive type was suggested.
A 15-year-old boy was referred to our hospital with presenting symptoms of nausea, vomiting, severe headache, delirium, and a complaint of mood and behavior change. He was the first child of consanguineous parents born at term with a birth weight of 3.1 kg. He had no history of intellectual disability, but a mild motor developmental delay was reported in his past medical history; he started walking at 18 months. He was diagnosed with bilateral cataracts at birth and underwent surgery in his 40 days of life, but no further workup was performed at that time. When he was 2.5 years old, he experienced three episodes of clonic seizure attacks during one month; however, EEG and MRI did not show abnormalities at that time. He did not experience any symptoms until 11 years of age when an episode of fever, confusion, and delirium occurred. CBC, blood biochemistry, lumbar puncture analysis, and brain MRI were all normal at that time, and a diagnoses of viral encephalitis was made. He experienced similar episodes at the age of 13. His parents stated that he exhibited behavioral and emotional problems like childish talk and mood instability during the attacks and turned normal after the episodes terminated. He also experienced headaches with migraine-like features during these episodes. The episodes resolved spontaneously within two weeks, and no specific trigger was noted.\nUpon physical examination, he was disoriented to time and place. He exhibited delirious state and childish behaviors like engaging in baby talk and short attention spans. He had a mild dry skin, mostly visible on the extremities and his face. Moreover, he had an abnormal gait and neurologic examination detected normal muscle tone and strength but reduced symmetrical reflexes in lower extremities. No significant abnormalities were found in other examinations.\nInitial blood tests of the patient were within normal limits, and his liver function tests, lipid profile, ammonia, and lactate showed no abnormality. Further, no pathologic results were found in primary metabolic screening for fatty acid oxidation disorders, organic acidemias, and amino acid disorders. Urine organic acids and homocysteine levels as well as plasma amino acids levels measured with high performance liquid chromatography were normal. Moreover, plasma levels of very-long-chain fatty acids (C26:0, C24:0/C22:0, and C26:0/C22:0) and pristanic and phytanic acids revealed no abnormalities. The auditory brainstem response test was performed, and no defects were reported. On the other hand, the nerve conduction velocity test revealed both sensory and motor polyneuropathy bilaterally in lower extremities.\nWith suspicion to mitochondrial or peroxisomal disorders, the mitochondrial treatment protocol (Vit B1, Vit B2, CoQ10, Vit E, b6, and L-carnitine selenium) was administered for the patient. The attack resolved in days with no significant clinical damage.\nWhole exome sequencing was requested due to the patient’s clinical features. DNA extracted from his blood was used to perform targeted gene capture using a custom capture kit. The obtained sequences were aligned to human reference genome (GRCh37/hg19) using the BWA program (, ) and analyzed using the Picard and GATK-Lite toolkit. The result indicated that the novel c.743_744delTCinsA mutation was located in the exon 4 of the PEX11B gene, leading to a frameshift and premature truncation of three amino acids downstream to the codon 248 (p.Leu248GInfsTer3). Sanger sequencing confirmed that the patient was homozygous for this variant. This novel variant was predicted to be damaging by Mutation Taster and considered as a pathogenic variant mutation of the disease.
A 39-year-old male with congenital glaucoma, epilepsy, hypertension, dyslipidemia, and diabetes and without a history of atopic disease had a history of multiple eyes examinations under anesthesia since the age of 1 year. Nonetheless, most of the medical records were narrative notes, and some of the anesthetic and medication records could not be retrieved. As a result, the medication list might have been incomplete.\nThe patient's history relating to allergy is summarized in . He developed his first episode of anaphylaxis at the age of 11 years during trabeculectomy performed under general anesthesia (GA) with thiopental and succinylcholine at a local hospital. The event was documented as a shock of unknown etiology. The second and third episodes of anaphylaxis occurred at the ages of 13 and 14 years, both of which involved cyanosis and hypotension shortly after induction of anesthesia during the eye examination. Consequently, the local hospital referred the patient to an academic hospital and issued an adverse drug reaction (ADR) card stating a suspicion of thiopental and succinylcholine allergy by guessing.\nDuring the ages of 15–28 years, he had multiple surgical operations at the same academic hospital to which he had been referred. All operative and anesthetic records had been previously destroyed due to the prolonged loss of contact for more than five years. The patient claimed the hospital did not use thiopental and succinylcholine according to the ADR card registered by the first local hospital. Nevertheless, the patient still suffered from three more episodes of anaphylaxis. Therefore, in accordance with the ADR unit, an anesthesiologist at the academic hospital specified the patient could be allergic to morphine and thiopental in the ADR card using informed guesswork. Nevertheless, the patient had an eye enucleation operation under GA without morphine and thiopental at the age of 29 years and developed anaphylaxis. After that event, the patient and his relatives were very frightened and discouraged, and they refrained from coming to the hospital for 10 years. The latest ADR record described an allergy to all anesthetic drugs except for propofol, succinylcholine, midazolam, and sevoflurane.\nTen years later, the patient visited our university hospital with chronic nasal congestion and was consequently diagnosed with chronic rhinosinusitis (CRS). He had no peripheral eosinophilia (absolute eosinophils = 201 cells/μL). He was treated with a 14-day course of amoxicillin/clavulanic due to recurrent bacterial sinusitis without any reactions. The otolaryngologist planned to perform an operation, so he referred the patient to an allergist to evaluate drug allergy. He was tested with different perioperative drugs according to . Standard concentrations according to the EAACI recommendation were used except for morphine, for which a lower than the recommended concentration [] was used because our experience suggests morphine at the recommended concentration usually provides a high false-positive rate in Thai patients. A skin prick test (SPT) was performed first on the forearm with the negative and positive control using normal saline and 10 mg/mL of histamine, respectively. Results were considered positive if a wheal diameter of ≥3 mm was read at 20 min. When the SPT was negative, we performed an intradermal test (IDT) on the volar side of the forearm. Results were considered positive if the wheal increased in diameter ≥3 mm compared to the original wheal with concurrent flare.\nThe first test results were negative. The patient's baseline serum tryptase was 3.82 μg/L, latex-specific immunoglobulin E (IgE) was 0 KUA/L, and complement 4 (C4) levels were 20 and 24 mg/dL at 2 different timepoints (normal range, 15–45 mg/dL). Because the patient had had severe immediate reactions, and all the initial test results were negative, we scheduled the next round of testing 6 weeks later. The second round of skin tests was performed with the same drugs at the same concentrations as the first tests. IDTs were positive for ketamine at 1 and 0.1 mg/mL concentrations, and SPTs were positive for morphine at 1 mg/mL concentration (). Positive tests for morphine were confirmed with SPTs performed at another two skin sites and negative skin tests to morphine and ketamine in healthy controls, the patient's brother, and mother (Figures and ).\nWe recommended the patients avoid ketamine and morphine. Alternative drugs were those testing negative, including fentanyl, propofol, thiopental, etomidate, midazolam, succinylcholine, cisatracurium, atracurium, and rocuronium. The ADR card was updated accordingly. Nonetheless, close observation for allergic symptoms was advised in the case of future anesthetic procedures with these alternative drugs. The patient underwent sinus surgery in the next 3 months after the second skin test using propofol, midazolam, sevoflurane, chlorhexidine, and cefazolin without any anaphylactic reactions. For all of the case history, images, and data to be published, written and informed consent was obtained from the patient. The patient was informed that de-identified data would be used in the scientific research and publications.
The patient is a 72-year-old Caucasian female with history of T4 N0 M0 squamous cell carcinoma (SCC) of the right floor of mouth and mandible.\nThe patient had a right segmental mandibulectomy and fibula-free flap reconstruction 4 years prior to the events of this case report (Fig. ). Three years following reconstructive surgery, the patient received restorative dental treatment in the form of mandibular dental implants to support an implant retained denture. The implant placement was carried out without incident.\nThe patient presented with extensive gingival enlargement in the floor of the mouth and lingual gingival tissues (Fig. ). The firm mass extended bilaterally and partially covered the healing abutments of the implants. The buccal gingivae around the implants were not as severely affected. As the mass presented in the same region as the previous SCC, a biopsy was arranged urgently.\nThe initial overgrowth was subsequently excised under local anaesthetic which leads to a recurrence 4 months later. This recurrence presented as a firm nodular enlargement over the mandibular ridge (Fig. ). This was also subsequently biopsied to rule out malignancy.\nThe patient underwent a series of biopsies to determine the cause for the gingival enlargement. An incisional biopsy was taken from the floor of the mouth (Fig. ). The floor of mouth biopsy showed mucosa with overlying fibrin and neutrophil polymorphs. The underlying stroma contained a proliferation of thin-walled vessels and fibrosis and neutrophil polymorphs permeating through the depth of the biopsy. In particular, there was no convincing evidence of residual squamous cell carcinoma either morphologically or on immunohistochemistry. This biopsy came to the conclusion of granulation tissue with inflammation. Gingival enlargement is characterised by excess extracellular matrix proteins, non-collagenous proteins and chronic inflammatory infiltrate dominated by plasma cells.\nThe second biopsy incisional biopsy (4 months following the first) was taken from the overlying mucosa of the mandibular ridge. This biopsy showed heavily inflamed connective tissue with prominent exuberant granulation tissue. There was no dysplasia or malignancy identified. The overall findings were granulation tissue with inflammation.\nA magnetic resonance imaging (MRI) scan was also requested following the second biopsy. The MRI scan found no abnormal signal at the resection/reconstruction site, and there were no enlarged lymph nodes. The radiologist concluded that there was no convincing MRI evidence for disease recurrence.\nAdvice was sought from specialists in oral medicine. It was concluded that the proliferative growth was induced by the patient’s use of amlodipine. The patient’s general medical practitioner was informed and asked to change the patient’s antihypertensive medication. It was then arranged for the remaining enlarged soft tissue mass to be excised under local anaesthetic by the maxillofacial surgeon.\nThe growth was excised uneventfully and without reoccurrence. Implant treatment was recommenced shortly after. The overgrown tissue was removed as it was obstructive for the patient and reduced her ability to undertake adequate oral hygiene around the dental implants. There was an expectation that non-surgical peri-implant therapy would be required, but due to the complete resolution of the gingival overgrowth after excision and alteration of her medication, this was not required. The patient required multiple appointments of oral hygiene instruction to allow the healing abutments to become visible and useable (Fig. ).\nAt the implant-retained wax rim and wax try-in stage, the occlusion was initially prescribed as a class 1 incisal relationship with bilateral buccal overjets (Fig. ). However, this did not provide sufficient lower lip support and tooth display for the patient to be satisfied, especially on her right hand side (Fig. ). This tooth position was also uncomfortable lingually for the patient due to a reduced tongue space.\nThus, the patient and dentist agreed to accept an altered occlusion. The new prescribed occlusion was balanced with simultaneous contacts anteriorly and posteriorly and mild lingual imbrication to provide the patient a more natural appearance (Fig. ). This additional lip support was also pleasing to the patient.
A 62-year-old female patient reported to a private dental clinic with pain in the right lower back tooth region for the past 2 weeks. Intraoral examination revealed the presence of reddish buccal gingival growth in relation to mesial aspect of tooth no. 47 measuring approximately 0.5 cm × 0.5 cm. Grade III mobility was evident in 47. The rest of the dentition exhibited generalized chronic periodontitis. The patient gave no history of tobacco usage in any form. Extraoral examination revealed a single palpable, nontender, mobile and firm submandibular lymph node on the right side. On the basis of above findings, the buccal growth was provisionally diagnosed as an inflammatory/reactive gingival growth and apical periodontitis in relation to 47. Since the patient insisted only on symptomatic medical management, she was prescribed antibiotics, analgesics and chlorhexidine mouthwash for 3 days. A complete hemogram and biochemical assay for blood sugar was requested and the patient was asked to report after a week. One week recall visit revealed unsatisfactory healing and blood investigation reports were all within normal limits, excepting a slightly elevated erythrocyte sedimentation rate. Due to the persistence of the lesion and poor response to medical therapy a likelihood of noninfectious and noninflammatory pathology was strongly suspected. Since the patient did not want any further conservative management and insisted on an extraction, the dentist decided to extract the tooth. Considering the innocuous appearance of the lesion, perceived lack of risk factors and the patients’ insistence of symptomatic management and unwillingness of the patient to undergo any radiographic examination, the dentist requested for an expert opinion from the speciality services. Considering the age of the patient, ambiguous clinical presentation and the refractory nature of the lesion, a differential diagnosis of OSCC and metastatic carcinoma to the gingiva was considered. Only after the expert opinion and counselling by the specialist, did the patient agree for immediate biopsy along with extraction and the radiograph was taken only on follow-up.\nOn the 2nd week recall, the patient reported with the panoramic radiograph and presented with a rapidly growing soft tissue mass in the extracted site. Clinical intraoral examination revealed an ovoid reddish, spongy mass measuring about 1 cm × 1 cm from the extracted site []. Orthopantomogram did not reveal any remarkable findings [].\nHistopathological examination revealed islands and sheets of dysplastic epithelium invading into the underlying connective tissue stroma with keratin pearl formation. The overlying epithelium showed hyperkeratinized stratified squamous epithelium with dysplastic features suggesting a diagnosis of well-differentiated SCC [Figures –].\nThe patient was referred to cancer speciality hospital for further management. A whole body positron emission tomography scan was done to rule out secondaries. The patient was administered radiotherapy fractionated at 60 Gy each session for a period of 5 weeks. The patient is continuously under follow-up 6 months postradiation and does not show any signs of recurrence [].
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative course was uneventful and the symptom of intermittent claudication disappeared. She was discharged on fourth postoperative day with antiplatelet (salicylic acid 100 mg, once daily) and statin (atorvastatin 20 mg, once daily) medication.
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.\nA histological examination revealed mammary Paget’s disease without invasion to underlying tissues (Fig. ), no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
A 63-year-old woman with relapsed AML and diabetes mellitus was admitted for induction chemotherapy with cytarabine and clofarabine as part of the management plan for allogeneic stem cell transplantation. Six days after chemotherapy, she developed loose stools and diffuse abdominal pain. She was found to have Clostridium difficile infection, and oral metronidazole treatment was started. Her abdominal pain persisted and began to localize to the right lower quadrant. She was neutropenic but remained afebrile. An abdominal and pelvic computer tomography (CT) scan showed a segmental hypoenhancing area in the mid appendix with minimal surrounding fat stranding concerning for appendicitis. There were no drainable fluid collections (fig. ). Given the patient's high risk of perioperative morbidity and mortality, she was initially treated with broad-spectrum intravenous antibiotics consisting of meropenem. The patient remained afebrile and hemodynamically normal on medical treatment. However, her right lower quadrant abdominal pain continued and she developed localized peritoneal signs. A repeat CT scan obtained 3 days later showed stable inflammation of the appendix with a new finding of an adjacent loop of small bowel with thickened wall. There remained no extraluminal air or drainable fluid collections to suggest perforation (fig. ). Since the patient was not responding to medical therapy, she was taken urgently to the operating room for an appendectomy for treatment of acute appendicitis.\nThe operation began with a laparoscopic approach. Upon inspection of the right lower quadrant, the appendix was found to be completely necrotic down to the base. The necrotic appendix was lying on top of an adjacent loop of terminal ileum that was also segmentally necrotic at the contacting surface (fig. ). The case was converted to open in order to perform an ileocecectomy with primary stapled anastomosis. The fascia was closed but the skin was left open to heal by secondary intention due to the infected wound classification.\nThe patient was admitted to the intensive care unit postoperatively and extubated on postoperative day (POD) 1. Despite empiric broad-spectrum antimicrobial therapy with meropenem, linezolid, and fluconazole, the patient spiked a fever to 38.5°C on POD2. She clinically deteriorated on POD4 and was re-intubated for tachypnea and hypoxia. A CT scan of the chest showed numerous peripheral cavitary lesions that were either septic emboli or fungal infection. A bronchoalveolar lavage was performed to aid diagnosis.\nOn POD5, pathological diagnosis of zygomycosis was made from the ileocecectomy specimen. Hematoxylin and eosin (H&E)-stained sections showed ischemic changes, hemorrhage, and thrombosed vessels filled with broad irregular aseptate hyphae (fig. ). Inflammatory cells were rare as expected in a neutropenic patient. Gomori methenamine silver (GMS)-stained sections also demonstrated characteristic wide ribbon-like aseptate hyphae that branch at wide angles, typical of Zygomycetes, involving both vessels and adjacent submucosa (fig. ) as well as invading through the muscularis propria of the appendix (fig. ). Antifungal therapy was immediately switched to amphotericin B.\nOn POD6, fungal overgrowth was found in the surgical wound. Culture of the bronchoalveolar lavage recovered Absidia spp., confirming disseminated angioinvasive zygomycosis. The patient's clinical condition continued to worsen with severe hypotension that required increasing doses of vasopressors. Given the patient's dismal prognosis of surviving such an overwhelming systemic fungal infection, goals of care were transitioned to comfort and she expired on POD8.
Our patient is an 8-year-old boy whose disease started with an unusual skin manifestation and extraordinary findings were seen during the course of treatment. At 6 months old he developed generalized red, nontender nodules. At the time, the patient had no systemic manifestation of any disease; therefore only biopsy of the lesion was taken. First biopsy was taken when he was 6 months old; the pathologic report of this biopsy was nonspecific inflammatory process. He developed a painless, cold abscess in the medial axis of his thigh at the age of 2. At that time patient had no abnormal findings in the physical examination or laboratory workup. Thus treatment for a simple abscess was done. At the age of 4, he developed a seronegative polyarticular arthritis which included proximal interphalangeal joints of hands, right elbow, both hip joints, and left knee which responded well to usual treatment for juvenile arthritis. The patient was on daily oral prednisolone and folic acid and weekly oral methotrexate therapy. His ANA level was on normal range. During the same year, another skin biopsy was taken which was in favor of keratoacanthoma (), and it also showed wart infection. Multiple eruptive keratoacanthomas of the patient responded well to oral isotretinoin therapy. At this time workup for immune deficiency disease was repeated. A review of family history revealed that the patient's parents were cousins. In addition, workup detected high eosinophil count in complete blood count and high level of immunoglobulin-E but due to financial limitations genetic study was not performed. According to some diagnostic criteria (the National Institute of Health clinical feature scores: 41 in 9-year-olds), he was suggested as hyper IgE syndrome patient (, ) []. At the age of 8, our patient developed an abscess in the left inguinal region and subsequently he was admitted to the hospital. Complete physical examination was done and nothing except left side inguinal abscess, scars of previous skin lesions, and retained primary teeth was detected (). In ultrasonography a collection was detected in subcutaneous region. So, treatment was started by draining the abscess and administering broad spectrum intravenous antibiotics. Few days after admission, the patient developed a nonspecific abdominal pain. Abdominal computed tomography showed mild-free fluid with no abscess formation; also an asymptomatic neural cyst at the root of T10 nerve and outside the spinal canal was seen. The abdominal fluid was not purulent and had no signs of malignancy. During hospitalization, the patient developed generalized tonic colonic convulsion and a fever with no neurologic deficits. Brain computed tomography scan showed an abscess measured 4.6 × 3.3 cm in the right frontal lobe (). The abscess was then aspirated. The aspirate showed no evidence of bacterial or fungal infections and pathologic report showed tissue inflammation with inflammatory cells. Gram stain and cultures for bacteria, fungus, and mycobacteria were all negative as well as polymerase chain reaction for mycobacteria and fungus. Patient was febrile for another 2 weeks so we employed broader spectrum antibiotics and IV-IG. After a week passed with no improvement in his condition, a magnetic resonance imaging (MRI) of brain was performed which showed expansion of existing abscess to contralateral frontal lobe (left side) (); hence full evacuation of the contents and wall of abscess was done. Repeatedly, diagnostic studies for bacterial, fungal, and mycobacterial infections were negative. After evacuating the abscess, patient's condition improved dramatically and fever stopped. The patient was given intravenous antibiotic for 4 weeks without further complications. In followups, the patient was visited monthly with no neurologic deficits or fever seen.
A 66-year-old man had been aware of left flank pain for 6 months prior to visiting his family doctor. The doctor carried out an X-ray of the kidney, ureter, and bladder and made a diagnosis of a staghorn calculus in the left kidney (). The patient was referred to our office for further examination and treatment. His previous medical history was a urinary tract stone 20 years ago. We performed no contrast-enhanced CT of the abdominal and pelvis, which revealed an 8 cm renal stone in the left renal pelvis (). Urine tests showed hematuria and pyuria, but no bacteriuria, while the results of blood tests were unremarkable with a serum creatinine concentration of 0.95 mg/dL. We diagnosed a staghorn calculus in the functioning left kidney and attempted to perform an ECIRS, first establishing hydronephrosis using an occlusion catheter to puncture in order to make a percutaneous trocar nephrostomy easy. However, we were unable to insert the trocar, despite the left kidney being punctured three times. A lithotripsy was only performed. Part of the left renal stone still existed, especially in the inferior calyx of the kidney (). Analysis showed the stone consisted of calcium phosphate. ECIRS was performed one month later, and we were able to insert the trocar at this time and carry out the procedure as planned (). Analysis of the stone showed it consisted of calcium oxalate (90%) and calcium phosphate (10%). At this time, we realized that the white fuzzy tissue was different from normal renal pelvic mucosa and therefore carried out urine cytology and a single targeted biopsy of the renal pelvic mucosa. Urine cytology identified squamous cells classified as class III. Histopathological examination showed a keratinized lesion and stratified squamous epithelium with atypical cells, although we were unable to determine whether these were malignant changes. ECIRS was performed and allowed the majority of the kidney stone to be removed (). One month after the last surgery, the patient complained of persistent left flank pain, with contrast-enhanced CT showing that almost all of the left kidney was invaded and replaced by a tumor. The tumor had expanded to around the left renal artery although there was no metastatic lesion (). We performed a left renal biopsy because we suspected a renal cell carcinoma or RPCa. Histological examination revealed an invasive urothelial carcinoma with squamous differentiation and a clinical stage of T4N0M0 (). We then performed two courses of neoadjuvant chemotherapy (cisplatin and gemcitabine). After two courses of chemotherapy, CT showed stable disease. We judged that this chemotherapy was ineffective, and it is difficult to operate radical nephrectomy in this case. We started to administer pembrolizumab. After we performed 7 courses, CT showed progress disease. We stopped to administer pembrolizumab and started palliative treatment.
A 33-year-old male was referred to our hospital with infection of the distal end of the catheter 20 days after the ventriculoperitoneal shunt. He has a past history of head injury in a road traffic accident six months ago. He presented with loss of consciousness and right temporal lobe uncal herniation. CT scan revealed right temporal lobe contusion with hematoma. Emergency craniotomy was performed for drainage of hematoma with decompressive craniectomy. Postoperative period was marked by lost consciousness. A left ventriculoperitoneal shunt was performed for traumatic hydrocephalus. Cranioplasty was accomplished after three months of decompressive craniectomy. On postoperative day 15, the patient experienced fever with temperature of 39℃ with increased intracranial tension. CT scan revealed recurrence of hydrocephalus. Blockage of peritoneal end of catheter was confirmed followed by replacement. Catheter tip was positive for staphylococcus epidermis infection. Peritoneal fluid did not show any infection. He was started on antibiotics. On postoperative day 20, oozing of pus from the abdominal incision site was noted, with wound gapping. Immediate debridement of the wound was done followed by delayed suture. The patient was then referred to our hospital. On admission he was unconscious with purulent fluid oozing out from the abdominal incision. Abdominal X-ray showed peritoneal end of the shunt was located accurately ().\nFurther replacement of peritoneal shunt might increase the chances of failure owing to the recurrent abdominal infection and inflammation. VA shunt was then considered. We decided to conserve the ventricular shunt and the pressure adjusted pump, with removal of the peritoneal shunt from the pump. A new distal catheter was connected to the pump. Under general anesthesia, the incision was made across the anterior border of the left sternomastoid muscle and the left common facial vein was identified. A small opening was made into the common facial vein and the shunt was then expected to pass down to the left jugular vein, subclavian vein and then to the right atrium. The passage was smooth till 6 cm of shunt remained out, then we encountered a resistance, which was subdued due to continued movement. After the complete insertion of the shunt catheter we severed the left common facial vein, ligated the distal end of the vein and the proximal end was ligated to the catheter. The chest X-ray done in the recovery room did not reveal the shunt at the T6 level (). An X-ray of neck demonstrated that the distal catheter tangled back in the jugular vein before the entry into subclavian vein (). Endovascular intervention via femoral vein intervention was then planned to draw the distal shunt into right atrium. Under local anesthesia, a 6F sheath was inserted into the right femoral vein by Seldinger method. A 5F guiding catheter was then advanced into the left subclavian vein, followed by imaging to determine the location of the shunt. A 4 mm Gooseneck loop snare was promoted through the left jugular vein to capture and ligate the tip of the shunt catheter. Finally, the shunt end was dragged into the right atrium smoothly. Post procedure chest X-ray confirmed the accurate position of the distal catheter of the shunt in right atrium (). Following endovascular re-positioning, the shunt function was optimal.
A 10-year-old boy reported to the Department of Pediatric Dentistry, with a chief complaint of mobile teeth in maxillary and mandibular posterior region and wanted to get them extracted. The medical history of the patient was noncontributory and no abnormality was detected on extra-oral examination. Intraoral examination revealed preshedding mobility in relation to all the present primary teeth, which included the maxillary second molar in the first quadrant, mandibular second molar in the third quadrant and mandibular first and second molar in the fourth quadrant. All the other teeth present in the oral cavity were normal.\nDuring the examination, it was found that maxillary second premolars were not present in the oral cavity and hence a radiograph was done to confirm the clinical findings. An orthopantomogram (OPG) was advised as it would cover the entire dentition and make visible any tooth abnormalities and also help us determine the eruptive status of other permanent teeth. The OPG revealed two very interesting findings, first as suspected the maxillary second premolars were missing along with the absence of right mandibular second molar. Second the right primary mandibular first molar was single rooted which is an extreme rarity []. The clinical and radiographic diagnosis, thus, confirming the case of hypodontia with root dysmorphology. A thorough examination of all tissues of the child-like skin, nails, ears, etc. and familial history revealed no contributory findings thus confirming the case of nonsyndromic hypodontia.\nAs the main reporting problem of the patient was mobile teeth which caused him discomfort and difficulty in eating it was decided to extract all primary teeth including the single rooted primary molar. Upon extraction, the single rooted molar was sent for histopathology examination. The sectioning of the tooth was performed and it revealed one single root and root canal [] and the histological ground section under ×10 magnification [] supported our findings of single rooted primary mandibular first molar. The patient is asymptomatic and is on follow-up so as to review the eruption status of permanent teeth.
An 8 year old male child along with his parents reported to the Department of Pedodontics with the chief complaint of bluish black swelling on the gums in the front region of the upper jaw []. Parents of the child were fearful; assuming the lesions to be malignant tumor. History of the case revealed that 61 was extracted 1 year back due to caries. The lesions started appearing 2 weeks back as translucent swellings over normal mucosa and it slowly increased to its present size. The color of the lesions also slowly changed from its normal red mucosa to the present bluish black color 1 week back. No fluid discharge or any other associated symptoms were associated. The general physical examination of the child showed no abnormalities. There was no history of any acute infection, trauma, and drug or food allergy in the recent past. Examination of the oral cavity revealed that the child was in the mixed dentition stage. All the permanent 1st molars had completely erupted and all incisors except 21 were in various stages of eruption. Carious lesions were present with respect to 52, 62 and 73. Soft tissue examination did not show any abnormalities except, the presence of gingival swelling with respect to 21. Clinically the gingival lesions appeared as bluish-black, circumscribed, fluctuant swellings on the buccal gingiva over the site of un-erupted 21. Swelling measured approximately 1.5 × 2 cm and was very soft and fluctuant. The overlying mucosa was smooth and no ulceration was present. X-rays of the lesions confirmed the presence of 21 in the stage of eruption and there were no signs of bone involvement or any radiolucency surrounding this tooth. It was clinically and radio graphically diagnosed as eruption cyst with 21.\nThe clinical condition was explained to the parents and they were advised to observe the swellings for another 2 weeks as it may rupture on its own and may not need any surgical intervention. Patient reported after 15 days. The swelling was still present and dull aching pain was present on mastication. The surgical procedure was explained to the parents and consent was obtained for the same. A blood investigation was carried out before the procedure. The treatment included incising the eruption cyst with BP blade and draining the contents of the cyst. A window was cut leading to the exposure of 21. Post operative instructions were given [].\nThe patient was reviewed after one week and a normal eruption pattern was observed.
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative course was uneventful and the symptom of intermittent claudication disappeared. She was discharged on fourth postoperative day with antiplatelet (salicylic acid 100 mg, once daily) and statin (atorvastatin 20 mg, once daily) medication.
A 4-year-old boy visited a local hospital due to repeated episodes of pneumonia since the age of three months. A chest radiograph and CT revealed an abnormal mass-like lesion in the right lower pulmonary lobe. An attempted total excision was unsuccessful, and only a biopsy was performed in the local hospital. The precise pathologic report of the outside hospital was not available except for information of a kind of vascular mass. Because the boy had long-standing and recurrent symptoms, he was referred to our vascular center for further evaluation and treatment. A plain radiograph showed increased right infrahilar opacity overlapping the cardiac shadow. The right lung was more lucent and smaller than the left one, suggesting an airway problem (). A precontrast CT scan revealed a soft tissue mass containing multiple and well-defined small calcific foci in the right lower lobe of the lung, which were suggested to be phleboliths (). After injecting the contrast material, the anterolateral portion of the mass was intensely enhanced without enhancement of the surrounding region (). The lesion was encasing the right bronchus intermedius and the right lower lobar bronchus, resulting in decreased caliber. The right inferior pulmonary vein was also narrowed by the encasing mass (). The mass abutted the posterior margin of the heart and superior pulmonary vein. Before surgery, an MRI was performed in our hospital three months after the CT scan performed at the outside hospital to further evaluate the mass demarcation with the surrounding tissues; especially in the airway and large vessels. The lesion was found to be isointense with the muscles on T1-weighted images and hyperintense on the T2-weighted images (). There were no signal differences between the enhancing and the non-enhancing part on a contrast enhanced CT on MRI. Because the intravenous administration of MRI contrast agent was not performed during MRI, the comparison of the enhancing pattern between the CT and MRI was not possible. Linear or dot-like signal voids within the mass suggested vessels and phleboliths. This mass abutted the right pulmonary artery and the pericardium, but there was no evidence of invasion into the myocardium. A whole body blood pool scintigraphy (WBBPS) was performed one hour after the injection of Tc-99m RBC. The results demonstrated dense abnormal blood pooling in the right infrahilar area similar to that of the heart, and small multifocal blood poolings in the right upper and the left lower extremities (). According to the imaging findings and the pathologic report of the outside hospital, a vascular malformation was the most probable preoperative diagnosis.\nBecause the lesion caused clinical problems, including frequent infection and compression of the airway, a right lower lobectomy was performed. A soft mass abutting the right pulmonary artery at the interlobar fissure was found at surgery. The mass adhered to the pericardium near the right inferior pulmonary vein. The resected specimen was identified as a poorly defined hyperemic mass measuring 5 × 5 × 3 cm at the right lower lobe of the lung. The mass was composed of thin-walled, dilated, sponge-like abnormal vascular channels of variable size and thickness. Because there was no elastic tissue in the wall of the vessels, a venous malformation was diagnosed (). There were no pathologic differences between the enhancing and the non-enhancing parts on a contrast-enhanced CT.\nThe patient has been followed uneventfully for 26 months after surgery. Follow-up chest radiographs and chest CT scan were taken every 12 months following surgery and have not revealed any evidence of a recurrent lesion. However, the vascular lesions in the extremities slightly increased in size on a follow-up WBBPS, probably combined with somatic growth.
A 38-year-old nulliparous woman, gravida 4, para 3, with a previous induced abortion in the first trimester and 2 ectopic pregnancies was referred at 21 + 2 weeks of gestation with absence of the nasal bone in 1 fetus. The couple reported infertility problems, and the woman has conceived via IVF with transfer of 3 cleavage embryos. Her medical history was negative for hypertension, diabetes mellitus, and other conditions. She had undergone bilateral salpingectomy due to ectopic pregnancies. She denied history of any congenital anomalies or chronic conditions. The couple was healthy and had no history of exposure to any medications or other teratogens. She had no remarkable family history. Ultrasound taken during the first trimester showed 2 different gestational sacs, indicating dichorionic twins. The IVF-derived gestational ages matched those determined by ultrasound measurements in the first trimester. The twins showed normal nuchal translucency during screening in the first trimester. At 19 + 1 weeks of gestation, amniocentesis was conducted on the dual amniotic sacs because of advanced age, which revealed normal karyotypes for each twin. Prenatal sonography showed absence of the nasal bone (Fig. ) in twin B at 21 + 2-weeks of gestation and no other structural anomalies. Subsequently, extensive prenatal genetic counseling and discussions with the laryngologist about potential neonatal clinical issues were conducted. In light of this uncertainty, the couple made the difficult decision to continue the pregnancy. The couple refused to undergo magnetic resonance imaging (MRI), and a serial follow-up scan was selected as the alternative management strategy. Sonography at 25 + 4 weeks confirmed the absence of the nasal bone in twin B. An ultrasound performed 5 weeks later also did not show the nasal bone in twin B. The mother subsequently received routine outpatient care according to the gestational age. Subsequent reports of ultrasonography were reviewed for anomalies, and no abnormalities were seen in growth, amniotic fluid volume, and other ultrasonic indexes. The pregnant woman delivered 2 live babies weighing 2030 g and 1940 g by cesarean section at 36 + 1 weeks of gestation. Twin B showed normal external nose and had no difficulties in breastfeeding and breathing after birth. Subsequently, the absence of the nasal bone was confirmed on a radiograph in twin B on postnatal day 3 (Fig. ). At the time of submission of this manuscript, the twin B was 2 years and 9 months old and showed normal breathing and eating functions.
A 24-year-old Chinese man was admitted to our Emergency Department presenting with a neck wound that had been slightly bleeding for six hours. The neck trauma occurred in a chaotic fight. The patient could not describe details of the injury, but he reported that the wound might have been caused by fragmentation of a beer bottle. On physical examination, there were no signs or symptoms of respiratory distress. The wound opening, measuring one cm, was identified at the submandibular area of the left side of the patient’s neck below the border of the mandibular angle. No glass fragments or other foreign bodies were detected, but slight swelling and bleeding were noted. Examinations of the oral cavity and pharynx revealed no abnormalities.\nAnteroposterior and lateral X-rays of the patient’s neck revealed subcutaneous emphysema and no foreign body in the soft tissues (Figure ). The wound was closed by suturing. The patient was then given antibiotics and referred to the Department of Stomatology ward for observation. There was significant relief of the subcutaneous emphysema and wound swelling in the first two days. However, he still felt pain and the movement of his neck was restricted. On the third day after a bout of violent coughing he had an abrupt onset of left-sided neck swelling with neck pain and shortness of breath. Physical examination discovered that the trachea was deviated to the right without any neurological deficit. A computed tomography (CT) scan revealed extensive subcutaneous emphysema in the neck and upper breast region, and a dense linear shadow at the level of the 7th cervical vertebra and 1st dorsal vertebra whose ends were embedded in the pre-vertebral soft tissue and parapharyngeal space (Figure ).\nA tracheotomy was promptly performed to relieve his shortness of breath. Once the skin and subcutaneous tissue were opened, a massive amount of fresh blood and blood clots poured out of the incision. Our initial clinical impression was that he had ruptured cervical arteries, and a cervical hematoma resulted in compression and marked displacement of the airway to the right. As the ongoing bleeding could not be controlled, an emergency exploration of the patient’s neck was initiated while an assistant compressed the bleeding site with gauze. His neck was opened on the left side under general anesthesia. On opening his platysma and retracting the sternocleidomastoid muscle laterally, a rapidly expanding and bulging hematoma was observed extending superiorly into the parapharyngeal space and inferiorly into the superior mediastinum. After evacuating the hematoma, an arterial tear was identified at the posteromedial wall of the CCA. The IJV wall was also torn in the region adjacent to the tear of the CCA. The points of perforation were associated with arterial pulsatile postoperative bleeding and venous extravasation of blood components, with surrounding adventitia appearing somewhat ragged, suggesting a pricking injury. A broken chopstick was noted lying across the pre-vertebral soft tissue with its tip embedded in the CCA and its butt in the right cervical pleura. The six-cm piece of chopstick was removed. The vascular defects were repaired with polypropylene 6–0 suture at the injury site, located approximately two cm distal to the bifurcation.\nThe patient was intubated and mechanically ventilated in the intensive care unit. A CT scan and an anterior-posterior view X-ray of the chest following cervical surgery revealed a pneumothorax, much fluid, and pulmonary atelectasis on the right side of the chest with pneumomediastinum (Figure ). A chest tube and closed drainage system was used to remove the gas and fluid from the intrathoracic space. A total of 800mL of dark red bloody fluid was drained. The hemopneumothorax resolved by the third day after the operation, and the chest tube was taken off suction. Mechanical ventilation was discontinued postoperatively the same day. A further CT of the chest showed that encapsulated pleural effusion was present in the right upper and lower lobes. Video-assisted thoracoscopic surgery was performed for the debridement and deloculation of the clotted hemothorax. In all, 400mL of retained clotted blood was cleared with a suction instrument intraoperatively. The patient was discharged one month later.
A 64-year-old male patient underwent cardiac resynchronization therapy (CRT) device with defibrillator implantation for dilated cardiomyopathy and recurrent ventricular tachycardia. During the implantation procedure, it was difficult to determine the location of the left axillary vein as although the left subclavian vein was punctured and a guide wire could be inserted, we could not insert a peel-away introducer across the costoclavicular junction and handle the inserted right ventricular lead due to mechanical resistance at the costoclavicular junction. To avoid the risk of difficult lead handling and future subclavian crush syndrome, a second puncture was performed at a more lateral site approximately two fingers away from the initial puncture point. Although a puncture needle should be inserted almost vertically in order to reach the lateral axillary vein near the junction of the cephalic and brachial veins, we were able to insert peel-away introducers and the left ventricle (LV) and right atrium (RA) leads without any difficulty. The LV and RA leads were positioned where the optimal values of sensing and pacing parameters were obtained. After starting biventricular pacing, the episodes of ventricular tachycardia decreased remarkably, suggesting successful electrical remodeling. The patient was discharged without overt complications.\nHowever, two weeks after the implantation of the CRT device, the patient started complaining of "electric shock-like" pain in the left axillary area radiating to the medial border of the left arm. The patient described the pain as being usually triggered by active shoulder movements, especially when pulling up his pants. During physical examination, typical pain in the left axillary area was reproduced whenever his left shoulder was passively abducted more than 60 degrees. However, there were no objective sensory changes or motor weakness. The patient's symptoms and signs suggested irritation of the left brachial plexus. Chest computed tomography scans showed the LV and RA leads running together into the lateral axillary vein along the lateral side of the pectoralis minor muscle causing a curvature with an acute angle (). Fluoroscopic examination in the supine position showed that the LV and RA leads were positioned at an acute angle directing towards the left brachial plexus whenever the patient's shoulder was passively abducted more than 60 degrees (; ). Severe left axillary and radiating arm pain recurred whenever the LV and RA leads formed such an acute angulation on fluoroscopic examination. Brachial plexus irritation by the angulated CRT device leads was strongly suspected. Analgesics and antibiotics were prescribed to control the pain and to treat the possible subclinical device-related infection. However, the patient complained of gradual worsening of the pain despite continued administration of high-dose pain killers. Six months after implantation of the CRT device, the patient was readmitted for adjustment of lead angulation due to worsening of the left axillary and radiating arm pain which impeded the patient's daily physical activities.\nDue to the fact that the LV and RA leads were inserted across the pectoralis major and minor muscles into the lateral axillary vein, which was located deep in the patient's chest, correction of the lead angulation by generator repositioning was technically impossible. Operators had to move the entry site of the LV and RA leads from the distal to the proximal axillary vein using the cut-down method. Under general anesthesia, the pectoralis minor muscle was cut and the axillary vein was exposed. The vein was clipped and incised transversely at a proximal site (). After disconnection of the LV and RA leads from the generator, we attempted to manually extract the disconnected leads through the transverse incision line. However, the leads were tightly adhered to the axillary venous wall, and the possibility of vascular injury and LV lead malpositioning due to extraction force was considered. Finally, we had to open the left axillary vein to separate the leads safely. The left axillary vein was incised longitudinally from the initial insertion site of the LV and RA leads to the more proximal site which was 3 cm away ( and ). The adhesions between the leads and vessel wall were then dissected carefully. Separated leads were moved to the proximal site through the longitudinal incision line and the remaining incision lines were closed. After adjusting the LV and RA lead insertion site, acute angulation was not observed during passive shoulder abduction more than 60 degrees on fluoroscopic examination (). After confirming successful lead repositioning, all of the procedures were completed without complications. Although curvatures of the LV and RA leads were slightly modified after the correction surgery, there was no significant change in the LV lead tip location and LV capture threshold. Neuropathic pain decreased remarkably two weeks later and analgesic agents could be withheld two months later. There were no symptoms and signs of left subclavian vein obstruction. The ranges of passive and active shoulder movements increased gradually but were nearly completely normalized at six months after the surgery.
A 37-year-old G10 P3063 African American female presented to the emergency department with complaints of abdominal pain and vaginal bleeding. Her obstetric history was significant for a full-term vaginal delivery followed by two full-term cesarean deliveries fifteen and five years earlier, in addition to a cesarean scar pregnancy diagnosed one year earlier. At the time of the latter, the patient underwent exploratory laparotomy, hysterotomy, and removal of the gestational sac. The uterine incision was closed with 0-vicryl in a continuous locking fashion. The pathology revealed a gestational sac with embryo which was lined by immature chorionic villi. The patient was discharged two days after surgery, had an unremarkable postoperative course, and decided to use withdrawal and condoms for contraception despite additional counseling.\nFollowing initial assessment in the emergency department in the present pregnancy, transvaginal ultrasound was obtained. An intrauterine pregnancy with a yolk sac but no fetal pole was found to be positioned low within the uterus. The patient was discharged at the time and instructed to continue management in the office setting. Repeat ultrasound performed one week later showed an irregular intrauterine gestational sac within the lower anterior endometrial wall within the cesarean section scar. The gestational sac has a mean internal diameter of 21 mm, corresponding to 7-week size. A yolk sac and an embryo are within the gestational sac. The embryo has a crown-rump length of 7 mm, corresponding to 6.5 weeks of gestational age. Exuberant vascularity surrounds the gestational sac wall on color Doppler. The myometrial wall anterior to the gestational sac was thinned to 1 mm ().\nThe patient underwent a repeat exploratory laparotomy via a vertical hysterotomy incision made above the lower transverse uterine scar due to abundant adhesions found at this level. The products of conception were identified and excised with the remainder of the uterine cavity being suctioned. The hysterotomy was closed using 2 layers of 0-vicryl. Bilateral salpingectomy was also performed as the patient desired permanent sterilization. The pathology of the submitted products of conception reported immature chorionic villi and implantation site tissue. The patient had an uneventful postoperative course and was discharged four days after surgery. There was no β-hCG value or ultrasound performed in the postoperative period at this point.\nThe patient had a follow-up appointment in the office one week following the surgery which was uneventful. Ten weeks later, the patient returned to the office with complaints of abdominal pain. Physical examination revealed a suprapubic mass compatible with an 18-week pregnancy with positive fetal heart tones. Formal obstetric ultrasound revealed a viable fetus at 19 weeks and 4 days of gestation with no anatomical defects (). The lower uterine segment myometrium was very thin and the placenta was found to be anteroposterior and right lateral, with multiple placental lakes in the fundal and lower uterine segment area. There was increased vascularity in the lower segment and laterally, a finding suspicious for placenta accreta. The placental findings were confirmed on subsequent ultrasound performed eight weeks later.\nAt 31 weeks of gestation, the patient presented with preterm premature rupture of membranes. In addition to the typical obstetric interventions involving steroids, magnesium sulfate, and latency antibiotics, pelvic MRI was obtained, which revealed an anteriorly located placenta invading the myometrium and extending to the external serosal surface. There appeared to be focal interrupted uterine serosa with tissue bulging out focally and extending to the proximal inferior vena cava with no invasion of the urinary bladder (). With a diagnosis of placenta increta, a team of physicians and surgeons was assembled and the patient underwent an uneventful cesarean hysterectomy at 32 weeks and 5 days of gestational age. The patient delivered a viable male infant weighing 1585 grams with Apgar scores of 8 and 9 at one and five minutes, respectively. The baby remained in the NICU for 28 days due to prematurity. The patient had an uneventful postoperative course and was discharged 6 days after her surgery. In addition to a third-trimester placenta with no acute chorioamnionitis, the pathology report described a uterus with placenta increta and placental tissue extending close to the uterine serosal surface.
A 76-year-old male presented with a history of solitary right kidney after a left nephrectomy for a nonfunctional kidney. He developed low grade stage Ta UC in the right renal pelvis that was initially diagnosed in 2002 with multiple recurrences as well as migration to the ureter and bladder. This was previously managed with endoscopic fulguration of the tumor periodically as he was inconsistent in his followup. He then presented in June 2012 with acute renal failure due to ureteral obstruction from the tumor. A percutaneous nephrostomy (PCN) was placed emergently by interventional radiology. He underwent an endoscopic procedure in September 2012, but due to large tumor volume he was unable to be completely treated at that last visit. His PCN was kept in place to attempt percutaneous management of his tumor at his next visit.\nThe patient was taken back to the operating room in November 2012 for the planned percutaneous fulguration. The case was started from a retrograde ureteroscopic approach to ablate the portions of the kidney that we felt would be easier managed ureteroscopically. We had fulgurated portions of the mid and lower pole when anesthesia staff noted that the patient was tachycardic and hypotensive (60s/40s), and the case was stopped to resuscitate the patient. During the evaluation, his PCN was pulled out and was found on the operating room floor. After the patient became more stable, we used a flexible cystoscope to place a right ureteral stent under fluoroscopic guidance. We were never able to commence the percutaneous portion of the procedure, and the patient was transferred to the surgical intensive care unit. He recovered from his urosepsis without sequelae and was able to be discharged home. Histopathologic evaluation of the upper pole lesion revealed a high grade urothelial carcinoma involving the collecting ducts.\nAt his follow-up visit a few weeks later, the patient was noted to have a soft tissue mass at the previous percutaneous nephrostomy tract site (). He also underwent a computed tomography (CT) scan which revealed the soft tissue mass that was found (). This was biopsied and showed an infiltrating high grade carcinoma with squamous features, including intercellular bridges and focal keratinization (). This tumor bears some morphologic similarities to the patient's previously diagnosed urothelial carcinoma. He received chemotherapy and radiation on his flank for the mass which eradicated the tumor from the outside (). The patient ultimately expired a few months later from metastatic disease.
Case 1 was an 11-year-old girl with a cytogenetic diagnosis of PWS due to mutation in the imprinting center. The diagnosis was confirmed when she was 5 years and 8 months old. She presented intellectual disability (IQ=68) and the main behavioral problems reported by her parents were: not being very active, feeling tired without reason, being too dependent, having poor motor coordination, skin picking, not following rules, being stubborn, and screaming a lot. She lived with her father, stepmother, and two older siblings; she was enrolled in the fourth grade of a mainstream elementary school. She had poor reading and writing skills. Her parents reported that despite their frequent requests for the school to control her food intake no action had been taken and after 5 months she had gained 10 kg.\nDuring the pre-intervention assessment, her parents reported that she was not very active and spent most of the time sitting, watching TV or playing with her dolls. She walked with difficulty when she had to cover longer distances and often stopped to rest.\nDuring the initial assessment, she remained quiet, listening attentively to the orientations for the tasks and demonstrated interest and willingness to start the PAP. Her parents received orientation from a nutritionist trained in PWS who offered menu recommendations adapted to the disorder. They also attended workshops held by a psychologist who gave advice about phenotypic behavioral characteristics and the behavioral management of PWS.\nAfter considering her availability, it was decided to carry out the PAP at our university twice a week and at her house once a week. She accepted positively all the PAP routines, and most of the time the inclusion of new exercises. In the face of new challenges, she understood that they should be overcome. A higher number of repetitions or changing to a heavier medicine ball was also almost always well accepted. If she complained about some change in the PAP, the instructor explained that the alteration was important for her health. She seemed to understand and the session continued. The increase in the number of repetitions was the main cause of complaints. However, the inclusion of games was a motivator to complete tasks. She was praised after completing set tasks to reinforce the behavior. In the final assessment, her parents reported that before the beginning of the PAP she used to have nocturnal enuresis, which ceased after the 12 weeks of training. She attended 95 % of the sessions. Table presents anthropometric and body composition results pre- and post-intervention. There were no initial results for uric acid and glucose for her, but after the PAP they were found to be at normal levels for sex and age (79 and 61.1 mg/dL respectively). In addition, she presented a reduction in total cholesterol (pre=166; post=159 mg/dL), very low-density lipoprotein (VLDL; pre=16; post=14 mg/dL), high-density lipoprotein (HDL; pre=42; post=33 mg/dL), and triglyceride (pre=82; post=72 md/dL), and a small increase in low-density lipoprotein (LDL; pre=109; post=112 mg/dL).
Case 2 was a 14-year-old boy with a cytogenetic diagnosis of PWS due to a gene deletion. The cytogenetic test was carried out when he was 10 years and 10 months old. He attended ninth grade elementary school; he had poor writing and reading skills. He had no history of fracture or surgery, but displayed some typical alterations such as myopia. He had minor health problems, such as rhinitis and sinusitis, and other health problems that require special care such as hypercholesterolemia, hypertension, fatty liver disease, and sleep apnea syndrome. He used a continuous positive airway pressure (CPAP) apparatus to facilitate air flow through his upper airway. From the first moment, he demonstrated interest in taking part in the PAP. Such interest was observed in his effort to take the initial assessment tests. He also demonstrated good physical condition and willingness, so that by the third week he was able to perform the complete set of tasks. From the fourth week, three repetitions of 5×40 meters run were added, as well as 5-meter anteroposterior and lateral exercises in a sand box. Whenever he demonstrated being tired or irritable, these exercises were reduced to one repetition. On Saturdays, training sessions took place on a street near his house. It is noteworthy that the street has a 30° angle incline and that the running practice happened in the ascending direction. He sometimes complained during the interval between repetitions; however, he accomplished all tasks after being encouraged. In order to provide new challenges, from the fifth week, a bonus activity was implemented. The activity consisted of a continuous run with increasing distance every week; it started with 60 meters and reached 200 meters in the last week. He also attended 95 % of the sessions.\nA positive aspect of the PAP was the participants’ willingness to perform tasks and their frequent request to continue them. This fact can be associated with the introduction of playful elements and the constant encouragement offered during the program. Table presents anthropometric and body composition results pre- and post-intervention. Case 2’s blood test results after the PAP presented an improvement in important health indicators, reaching health-related values for sex and age for uric acid (pre=7.2; post=5.5 mg/dL), total cholesterol (pre=235; post=182 mg/dL), LDL (pre=153; post=119 mg/dL), VLDL (pre=29; post=19 mg/dL), and triglyceride (pre=143; post=95 mg/dL). An increase in glucose (pre=87; post=115 mg/dL) and a reduction in HDL (pre=53; post=44 mg/dL) were also observed.\nTable describes the results of PRODOWN physical fitness assessment tests and level of daily physical activity (pedometer and PALQ). Both participants improved their performance in the post-intervention test of upper limb muscle power, agility and 20-meter displacement speed. The female participant (Case 1) demonstrated an improvement in the lower limb power test. The male participant (Case 2) also presented an improved level of physical activity, with a higher number of steps and distance covered, as well as an increase in PALQ total score. For the 6-minute run test, there was little variation for the female participant and a reduction in performance for the male participant.
A 27-year-old woman applied for a breast reshaping surgery for aesthetic purposes. There were no other complaints in her medical history. The patient underwent simultaneous mastopexy according to classical Lejour vertical scar technique and breast augmentation surgery using round silicone TSF - 415 mL implants under the pectoral muscle and a breast lift under general anesthesia (). During the operation proper hemostasis was achieved using electrocoagulation. Drains were removed next day after the operation with minimum serohemorrhaging fluid volumes. The later postoperative period was also uneventful.\nThe patient was discharged from the clinic on the second day after the surgery. Five weeks after the operation patient arrived at the clinic because of tenderness and swelling of the right breast. The patient stated that she had not sustained any traumas. During clinical examination, the upper right breast area was found to be significantly swollen and firm (). Ultrasound examination showed a 2.5 cm heterogeneous liquid strip accumulated around the implant (). The implant was intact. Complete blood count showed an increased amount of leukocytes, and red blood cells and hemoglobin were at the lower limit of the normal level.\nNo coagulopathies were found. The patient was taken to the operating room where she underwent revision surgery. The purpose was to remove the fluid and to find and stop the cause of its accumulation. During the operation (), a blood clot of 650 mL was removed (). Bleeding from one of the internal mammary artery branches in the implant pocket between the rib cage and the pectoral muscle lower pole was detected and stopped. After the revision, the implant was returned to the lodge. Vacuum drainage was used for one day only. One year after the surgery, there was no recurrence of bleeding, also no clinical evidence of the implant capsule contracture formation was found ().\nAll procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave her informed consent prior to her inclusion in this case report. Any details that might disclose the identity of the patient under study were excluded.
A 5-year-old female initially presented to the emergency department (ED) after trauma, which was thought to be responsible for left eye swelling and headaches. Persistent eye swelling and headaches led to hospital admission. Imaging work-up demonstrated lytic lesion in the left supraorbital region with associated soft tissue lesion on computed tomography (CT) scan of the head []. There was increased uptake on bone scan []. This mass was biopsied and the findings were consistent with LCH. The patient was treated with vinblastine with complete resolution of the lytic lesion 8 months after diagnosis. Patient was lost to follow-up subsequently due to social issues.\nPatient represented to the ED at 11 years of age with worsening headaches, unsteady gait and blurry vision. Magnetic resonance imaging (MRI) at the time of admission demonstrated enhancing lesions in the cerebellum []. Post-contrast T1 post-contrast sagittal image showed enhancing lesions []. Diffusion weighted images showed multiple areas of diffusion restriction []. Corresponding ADC map confirmed dark areas consistent with increased cellularity []. Due to the mass effect from vasogenic edema in the posterior fossa, patient also had obstructive hydrocephalus. Patient underwent an emergent ventriculostomy drain placement and subsequently underwent stereotactic biopsy of the right cerebellar lesions. Follow up MRI brain performed 2 days later to evaluate the improvement in the compression of the brain stem in-fact demonstrated worsening cerebellar edema []. There was significant brain stem compression []. Pathology demonstrated findings consistent with LCH. Her condition started to deteriorate. This prompted emergent posterior fossa decompression via suboccipital craniotomy and C1 laminectomy. Complete laboratory and radiology work up including skeletal survey was performed. No osseous lesions were identified at the time of the second presentation. Patient was discharged to inpatient rehabilitation service in stable condition approximately 2 weeks after admission. She completed 12 cycles of cytarabine and IVIG subsequently and tolerated them without incidence []. She was discharged from rehabilitation and she returned to school and resumed activities of daily living. She is in complete remission for 15 months. MRI of the brain performed as a follow up examination demonstrated no residual lesions.
A 59 year-old female patient, who has been employed as rehabilitation worker, has observed gradually enlarging formations under both her right and left scapula for approximately eight months. In anteflexion, elevation of the upper extremities and when stretching the arms forward, swellings reaching up to the rear axillary lines appear bilaterally subscapularly. They were of soft consistency at palpation. The patient also described pain in the upper extremities, and in the region of arms. She had no recollection of any accident or fall. However, she had undergone neurosurgical operating procedures of disc extrusion in the cervical and thoracic spine, and the findings of bilateral resistances were present already pre-operatively. In the another surgical workplace repeated punctures and partial resection of the swelling on the right side were implemented 5 months ago, and it came to its subsequent recurrence.\nThe magnetic resonance ((b) and (c)) on thoracic wall showed in dorsolateral parts in subscapular regions in the level of 3rd to 7th rib symmetrical limited fluid collections with dimensions of 120 × 37 x 115 mm on the right side with a volume of 250 ml and on the left side 120 × 24 x 90 mm with a volume of 130 ml. The collections were localised in the intermuscular spaces between the external intercostal muscles and the heads of the muscle serratus anterior. The contents of collections were moderately heterogeneous with sporadic internal septa. Cystic formations had slightly distinct signal, native image in T1 weighing displayed hypersensitive contents on the right side. It could be a case of chronic post haemorrhagic changes. Postcontrastly the collections were without amplification of signal intensity. On the left side postcontrastly there was present a moderate reinforcement of capsule of fluid collection. In diffuse weighing the lesions were without marks of diffusion restriction. Axillary lymphatic nodes were of physiological size, the displayed pulmonary parenchyma was without inflammatory and focal changes, without mediastinal and hilar lymphadenopathy, the pleural cavities without effusion, the pleura was without hypertrophy, the recorded skeleton was without traumatic change.\nOwing to progressing swelling and increasing difficulties a surgical resection was indicated in the female patient. She was operated on under general anaesthesia, and a resection of the encapsulated collections of fluid was implemented bilaterally ((d)), two Redon drains were introduced. In the left collection serous fluid was present, on the right side also serous fluid with admixture of old blood was present. A histological examination of cystic collections proved that it concerned pseudocystic lesions with relation to subscapular bursa without marks of malignancy. Their walls were created by collagenous, hyalinised and vascularised connective tissue with predominately perivascular nonspecific chronic inflammatory cellulation ((a)), the internal surface of which was lined by a layer of fibrin and by a nonspecific granulation tissue with a focally accentuated xanthogranulomatous, siderophagous and giant-cell reaction without epithelium ((b)). In the lumen of the cysts there were remnants of blood clots with fibrinous or fibrinoid substances with dispersive admixture of siderophages, lymphocytes, neutrophils and giant polynuclear cells ((c)). The proof of amyloid by Congo red was negative. On the lesion periphery soft-tissue structures were caught, including striated muscularis. The drains were removed the 10th postoperative day due to higher production, the surgical wounds were healed-up per primam intentionem. After the operation the female patient had a full range of movements and was without trouble and pains.
In September 2008, a 70 years old female was diagnosed with a lobular carcinoma after a core biopsy of a mass in her left breast. A month later, she underwent skin sparing mastectomy and axillary clearance, the histological examination confirmed a grade 2 invasive lobular carcinoma, estrogen receptor positive (ER+), progesterone receptor negative (PR−), and human epidermal growth factor receptor 2 negative (Her2−). There was no vascular space invasion, no in situ component and the axillary tissue included eight lymph nodes, three of those contained metastatic lobular carcinoma with extracapsular spread. A CT scan to chest and abdomen and a bone scan showed no evidence of any metastatic disease. Subsequently, she had radiotherapy and was started on adjuvant hormonal treatment, but because of her past medical history which includes previous nephrectomy for pelvic ureteric junction (PUJ) obstruction 10 year ago, arthritis and essential hypertension, chemotherapy was not considered. In early 2010, the patient was referred to the Department of Plastic Surgery for breast reconstruction, as she continued to show no clinical evidence of any recurrence, she underwent reconstruction with a pedicle transverse rectus abdominis myocutaneous (TRAM) flap.\nOne month later she had multiple episodes of abdominal pain and constipation which needed hospital admission. A CT scan showed evidence of small bowel obstruction (); a laparotomy and resection of a thickened and narrowed terminal ileum were carried out followed by bowel anastomosis. The histological analysis confirmed the presence of widely infiltrated small bowel by well-differentiated epithelial cells, some of which contained intracytoplasmic lumina and formed a single file pattern of infiltration (). The appearances were those of metastatic lobular carcinoma of breast, which was ER positive and E-cadherin & Her 2 negative (), invaded the mucosa, the mesentery, and appeared to extend beyond the mesenteric margins of excision. A subsequent chest/abdomen CT scan and a bone scan showed no signs of other metastasis. Contralateral carcinoma was excluded by clinical examination and mammogram. The patient was started on a new hormone therapy.\nUnfortunately, 3 months later, the patient had new episodes of diarrhoea with fresh blood; sigmoidoscopy showed a narrowed lumen and firm swollen mucosa at the upper rectum (); biopsies revealed the presence of metastatic lobular carcinoma of breast, the tumour foci stained positive with cytokeratin 7 (CK7), pancytokeratins, and ER. Staging CT scan identified left hydronephrosis caused by compression on the ureter from the metastasis in the rectum (). No extraintestinal spread reported; the patient had a ureteric stent put in, and she was subsequently started on palliative therapy.
A 50-year-old male was referred to our institution for review after an incidental finding of a 2.5 cm enhancing lower pole mass on the left kidney. This mass was first noted on ultrasound imaging as part of his investigations for symptoms of bloating and constipation. A computed tomography scan with intravenous contrast was then performed to further characterise this lesion, which showed a low density but mildly enhancing lesion. Magnetic resonance imaging (MRI) was performed to exclude angiomyolipoma. It revealed a 26 × 21 mm left renal lower pole exophytic mass with a low T2 signal suggesting the possibility of a renal cell carcinoma (see ). The patient then underwent an ultrasound-guided biopsy of the mass to aid with diagnosis and assist in management options. The lesion was first accessed using a 17-gauge needle with a coaxial sheath and 2 fine needle aspiration (FNA) biopsies were performed. This was followed by core biopsies using an 18-gauge core biopsy needle also done with the coaxial sheath in place. Two passes were made to obtain 6 cores, all embedded in 2 blocks. The core sizes were 6 mm, 5 mm, 4 mm, 4 mm, 4 mm, and 3 mm in length. Pathological assessment of the FNA and core biopsy specimens confirmed the presence of a low-grade neoplasm consisting of closely packed cells with small rounded nuclei forming clusters and some mucin filled tubules. Given this finding, the patient underwent a subsequent open left partial nephrectomy 8 weeks later. The procedure involved a lower pole partial nephrectomy, with frozen section confirming clear parenchymal margins. The perinephric fat over the tumour was initially reflected off during surgery and sent separately with a marking suture placed where the fat was adherent over the tumour site. There was no tumour capsule disruption or spillage or any other complication during the procedure.\nMacroscopically, there was a lobulated grey partly necrotic, noncystic tumour measuring 23 × 20 mm (see showing the bisected specimen). Microscopically, the lesion was well demarcated showing a complex papillary growth pattern (see ). Immunochemically it was strongly positive for both alpha-methyl CoA racemase and CK7. Histologically this was a type 1 papillary renal cell carcinoma. During examination of the fat overlying the tumour, viable tumour was noted seeding along the previous percutaneous biopsy tract, with it growing within the fibroblastic response that marked the biopsy tract (see Figures and ). His recovery was uneventful and he was discharged on day 6 postoperatively. He remained well 1 month after his procedure. Follow-up imaging will be sought.
A 22-year-old male presented to the accident and emergency department at a tertiary training hospital with a history of having been involved in a road traffic accident. He was reported to have been an unrestrained driver of a vehicle that was involved in a head on collision approximately four hours prior to time of presentation.\nThe patient came in complaining of mild epigastric pain for 4 h. He was examined using the ATLS protocol. He was talking on presentation and he had no neck pain but still had a cervical collar applied. His breathing was not laboured and examination of the chest was normal. His vital signs were stable at this point in time with a Blood pressure of 110/80 mmHg, a pulse rate of 80 beats per minute and a respiratory rate of 16 breaths per minute. Positive findings were noted in the abdominal examination. He was found to have slight abdominal tenderness in the epigastric area with no abdominal rigidity and normal bowel sounds on auscultation. He had no flank ecchymosis or seat belt sign noted. Digital rectal examination was normal. His secondary survey revealed no further abdominal findings. His initial laboratory results were also normal. A chest radiograph did not show any evidence of free air under the diaphragm. A focused abdominal ultrasound for trauma (FAST) scan done showed minimal peri-hepatic fluid with no obvious solid organ injury. An abdominal Computed Tomography (CT) scan with intravenous contrast done was normal. The patient was admitted to the surgical ward and was started on analgesia, kept Nil Per Os (NPO) and was to have vital sign monitoring with serial four-hourly abdominal examinations.\nEight hours into his admission, he was noted to have a temperature of 39 °C, a blood pressure of 90/50 mmHg, and a pulse rate of 120 beats per minute. Physical examination revealed a diffusely tender abdomen with guarding and reduced bowel sounds. He also reported worsening epigastric pain that was not responding to analgesia with vomiting. Repeat blood works showed he had an elevated white cell count of 21.3 × 109/l and normal serum amylase and lipase. In addition to the treatment he was getting he was also started on antibiotics and antipyretics. The patient was prepped for an emergency laparotomy and consent obtained for the same as he now had peritonitis.\nAt laparotomy, a perforation of D4 on the anterior wall was found involving less than 50% of the circumference with minimal abdominal contamination. No other injuries were noted and all solid organs were normal. The lacerated edges were freshened and repaired in a single layer using interrupted 3-0 polyglactin suture. An intra-abdominal drain was left in-situ.\nPost operatively the patient was admitted to the High dependency unit. On post-operative day one, his blood pressure was 110/70 mmHg, a pulse rate of 90 beats per minute, respiratory rate of 18 breaths per minute and an SPO2 of 96% on room air with a urine output of 2mls/kg/hr. The drain on day one was minimally active with less than 50 ml noted. He was started on incentive chest spirometry and encouraged to start ambulation. Post-operative day two, his vital signs remained stable, He had no fever and was in less pain and was allowed to start feeding as he tolerated. He was already ambulating and the drain remained minimally active. His wound on examination remained clean and showed no features of infection. Blood works repeated 48 h post laparotomy, showed a drop in his white cell count to about 14.6 × 109/l. His amylase and lipase remained normal. He was stepped down to the General surgical floor and was allowed to go home on the fifth post-operative day.
A 50-year-old man was recruited for participation in a clinical trial examining the effect of dietary glutamate on fibromyalgia and IBS symptoms. All subjects were asked to report all symptoms that they were experiencing at baseline, then after 4 weeks on the dietary intervention, and at the end of each challenge week. In addition to his fibromyalgia and IBS symptoms, this man additionally reported OCD symptoms. He reported that he had experienced his OCD symptoms daily since he was 11 years old, and that they had always been nonresponsive to treatment. His obsessions revolved around the need to perfect certain movements, and his compulsions included the repetition of activities such as repeatedly getting up and down from a chair, in and out of the shower, etc. These compulsions took up a significant amount of time per day and interfered with his daily activities, including his ability to hold down a job.\nThe 50-year-old subject had undergone multiple unsuccessful pharmacological OCD treatments over the 39 years he had been experiencing symptoms. During his participation in the fibromyalgia study he was not currently taking medication for any of his symptoms (due to reportedly not tolerating the side effects of medications). Participation by individuals with a comorbid mental health diagnosis was deemed ethical by the research team and university IRB under certain circumstances. While individuals in acute mental health distress (e.g., active psychosis) were excluded from the study, participants with a mental health diagnosis that was stable for the past 6 months were eligible for participation.\nDetails about the study and overall results of this clinical trial in which he participated have been published previously []. However, a brief overview of the study design is included here ().\nAfter recruitment, all subjects received in-depth training on how to follow a 1-month low-glutamate diet, which restricted intake of common flavor enhancing food additives with free (i.e., not bound to a protein) glutamate. Foods with naturally occurring higher levels of free glutamate were also excluded from the diet (such as soy sauce and aged cheeses like parmesan). The additives excluded in this study are considered ‘excitotoxins’ due to their ability (when present in high enough amounts) to overexcite a neuron to the point that it dies [,]. Glutamate is the most ubiquitous neurotransmitter in mammalian systems, and disordered glutamatergic neurotransmission has been implicated in many disorders, including OCD [,,], FM [,,,], and IBS [,]. The excitotoxin elimination diet used in this study required that subjects make one-for-one substitutions in the diet, replacing products which contained free glutamate, with other similar products which were free of these food additives, as opposed to improving the diet quality overall. For example, if a subject was consuming Doritos®, which can contain as many as 11 excitotoxins, they were asked to substitute these with simple corn tortilla chips, which have three ingredients: corn, oil and salt. This direct substitution removes the exposure to free glutamate, but does not increase the nutrient density of the diet.\nAfter 1 month on the diet, subjects were again queried about their symptoms. Those who had >30% of their FM and IBS symptoms remit on the diet were eligible to go onto a double-blind, placebo-controlled, crossover challenge. Subjects came in fasting, and were randomized to receive monosodium glutamate (MSG) for three mornings of 1 week and placebo for 3 days of the other week. The main outcome measure was examining whether symptoms returned after each week of the crossover challenge. All fibromyalgia and IBS symptoms were formally assessed for remission (please see Holton et al. for a description of the measures []), while the subject's OCD symptoms were self-reported.\nAt the end of the 1-month excitotoxin elimination diet, the 50-year-old subject reported complete remission of all of his symptoms, including those related to his OCD. He expressed profound surprise at the remission of his OCD symptoms in particular, reporting that no medication had ever been able to help his symptoms during the past 39 years. During the 2 challenge weeks, his symptoms returned when challenged with MSG (week 1), and did not return when challenged with placebo (week 2). Over the 3 days of exposure during the MSG challenge week, all of his symptoms returned at the end of day 1 and peaked on the evening of day 3. The symptoms then slowly subsided over the following 4 days. He reported that the OCD symptoms experienced during the challenge week were typical, again presenting as needing to perfect movements (in addition to the return of his fibromyalgia and IBS symptoms). This response during the double-blind, placebo-controlled challenges confirmed that it was the removal of free glutamate from the diet, as opposed to other inadvertent dietary changes, that resulted in symptom improvement.
Paramedics brought a 45-yr-old man into our medical center immediately after a high-velocity crush injury. On admission to the emergency room, the patient was noted to have a large open wound in anterior aspect of left knee. His left foot was pale and cool. Distal pulses of dorsalis pedis artery and posterior tibial artery were absent, and only femoral pulse was palpable on the injured left lower extremity. He was alert with respiratory rate of 22, pulse rate of 98, and blood pressure of 100/80. Neurological examination relating to his left leg was grossly normal.\nThe knee joint was open, and a portion of the patellar tendon was lost. About 50% of the patellar tendon was remained, but it was detached from the inferior pole of the fractured patella. Distal femoral condyle, and metaphysis were absent. All of the collateral ligaments and the cruciate ligaments of the knee were lost together. Only the biceps tendon and a portion of the semimembranosus tendon were attached to the proximal tibia and fibula around the knee. Plain radiography showed severe bone loss of distal femur, fractures of patella and proximal tibia (). Femoral arteriography demonstrated a complete occlusion of the left popliteal artery ().\nOur surgical orthopedic team performed an emergency operation within 4 hr of triage. First, we debrided contaminated soft tissue aggressively and fixed the patellar fracture. Then we repaired the ruptured patellar tendon with pull-out sutures through the patella. Primary fracture fixation of the distal femur was impossible because expelled fragments of the distal femur were lost. Prior to repair of the popliteal artery, we applied an external fixator across the knee joint. Then we positioned the patient in prone position to explore the popliteal artery. The same orthopedic surgical team explored the popliteal artery via posterior approach of knee. The left popliteal artery was contused but its continuity was maintained by adventitial tissue. We made a small longitudinal incision to a suspected portion of injury of the popliteal artery. The intima of the popliteal artery was torn and dissected, and a large thrombus occluded the popliteal artery completely (). The popliteal vein was moderately contused, but tibial nerve was grossly intact. We excised a segment of the contused and thrombosed popliteal artery in 1.5 cm length. We were able to easily perform an end-to-end repair of the artery only with mild mobilization of the proximal part of the popliteal artery because severe bone loss of the distal femur made approximation of ends of the popliteal artery to be ease. After the direct repair of the popliteal artery, distal pulse was palpable and limb circulation was recovered. Then we waited for 30 min watching for circulation, swelling of the leg and compartment syndrome. We decided not to perform a fasciotomy of the low leg to prevent compartment syndrome because we could not find cyanosis, swelling or hardness of muscle compartments of the low leg, such as associated signs of compartment syndrome.\nAt 4 days after the emergency operation, we performed debridement again and inserted antibiotics (vancomycin)-mixed cement beads into the defect of the distal femur to prevent infection. The patient received 2nd-generation cephalosporin and aminoglycoside antibiotics during the initial 2 weeks and he received more 2nd-generation cephalosporin antibiotics during the following 2 weeks ().\nAfter 6 weeks, we performed a reconstructive total knee arthroplasty with modular segmental endoprosthesis, MUTARS® (Implantcast, Buxtehude, Germany) to treat the large bone loss of the distal femur (). Simultaneously, we carried out patellar tendon augmentation using a semitendinosus allograft because gracilis and semitendinosus were lost at the initial trauma (). Furthermore, a medial gastrocnemius rotational flap with meshed skin graft was followed because conditions of the repaired patellar tendon and anterior skin of the knee were not healthy for rehabilitation of the knee joint ().\nOne week after the reconstruction, physiotherapy team commenced continuous passive motion of the knee and crutch ambulation began 2 weeks after reconstruction.\nAt his most recent follow-up visit, 36 months postoperatively, the patient does not complain of pain, and can ambulate without support. The range of motion of the knee joint is 10 degrees to 55 degrees. Power of quadriceps muscle is 4/5, and the knee society knee score in pain is 79 and functional score is 50. The patient shows a mild limping gait because of 1.5 cm shortening of the left leg after the reconstruction arthroplasty. However, the patient can ambulate independently and is satisfied with the results ().
A 30-year-old gravida 3, para 3 presented with low back pain, seven months after her third delivery.\nHer first two deliveries were normal vaginal deliveries without any problems. In both pregnancies, low back pain occurred from the second trimester, and spontaneously improved after delivery. She was naturally healthy with no history of metabolic bone disease, menstrual abnormalities, previous fractures, or eating disorders. She also had no reported family history of osteoporosis or malignancy.\nDuring her third pregnancy, she again became aware of low back pain from the second trimester. She had no problems with walking or activities of daily living. As it was similar to the lower back pain of previous pregnancies, it was thought to be pregnancy-associated low back pain and was not specifically examined. The pregnancy course was good, with a normal vaginal delivery at term. Her baby was healthy.\nHowever, her low back pain persisted after 5 months postpartum. She visited an orthopaedic clinic and was treated conservatively with analgesics. Her low back pain worsened sharply 7 months after delivery, so she went to another orthopaedic clinic. She had no episodes of trauma. A spinal X-ray and MRI were taken to rule out spinal lesions. Multiple compression fractures were observed at Th11, L1 and L5 (Fig. ). She was referred to our hospital to investigate the cause.\nThe patient was 162 cm tall, weighed 69 kg, and had a body mass index of 26 when she visited our hospital. The pain was localized to the mid-lumbar region above the sacrum and was accompanied by tenderness. She had difficulty walking due to back pain and used a wheelchair at the time of her visit. The pain was exacerbated by flexion and activity and was partially relieved by rest. Analgesics had limited effect. No sensory or movement impairment was observed in her lower limbs. She continued to breastfeed. Both breasts were rather firm, which was thought to be attributable to the breastfeeding period. No difference between the left and right breasts was observed, and the patient reported no changes in skin (e.g., indentations), secretions other than milk, or pain in her breasts.\nWe suspected pregnancy- and lactation-associated osteoporosis (PLO) as the cause of the multiple compression vertebral fractures. Dual-energy X-ray absorptiometry revealed a bone mineral density (BMD) of 0.854 g/cm2, T-score: −1.4 for the lumbar spine (L2–L4), and BMD: 0.801 g/cm2, T-score: 0.2 for the femoral neck, which are within normal ranges.\nBlood test results are shown in Table . They indicated hepatic dysfunction and elevated serum calcium. The bone resorption marker was high. We decided to perform systemic CT because of her unexplained hepatic dysfunction. It showed multiple contrast-enhanced masses in both breasts, multiple lymph node metastases, multiple bone metastases in the spine, lung metastasis, and liver metastasis (Fig. ). We suspected advanced breast cancer. Bilateral needle biopsies of her breast tissue revealed invasive HER2-positive ductal carcinoma (Fig. ). Her low back pain was caused by a compression fracture from spinal metastasis of breast cancer. She started chemotherapy with paclitaxel and trastuzumab at 8 months postpartum. Two and a half years after the start of treatment, she is in complete clinical remission.
The patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general anesthesia. The ISH was confirmed (Fig. c). Four U red blood cell and 400 ml fresh frozen plasma were transfused. After fluid resuscitation and blood transfusion, her hemodynamic became stable. During the 3-h intra-operative observation, the hematoma did not expand. Therefore, a non-sucking drainage tube was placed under the liver and she was sent to ICU ward. Next morning, she was transferred to the ordinary ward. The upper abdominal pain gradually relieved. Five days after the laparoscopic exploration, another CT scan showed that the hematoma was largely resolved and we removed drain tube (Fig. d). She was discharged, 10 days after readmission.\nTotally, 13 papers, including 16 cases of ISH after LC were reported from 1994 to 2015 (Table ). Nearly half of the patients had instability of hemodynamics. All of the cases were female patients. Age of patients ranged from 25 to 78. All hematomas were mainly located in the right lobe of liver, and some of them extended to the left lobe of liver. Only one case was ruptured at diagnosis. Hepatic capsule laceration was found in two cases, one of whom also took NSAIDS (non-steroids anti-inflammatory drugs) to control the pain after operation. Totally, 58.8% of patients took NSAIDS to control the post-operative pain, and most of them used Ketorolac, however, 35.3% of the patients still did not have definitive risk factors. The time interval to diagnose ISH after LC ranged from seven hours to six weeks. They were diagnosed most commonly (35.5%) within one day after LC. All patients had abdominal pain and 47.1% of the cases developed hypovolaemic shock.\nTreatment strategies included: conservative treatment (antibiotics, blood transfusion, strict bed-reset), percutaneous drainage under CT or B ultrasound guidance, selective embolization of the bleeding vessel, laparoscopic exploration and laparotomy. Eighteen percent of patients had stable condition without fever and underwent conservative treatments. The only case of angioembolization was complicate by infection and required percutaneous drainage. For the patients with stable condition, fever and serious compression of inferior venal cava (IVC) always were indications for percutaneous drainage under CT or B ultrasound guidance. In these 17 cases, 29.4% of the patients underwent percutaneous drainage. For the patients with hemodynamic instability, emergent reoperation was adopted. Totally, nine cases underwent reoperation, including two case of laparoscopic operation and seven cases of laparotomy. For our case, we only performed laparoscopic exploration and did not perform evacuation or drainage of the hematoma, since the hemodynamic became stable after plenty fluid resuscitation and the hematoma did not expand, during the 3 h of intra-operative observation. For another case, laparoscopic exploration found small capsule laceration, and hemostasis was performed. In the seven cases of laparotomy, six patients underwent evacuation and drainage of hematoma, only one case underwent only laparotomy without evacuation or drainage.\nAll patients survived. Most of patients stayed one to two weeks after readmission, however, the longest hospital stay was up to 31 days after reoperation.
A 78-year-old male patient was diagnosed as hypertension and on medication came to our hospital after having a hematoma evacuation in an American hospital because of left thalamic hemorrhage and right hemiplegia. In the computed tomography (CT) of his brain after hospitalization, intracerebral hemorrhage in the left frontal lobe and intraventricular hemorrhage were discovered. This led to operating hematoma evacuation, and a month later, ventriculoperitoneal shunt was installed because of hydrocephalus. Two months later, he was transferred to the rehabilitation medicine department for comprehensive rehabilitation. In the neurological examination at the time of transfer, his conscious state was maintained, but conversation was impossible and verbal responses were not observed due to the tracheostomy. He was already diagnosed as dysphagia at the time of hospitalization in the U.S. and had percutaneous endoscopic gastrostomy. When he was transferred to our hospital, he was still having nutrition support through the percutaneous gastrostomic tube. A month later, soft tissue infection occurred around the tube, so ceftriaxone was applied for antibiotic therapy, and the tube was replaced after the inflammation was relieved while the existing passage of gastrostomic tube was maintained. In the videofluoroscopic swallowing study carried out a month later, aspiration was still found so the gastrostomic tube was maintained, which led to the same result when the test was carried out three months later. Due to the malfunction of the gastrostomic tube a month later, the tube was replaced with the passage maintained, but was inserted again because the tube was dislodged during sleep two weeks after the replacement. In the videofluoroscopic swallowing study carried out 4 months later, aspiration still continued with decreased amount, and intermittent spontaneous swallowing activities were observed. However, we decided to maintain the tube and replaced it due to dysfunction. Three months after the replacement, the erythema and exudate containing blood clots were observed on the skin around the tube insertion (). In the blood test, the infectious signs were found with white blood cells 12,700/ul, segment neutrophils 76.6%, erythrocyte sedimentation rate 73 mm/h, and C-reactive protein 17.12 mg/dl, while body temperature was maintained under 37℃. Urinalysis and urinary chemistry was not specific, bowel sounds was normal, but abdominal tenderness and rebound tenderness could not be examined due to the patient's cognitive dysfunction. No anomalies were seen in the plain X-ray of chest and abdomen. Since infection in the gastrostomic tube insertion site was suspected, the tube was removed after microbiological culture. Ceftriaxone was applied for the purpose of empirical antibiotic therapy, and peripheral parenteral nutrition was initiated. The nasogastric tube was inserted the next day for the medication of hypertension, and was confirmed to have been located at the epigastrium by auscultation. The nasogastric tube was used only for medication. Ceftriaxone was maintained because Klebsiella pneumoniae sensitive to β-Lactam antibiotics was identified. Three days after removing the percutaneous gastrostomic tube and starting antibiotic therapy, the blood test became normal, but the erythema around the part of the tube insertion and the exudate containing blood clot did not improve. Since complex infection of anaerobes was suspected, metronidazole was orally administered. At the same time, CT was performed 4 days after the nasogastric tube insertion because of possible subcutaneous and intraperitoneal abscess. The abscess was not found by CT, but the terminal portion of the nasogastric tube penetrated the gastric mucous membrane and was located beneath the skin through the gastrocutaneous fistula with soft tissue infection around the gastrocutaneous fistula (). We thus diagnosed it as skin infection by the mislocation of the terminal portion of the nasogastric tube, removed the tube, administered 2 g of ceftriaxone and 1,500 mg of metronidazole daily, and inserted a central venous catheter for the purpose of total parenteral nutrition. Twenty days later, the skin around the removed gastrostomic tube was found to be normal, blood test was normal, and no indurate nodules were observed. Percutaneous endoscopic gastrostomy was thus performed on the spot 5 cm away from where the previous gastrostomic tube was inserted. No additional complication was observed.
A 37-year-old pregnant woman comes to the clinic for a routine checkup. This is her second pregnancy. She had her first child when she was 35 years old and had an amniocentesis at 18 weeks to test for Down syndrome. The amniocentesis was negative. She is currently 8 weeks pregnant and would like to know as soon as possible of any abnormalities. An ultrasound can be done in the first trimester for diagnosing Down syndrome, but it is unknown if the results are as reliable as the conventional test of amniocentesis.\nThis scenario represents the domain of diagnostic accuracy. The question can be formulated as follows: Among pregnant women over the age of 35 (patient/problem), what is the accuracy of ultrasound (intervention/experimental test) compared to amniocentesis (control/conventional test) in detecting Down syndrome in fetus (outcome)? Again, the RCT can be eliminated because, in order to determine diagnostic accuracy in an unbiased manner, both tests need to be administered to the same subset of the population. In the case-control study, subjects with the outcome of interest are selected and then matched with healthy controls. Since we do not know whether or not the outcome of Down syndrome is present, a case-control study cannot be used. The cohort study group's subjects are selected based on exposure status followed over time and the incidence of the outcome is calculated. In this clinical scenario, no exposure is described and we are not interested in calculating the incidence of Down syndrome. Accordingly, the characteristics of the cross-sectional study make it the best choice to answer this clinical research question. A cross-sectional study would allow two observations from the same group to be determined. In this case, a sample of pregnant women over the age of 35 would be given both an ultrasound and amniocentesis. The results of the tests would be recorded and the number of true positives and negatives versus the false positives and negatives would be calculated along with positive and negative predictive values.
A 35-year-old French male unrelated donor 10/10 was selected to perform a PBSC donation for allogeneic HSCT to a European patient. The donor gave his consent for the stem cell collection and for the analysis of the clinical features and biological parameters involved in this cell collection. Less than 30 days before the collection procedure by apheresis, the donor was evaluated during a preapheresis consultation by both the hematologist and apheresis physician. The patient was declared able to receive the injection of G-CSF and undergo the apheresis process. He had no significant medical history and showed no previous psychiatric episodes. The donor understood the stages of the PBSC donation, agreed on the medications (subcutaneous injections of G-CSF) and apheresis sessions, and signed the agreement.\nAs usual, the day before the injection, the nurse in charge of the allogeneic HSCT coordination phoned the donor to ensure that there were no clinical or logistical problems. Two days after beginning of the G-CSF injections (ie, 2 days before the apheresis sessions), the donor’s sister called the apheresis center explaining that the donor felt very tired and had developed psychiatric complications such as hearing voices. The medical staff decided to hospitalize the donor in emergency for a psychiatric evaluation in order to treat him, appreciate whether he still had his discernment, and know whether he still agreed on continuing the PBSC donation process. The practitioner in charge of unrelated donors in the French donor registry was informed.\nAfter visiting the donor, the first psychiatrist concluded that the patient had occurrence of a strong depression and absence of psychosis and treated him with antidepressive and sedative oral medications. The psychiatrist concluded that the donor still had his discernment, that the PBSC harvesting could continue during a short hospitalization in a hematological unit, and that a hospitalization in a psychiatric unit was necessary after PBSC harvesting. The donor still agreed to perform the PBSC harvesting. In parallel, the donor informed us that he had a brother who had been followed up for acute myeloid leukemia and treated by allogeneic HSCT and who unfortunately died from acute graft-versus-host disease 1 year before. At that moment, ie, 2 days before the apheresis, the G-CSF injections were still given. The physician in charge of the French allogeneic donor’s registry informed the European hematological team in charge of the recipient. Besides this, the recipient had already received the complete myeloablative regimen.\nThe day after, ie, the day before the planned PBSC collection, a second psychiatrist examined the patient and concluded that the patient was experiencing a psychotic syndrome. The psychiatrist decided to hospitalize the donor in a psychiatric unit, under enforcement. All these decisions led to the withdrawal of the PBSC donation process and G-CSF injection. The apheresis and hematological staff worked together to ask for further complementary psychiatric expertise. At the same time, the staff questioned the ethical committee who concluded that the donation could not proceed further without the donor’s discernment. As the recipient had received the entire myeloablative conditioning regimen, the registry staff looked for HLA-compatible 4/6 or 5/6 cord blood (CB) units in emergency.\nThe day after, the donor was evaluated by a third psychiatrist independent from the apheresis, hematological, and registry staff. The psychiatrist concluded that the donor was going through a depression without evidence for a psychosis and that he still had his discernment and still agreed on performing the PBSC donation for the unrelated donor. The medical enforcement was removed, and the G-CSF injection was prescribed again.\nThe PBSC harvest started with a 1-day delay. A fourth psychiatrist and nurse specialized in psychiatry evaluated the donor just before, and were present during, the PBSC apheresis session. The psychiatric expert in allogeneic organ and cell donations confirmed the diagnosis of major depressive episode according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria without mood-incongruent delusions or hallucinations. These last two psychiatrists confirmed the need for antidepressive medication. Again, the donor signed an agreement stipulating that he agreed to perform one or two apheresis sessions. The apheresis sessions were performed by spectra device and were uneventful. An amount of 1.70×106 CD34+HSCs/kg (depending on the recipient’s weight) was collected during the first apheresis session. The donor and psychiatric team in charge agreed to perform a second apheresis session, which permitted collection of 0.75×106 CD34+HSCs/kg. No complication occurred during and after the first and second apheresis sessions.\nA total of 2.45×106 CD34+/kg allogeneic PBSC was infused to the recipient with a 36-hour delay. The recipient engrafted within 25 days. In parallel, 3 weeks after beginning of the treatment, the donor went back home and worked normally.
A 48-year-old male patient presented with chronic neck pain with cervical post laminectomy syndrome following two cervical spine surgeries with no significant medical problems. The pain was not responsive to conservative medical management including oral opioid therapy. The patient underwent a successful intrathecal opioid trial followed by Intrathecal drug delivery system (IDDS) implantation (Medtronic Synchromed II 40 ml pump) in August 2007. The patient had a history of PDPH following the intrathecal opioid trial before permanent placement and was treated with epidural blood patch to control the headache after failed conservative management. He was followed by his pain physician for intrathecal pump refills and management without problems with good pain control. In December 2013, the elective replacement indicator (ERI) showed 4 months remaining, and non-critical alarm (single tone) started in January 2014. The patient was scheduled for removal of native pump and replacement with new intrathecal pump. In February 2014, the old intrathecal pump was surgically replaced with a new one and it was placed in the same place over the left side of his abdominal wall. Strict aseptic precautions were followed throughout the procedure. He was discharged home the following day without any immediate postoperative complications. The patient followed up with his pain physician weekly during the subsequent 2 weeks. The wound healing was uneventful, and the pump analyses were normal during the follow-up visits. Despite his pain physician’s request, the patient did not follow up with his pain physician for the subsequent four weeks because of bad weather and lack of symptoms.\nSix weeks following the IDDS replacement, the patient woke up in the morning complaining of headache, photophobia, and nausea. He also observed redness and warmth over the left lower abdominal incision site. He denied any drainage or fever. The patient presented to the pain clinic later that day. On examination, patient had localized erythema over the left abdominal wall over the surgical area. There were no signs of tracking of redness over flank or paraspinal area (). Intravenous antibiotics were started, and, under general anesthesia, the intrathecal pump and the catheter system were explanted through the left lower abdominal and left paraspinal incisions respectively with placement of purse string suture around the paraspinal catheter removal site. The system was withdrawn through the abdominal incision in order to prevent tracking of the infection towards the back. Considering the patient’s symptoms (photophobia, nausea, and headache) and the risk of infection spread from abdominal wound to CNS, the surgical wounds were left open without primary closure under wet and dry dressings. The patient was discharged home the next day with a PICC line on intravenous antibiotics and oral opioid medication. Wound cultures shown methicillin sensitive staphylococcus aureus (MSSA) sensitive to Nafcillin.\nThe patient presented 10 days after explantation of the intrathecal pump to the emergency room with persistent headache worsened with sitting and standing positions. He also had wet dressing over the paraspinal wound. On examination, clear fluid (cerebrospinal fluid-CSF) was noticed leaking from the paraspinal wound (). Initially, the patient was managed conservatively with bed rest, oral analgesics, hydration and caffeine for 24 hours (-). His symptoms did not resolve and he was referred to neurosurgery for surgical management for persistent and significant CSF leak with severe headache and an open paraspinal surgical wound. He underwent bilateral laminectomies at L2 and L3 with exploration of lumbar wound and dura matter. Immediately after removing the inferior portion of the L2 lamina, the surgeon encountered a brisk CSF leak from a pinhole opening surrounded by ligament and scar tissue. Dural repair of the CSF leak was performed with a tiny piece of muscle using a stitch with 4-0 nylon suture. All the leakage immediately stopped at that point, and there was no extrusion of any rootlets or nerve material (). The postoperative period was uneventful with complete relief of the headache.
A seven-year-old girl child was brought to us with a painless swelling over the left knee joint since six months. Before presenting to us, she was treated by three physicians of different specialties. Initially, the lesion started as a small hard painless raised lesion over the dorsum of the left knee and gradually increased in size. The lesion was preceded by trauma at the site two months prior to onset. Parents consulted an orthopedic surgeon and the lesion was excised. After 1 month, a similar lesion again developed on the lower part of the anterolateral aspect of thigh just above the left knee. She was seen by a plastic surgeon and the lesion was excised and antibiotics were prescribed. The histopathology report of that time suggested nonspecific dermatitis. Two months later, similar painless swelling reappeared at the same site (dorsum of left knee) associated with fever and she was taken to a pediatrician. After one month of treatment, when no improvement was observed, the child was referred to us. On examination, an erythematous, ill-defined, nontender, and indurated swelling with smooth and rounded edges of size 5 cm × 4 cm with crusting over the surface was noted on the dorsum of the left knee joint []. The swelling was freely mobile and was not attached to the underlying structures. The lesion could be lifted up easily by inserting a finger beneath. The overlying skin was erythematous with one linear hypopigmented scar of length 4 cm on the left knee and one transverse scar of length 2 cm was found just above the left knee. There was no regional or peripheral lymphadenopathy. General and systemic examination revealed no abnormality. We considered a differential diagnosis of subcutaneous zygomycosis, lupus vulgaris, and soft tissue tumor. Routine hematological and biochemical investigations were normal, chest X-ray showed no abnormality, and Mantoux test was negative. Incisional skin biopsy specimen was sent for histopathological examination and fungal culture. Histopathology revealed inflammatory granulomatous reaction with dense and diffuse eosinophilic infiltrate and few multinucleated giant cells. The central portion showed fragments of broad, aseptate hyphae with peculiar eosinophilic material around the hyphae (Splendore–Hoeppli phenomenon) []. Periodic acid Schiff [] and Gomori methenamine silver stain [] showed thin-walled, broad, and aseptate fungal hyphae. Fungal culture on Sabouraud dextrose agar at 30°C after three days of incubation showed creamy white, heaped up, and furrowed colonies which identified the fungus as Basidiobolus ranarum []. The child was started on antifungal therapy with itraconazole at a dose of 4 mg/kg (100 mg/day) for 12 weeks. The lesion healed completely after two months of treatment []. However, she was advised to continue the treatment for 12 weeks. The treatment period was uneventful. She was followed up for six months and there was no recurrence.
A 39-year-old female was seen in consultation after having presented to the emergency department with complaints of left-sided headache and left facial paresthesias. A head computed tomography (CT) scan revealed an osseous mass in the left frontal and anterior ethmoid sinus extending into the right frontal sinus (Figures and ). An MRI of the brain identified a left-sided frontal sinus tumor that was benign in appearance and of bone origin (). Radiologic impression was a fibro-osseous lesion either representing a fibrous dysplasia or an atypical osteoma. On examination, the patient had no facial asymmetry with no facial nerve dysfunction and she reported some paresthesias on the left side on sensory exam in the V1 distribution. Flexible nasal endoscopy was normal on the right and showed a slightly irregular edematous mucosa in the left superoanterior surface of the bulla ethmoidalis. A specific mass was not identified.\nThe patient had undergone an incomplete endoscopic resection of the osseous lesion one year previously due to an inability to address the posterior attachment of the lesion to the skull base. Furthermore, the specimen from that procedure did not provide a pathologic diagnosis. Nonetheless, the patient's headache did improve for several months following that procedure. However, by the time of presentation now, she had six months of progressively worsening left-sided headache despite both topical and systemic treatments for sinus disease and medical management for her headaches.\nThe patient was ordered a CT scan of the paranasal sinuses that showed significant interval growth of the osseous mass since the scan prior to her endoscopic procedure. The mass now crossed the midline into the right frontoethmoidal recess. Given the inability to attain symptom control with medical treatment for this patient, surgical options were considered. After discussing the surgical options, the patient consented to proceed with an open bicoronal osteoplastic flap approach to the frontal sinus in order to access the full extent of the lesion bilaterally and remove it from its extensive attachment to the anterior skull base. This was completed without CSF leak or other complications. The patient was hospitalized for one night and was discharged the following day. She had immediate relief from her longstanding left frontal headache. Pathologic analysis of the specimen was completed and it revealed a bone tumor with a histological appearance consistent with PDB. Both burnt-out and focally active forms of PDB were identified (Figures and ).\nPostoperatively, the patient did extremely well with complete resolution of her symptoms. Given the pathologic diagnosis, she was referred to a rheumatologist for further evaluation for PDB. A whole-body bone scan with (single-photon emission computed tomography) SPECT demonstrated abnormal bony uptake in the left frontal bone in keeping with postsurgical changes (). An alkaline phosphatase level was drawn and it was within normal limits. The staff rheumatologist's impression was monostotic PDB of the skull inactive and no additional therapy was indicated. The patient is now 8 months postoperatively and symptom free. There were no long-term sequelae from the bicoronal approach and osteoplastic flap.
21-year-old male patient referred to department of oral and maxillofacial surgery with a complaint of drainage from a cutaneous lesion which was approximately 2 cm diameter under his chin (). According to the history of the patient, he had first become aware of the lesion 6 months before contacting with the author. Initially, the lesion was diagnosed as a carbuncle by the physician and had been treated with combine systematic antibiotics (1 gr amoxicillin and clavulanate every 12 hours and 150 mg clindamycin every 6 hours for 7 days). After using these medicines the patient reported that for a while drainage was stopped and the lesion decreased in size. Since there was repeated occurrence (the lesion gradually increased and drainage started) of the lesion, he referred to our dental clinic for an alternative solution.\nExtraoral examination revealed that there was a cutaneous lesion on his chin (). Intraorally, although he had class III restorations on his mandibular anterior teeth (mesial sides of 32 and 42 and distal sides of 31 and 41), the teeth and periodontal tissues at anterior region of mandible seemed healthy. Furthermore, there was no pain either palpation or percussion. Dental ethology of sinus tract of odontogenic origin can be confirmed with the use of gutta-percha or similar radiopaque material but since the patient did not accept any extraoral interventions an intraoral periapical radiograph was taken without gutta-percha and it showed radiolucency around lower right central incisor which was the only reason that can cause cutaneous lesion. Radiolucency indicated inflammation of pulp that causes chronic apical periodontitis (). The treatment started with root canal treatment (). 2 days after the filling of the root canal, apical resection was performed and platelet-rich fibrin (PRF) was administered into the bone cavity and a PRF membrane was used to close the site as well. Following soft tissue closure with 3–0 silk sutures (), patient was instructed to take amoxicillin (1000 mg) 3 times per day for five days and to use antiseptic (povidone-iodine 7.5%) mouthwash 3 times per day for seven days. Flurbiprofen (100 mg) was also prescribed postoperatively to be taken as required. Sutures were removed after seven days and the wound healed uneventfully.\nIn this presentation, no sinus excision was performed extraorally. At the third month follow-up, radiographical, intraoral, and extraoral examinations revealed complete healing of bone at periapical lesion area and spontaneous healing of orocutaneous fistula. Additionally, during the healing period, his old restorations on lower anterior incisors were renewed as shown in .\nPreparation of PRF. A blood sample of patient was taken directly into 10 mL glass-coated plastic tube which was not containing anticoagulant and immediately centrifuged (Elektro-mag M415P) at 3000 rpm for 10 min, approximately 10 min before the surgery. The platelet-poor plasma that accumulated at the top of the tubes was discarded. PRF was dissected approximately 2 mm below its contact point with the red corpuscles situated beneath, to include any remaining platelets that may have localized below the junction between the PRF and red corpuscles [].
A 72-year-old male presented to the Mayo Clinic Cardiac Catheterization Laboratory for routine posttransplant surveillance coronary angiography after undergoing a second orthotopic heart transplantation at another institution four months ago. He received his first heart transplant 30 years ago for dilated cardiomyopathy which was complicated by progressive cardiac allograft vasculopathy. In 2019, he was listed and received a second cardiac transplantation at an outside medical center. The early postoperative course was uneventful, and he was on a stable immunosuppressive regimen with prednisone, tacrolimus, and mycophenolate mofetil. A postoperative coronary angiography was attempted four weeks following the transplantation, but the left coronary artery could not be selectively engaged due to the reported inferior origin of the left main artery with likely posterior rotation. He reported being told by his physicians that they “were unable to find his heart arteries.” He subsequently transferred his posttransplant care to the Mayo Clinic. As a part of the routine postoperative surveillance, he was scheduled for a coronary angiogram, right heart catheterization, and endomyocardial biopsy.\nThe review of the earlier angiogram had raised the suspicion of an anomalous left coronary artery. During coronary angiography, the right coronary artery was engaged without difficulty using a 6Fr Williams right catheter and looked normal in appearance ( and Online ); the left coronary artery was also seen arising posterior-inferiorly adjacent to the right coronary ostium. Selective injection from this position using a 6Fr multipurpose catheter revealed an anomalous left coronary artery arising from the right coronary sinus (Figures , , and and Online Videos , , and ). The long left main artery followed a retroaortic course before bifurcating into the left anterior descending and left circumflex arteries which otherwise appeared normal in appearance. We had discussed obtaining a dedicated coronary computerized tomographic scan to delineate his coronary anatomy; however, given his advanced renal disease, this was deferred after discussion with colleagues in heart failure and cardiac transplantation. Given his asymptomatic status, he was managed conservatively with routine posttransplant surveillance.
A 6-month-old boy was referred from an outside hospital for evaluation of amniotic band syndrome and peripheral nerve palsy to his left upper extremity. The patient’s past medical history is significant for a birth by cesarean section at 32 weeks and being a twin. He is otherwise healthy. The gravida 2, para 2 mother had an uncomplicated pregnancy till the time of birth. While at an outside hospital, the patient was evaluated for an arm that was completely flaccid below the elbow with no wrist or finger movement. There was a midhumeral constriction band just distal to the deltoid insertion. The patient did have shoulder function with deltoid and pectoralis muscle function. He underwent multiple Z-plasty releases, performed circumferentially around the entire midhumeral arm in series to the constriction at 3 months of age. He did not show any neurological improvement by 6 months of age. Physical examination at 6 months of age and 3 months following initial release revealed no peripheral motor or sensory nerve function below the site of the released constriction band; however, forearm and finger tone was present with no flexion or extension contractures (). There was a significant limb-length discrepancy and the patient had weak radial and ulnar arteries by signal. After extensive consultation, the family elected for surgical exploration for possible nerve revision or repair. No preoperative electromyogram (EMG) testing or imaging was performed. The patient at the time of the surgical exploration was 7 months old.\nIntraoperatively, a curvilinear incision was made over the constricted tissue and prior scar, extending proximally to the axillary fossa. The neurovascular bundles were identified proximally and followed distally into the band site. Extensive fibrous scarring was evident within the constriction site anteriorly and the caliber of the median and ulnar nerves was tapered. The brachial artery was not continuous through the zone of injury and ended proximal to the antecubital fossa. The ulnar nerve was identified within excessive scar tissue in the cubital tunnel and was dissected proximally. It appeared to be tethered to the humeral bone just proximal to the elbow. Both the median and ulnar nerves were in continuity distal to the band; however, the nerves were clearly atrophic within the band (). Distally, the nerves had intact blood supply and appeared normal in caliber and appearance. Interestingly, no neuroma was identified within the area of compression. The damaged portion of the ulnar and median nerves was resected, leaving a 5-cm gap between normal neural tissues.\nTo repair the defect, the sural nerve was taken from the lower extremity and used as a graft for both the median and ulnar nerves. The 9-0 nylon epineural sutures were used to approximate the grafted sural nerve and Tisseel Fibrin Sealant (Baxter International Inc., Deerfield, IL, USA) was added for support (). With extensive dissection through the scar to release the median nerve, it was evident that the blood supply to the hand became tenuous and positioning caused vascular congestion. Doppler signal were unable to capture the radial and ulnar arteries; however, the hand did demonstrate swift capillary refill. The decision was made to not explore the radial nerve due to collateralization being the only source of distal perfusion with brachial artery disruption. The patient was placed in a sling and remained in the hospital for 2 days of vascular observation to the viable, warm hand.\nWith 2 years of follow up, the patient has regained protective sensation to the extremity but has minimal motor functional return. Return of sensation is in the median nerve distribution. Consequently, no further diagnostic nerve function testing was undertaken. The patient currently is adaptive to the limited movement of the extremity, and no further surgical interventions are planned with continued observation.
In June 2015, a 43-year-old woman presented at another hospital with a swelling on the lateral side of the right knee, which clinically resembled a cyst of the lateral meniscus. A magnetic resonance imaging (MRI) scan revealed a cystic mass lying over the lateral meniscus, the femoral epiphysis and the tibial condyle. These findings seemed to be consistent with the clinical diagnosis of a cyst. For this reason, an arthroscopy was planned. A first attempt to decompress the cyst arthroscopically through a medial incision failed. The doctors then accessed the mass through a lateral incision and found that the formation had a solid consistency rather than fluid. Considering the macroscopic aspect of a malignant lesion, the tumor was enucleated and a drain was placed several centimeters below the lateral scar. The histopathologic examination demonstrated that the lesion was a high-grade pleomorphic sarcoma. In September 2015, the woman approached our tertiary referral center for musculoskeletal oncology, which boasts the presence of a multidisciplinary team. We planned the oncological re-excision on new computerized tomography (CT) scans to achieve wide healthy resection margins. The oncology–orthopedic surgeon performed the surgical re-excision, while the plastic surgeon harvested an adipo-cutaneous propeller flap based on a peroneal artery perforator at the middle third of the same leg. In addition, we used a random local flap harvested from the popliteal region to cover part of the donor site (–).\nThe histopathologic examination demonstrated the complete resection of the tumor with more than 3 cm cuff of healthy tissue. The patient spent 1 year and 9 months without significant complications after adjuvant radio- and chemotherapy. The woman underwent a trimestral follow-up until she suffered from a tibial plateau fracture in June 2017. The injury was treated by open reduction and internal fixation (ORIF) through the incision of the medial margin of the propeller flap. We assisted to a delayed wound healing probably due to the previous radiotherapy. After 4 months, the patient noticed a painless swelling that gradually increased in size over her right external distal third of the leg; this spot corresponded to the original proximal edge of the propeller flap (). Positron emission tomography (PET)–CT scan revealed a subcutaneous nodule, with no other relevant standardized uptake value (SUV) focuses. In the same month, we performed a wide local excision of the suspected recurrence and repaired the defect with a split-thickness skin graft (STSG). During the same procedure, we revised the proximal wound dehiscence and repaired it with a proximally based lateral gastrocnemius flap. We used STSG to cover the muscular flap ( and ). Histology confirmed the complete excision of the recurrent tumor within the soft tissue of the flap compatible with a recurrence from the previously excised sarcoma. We speculated that the cause of the recurrence was the implantation of tumor cells at the time of the first surgery in correspondence of the exit point of the drainage. This spot probably fell within an area not covered by a significant dose of radiations. Clinical examination and repeated MRI in November 2019 did not demonstrate any further evidence of the disease ().
A 31-year-old lactating woman was referred for investigation of multiple sclerotic bone lesions, 7 months since inception of breastfeeding. Following appropriate radiation safety advice where the patient was instructed to discard expressed breast milk for 4 hours, the patient was injected with 5.4 mCi (200 MBq) 18F-FDG and imaged on a GE Discovery PET/CT camera (Figures and ).\nThe unilateral diffuse intense FDG uptake corresponding to dense soft tissue in the right breast was likely due to secretory hyperplasia as further questioning confirmed that the patient had been breastfeeding only with the right breast due to her infant's preferences, as the infant was refusing to feed from the contralateral left breast. No significant FDG uptake was seen in the contralateral left breast which was not used for breastfeeding, 7 months after childbirth, although it also demonstrated dense soft tissue to a lesser degree. The sclerotic bone lesions were not FDG avid, likely due to a separate non-FDG avid benign condition or bony metastases from a non-FDG avid primary malignancy.\nExtensive investigations were carried out to rule out the possibility of metastatic breast cancer. Serial bilateral breast ultrasound at the time of the PET study and 5 months later demonstrated stable bilateral similar well-defined hypoechoic lesions in the right breast measuring 15 mm and in the left breast measuring 21 mm, favouring benign aetiologies such as fibroadenomas or galactoceles. Percutaneous biopsy of the larger left breast lesion confirmed a fibroadenoma. In discussion with the patient, the second smaller lesion with similar appearances in the right breast was not biopsied in light of its stable benign appearance and in keeping with the patient's preferences. Percutaneous bone biopsy of a sclerotic lesion in the left iliac bone was nondiagnostic due to bone dust contamination. The patient subsequently underwent an open surgical biopsy of the left posterior ilium where visible sclerotic lesions were evident on gross examination during the surgery. The histopathology findings of this surgical biopsy were nonspecific, but favoured bone dysplasia with no malignant cells seen.
A 38-year-old white woman presented with swelling and pain in her right upper limb that had begun 48 hours previously and that was unrelated to trauma. She was a keen amateur swimmer and had increased training in the days before the onset of the swelling. She had a history of bilateral shoulder recurrent luxation during childhood, which led to an operation on her left shoulder when she was 24-years old. Her history did not reveal any risk factors for venous thromboembolic disease (VTE): she had not recently travelled or had prolonged immobilization, nor had there been any recent surgery (the shoulder surgery occurred 14 years prior and was on her left shoulder, which was not the site of the swelling and pain that precipitated this case). Furthermore, she had no family history of thromboembolic disease or thrombophilia and was not taking oral contraceptive pills. The only historical detail of interest was bilateral recurrent shoulder dislocation in childhood, although there was no episode prior to the presentation of this PSS.\nThere were no signs of arterial disease; humeral, radial, and ulnar pulses on her upper limbs were present and good capillary filling was observed without skin changes. An examination revealed an increased diameter of her right upper limb, as well as an edema in all her right upper limb and deltopectoral collateral circulation. Upper limb mobility and sensitivity were normal and preserved, without paresthesia or dysesthesia that could be suspicious for nerve or arterial compression. Following the protocol of our center, ultrasound tests were performed to detect deep venous thrombosis (DVT), to evaluate compression, occupation of light, and color flow, and Doppler ultrasound was used to assess the phasic flow. The duplex ultrasound revealed a lack of compressibility, permeability, and phasic flow in the middle third and proximal region of her subclavian vein; right subclavian vein thrombosis was diagnosed. Computed tomography angiography (CTA) of her supra-aortic trunks, thorax, and upper extremities confirmed thrombosis in her right subclavian vein, just below her collarbone and her first rib (Fig. ). Multiple collateral veins in her right upper limb were observed, which enlarged the limb compared with her contralateral limb. No other findings of interest were noted.\nVenography was performed via her right cephalic vein, confirming thrombosis, a profuse collateral network, and proximal subclavian vein patency (Fig. ). With a multi-side-hole catheter placed in the thrombus, a 250,000 IU urokinase bolus was administered for local fibrinolysis, followed by a continuous perfusion of 100,000 IU/hour for 24 hours.\nAfter 24 hours, venography showed partial recanalization of the thrombus and a persisting moderate residual stenosis (Fig. ). Percutaneous transluminal angioplasty of the stenosis was performed with a 6×40 mm balloon.\nAfter a further 24 hours she was showing clinical improvement and was discharged. During the first week ambulatory treatment with low molecular weight heparin (LMWH) was provided at a therapeutic dose; for the subsequent 3 months ambulatory treatment comprised prophylactic doses of LMWH together with an elastic compression sleeve and physiotherapy. She was advised on preventive measures; she was recommended to abstain from exercises involving the upper extremity and swimming (identified as the precipitant element). This was combined with in-hospital and at-home physiotherapy, which provided advice and education on exercise and lifestyle modifications.\nShe was followed-up via ambulatory consultation (after 15 days, 1 month, 3, 6 and 12 months, and then yearly) to monitor her return to normal/working life and physical condition (including eco-Doppler). At the 6-month follow-up, the permeability of her subclavian vein was examined by ultrasound: clinical improvement had been maintained with no swelling and no functional impact; duplex ultrasound demonstrated subclavian vein patency.
A 35 year old male presented to our outpatient clinic with complaints of intermittent vague pain with clicking on his left knee joint for 2 years. On physical examination, there was elastic resistance and clicking during the terminal extension. There was no evidence of any ligamentous instability or malalignment. Simple radiography was not remarkable. Coronal and Sagittal MRI of left knee revealed complex tear with intrameniscal degeneration with diagnosis of incomplete discoid medial meniscus []. The patient underwent arthroscopy of his left knee under general anesthesia. Arthroscopy revealed medial hemiplateau to be completely covered by complete type of discoid medial meniscus and apical margin of the discoid medial meniscus was amalgamating into the anterior cruciate ligament [].\nProbing of the meniscal surface revealed central softening with dimpling, which suggested intrameniscal degeneration. In addition, there was complex tear from the mid to posterior horn which extended to the anterior cruciate ligament []. Using no. 11 scalpel blade and basket forceps, we performed an arthroscopic one piece resection and shaping. The initial resection was started from the tear edge of the posterior horn including the amalgamating portion to anterior horn close and without injuries to anterior cruciate ligament fiber and the articular cartilage []. Next, the anterior portion was resected using no. 11 scalpel blade in a similar manner. Finally, the remaining medial portion was completely transected by straight and angled basket forceps up to the tear edge with smooth inclination and balancing []. Resected meniscal fragment was extracted with arthroscopic grasper. We checked the residual rim stability and width with a probe, which was approximately 6 mm, and inspected for intraarticular residual debris or meniscal fragment. After surgery, the patient used disposable knee supporter for 3 days and was encouraged to perform ranges of motion and quadriceps exercise. Full range of motion was achieved within a week after index arthroscopic surgery. At 30-month followup, there was no pain or mechanical symptoms including elastic resistance to the terminal extension or clicking during motion. In addition, patient taking part in many sports activities, such as football, basketball, jogging. Finally, the clinical results were excellent on subjective and objective evaluation according to the Ikeuchi grading system.
A 50-year-old post-menopausal woman was seen by a dentist for the pain in the left side of the upper lip. After thorough examination of the patient, the dentist diagnosed it as chronic periodontitis and pulpitis of the left upper second incisor. The dentist advised her oral hygiene and extraction at a later date. She was advised to take oral paracetamol 500 mg thrice daily for 3 days. Two weeks after this episode of visiting a dental clinic, the patient developed swelling of the upper lip [] with mild puffiness of the face. The patient was also suffering from osteoarthritis of both knees and used to take diclofenac sodium 50 mg twice daily or Ibuprofen 400 mg thrice daily frequently and irregularly by her own by purchasing over the counter (OTC). When she visited the same dentist again for consultation, it was diagnosed as angioedema of the upper lip, an allergic phenomenon[] due to nonsteroidal anti-inflammatory drugs (NSAIDs), and advised to consult a physician for further management.\nWhen the patient was referred to the physician for the management of angioedema of the upper lip with the history of taking NSAIDs for arthalgia, she was advised to stop taking NSAIDs and was prescribed corticosteroids (methyl prednisolone) 10 mg thrice daily along with Ranitidine 150 mg twice daily. Then, the physician tapered the dose of steroids in 10 days in two clinical visits. When reviewed again after 15 days, she was asymptomatic and the edema of the upper lip subsided completely.\nAfter a week she developed the similar swelling of the upper lip again []. This time there was no history of taking NSAIDs. She was again referred to the physician for review and found no obvious focus of infection. She was prescribed oral antibiotic amoxicillin 500 mg thrice daily anticipating subclinical soft tissue infection around the mouth and nose.[]\nThe patient was subjected to laboratory investigations[] to rule out soft tissue infections around the mouth (hemogram, blood sugar, and nasal smears). The C1 esterase inhibitor estimation to rule out angioedema was deferred by the patient due to its high cost. Since other routine investigation results were within the normal limits without any obvious improvement in her clinical conditions, the antibiotics were stopped and referred to another dentist for the second opinion.\nThe dentist reviewed and raised the suspicion of the periapical abscess and ordered for X-ray of upper incisors on the left side. The X-ray revealed the radiological features of periapical abscesses of the upper incisor tooth [] The patient was treated by immediate tooth extraction and exudate in the abscess cavity was drained.[] The patient was given paracetamol 500 mg thrice daily as an analgesic.[] The edema subsided, the patient's condition was restored clinically normal [Figures and ] and was able to do her routine work. She was reviewed periodically in dental clinic. When the clinical condition favored, the artificial tooth was fixed to fill the gap.
During dissection of about 60-year-old male cadaver, we observed anomalous positions and branching pattern of the renal vessels causing a congested renal hilum. The variation was bilateral (). The hilar region was dissected carefully and the structures and their relations were clearly defined. The normal architecture of bean shaped kidney was totally distorted bilaterally. Formation of renal pelvis was normal on both kidneys but the variation is as reported below.\nRenal artery (RA) with its normal origin and course from abdominal aorta divided immediately into 2 branches (). The superior branch pierced the upper pole of the kidney without passing through the hilum. It represented the aberrant artery (AA). It gave a thin branch which descended down to the hilum. The inferior branch coursed forward to the hilum and just before entering the substance of the kidney it gave six divisions. The upper 4 branches reached the hilum passing anterior to the renal vein, whereas the lower 2 branches passed posterior to it. The 2 tributaries of renal vein (RV) after emerging from the hilum united to form a single trunk as right renal vein outside the hilum and it drained into the inferior vena cava.\nThe hilum was wide and situated on the anterior surface instead of its normal anatomical situation in the medial border ().\nLeft renal artery arose from abdominal aorta, before entering the hilum branched into 2 divisions. Anterior division presented an arched course superficial to the tributaries of renal veins and gave 6 branches. The upper 2 branches of it represented the aberrant arteries and entered the upper pole of the kidney. One of the aberrant arteries before piercing the substance of the kidney gave the right inferior suprarenal artery. The posterior division ran behind the renal pelvis and posterior division of renal vein and gave 3 branches. So altogether, 8 branches pierced the renal hilum and 2 branches pierced the upper pole of the kidney.\nAnterior and posterior tributaries of renal vein after emerging separately from hilum of the left kidney united to form a single trunk that drained into inferior vena cava. Before the union, the posterior division joined the anterior division in a twisted manner. Anterior division received left testicular vein (LTV). The left suprarenal vein (LSRV) drained into the trunk of the left renal vein. So the arrangement of the structures in the hilum of left kidney from anterior to posterior aspect was anterior division of the renal vein-anterior division of renal artery-renal pelvis-posterior division of renal vein-posterior division of renal artery (A-V-P-V-A).\nThe schematic representation of bilateral renal hilar pattern with distorted shapes of kidneys is shown in .
A 60-year-old male presented with slowly progressive drowsiness was admitted to our hospital. Magnetic resonance imaging (MRI) revealed an obstructive hydrocephalus caused by midbrain tumors [Figure and ]. He had past history of a malignant lymphoma of the stomach, which had occurred 10 years earlier. ETV and an endoscopic biopsy were performed to treat the hydrocephalus and to confirm the histology of the tumor.\nThe operating sheath was inserted into the right lateral ventricle through a right-sided coronal burr hole. The endoscope was advanced into the third ventricle through the sheath and the foramen of Monro. The floor of the third ventricle was thin and translucent. Under continuous visual control, the biopsy forceps and a 4-French Fogarty balloon catheter were used to perforate and widen the stoma. The basilar tip and bilateral posterior cerebral artery were visible below the stoma, but there was no injury to these arteries. A biopsy was not performed because the tumor did not appear on the surface of the ventricle, but cerebrospinal fluid (CSF) cytology revealed malignant lymphoma cells. After some minutes of irrigation, no bleeding was confirmed, and external ventricular drainage was then inserted into the right lateral ventricle.\nThe patient was in our intensive care unit with continuous monitoring of heart rate and blood pressure. His systolic blood pressure was stable in the range of 130–110 mmHg. He was drowsy, but did not exhibit confusion or other signs of significant pain. After the procedure, the initial level of ventricular drainage was 10 cm H2O. About 220 ml of CSF was drained in the first day after surgery. The patient remained drowsy, but a computed tomography (CT) scan the day after the operation showed no abnormal findings except dilated lateral ventricles. The CSF continued to drain. Two days after the operation, we set the level of ventricular drainage to be the same as that on the first day. About 300 ml of CSF was gradually drained with about 16 h before the bleeding began. The patient suddenly became comatose, and the bloody CSF was rapidly drained immediately. An emergency CT scan revealed a diffuse SAH []. Cerebral angiograms demonstrated a saccular aneurysm of the left internal carotid-posterior communicating artery []. No other causes for the SAH were found. Endovascular coil embolization of the ruptured aneurysm was then performed, and the conditions of the patient gradually improved. Subsequently, he received systemic chemotherapy and irradiation for intracerebral malignant lymphomas. After a month of rehabilitation, he returned to his previous state of consciousness.
This patient was a 67-year-old previously healthy Korean female with no significant past medical or surgical history, who presented with a 7-day history of progressively worsening abdominal pain. She had recently come to America from South Korea to stay with her daughter about 13 months ago. The patient’s vital signs were within normal limits. Abdominal examination was significant for diffuse tenderness to palpation, distention, and voluntary guarding. White blood cell count was 16 000 /µL and alkaline phosphatase was 133 U/L. Computed tomography (CT) scan of the abdomen showed a large hepatic abscess noted in the right lobe of the liver ().\nThe patient was treated aggressively for septic shock over the next several days with vancomycin and zosyn. The patient was taken to the operating room for an exploratory laparotomy for likely perforated hepatic abscess. A large hepatic abscess was noted within the right lobe, with free suppurative fluid in the abdomen. There was an extensive amount of fibrinous exudute present within the abdominal cavity, which was irrigated thoroughly with normal saline. The abscess cavity was opened and Penrose drains were placed into the abscess cavity and brought out through the skin to allow for drainage. The abdomen was closed in the standard fashion. Postoperatively, the patient was admitted to the surgical intensive care unit and treated for septic shock. Intra-abdominal cultures taken during the surgery were positive for Klebsiella pneumoniae. Despite intravenous antibiotics therapy, the patient continued to have severe sepsis. Infectious Disease services were consulted to assist in the patient’s management. Her antibiotic course was later changed to imipenem, vancomycin, and fluconazole due to the development of microbial resistance. On postoperative day 7, the patient developed swelling and purulent drainage from the left eye. A CT scan of the orbits showed a detached retina on the left with opacification and endophthalmitis ().\nIntravitreal injections of vancomycin and ceftazidime antibiotics were given for 8 days and the patient was subsequently taken to the operating room for enucleation and washout by the ophthalmology service. Pathology was consistent with Panophthalmitis. Tissue cultures of the eye, optic nerve, and bronchial washings were also positive for Klebsiella pneumoniae. Despite aggressive medical and surgical efforts, the patient eventually succumbed to multiorgan system failure from septic shock on postoperative day 45.
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative course was uneventful and the symptom of intermittent claudication disappeared. She was discharged on fourth postoperative day with antiplatelet (salicylic acid 100 mg, once daily) and statin (atorvastatin 20 mg, once daily) medication.
The present patient was a 60-year-old Chinese man who had ruptured his Achillies tendon 4 months prior and underwent an incision and reconstruction in our institution in 2008. Before the rupture, local hormone injections had been used to treat Achilles tendon periarthritis. Considering that the rupture site was only 1.5 cm away from the posterior superior process of the calcaneus, the defect was large, approximately 4 cm, and the remaining scar tissue was fragile, so the gastrocnemius aponeurotic flap was used to rebuild the Achilles tendon. During the operation, several no. 1 and no. 4 silk sutures were used to fix the aponeurotic flap and eliminate the gap between it and the remaining scar tissue at the front.\nWhen the sutures on the wound were removed 2 weeks after the operation, it was found that the skin was damaged in two places and purulent secretions were exuding. Because this was a local infection, no bacterial culture of secretions was performed. Neither defect was in the incision, and the proximal defect was far from the surgical incision. This incision was found to have ischemia and blackening during dressing changes. After 3 months of local dressing changes, there was no obvious improvement, so endoscopic treatment was performed.\nThe patient was placed in a prone position and received spinal anesthesia. A pneumatic tourniquet was applied to the affected lower extremity. The patient already had a defect into which the surgical instrument could be inserted. The other port selected was located at the top of the other side of the original defect (Fig. ). Next, the inflammatory tissue was cleaned. Recent preoperative MRI images were used to identify areas with Achilles tendon weakness and degeneration. After the lesion was identified, the damaged tissue was cleaned by curettage, during which time the tendon was protected. All nonabsorbable sutures in the surgical field were removed (Fig. ). After the wound and Achilles tendon tissue were rinsed, primary suturing of the wound was performed. A rubber strip was placed in the proximal wound and removed 1 day after the operation.\nWe used intravenous second-generation cephalosporin as the prophylactic antibiotic for 1 week and then switched to oral medicine for 2 weeks; a short leg plaster was applied for 2 weeks. The wound suture was removed 3 weeks after the operation. The patient performed ankle joint range-of-motion exercises without weight-bearing for 2 weeks after that and then began to walk with weight-bearing while using a heel cushion. The cushion heel thickness was 2 cm from weeks 5 to 8 after the surgery, and the patient used crutches; from weeks 9 to 12 after the surgery, a cushion heel thickness of 1 cm was used. The patient stopped using crutches 3 months after the surgery. To minimize the risk of falling, the patient was instructed not to jump or lift the heel for the next 3 months. After that, he began to walk normally, and 6 months after surgery, he could do double heel exercises. He started doing single heel exercises 12 months after surgery.\nThe patient's recovery was satisfactory at the last the follow up in 2011 (3 years after the operation). The wound had healed completely, and no abnormality was noted during heel lifting or other movements.
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.\nA histological examination revealed mammary Paget’s disease without invasion to underlying tissues (Fig. ), no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
A 59 year-old female patient, who has been employed as rehabilitation worker, has observed gradually enlarging formations under both her right and left scapula for approximately eight months. In anteflexion, elevation of the upper extremities and when stretching the arms forward, swellings reaching up to the rear axillary lines appear bilaterally subscapularly. They were of soft consistency at palpation. The patient also described pain in the upper extremities, and in the region of arms. She had no recollection of any accident or fall. However, she had undergone neurosurgical operating procedures of disc extrusion in the cervical and thoracic spine, and the findings of bilateral resistances were present already pre-operatively. In the another surgical workplace repeated punctures and partial resection of the swelling on the right side were implemented 5 months ago, and it came to its subsequent recurrence.\nThe magnetic resonance ((b) and (c)) on thoracic wall showed in dorsolateral parts in subscapular regions in the level of 3rd to 7th rib symmetrical limited fluid collections with dimensions of 120 × 37 x 115 mm on the right side with a volume of 250 ml and on the left side 120 × 24 x 90 mm with a volume of 130 ml. The collections were localised in the intermuscular spaces between the external intercostal muscles and the heads of the muscle serratus anterior. The contents of collections were moderately heterogeneous with sporadic internal septa. Cystic formations had slightly distinct signal, native image in T1 weighing displayed hypersensitive contents on the right side. It could be a case of chronic post haemorrhagic changes. Postcontrastly the collections were without amplification of signal intensity. On the left side postcontrastly there was present a moderate reinforcement of capsule of fluid collection. In diffuse weighing the lesions were without marks of diffusion restriction. Axillary lymphatic nodes were of physiological size, the displayed pulmonary parenchyma was without inflammatory and focal changes, without mediastinal and hilar lymphadenopathy, the pleural cavities without effusion, the pleura was without hypertrophy, the recorded skeleton was without traumatic change.\nOwing to progressing swelling and increasing difficulties a surgical resection was indicated in the female patient. She was operated on under general anaesthesia, and a resection of the encapsulated collections of fluid was implemented bilaterally ((d)), two Redon drains were introduced. In the left collection serous fluid was present, on the right side also serous fluid with admixture of old blood was present. A histological examination of cystic collections proved that it concerned pseudocystic lesions with relation to subscapular bursa without marks of malignancy. Their walls were created by collagenous, hyalinised and vascularised connective tissue with predominately perivascular nonspecific chronic inflammatory cellulation ((a)), the internal surface of which was lined by a layer of fibrin and by a nonspecific granulation tissue with a focally accentuated xanthogranulomatous, siderophagous and giant-cell reaction without epithelium ((b)). In the lumen of the cysts there were remnants of blood clots with fibrinous or fibrinoid substances with dispersive admixture of siderophages, lymphocytes, neutrophils and giant polynuclear cells ((c)). The proof of amyloid by Congo red was negative. On the lesion periphery soft-tissue structures were caught, including striated muscularis. The drains were removed the 10th postoperative day due to higher production, the surgical wounds were healed-up per primam intentionem. After the operation the female patient had a full range of movements and was without trouble and pains.
A 7-year-old male child was admitted in the Paediatric department of our tertiary care hospital for evaluation of eosinophilia. A bone marrow biopsy from posterior iliac crest was planned for definitive diagnosis. After sedation and left lateral position, an autoclaved reusable 14-gauge trephine biopsy needle of unknown make was inserted percutaneously after all aseptic precautions. The inner stylet was removed and the hollow needle was advanced. Due to the resistance felt, the operating surgeon tilted the needle to change the trajectory while the needle was still in the bone. This led to a needle facture with the distal part being embedded in the bone. The procedure was aborted and the broken needle fragment was left in situ. Subsequently an Orthopedic Department consultation was made and X-rays along with a Computed Tomography (CT) scan was ordered to locate the broken needle. The radiological investigations showed the presence of 2.7 cm needle fragment traversing the right sacroiliac joint with the needle tip lying just 3 mm posterior to the anterior cortex of the sacrum (). As the needle was lying in the joint, after counselling the parents, it was decided to extract the needle fragment.\nIn the operating room, after induction with general anaesthesia, preoperative antibiotics were administered and the patient was placed in left lateral position. As there were two puncture marks 2 cm apart over the skin, it was decided to visualize the foreign body under fluoroscopy to aid in localization. A skin incision of 2.5 cm was made and after superficial and deep dissection the needle end was localized which was bent and buried in the cortex. The surrounding cortex had to be undermined using a drill bit of 2.5 mm to expose the needle end which was then removed with a plier (). Confirmatory C arm shoots were taken. The needle length was measured and was found to be matching with the CT scan measurement (). The core of bone extracted from the broken needle was placed in formalin and sent for histopathological analysis. Post thorough wash the wound was instilled with a local anaesthetic agent and closed in layers. A dressing was applied, and the patient was extubated uneventfully. The patient was allowed to bear weight as tolerated following the procedure as the defect was not deemed a significant fracture risk. The patient had an uneventful 15 month follow up.
A 32-year-old female patient developed depression, anxiety and subtle gait disturbances during the second trimester of her first, otherwise uncomplicated pregnancy. Her main complaint upon her first visit to the emergency department was having difficulty finding words and concentrating, as well as having a fear of falling while walking. She felt anxious and hopeless and showed mildly decreased cognitive function, achieving a score of 24 points on the Mini Mental State Examination. Perinatal depression was suspected, and she was treated by the Department of Psychiatry for six months without significant improvement in her symptoms. Upon completion of her treatment, the patient displayed an unusual wide-based, shuffling, very slow and highly fluctuating gait. She walked in small steps and sometimes staggered severely, but her symptoms were variable, and she did not fall. Therefore, her gait disturbances were classified as psychogenic. However, cerebral MRI showed confluent white matter lesions suspicious for CADASIL. The patient had been treated for mild hypertension since the age of 29 but had otherwise been healthy. Her family history was negative for any hereditary diseases, but her reported history was fragmented because she had broken off all contact with her father at the age of 18.\nThe patient subsequently presented to us ten months after symptom onset and six months after she had given birth to a healthy girl. She presented with conspicuous global bradykinesia with severe slowing and hesitation in her fine motor skills and symmetric rigidity in all her extremities, but without tremor. She also exhibited reduced spontaneous speech with slight amnestic aphasia and ataxic dysarthria, with loss of modulation. Her gait disturbances had worsened, as she could walk only short distances independently, and she had difficulty lifting her feet of the ground without external instruction but showed no typical freezing behaviors. Apraxia was an important finding, as it was evident in both her fine motor skills and her gait. Another MRI revealed the presence of increasingly symmetrical, confluent FLAIR hyperintensities with partly restricted diffusion, but without contrast enhancement (). Wideranging blood and CSF analyses, as well as electrophysiological tests, were not suggestive of a diagnosis. In particular, there was no evidence of an infectious or autoimmune cause of her symptoms.\nThe marked parkinsonian features, which improved slightly on levodopa, combined with the progressive leukoencephalopathy and spotty frontal calcifications demonstrated by CT () led us to test for HDLS. Genetic testing revealed the presence of a heterozygous mutation (c.2541G>C) in the CSF1R gene leading to a change in the corresponding amino acid sequence (p.E847D). This mutation was first described in a patient who presented with cognitive decline and spastic paraparesis at the age of 44 [].\nThe patient exhibited signs of progressive pyramidal as well as extrapyramidal motor dysfunction and rapidly progressing dementia during the following months ( in the online-only Data Supplement). Eighteen months after symptom onset, the patient was admitted to a nursing home. By that time, she was not able to sit, stand, communicate or recognize faces. She presented with a combination of rigid-spastic muscle tonus, pyramidal signs and primitive reflexes. The patient died 28 months after symptom onset.
A 75-year-old man underwent pancreaticoduodenectomy for distal bile duct carcinoma. He developed pancreatic anastomotic leakage postoperatively. Contrast-enhanced computed tomography (CT) showed fluid collection around the pancreatic anastomosis and main portal vein (). The fluid had been discharged from abdominal drains that had been placed intraoperatively. Eleven days postoperatively, the patient developed sentinel bleeding from a drainage tube placed in the foramen of Winslow. He remained hemodynamically stable and was managed by transfusion of 4 units of packed red blood cells and intravenous fluids. Emergency angiography was also performed. Common hepatic arteriography showed protrusion and dilatation at the stump of the gastroduodenal artery. Although this later proved to be incorrect, we considered the stump of the gastroduodenal artery as the cause of hemorrhage. This patient showed an anatomical variant of the hepatic artery, with the left hepatic artery arising from the left gastric artery. We therefore embolized the common hepatic artery using microcoils. After embolization, arterial flow to the liver was preserved through collateral flow from the left hepatic artery.\nAt the same time, to exchange the drainage tube located in the foramen of Winslow, traction was placed on the drain and contrast medium was injected via the drainage tube. This contrast study showed not only the peritoneal cavity due to pancreatic leakage, but also the main portal vein, indicating portal vein injury (). The point of damage to the portal vein was just above the confluence of the splenic and superior mesenteric veins. Recurrent hemorrhage from the drain then occurred. The drainage tube was subsequently reinserted, and tentative hemostasis was achieved. Three hours later, recurrent hemorrhage from the drain occurred once more. The hemoglobin levels dropped from 10.4 to 9.1 g/dl within a period of 3 h, and systolic blood pressure decreased from 120 mmHg to 80 mmHg. The patient was taken to an operating room for definitive surgical repair. However, surgical repair was difficult because of severe postoperative intra-abdominal adhesions. The therapeutic strategy intraoperatively was therefore changed to stent-graft deployment.\nThe intrahepatic portal branch was punctured using an ultrasound-guided transhepatic approach, and a 5-F sheath inserted into the main portal vein. Portography showed no contrast extravasation. The splenic vein, gastric vein, and inferior mesenteric vein were embolized using coils and microcoils to prevent type 2 endoleak. The 5-F sheath was then exchanged for a 12-F sheath. On CT, the diameter of the main portal vein was 15 mm and that of the superior mesenteric vein 13 mm. A Gore Excluder contralateral leg endoprosthesis (16-14.5 mm × 70 mm; W. L. Gore & Associates, Flagstaff, AZ, USA) was loaded in a reversed position into the sheath using the upside-down technique (). The stent-graft was deployed by a pusher rod. Subsequent portography showed favorable portal flow to the liver through the stent-graft (). At the end of the procedure, the punctured hepatic tract was closed with 6 mm coils.\nAfter the procedure, the patient remained free of further hemorrhage. Pancreatic anastomotic leakage was improved and the patient was discharged 2 months later. As of 12 months after the procedure, the patient remains alive and portal flow through the stent-graft was intact.
A 38-year-old gravida 1, para 0 was transferred to our unit at 26 weeks of gestation with severe right iliac fossa pain and a suspicion of threatened preterm labour. She presented with a 3 day history of right iliac fossa pain, nausea, vomiting and diarrhoea. Vaginal examination and her fetal fibronectin test was negative. However, transabdominal and transvaginal ultrasound examination revealed a 6.0 × 5.5 × 5.9 cm vascular mass within the right pelvis with a clear arterial feeder and turbulent swirling intraluminal flow, leading to the diagnosis of a pseudoaneurysm (Fig. ). The diagnosis was subsequently confirmed by Magnetic resonance imaging (MRI) (Fig. ). The patient was discussed in our multidisciplinary team meeting with interventional radiologists, vascular surgeons, and anaesthetists. The risk of imminent rupture was assessed as high due to the severity of her symptoms and a 5–10 mm overall increase in the size of the pseudoaneurysm documented by sequential MRI 14 days apart. Surgery was considered high risk and so selective embolization of the pseudoaneurysm was performed. This was performed under local anaesthetic in the Interventional Radiology suite with full preparation for emergency delivery by the obstetric and anaesthetic team in case of fetal distress. The right uterine artery was identified angiographically from a contralateral femoral arterial puncture and selectively catheterised using a microcatheter. The artery was small but extravasation into the presumed pseudoaneurysm was identified near its proximal portion. The artery was embolised with a series of microcoils across the neck of the pseudoaneurysm to block flow. The procedure was uneventful and the fetus showed a continuous reactive heart rate pattern. Follow up ultrasound showed a completely thrombosed pseudoaneurysm with no flow. She had regular follow ups in the antenatal clinic with no sign of recurrence. A planned caesarean section was performed at 38 weeks gestation. A healthy baby boy was born weighing 2696 g with a blood loss of 1100mls. During the caesarean section, the thrombosed pseudoaneurysm was seen below the right broad ligament and all other pelvic organs looked completely normal (Fig. ). An ultrasound scan 3 months postpartum showed a small completely thrombosed pseudoaneurysm (Fig. ).
A 62-year-old female presented at our institution with a history of an enhancing subcutaneous mass on the right hand over the past 10 years. Over the last 3 years, she experienced episodes of moderate pain and paraesthesias on the first and second fingers. She had no medical history and had no history of hand trauma. Physical exam identified a 3 cm long subcutaneous tumor on the center of the right palmar region, with a hard consistency on palpation, slightly mobile for lateral movement []. Neurological examination revealed hypoesthesia on the first, second, and third fingers, associated with handgrip impairment due to the tumor, not for weakness. Tinel's sign was present in the wrist, proximally to the mass. No other cutaneous or soft tissue lesions were noted. Ultrasound exam performed in other institution identified a 3.0 cm × 2.6 cm hypoechoic nodular image with irregular borders. The electromyographic examination inferred carpal tunnel syndrome due to a partial conduction block of the median nerve at the wrist. Magnetic resonance image (MRI) revealed a 3.0 cm × 2.6 cm × 1.6 cm heterogeneous lesion in the palmar region attached to the median nerve []. The patient underwent surgical resection of the lesion. After the section of carpal ligament and exposure of the median nerve, a gross total resection of the well-encapsulated mass was achieved. The lesion was found to originate in the median nerve close to its division in the palmar region. The tumor was stuck to the lateral and medial branches, and a careful dissection was performed in order to remove the tumor in one piece without damaging to the nerve structures. Gentle interfascicular dissection was needed in the proximal part of tumor attached to the median nerve []. Microscopic examination revealed a uniform lesion consisting of lobules of mature adipose tissue separated by fibrocollagenous septae, without neural elements in between []. Immediate pain relief was reported after surgery, and no new neurological deficit was identified. On clinical examination 2 years after surgery, the patient was free from hypoesthesia and paresthesia, with no evidence of tumor recurrence.
A 16-year-old, Sinhala ethnic Sri Lankan woman in her first pregnancy, was admitted with severe preeclampsia at 29 weeks of gestation. She has made her booking visit at ninth week of gestation and all the booking investigations were normal except for the platelet count which was 112,000 per liter. During her pregnancy, the lowest platelet count was 80,000 per liter at 27 weeks of gestation and no specific intervention has been done except for regular monitoring of the platelet count. She had been diagnosed with gestational hypertension at 22 weeks of gestation and prescribed labetalol and methyldopa. Other than that, she has had few erythematous, itchy macular lesions over the palm of her right hand from early in the first trimester onwards and had persisted throughout the pregnancy. She has had mild pain in her right small finger from first trimester onwards. But she had not worried about these symptoms so they had gone unnoticed. She had been apparently well until late 28 weeks of gestation and then she has developed a severe headache and worsening of bilateral lower limb oedema with frothy urine leading to hospitalization. She was diagnosed with severe preeclampsia (blood pressure of 185/115 mmHg) at 29 weeks of gestation. An emergency caesarean delivery was arranged soon after this presentation. Her baby was admitted to the premature baby unit with a birth weight of 1000 grams. She was in intensive care unit in first 24 hours after delivery and received intravenous magnesium sulphate as a prophylactic anticonvulsant.\nHer pain in the right finger worsened after delivery and erythematous macular lesions have been increased in number and spreading over the dorsal aspect of the right forearm. She was not worried and lesions have gone unnoticed especially with her dark skin complexion. Her blood pressure was under control with oral nifedipine. At the eighth postpartum day, her right small finger was noted to be cold with increased pain. Discoloration of the above skin lesions was more prominent and started to appear over the palm and the ventral aspect of the forearm of the right hand too, with preserved capillary refilling time. Both radial and ulnar artery pulsations were felt. There were no similar lesions in any other part of the body. She was soon transferred to a medical ward for further management.\nShe was subjected to an urgent arterial duplex study, which revealed proximal ulnar artery thrombosis in the right side with partial occlusion to the blood flow. And soon she was started on unfractionated heparin and eventually bridged with oral anticoagulants (warfarin) in order to archive the target international normalized ratio (INR) of 2.0-3.0. With anticoagulation treatment, her symptoms and signs were markedly improved. Sequential macroscopic changes of the affected arm and fingers have been shown in .\nRoutine laboratory analyses were within the normal range including subsequent platelet count, but she got positive results for direct Coombs test. Her reticulocyte count was high with normal haemoglobin concentration. Her ANA titre was strongly positive (1:320). And also anti-cardiolipin antibodies (anti-CL) and anti-β2 glycoprotein-I (anti-β2GPI) levels were also noted to be positive. However, her ds DNA and C3/C4 levels were within normal limits. Her blood pressure readings too have come back to normal level with no requirement of medications. Also proteinuria was settled. Her laboratory tests for APS were positive even after 12 weeks of initial testing. Therefore, it was diagnosed as a case of primary APS.
This report presents a case of 28-year-old male, who was referred to the Department of Orthopedic Surgery in the Jordan University Hospital complaining of right gluteal pain and feeling of unusual hard mass for 2 years. The pain was insidious and increased over time, he described it as a burning sensation that radiates from the gluteal area to the posterior side of the thigh, which was exacerbated on walking but relief with rest and there was no night pain. He also reported a progressive limitation of right hip extension which significantly interfered with his daily activities.\nThrough the 2 years before the presentation, the patient was assessed by multiple general physicians one of them diagnosed him as a muscle stiffness and another one ordered a lumbosacral magnetic resonance image (MRI) to rule out disc prolapse. For that, the patient had been receiving several courses of para spinal muscle strengthening physical therapy and core body exercises, but with minimal benefit. The patient visited a general orthopedic surgeon 1 month before the presentation which ordered a pelvic radiography that showed an osseous mass related to the right femur neck (). Therefore, the patient was transferred to our hospital for further evaluation.\nOn physical examination, there were multiple tender points in the gluteal area and over the greater trochanter, with restricted passive and active extension of the right hip joint, but there was no weakness and symmetric power 5/5 in both lower limbs. The results of the laboratory tests (complete blood count, erythrocyte sedimentation rate, C-reactive protein, kidney function test, and electrolyte) were within normal limits.\nComputed tomography scan (CT scan) was ordered and showed a right femoral neck posterior-inferior osseous mass with cortical and medullary continuity on the axial view (). MRI – sagittal short tau inversion recovery fast spin-echo (SAG STIR fast IR) showed the posterior relation of the OC to the femur neck, and the high intensity cap which goes with the diagnosis of OC (). MRI – sagittal view T1 in (a) and T2 in (b), showing the posterior relationship of the OC to the right femur neck (). MRI – axial views show the cartilage cape low enhancement in T1(a) and high enhancement in T2(b) ().\nThe plan was to remove the mass, and the risks of intra-operative femur neck fracture, sciatic nerve injury and incomplete resection were discussed with the patient. The operation was in lateral position through a lateral approach to the hip. The hip capsule was stretched and the mass was intra capsular in posterior relation to the femur neck with a stalk. It was removed as close as possible to the femur neck using the saw and osteotome. It was completely removed without a fracture to the femur neck (, ). Then, we fixed the femur neck with two fully threaded cannulated screws as a prophylactic fixation (, ). The mass was sent for histopathology evaluation (), which confirms the diagnosis of OC.\nThe patient started full weight bearing and hip range of motion rehabilitation program in supine and prone position directly on the next day of the operation. After 4-months of out-patient follow ups, the patient reported a significant improvement in his hip extension and a complete resolution of the burning sensation in his gluteal area.
A 75-year-old lady presented to our emergency room after a trivial fall and severe pain in her right thigh and inability to walk. There was a history of BP intake for the treatment of osteoporosis for 5 years duration. There was no history of prodromal thigh pain. Radiographs of the right femur showed a complete fracture of the right femur shaft at the isthmus with the transverse lateral cortex, medial spike, and increased cortical thickening suggestive of atypical nature of this fracture (). As per the criteria given by the Task Force of ASBMR, the patient had all major and minor criteria except that the patient had no prodromal symptoms and bilateral association (). These signs led to a diagnosis of Atypical fracture of the femoral shaft. The radiograph of the contralateral femur showed no signs of an incomplete fracture. Subsequently, BP was stopped and the patient underwent closed intramedullary nailing with post-operative radiograph showing acceptable reduction and stable fixation (). Postoperatively, the patient was started on active exercises and non-weight-bearing with a walker on day 1, and subsequently, the patient was discharged on day 3. The radiographs at 3months showed evidence of callus formation, and the patient was advised weight-bearing walking. Subsequent radiographs at follow-ups showed slow healing of the fracture with minimal callus formation. At 9 months, the patient again presented to the emergency room with thigh pain after getting up from sitting position. Clinical examination showed varus deformity of the right thigh with radiographs showing refracture with segmental breakage of the nail at the level of fracture and distal bolts with minimal callus formation (). This led to the impression that the AFF in the diaphyseal region did not unite in 9 months. Subsequently, the patient was treated with exposure of the fracture site, removal of the nail, and fibrous union. The sclerotic bone ends were removed until there was punctuate bleeding from the bone ends. The fixation was performed with K-nail and augmented plating, as shown by Sancheti et al. [] and was supplemented with osteoperiosteal flaps and iliac crest bone grafting (ICBG) (). Postoperatively, the patient was started on active exercises and non-weight-bearing walking with walker support on day 2and was discharged from the hospital on day 5. The patient was followed up regularly at 1-month intervals. The radiographs at 3 months showed good callus formation and the patient was advised to complete weight-bearing. The fracture healed successfully at 6 months and the patient started walking without support. At 1-year follow-up, the patient had full hip and knee range of motion and radiographs showed complete fracture healing with consolidation ().
A 20-year-old woman with a history of root canal treatment of the upper maxillary (left) central incisor was referred to our department from a private clinic. The root canal treatment had been initiated 4 months prior but could not be finished. A clinical examination revealed a temporary filling on the palatal surface. The coronal part of the tooth was discolored, and multiple visible cracks were present on the buccal surface (). The tooth was asymptomatic; the mobility was normal, and the probing depth at all sites was ≤ 3 mm. A periapical radiograph revealed a lesion around the apex and an enlarged and clearly irregular root canal (). When specifically asked, the patient denied knowledge of any previous dental trauma. Upon checking the electronic documentation of the faculty of the institution, we found that the patient had visited the department 2 years prior for other reasons, and X-rays were taken at that appointment. From a comparison of the periapical X-rays, it was clear that something must have happened since her last visit (). After gaining her confidence, the patient and her mother admitted that the patient had suffered from domestic abuse at the hands of her boyfriend, but that had been taken care of by the police. At this point, a small-field-of-view high-resolution cone-beam computed tomography (CBCT) scan was taken to investigate the extent and irregularity of the lesion. The scan confirmed the presence of a periapical lesion, which had destroyed most of the buccal bony wall around the root. The scan also showed massive internal resorption inside the root canal (). The patient was informed of the findings and the poor prognosis of the tooth, but since she desperately wanted to keep her tooth, she provided consent for endodontic treatment, which was initialized at a later appointment. The patient was also informed that due to the irregular nature and more pronounced buccolingual extent of the resorptive lesion and the massive destruction of the buccal bony plate, which cannot be seen or monitored on periapical X-rays, it would be beneficial to control the steps of the treatment and perform the monitoring via CBCT scans. The patient was informed of the extra radiation exposure resulting from the CBCT scans, but she insisted on undergoing scans instead of periapical X-rays when deemed beneficial by the clinicians.\nThe working length was established with an electronic apex locator (Root ZX, J. Morita Corp., Tokyo, Japan) and confirmed via radiography. The canal was subjected to instrumentation only with NiTi files (K-File Nitiflex, Dentsply-Maillefer, Ballaigues, Switzerland), stainless steel hand files (K-File, Dentsply-Maillefer), and Hedstrom files (ReadySteel, Dentsply-Maillefer). The last instrument used for apical preparation was a size 120 file, and at that point a definite apical stop could be established. The site was irrigated with copious amounts of 5% sodium hypochlorite. At the time of drying, the electronic apex locator, the hand files, and the paper points indicated no sign of perforation. At the most apical part of the resorption defect, the root canal appeared extremely thin; thus, the use of warm gutta-percha for obturation was deemed risky and difficult to control. An approximately 4- to 5-mm-thick mineral trioxide aggregate (MTA) plug (MTA+, CERKAMED Medical Company, Stalowa Wola, Poland) was made to establish a proper apical barrier without error in the affected apical part (). The MTA was covered with a moist cotton pellet, and the tooth was temporized with Cavit W filling material (3M ESPE, Seefeld, Germany) for 48 hours. At the next appointment, the root canal was adhesively treated with a dual-cure self-etch adhesive system (Gradia Core Self-Etching Bond, GC Europe, Leuven, Belgium) and was filled with SFRC (EverX Posterior, GC Europe) according to the Bioblock technique [] to the point of the root canal orifice. During this procedure, an approximately 4-mm-thick increment of SFRC material was placed in the root canal and applied to the most apical part to make contact with the MTA plug. This can be accomplished by pressing alternately with any small-headed microbrush and a periodontal probe or plugger. After the first layer appeared to be in position, a light-transmitting FRC post (1.4 mm GC Fiber Post, GC Europe) was inserted into the canal to facilitate the transmission of the light to the apically-positioned layers. The light-transmitting post was withdrawn to 0.5–1 mm from the surface of the uncured SFRC layer so as not to directly contact it. The first layer of SFRC was light-cured through the post for 80 seconds using a light source with an average power density of 900 mW/cm2. This was continued to the level of the cemento-enamel junction. After the root canal was filled to that level, the coronal portion of the tooth was internally bleached several times with sodium perborate (made by the pharmacy of the University of Szeged) mixed with distilled water at a ratio of 2:1 (g/mL) and covered with glass ionomer filling (Equia Fore, GC Europe). After the desired color was reached, the coronal cavity and the SFRC material in the orifice were refreshed with a diamond bur, adhesively treated (G-premio Bond, GC Europe), and restored with SFRC and a 2-mm-thick composite covering on the palatal aspect (G-aenial Anterior, GC Europe) ().\nA follow-up CBCT scan was taken 1 year after the final root canal treatment and revealed continued healing of the periapical radiolucency and reformation of the buccal bony wall around the apex (). The tooth has remained asymptomatic ever since, and the patient was satisfied with the result.
The patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general anesthesia. The ISH was confirmed (Fig. c). Four U red blood cell and 400 ml fresh frozen plasma were transfused. After fluid resuscitation and blood transfusion, her hemodynamic became stable. During the 3-h intra-operative observation, the hematoma did not expand. Therefore, a non-sucking drainage tube was placed under the liver and she was sent to ICU ward. Next morning, she was transferred to the ordinary ward. The upper abdominal pain gradually relieved. Five days after the laparoscopic exploration, another CT scan showed that the hematoma was largely resolved and we removed drain tube (Fig. d). She was discharged, 10 days after readmission.\nTotally, 13 papers, including 16 cases of ISH after LC were reported from 1994 to 2015 (Table ). Nearly half of the patients had instability of hemodynamics. All of the cases were female patients. Age of patients ranged from 25 to 78. All hematomas were mainly located in the right lobe of liver, and some of them extended to the left lobe of liver. Only one case was ruptured at diagnosis. Hepatic capsule laceration was found in two cases, one of whom also took NSAIDS (non-steroids anti-inflammatory drugs) to control the pain after operation. Totally, 58.8% of patients took NSAIDS to control the post-operative pain, and most of them used Ketorolac, however, 35.3% of the patients still did not have definitive risk factors. The time interval to diagnose ISH after LC ranged from seven hours to six weeks. They were diagnosed most commonly (35.5%) within one day after LC. All patients had abdominal pain and 47.1% of the cases developed hypovolaemic shock.\nTreatment strategies included: conservative treatment (antibiotics, blood transfusion, strict bed-reset), percutaneous drainage under CT or B ultrasound guidance, selective embolization of the bleeding vessel, laparoscopic exploration and laparotomy. Eighteen percent of patients had stable condition without fever and underwent conservative treatments. The only case of angioembolization was complicate by infection and required percutaneous drainage. For the patients with stable condition, fever and serious compression of inferior venal cava (IVC) always were indications for percutaneous drainage under CT or B ultrasound guidance. In these 17 cases, 29.4% of the patients underwent percutaneous drainage. For the patients with hemodynamic instability, emergent reoperation was adopted. Totally, nine cases underwent reoperation, including two case of laparoscopic operation and seven cases of laparotomy. For our case, we only performed laparoscopic exploration and did not perform evacuation or drainage of the hematoma, since the hemodynamic became stable after plenty fluid resuscitation and the hematoma did not expand, during the 3 h of intra-operative observation. For another case, laparoscopic exploration found small capsule laceration, and hemostasis was performed. In the seven cases of laparotomy, six patients underwent evacuation and drainage of hematoma, only one case underwent only laparotomy without evacuation or drainage.\nAll patients survived. Most of patients stayed one to two weeks after readmission, however, the longest hospital stay was up to 31 days after reoperation.
An 8-year-old boy presented to our clinic complaining of numbness of the little finger and the ulnar aspect of the ring finger. Ten days prior to presentation, the patient sustained a 1 cm laceration at the level of the distal wrist crease after falling on a piece of broken glass. On examination, he had weakness of abduction and adduction of the fingers. Movement of the thumb was unaffected.\nThe injury was managed at the emergency department by thorough wound irrigation. There was a partial irregular cut of about 30% of the radial aspect of the FCU with intact ulnar nerve and ulnar artery. The skin was sutured. After the primary management the patient was sent to our orthopaedic clinic for further follow up. The initial examination one week after the injury revealed a clean wound, no hematoma or swelling, normal sensation of the fifth and ulnar side of the fourth finger, and normal abduction and adduction of the digits. However a gradual numbness and weakness of intrinsic hand muscles was noted after 10 days that gradually worsened. On subsequent follow up a total ulnar nerve deficit was noted distal to the injury, at the wrist level involving motor and sensory branches.\nThree weeks after the initial injury he developed marked weakness of all ulnar supplied intrinsic muscles with total sensory loss at the fifth and the ulnar side of the fourth fingers. Due to the progressive nature of his symptoms, exploration and decompression of the Guyon's canal was done under general anaesthesia. Exploration revealed normal healing of skin and subcutaneous tissue with excessive scar tissue at the radial edge of the FCU which spanned the ulnar nerve, narrowing the entrance of Guyon's canal and causing severe compression and cicriatrical constriction of the nerve.\nThe ulnar nerve was completely intact (Fig. ). No organized hematoma or lesion of ulnar artery was observed. Adhesions were released, excised and Guyon's canal was completely released. Physiotherapy was started immediately post-operatively, encouraging the patient to move the wrist and fingers. Sensation was markedly improved by the first post-operative day with nearly complete return of motor function at one week. At three months, the recovery was complete.
A 40-year-old Caucasian gentleman visited our hospital with complaints of sudden onset of diplopia of two weeks duration. The night before the onset he was at a dance party where he consumed alcohol and cocaine. The dance consisted of violent head banging movement. The diplopia was worse on moving the eye either in vertical or horizontal gaze. He visited the eye casualty the next day and was advised a magnetic resonance imaging (MRI) scan. He instead went for a holiday and came to our institution two weeks later. There was no associated history of decreased vision, eye pain, headache, flashes, floaters, headache, nausea and signs and symptoms of raised intracranial pressure. There was no associated significant past ocular and medical history. His personal history included consumption of a bottle of wine daily since 20 years and occasional cocaine use since three to four years.\nExamination revealed visual acuity of 20/20 in each eye with normal anterior segment and fundus in both eyes. Neuro-ophthalmic and orthoptic assessment confirmed pupil-sparing IIIrd and IVth nerve paresis of the left eye and Hess Chart performed on the patient is shown in ,. Systemic and other neurological examination was unremarkable.\nAll the blood investigation were within normal limits. Urgent MRI reported an area of increased signal intensity in the brainstem mainly in the left side with mass effect . There was also a small area of low density within it more superiorly. Magnetic resonance angiography revealed an area of high signal intensity in the vicinity of the posterior communicating region on the left side . This represented a vascular event probably due to a small bleed arising from the vertebral basilar region. No communicating artery aneurysm could be detected.\nUrgent referral to a neurologist was made and MRI stereotactic stealth biopsy was performed. A diagnosis of Grade 3 anaplastic astrocytoma was made. No ocular surgery or for tumor was done. His symptoms and general health had deteriorated in the first week in the interim when we first saw him till he was seen in peripheral hospital. His ocular symptoms started to improve four weeks from then significantly, that there was no diplopia in primary gaze. He was followed in the ophthalmology department in a tertiary hospital eight weeks later and then at six months and was subsequently discharged with complete recovery of eye movements. Subsequently, he was doing well and was discharged and is being currently followed by an oncologist/radiotherapist.
The patient was a 41 years old, non-smoking female who suffered from chronic dyespia, recently complaining of weight loss, nausea, and vomiting. In the physical exam, however, there were no other signs and symptoms recognized except for weight loss. Upper GI endoscopy was done and there was a huge necrotic mass in the first duodenal section which had obliterated the lumen. A biopsy was taken and the result was a poorly differentiated adenocarcinoma with vascular invasion. A CT scan revealed that there was a mass measuring 10.12 cm and multiple liver metastasis yet lab tests showed that renal and liver functions were normal: carcinoembryonic antigen (CEA)=0.34 and hemoglobin=8.5. Because of the liver metastasis, neoadjuvant chemotherapy was done with capecitabine and oxaliplatin and we decided to refer her to surgery if the response to chemotherapy was good. After 4 courses of chemotherapy, we evaluated her with a CT scan with the results showing that the size of the duodenal mass and liver metastasis had increased (12.12) yet chest CT scans and lab tests were normal (CEA=1.46). Due to pain, mass effect, and no response to chemotherapy, we started radiation therapy (RT) with a local field with a total dose of 45 Gy in 25 fractions and there was quickly a dramatic response to radiation therapy. We have CT before and after RT (). Once the pain subsided, we started chemotherapy again with capecitabine and irinotecan and over a 4 course, the mass size was 4.4 cm and the liver metastasis had become smaller (). We referred her for radiofrequency ablation for the liver metastasis and then to the surgery department. Radiofrequency was done but yet the patient was inoperable so we continued chemotherapy with capecitabine and irinotecan for another 2 courses. After seven months of radiation therapy, ascites and peritoneal seeding were happening so we did palliative care for her. Because lab tests were normal and the patient could tolerate further treatment, she received chemotherapy with Gemcitabine along with D1 and D8 every 3 weeks until she died 13 months after the first diagnose.
We present the case of a 34-year old female patient with metastatic malignant melanoma undergoing treatment with the anti-CTLA-4 antibody ipilimumab. The clinical course of disease is shown in . Six days after the third infusion, the patient reported a persistent headache since 2 d. She interpreted this symptom as a symptom of premenstrual syndrome as she was waiting for her menstrual period and had already experienced similar headaches. There were no other symptoms such as nausea, impaired eyesight or fever. Laboratory testing was inconspicuous and showed normal values for routine parameters and for thyroid-stimulating hormone (TSH). Hyponatriemia as sign of cortisol deficiency was not present. A prescription for ibuprofen (administered 2 times daily in a dosage of 400 mg) was given which helped to manage the pain at first. Two days later, as the headache did not subside, the patient was examined again. She then presented a light periorbital swelling and was examined from a neurologist and an ophthalmologist who both could not find any cause for the symptoms. A CT scan of the head and brain, a cerebrospinal fluid puncture and a measurement of the intraocular pressure were performed and did not show any abnormalities. Again, laboratory testing was normal. Pain medication was adapted and the patient left with the requirement to contact us if the headache would get worse. Almost a week later, the patient was emergently seen. She was experiencing an excruciating headache with nausea and had been vomiting. Periorbital swelling had increased. Laboratory results showed thyroid malfunction and a MRI scan of the brain confirmed the diagnosis of hypophysitis (). In addition, a cellulitis of the periorbital subcutaneous fat tissue was observed (). The patient was treated with dexamethasone in a dosage of 4 mg every 6 hours. After the first dose, she already experienced a relief of her symptoms. One day later, the symptoms and swelling declined almost completely, but vitiligo began to develop on the face of the patient. A MRI scan of the brain performed 2 d later showed a decrease of inflammation in the periorbital region whereas the signs of hypophysitis had improved only slighly. A hormone substitution with hydrocortisone and levothyroxine was begun. The vitiligo continued to spread over the next weeks and finally involved more than half of the body surface area. A tumor staging showed progressive disease and treatment with the anti-PD1 antibody nivolumab was initiated. However, metastases grew rapidly and the patient developed multiple brain metastases. She died 12 months after detection of first distant metastases.
A 16-year-old, Sinhala ethnic Sri Lankan woman in her first pregnancy, was admitted with severe preeclampsia at 29 weeks of gestation. She has made her booking visit at ninth week of gestation and all the booking investigations were normal except for the platelet count which was 112,000 per liter. During her pregnancy, the lowest platelet count was 80,000 per liter at 27 weeks of gestation and no specific intervention has been done except for regular monitoring of the platelet count. She had been diagnosed with gestational hypertension at 22 weeks of gestation and prescribed labetalol and methyldopa. Other than that, she has had few erythematous, itchy macular lesions over the palm of her right hand from early in the first trimester onwards and had persisted throughout the pregnancy. She has had mild pain in her right small finger from first trimester onwards. But she had not worried about these symptoms so they had gone unnoticed. She had been apparently well until late 28 weeks of gestation and then she has developed a severe headache and worsening of bilateral lower limb oedema with frothy urine leading to hospitalization. She was diagnosed with severe preeclampsia (blood pressure of 185/115 mmHg) at 29 weeks of gestation. An emergency caesarean delivery was arranged soon after this presentation. Her baby was admitted to the premature baby unit with a birth weight of 1000 grams. She was in intensive care unit in first 24 hours after delivery and received intravenous magnesium sulphate as a prophylactic anticonvulsant.\nHer pain in the right finger worsened after delivery and erythematous macular lesions have been increased in number and spreading over the dorsal aspect of the right forearm. She was not worried and lesions have gone unnoticed especially with her dark skin complexion. Her blood pressure was under control with oral nifedipine. At the eighth postpartum day, her right small finger was noted to be cold with increased pain. Discoloration of the above skin lesions was more prominent and started to appear over the palm and the ventral aspect of the forearm of the right hand too, with preserved capillary refilling time. Both radial and ulnar artery pulsations were felt. There were no similar lesions in any other part of the body. She was soon transferred to a medical ward for further management.\nShe was subjected to an urgent arterial duplex study, which revealed proximal ulnar artery thrombosis in the right side with partial occlusion to the blood flow. And soon she was started on unfractionated heparin and eventually bridged with oral anticoagulants (warfarin) in order to archive the target international normalized ratio (INR) of 2.0-3.0. With anticoagulation treatment, her symptoms and signs were markedly improved. Sequential macroscopic changes of the affected arm and fingers have been shown in .\nRoutine laboratory analyses were within the normal range including subsequent platelet count, but she got positive results for direct Coombs test. Her reticulocyte count was high with normal haemoglobin concentration. Her ANA titre was strongly positive (1:320). And also anti-cardiolipin antibodies (anti-CL) and anti-β2 glycoprotein-I (anti-β2GPI) levels were also noted to be positive. However, her ds DNA and C3/C4 levels were within normal limits. Her blood pressure readings too have come back to normal level with no requirement of medications. Also proteinuria was settled. Her laboratory tests for APS were positive even after 12 weeks of initial testing. Therefore, it was diagnosed as a case of primary APS.
An 82-year-old male presented to our outpatient department with acute left knee pain. He had no history of trauma. Before he visited our hospital, he had undergone several times of therapeutic arthrocentesis for treatment of left knee joint effusion at a local clinic. The patient has recalled that all the aspirates to be bloody. He had been taking antiplatelet agents for 2 years, after percutaneous coronary intervention. On presentation, there were no visible joint effusion in both knees, and he was wearing a knee immobilizer. After consultation with the cardiology department, we recommended the patient to discontinue the antiplatelet agent for a week and to take a rest for a while. A month after his initial presentation, the patient visited our emergency department with the same left knee pain. After experiencing left knee pain the day right after his initial OPD visit, he visited another local clinic and was recommended for MRI testing, followed by arthroscopic examination and synovectomy. There were no definite findings of meniscal tear but only degenerative changes in the medial meniscuson MRI (Fig. ). Despite arthroscopic procedures, his left knee joint hemarthrosis showed no improvement, and as a result, the patient was transferred to our emergency department from the local clinic.\nOn presentation, the patient showed moderate effusion on his left knee (Fig. ), with resting pain. After excluding the diagnosis of infection by joint fluid analysis, we consulted with the cardiology department about the matter and decided to hold the antiplatelet agent. Although his degree of knee joint effusion showed improvement after 4 days of bed rest, knee pain on rest continued. No focus of intra-articular bleeding was revealed on arthroscopic examination, which was performed at the local clinic. We consulted this case with the department of radiology to find out any abnormalities of the genicular arteries angiographically. Angiographs revealed hypervascularity of the superior and inferior lateral genicular artery and the superior medial genicular artery (Fig. ). One-step embolization was conducted using microcatheter and 50 to 150 μm gelfoam particles. The hypervascular lesions markedly subsided after embolization(Fig. ).\nAfter embolization and 3 days of bed rest, the patient was permitted for partial weight bearing. We closely monitored for the relapse of symptoms during the 3 days after partial weight bearing. After confirming that no symptoms relapsing for 3 days, we decided to discharge the patient and to resume the antiplatelet agent. There were no signs of recurrence on outpatient follow-up sessions until 1 year after embolization (Fig. ).
A 51-year-old Madheshi woman came to our neurology clinic with the chief complaint of sudden decrease in the tone and texture of her voice for the past 15 days. Her voice was very feeble but understandable and she noticed it was better by the time she got up from her bed only to worsen through the day to become nearly inaudible. She had noticed a slight change in her voice texture in the first several days which she had ignored in the beginning as it was not worth bothering about. She had no complaint of choking or coughing or aspiration or any throat discomfort. When asked for any other related and/or unrelated things she noticed in her habits, she complained about having constipation for many years otherwise she was apparently well. She had never visited hospital for any problem and no interventions had been done in the past. She denied smoking tobacco, drinking, or any other recreational drugs abuse. There was no one in her family or her parents’ family with any kind of known chronic disease. Her biological father had controlled hypertension with medication. Her psychosocial history was not significant. She came from a middle income family, and she had retired recently as an accountant for a small company. Her symptom progressively aggravated in later days to the extent that she not able to produce sound properly. It usually waned in the early morning or after enough voice rest only to wax throughout the day.\nOn physical examination, a systemic examination did not reveal any abnormality. On neurological examination, her muscle power was intact: 15/15 on Medical Research Council (MRC) scale. She had no imbalance and was able to tandem on walking. An examination of her gag reflex and other cranial nerves revealed no abnormal reflexes. Deep tendon reflexes were intact. Her speech articulation was intact and revealed no scanning of speech. Speech production was adequate and non-painful; her tone was non-nasal but the intensity was low and slow. Other neurological examinations also did not reveal any abnormality. Other systemic examinations were also non-significant.\nConcerned with her problem, she had visited an ear, nose, and throat (ENT) department for her problem and was screened for possible laryngeal disorder for hypophonia. There was no obvious laryngeal pathology found and the treatment initiated by the ENT department had no satisfying outcome. She visited our neurology clinic. The differential diagnoses considered were Parkinson’s disease (PD) or a bulbar variant of motor neuron disease (MND), and MG. MRI scanning of her brain and screening of her whole spine appeared normal. Laboratory investigations including a hematologic panel, infectious disease screening panel, and myopathy panel involving creatinine kinase and creatine phosphokinase-N-acetyl cysteine (CPK-Nac), were all within normal range. She was suspected to have MG as other diseases were ruled out. A Quantitative Myasthenia Gravis (QMG) test was performed on our patient and her QMG score was 1 (for speech). She was given neostigmine challenge test with intravenously administered injection of 2.5 mg neostigmine and the result was positive after more than 30 minutes. There was significant improvement in her voice quality and she felt her fatigability improved as well. She gained a good quality of speech within an hour. QMG scoring was repeated, and she scored QMG score of 0. The longer duration of the medicine gave us enough time to assess the improvement. The laboratory test for the AchR antibody (AchR ab) is not available in Nepal. We had to send AchR ab to India, and the report received after waiting several weeks was positive. Quantitatively, it was significantly higher, 1.11 nmol/l than the normal range (0.0–0.4 nmol/l). She was later maintained on 60 mg of orally administered pyridostigmine with 12 hourly administrations and subsequently increasing to 6 hourly along with steroids.\nPlain and contrast-enhanced computed tomography (CT) scans of her head, neck, and chest were done, and they revealed a mass in the anterior mediastinum: a well-defined, smooth outlined, approximately 4 × 2.5 × 2 cm, soft density nodule showing poor enhancement in the anterior mediastinum in the thymic space with maintained fat plane with the adjacent vessels and structure. Thymoma was suspected and she was sent to the surgical department for further surgical intervention.\nShe returned to our neurology clinic around 2 months after her first visit to us as a follow-up visit. She had undergone a successful surgery. She was doing well. Prednisolone was already tapered off. She was tapering down pyridostigmine as well, with a maintenance dosage of pyridostigmine 60 mg 12 hourly and planned to put off the medication. Her voice was clear and well maintained and she had no complaint of fatigue. She had no fresh complaint and was doing all her daily and professional activities very well.
In October 2014, a 48-year-old woman was referred to the Department of Oncology at the Medical University of Vienna. Because of acute dyspnea, vertigo and precollaptic condition, the patient had been admitted to a peripheral emergency department 2 weeks before. Since pulmonary embolism was suspected, an immediate CT scan was performed, which showed multiple pulmonary nodules and a circumferential pericardial effusion. Subsequent transthoracic echocardiography confirmed a pericardial effusion of 3 cm with an end-diastolic compression of the right atrium and ventricle besides normal performance and size of the left ventricle.\nBecause of rapidly worsening clinical condition due to tamponade physiology, an emergency pericardiocentesis was done but the patient developed hemodynamic instability. Since iatrogenic trauma of the right atrium was suspected, the patient was transferred to the surgery department, where an emergency sternotomy had to be performed. During surgery, a 6 × 3 cm big right atrial mass was detected and subsequently entirely resected. The defect of the right atrium was restored with a nonvascularized pericardial autograft.\nThe patient's postoperative course was without any complications and a control echocardiography showed minimal pericardial effusion, a normal left ventricular systolic function as well as normal ejection fraction. Since histology revealed cardiac angiosarcoma (tumor cells stained positive for CD34), the patient was transferred to our oncology department for further examination and treatment.\nBesides progressive multiple pulmonary nodules, a postoperative CT scan of the chest and abdomen showed no further distant metastases and no evidence of recurrence of the angiosarcoma in the right atrium. The patient had no prior medical history nor concomitant medication and after careful consideration, the patient was included in a clinical trial in which the combination of paclitaxel 70 mg/m2, days 1, 8 and 15 each 28 days, plus pazopanib 800 mg/day was applied.\nDuring the first administration of paclitaxel at the end of November 2014, the patient suffered from severe hypersensitivity anaphylactic reaction with dyspnea, hypotension and chest pain despite intensified pretreatment with cortisone, diphenhydramine hydrochloride and ranitidine. An electrocardiogram revealed no cardiac problem and after additional i.v. corticosteroids, ranitidine and i.v. hydration, the patient's condition improved rapidly. According to the protocol, paclitaxel treatment was stopped and the patient continued with pazopanib 800 mg/day monotherapy. Pazopanib was tolerated well with the exception of newly diagnosed arterial hypertension grade I–II, which, however, was efficiently treatable with oral medication.\nA CT (thorax/abdomen) in January 2015 showed stable pulmonary disease without recurrence of cardiac angiosarcoma and the patient continued with pazopanib 800 mg/day. In March 2015, a CT (thorax/abdomen) revealed partial remission of pulmonary metastases (reduction of both number and size of pulmonary metastases) and a new liver metastasis. Therefore, the patient was discontinued from the clinical study (as progressive disease according to RESIST occurred). Pazopanib was maintained (800 mg/day) and docetaxel was intended to be added. Despite intensified pretreatment with corticosteroids and antihistamines, the patient again suffered from severe hypersensitivity reaction and docetaxel was stopped immediately during the first application. However, pazopanib monotherapy (800 mg/day) was kept.\nA subsequent CT (thorax/abdomen) in June 2015 showed a complete remission of all pulmonary metastases and a partial remission in the liver, both of which were confirmed in a CT (thorax/abdomen) in November 2015. The last CT scan in March 2016 revealed complete remission in the lungs and liver. Thus, pazopanib was continued (800 mg/day) and the patient still is in an excellent condition (ECOG 0).
A 38-year-old female patient, gravid 3 para 2 abortion 1 was referred to our hospital with a one-year history of vaginal mass. One year before admission, the patient felt vaginal uncomfortable and found a mass in her vagina. The patient, lived in a remote rural area, did not go to the hospital for further examination due to her poor economic condition. She experienced discomfort in the vagina and felt the vaginal mass was growing progressively in the past year before admission. Her general medical history revealed no surgery and disease. At the time of consultation, vaginal examination demonstrated a large fixed mass was located in the right lateral wall of the vagina and occupied the upper and middle third of the vagina. Laboratory blood test results, including serum tumor markers, were all within the normal ranges. Abdominal computed tomography (CT) showed a 17.6 cm× 10.4 cm solid mass in pelvic cavity (Fig. ). The urinary bladder, rectum and uterus were displaced to the left side of the pelvic cavity, but there was no ascites and enlargement of pelvic and para-aortic lymph nodes. Transverse (Fig. a), sagittal (Fig. b) and coronal (Fig. c) CT images revealed the tumor mass was highly suspected to originate from vagina.\nExploratory laparotomy was carried out to remove the mass after adequate preoperative preparation. Intraoperatively, a solid mass with the size of about 18 cm in diameter was found from pelvic floor to pelvic cavity. The lower boundary of the tumor mass was at the level of vaginal orifice. The urinary bladder, rectum, uterus and bilateral adnexa were separate from the mass and displaced to the left side of the pelvic cavity. The boundary between the mass and the surrounding urethra and bladder was clear, and there was no invasion to adjacent organ or metastasis. After Separating the tumor from the surrounding tissue, we found the tumor had a thin, fibrous capsule and originated from the right lateral wall of vagina. The tumor mass was completely removed by blunt dissection.\nPathological finding revealed the large mass was multinodular and the cut section was gray-white, with areas of necrosis. Cytopathologic features of the tumor mass showed hypercellularity and infiltrative overgrowth of spindle cells with nuclear atypia (Fig. a-c). Histological examination revealed the features of spindle cells with high to moderate cellularity, pleomorphism and moderate to marked cellular atypia with cells disposed in loose fascicles, with a storiform pattern in some parts. The mitotic index was high, and variable amounts of necrosis can be seen (Fig. a-c). Its mitotic count was 8 mitoses per 10 high power fields (HPF). In addition, well-differentiated liposarcoma component could be find in the excision specimen (Fig. d), which may contribute to the diagnosis of dedifferentiated liposarcoma. The mesthothial tumor was suspected, and then detection of a serial of markers were performed. The tumor lacks epithelial component and cells were rarely stained with p53. These findings didn’t support a diagnosis of anaplastic carcinoma of the vagina. Further, the tumor didn’t express desmin, ck-pan, α-smooth muscle actin, S-100, myoglobin and CD34, suggesting a dedifferentiated tumor (Fig. ). Overexpressions of human murine double minute 2 (MDM2) and cyclin-dependent kinase 4 (CDK4) were detected. In addition, detection of MDM2 gene amplification was performed by fluorescence in situ hybridization analysis, and the tumor was positive for amplification of the MDM2 gene (Fig. ). The final histological and immunohistochemical results confirmed the diagnosis of DDLPS deriving from vagina.\nThe patient was discharged 7 days after surgery without any immediate postoperative complications. Medical oncology was consulted, and additional chemotherapy were recommended. Six courses of combination chemotherapy with a regimen of pirarubicin plus ifosfamide (pirarubicin 30 mg/m2, ifosfamide 2000 mg/m2) were performed for the patient. The patient remains well with no evidence of disease recurrence with 13 months of follow-up. We are still following-up this patient.
An 81-year-old man visited the gastroenterologist because he had been suffering from iron deficiency anaemia without obvious blood loss for a few months. Apart from intermittent pain in the right upper abdominal region, there were no other symptoms. His weight remained constant and he did not lose his appetite. Defecation was regular, once a day. His medical record consisted of diabetes mellitus type II, hypertension, impaired renal function and an ear operation many years before. He had no history of gastrointestinal problems. Family history revealed two brothers who had died of colorectal cancer at old age. With a body mass index of 28 he was overweight. Examination of the abdomen did not reveal any unusual findings. No abnormality was palpated during digital rectal examination. A complete blood count revealed anaemia (Hb 6.7 mmol/l) and iron deficiency (9 µmol/l).\nThe patient underwent colonoscopy. Diverticulosis was seen in the sigmoid. Three polyps were removed during the colonoscopy. A bleeding tumour was found in the ascending colon, 80 cm from the anal sphincter. Definitive pathology revealed an adenocarcinoma in the ascending colon. An abdominal CT scan confirmed the presence of a process in the ascending colon. It also showed a liver lesion with a diameter of 9 mm, suspicious of liver metastasis. The CT scan did not reveal any other unusual findings. Ultrasonography of the upper abdomen confirmed a liver lesion, with a diameter of 13 mm, suspicious of liver metastasis with an atypical hepatic haemangioma in the differential diagnosis. MRI scan showed a liver lesion in segment V, suspicious of liver metastasis.\nThe patient underwent simultaneous right hemicolectomy and wedge resection of the liver lesion. During perioperative inspection of the upper abdomen, a gallbladder deformity was seen (fig. ). The fundus of the gallbladder was folded like a cap. The patient underwent cholecystectomy to make the wedge resection of the liver metastasis in segment V easier to perform. The surgery proceeded without complications. Pathological examination confirmed the presence of both an adenocarcinoma in the ascending colon and a liver metastasis. There were slight inflammatory changes in the gallbladder, but it did not show stones or a tumour. The patient recovered from surgery without any problems and was discharged after 12 days. The deformity of the gallbladder was, in retrospective, detected on the preoperative MRI scan (fig. ).
A 43-year-old female previously had a laparoscopic tubal ligation, presented with recurrent left flank and inguinal pain. The pain was severe in nature. She had similar episode three months prior to presentation. The symptoms at that time were relieved with analgesics, antibiotics, and infusions. Also three urinary tract infections occurred in the previous year after the laparoscopic tubal ligation and treated with antibiotherapy. Pulse rate of 90/min, a respiratory rate of 34 cycles/min, and a blood pressure of 110/90 mmHg were detected. Abdominal examination revealed tenderness in the left lumber and left hypochondrial regions. No masses were palpable within the abdomen. The cardiovascular, neurologic examinations were essentially normal. Ultrasonography revealed Grade 2 hydronephrosis of the left kidney. She was referred to our center for further management, after an unsuccessful attempt at retrograde balloon dilatation and ureteral stent insertion to the left ureter because of hydronephrosis. Both an IVU (intravenous urogram) and retrograde ureterogram were performed to determine the site and degree of stricture at that center ().\nAt our hospital ureteroscopy guided double J stenting was planned initially. A 4.8 fr double J stent was inserted with the help of fluoroscopy as shown in . After 2 months followup, regression of the hydronephrosis was seen on ultrasonography. But the pain persisted in going on. After discussing benefits and the risks of various treatment modalities, open surgical exploration was planned. The exploration was done via a left Gibson incision. Dilatation of the proximal and midureter and an area of stricture was observed in distal ureter nearly 5 cm in length. Interestingly the shape of the ureter was like an Omega (ω) at that region and as the exploration was done, it was understood that a suture has pulled the ureter from the lateral serosa of the upper part to the lateral serosa of the lower part as seen in . Also the luminal segment of the ureter was intact so that a double j stent could be inserted. Intraoperatively the strictured area was excised and a successful reconstruction was performed with open ureteroureterostomy. The patient remains asymptomatic, with normal renal sonogram, 2 months after the procedure.
A 52-year-old man presented with lower-limb weakness and was admitted. He was diagnosed with SCLC, limited disease, at another hospital 5 years ago. He had been recommended concurrent chemoradiotherapy at that time but had wanted to be treated with chemotherapy only. Thus, he was started on irinotecan and carboplatin. After 6 cycles, complete remission was noted, and prophylactic cranial irradiation was given. A year later, he had relocated residence and visited our hospital, presenting with relapsed lung cancer but refusing treatment. After 7 months, further disease progression and pancreatic metastasis was noted on computed tomography (CT) scanning. The patient received 6 cycles of a combination of etoposide and cisplatin. Meanwhile, superior vena cava syndrome occurred, and radiation therapy was delivered in the middle of chemotherapy. A CT scan for the response showed disease progression. He was started on cisplatin, doxorubicin, and cyclophosphamide (CAP) and also received palliative brain radiotherapy due to brain metastasis during the chemotherapy.\nAfter 6 cycles of CAP, the cancer remained stable. However, in his fifth year of cancer diagnosis, he presented with lower-limb weakness and was admitted. He noticed weakness in both legs 2 weeks prior to admission and developed numbness throughout the lower extremities. After admission, he developed weakness in both arms. A neurological examination revealed no nuchal rigidity or Kernig's sign as well as absence of deep tendon reflexes. Magnetic resonance imaging (MRI) of the brain showed some unidentified bright objects (fig. ). However, there was little possibility of brain metastasis or embolic infarction when comparing the patient's symptoms and physical examination with the MRI lesions. To evaluate neurologic problems, spinal cord MRI was performed. It revealed a fracture of the second lumbar vertebra that seemed to be benign (fig. ). However, the ascending paralysis, from the lower extremities to the upper extremities, did not correlate with the cord compression lesion either. Nerve conduction studies showed decreased amplitudes and slow velocities of compound muscle action potential and sensory nerve action potential in the extremities. The results were consistent with sensorimotor polyneuropathy. A lumbar puncture yielded cerebrospinal fluid protein 94 mg/dl, albumin 61.3 mg/dl, glucose 173 mg/dl, and white blood cells 1/μl. These were assessed as being due to albuminocytological dissociation, and there were no signs of meningitis. Antiganglioside antibodies were not tested.\nThe patient was diagnosed with GBS and was recommended treatment with intravenous immunoglobulin (IVIg), which he refused. He received supportive care, and his general weakness worsened. He died 18 days after diagnosis.
A 33-year-old male patient presented to a tertiary care hospital with intermittent abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities, of 3 days duration. He was conservatively managed in a surgical unit as partial intestinal obstruction and was awaiting diagnostic laparoscopy. The patient developed confusion and found to have systemic hypertension, and, therefore, was transferred to a medical ward for further management. He is a non-diabetic and did not have a previous history of hypertension. The drug history revealed usage of over-the-counter analgesics for 6 weeks.\nThe past medical and surgical history revealed similar neurovisceral attacks requiring five acute hospital admissions over 2 years, which ended up in questionable diagnoses. The sixth acute attack raised the suspicion of an acute porphyria. The first attack in January 2013 led to a diagnosis of appendicitis. Because the symptoms worsened following the surgery an emergency laparoscopic exploration was done. But the exploration revealed no cause to explain the worsening symptoms. The second attack was managed as sinus tachycardia and he was started on beta adrenergic blockers. The third attack which was associated with a fever was conservatively managed for a questionable renal colic. Forth attack was complicated with transient hyponatremia and transiently high serum creatinine levels. These complications were attributed to a questionable interstitial nephritis based on the fact that patient had used 50 mg of diclofenac sodium twice a day for 6 weeks, repeating the prescription given by a general practitioner. Another attack in 2015 was managed as partial intestinal obstruction and diagnostic laparoscopy was done. In all these presentations, findings from the ultra sound scans and diagnostic laparoscopy did not support a diagnosis of intra-abdominal pathology.\nOn examination he was thin built (BMI = 20 kg/m2) and pale. Brachial blood pressure was 160/90 mmHg. There were scars of previous appendectomy and laparoscopy surgeries on the abdominal, but, otherwise, the abdominal examination was unremarkable. Muscle power was 4/5 in all four limbs (could not move against a good resistance).\nThe laboratory investigations performed during this admission showed severe hyponatraemia of 115 mmol/L (136–145) with serum osmolality of 255 mOsmol/Kg (275–295) and urine osmolality of 460 mOsmol/Kg (50–1200 mOsmol/Kg). Serum creatinine concentration was 106 µmol/L (80–115) with blood urea level of 20 mg/dL (6–20). Hemoglobin concentration was 8.2 g/dL (13.5–17.5) and the red cell morphology was normochromic and normocytic. The total cholesterol level was 282 mg/dL (5th to 95th centile; 142–258) with LDL fraction of 225 mg/dL (5th to 95th centile; 78–185). Serum ferritin level was 646 ng/mL (20–250). Arterial blood gas analysis was suggestive of a metabolic acidosis. Echocardiogram showed evidence of left ventricular hypertrophy. There were no significant radiological findings in abdominal X-ray film or abdominal ultrasonography. Blood lead concentration was 3 μg/dL (< 5 μg/dL).\nA urine sample collected during the acute attack was sent to the Department of Chemical Pathology for biochemical analyses. On standing the urine sample gradually turned dark brown. The Watson and Schwartz test for urinary porphobilinogen (PBG) was positive (Fig. ). Spectrophotometry of urine for total porphyrins showed a “Soret band”. Urine total porphyrin level, calculated using Allen corrected absorbance of the urine sample was 5505.5 nmol/L (< 300 nmol/L). Genetic studies were carried out in an overseas laboratory. The full analysis of HMBS gene was performed by PCR amplification of extracted DNA followed by exon specific primer extension analysis of all exons, exon intron boundaries and promotor regions. The gene analysis revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene. Targeted mutation analysis was performed by PCR amplification of extracted DNA followed by allele specific primer extension analysis, in five first-degree relatives. Among these, four were heterozygous for the same HMBS gene mutation (Fig. and Table ).\nSince heme arginate is not available in Sri Lanka the patient was managed only symptomatically. Carbohydrate loading with intravenous dextrose and oral carbohydrates was the only feasible option. All the medications used for symptomatic management were checked for safety in acute porphyrias. Patient was discharged from the ward after symptoms gradually improved over 6 days to a degree that he can be managed as an out-patient. Response to treatment could not be assessed due to unavailability of quantitative tests to measure urinary aminolevulinic acid (ALA) and PBG in Sri Lanka. The patient was educated regarding precipitating factors of acute porphyria. A diagnostic card with information regarding medications to avoid was provided to the patient. Patient was followed up at the clinic with regular renal functions, hemoglobin and blood pressure monitoring. Follow up of the patient over 1 year following diagnosis revealed that patient suffered from two mild attacks which didn’t require in-patient management. Nerve conduction studies were not carried out because neurological symptoms were not observed in-between acute attacks.\nPre-symptomatic relatives who inherited the HMBS mutation were also advised to avoid the trigger factors of acute attacks such as certain medications, fasting, alcohol and hormones. The brother of the proband was counseled regarding the risk of his children inheriting the HMBS mutation and recommended targeted mutation analyses for both children.
A 28-year-old female was admitted for deceased donor renal transplantation (DDRT). Her end-stage renal failure was secondary to reflux nephropathy. She had a previous deceased donor renal transplant at the age of five that had failed after 16 years. The initial transplant was straightforward and no difficulties were encountered with respect to recipient vascular anatomy (arterial and venous anastomoses were to the aorta and IVC, resp.). She was established on haemodialysis and had been on the waiting list for seven years. In addition to her renal disease, the patient had adolescent onset severe kyphoscoliosis and had undergone surgical reconstruction for vaginal atresia.\nThe donor was a 36-year-old male, brain stem dead donor, who had died secondary to a hypoxic brain injury. The right kidney was allocated and had a single renal vein and two renal arteries on an aortic patch. The HLA mismatch to the donor was 2A, 2B, and 1DR.\nPreoperatively there was difficulty in identification and intubation of the external urethral meatus. The placement of the urinary catheter was confirmed with an on-table cystogram. A standard left iliac fossa Gibson incision and an extraperitoneal approach were used for implantation. The left external iliac artery was absent. The left external iliac vein was patent and of normal calibre. There was a tortuous collateral artery 2-3 mm in diameter running across the pelvis to the left of the external iliac vein just above the inguinal ligament. This then divided with a branch continuing under the inguinal ligament and another branch running across to the surface of the bladder. A normal pulse was palpable in the left common femoral artery just below the inguinal ligament. Upon further proximal dissection, no internal iliac or common iliac artery could be identified. The external iliac vein appeared to be draining into a left sided inferior vena cava (). Further extension of the dissection to explore the right-sided anatomy was not deemed safe due to the patient's body habitus.\nAn on-table angiogram was performed to map the recipient arterial and venous anatomy. This confirmed that the abdominal aorta was located on the right with only a single right iliac system and absence of the left iliac system. The common femoral artery on the left was formed from a hypertrophied lumbar artery and further collaterals from the right internal iliac artery in the pelvis (). A venogram confirmed the presence of a duplex inferior vena cava. Following angiographic mapping of the vascular anatomy, the left iliac fossa wound was closed and a midline laparotomy was performed. The aorta and right IVC were isolated above the site of the previous transplant. Unfortunately, when the kidney was removed from cold storage it was found to be frozen and transplantation had to be abandoned.\nIn view of the difficult anatomy, extensive dissection, and difficult match-ability of the recipient, a compassionate allocation of a deceased donor kidney was sought from the national allocation scheme. Three days later a kidney was allocated to the recipient from a 57-year-old male brain dead donor with an HLA mismatch of 0A, 1B, and 1DR. This was successfully implanted through the previous laparotomy incision onto the aorta and the right IVC (). The patient experienced delayed graft function (DGF) and was discharged home on day 20 after establishing normal renal function.
A 16-year-old, Sinhala ethnic Sri Lankan woman in her first pregnancy, was admitted with severe preeclampsia at 29 weeks of gestation. She has made her booking visit at ninth week of gestation and all the booking investigations were normal except for the platelet count which was 112,000 per liter. During her pregnancy, the lowest platelet count was 80,000 per liter at 27 weeks of gestation and no specific intervention has been done except for regular monitoring of the platelet count. She had been diagnosed with gestational hypertension at 22 weeks of gestation and prescribed labetalol and methyldopa. Other than that, she has had few erythematous, itchy macular lesions over the palm of her right hand from early in the first trimester onwards and had persisted throughout the pregnancy. She has had mild pain in her right small finger from first trimester onwards. But she had not worried about these symptoms so they had gone unnoticed. She had been apparently well until late 28 weeks of gestation and then she has developed a severe headache and worsening of bilateral lower limb oedema with frothy urine leading to hospitalization. She was diagnosed with severe preeclampsia (blood pressure of 185/115 mmHg) at 29 weeks of gestation. An emergency caesarean delivery was arranged soon after this presentation. Her baby was admitted to the premature baby unit with a birth weight of 1000 grams. She was in intensive care unit in first 24 hours after delivery and received intravenous magnesium sulphate as a prophylactic anticonvulsant.\nHer pain in the right finger worsened after delivery and erythematous macular lesions have been increased in number and spreading over the dorsal aspect of the right forearm. She was not worried and lesions have gone unnoticed especially with her dark skin complexion. Her blood pressure was under control with oral nifedipine. At the eighth postpartum day, her right small finger was noted to be cold with increased pain. Discoloration of the above skin lesions was more prominent and started to appear over the palm and the ventral aspect of the forearm of the right hand too, with preserved capillary refilling time. Both radial and ulnar artery pulsations were felt. There were no similar lesions in any other part of the body. She was soon transferred to a medical ward for further management.\nShe was subjected to an urgent arterial duplex study, which revealed proximal ulnar artery thrombosis in the right side with partial occlusion to the blood flow. And soon she was started on unfractionated heparin and eventually bridged with oral anticoagulants (warfarin) in order to archive the target international normalized ratio (INR) of 2.0-3.0. With anticoagulation treatment, her symptoms and signs were markedly improved. Sequential macroscopic changes of the affected arm and fingers have been shown in .\nRoutine laboratory analyses were within the normal range including subsequent platelet count, but she got positive results for direct Coombs test. Her reticulocyte count was high with normal haemoglobin concentration. Her ANA titre was strongly positive (1:320). And also anti-cardiolipin antibodies (anti-CL) and anti-β2 glycoprotein-I (anti-β2GPI) levels were also noted to be positive. However, her ds DNA and C3/C4 levels were within normal limits. Her blood pressure readings too have come back to normal level with no requirement of medications. Also proteinuria was settled. Her laboratory tests for APS were positive even after 12 weeks of initial testing. Therefore, it was diagnosed as a case of primary APS.
A 41-year-old male with no significant medical history presented to an outside hospital with a 10 day history of continuous headaches, initially rated as 2/10 but occasionally rising to 4/10 on the visual analog pain scale. His headaches were localized to the right occipital region and were unresponsive to acetaminophen and ibuprofen. He had some mild gait difficulty but no nausea or emesis. A computed tomography (CT) scan identified a mixed density 6.0 cm intraventricular mass with dilatation of the left lateral ventricle and a 1.4 cm rightward bowing of the intraventricular septum [].\nHe was started on dexamethasone and referred to our hospital for further workup. He underwent a preoperative magnetic resonance imaging (MRI) of the brain, with and without gadolinium, which showed a heterogeneously enhancing lesion with a cystic component. The lesion was emanating from the roof of the left lateral ventricle from the region of the corpus callosum [-].\nOn neurological examination, there were no significant deficits.\nIt was decided to surgically resect the lesion. The primary goal of the surgery was to debulk the majority of the lesion and restore CSF flow pathways. Therefore, we chose to approach the lesion along its long axis through the left frontal horn of the ventricle. The patient was counseled preoperatively that a second staged parieto-occipital approach might be necessary to remove the remainder of the lesion, depending on the pathology and the extent of resection during the initial surgery. A bifrontal craniotomy with the left interhemispheric transcallosal approach was performed for resection of the tumor. The interhemispheric approach was chosen over the transcortical trans-ventricular approach because of the extension of the tumor into bilateral lateral ventricles. The interhemispheric approach, being a midline approach, gave us access to bilateral ventricles without significant brain retraction and without traversing the cerebral cortex. An endoscopic portal approach was not used considering the size and extension of the tumor into the lateral ventricles. While the endoscopic approach might have been well suited for a biopsy of the lesion, it is not optimal for debulking and dissection of large lesions.\nIntraoperatively, using a left interhemispheric approach, a small (<1.5 cm) corpus callosotomy was performed to enter the left frontal horn of the lateral ventricle where the tumor was debulked using bipolar cautery, suction, as well as a cavitron ultrasonic aspirator (CUSA). Within the left lateral ventricle, there was large cyst that was exerting mass effect on the septum pellucidum and displacing it into the right lateral ventricle. The cyst was drained. The solid portion of the tumor was emanating from the lateral wall and roof of the left ventricle, from the region of the posterior corpus callosum. The CUSA was used debulk the solid portion of the tumor. On debulking of the tumor, the ventricle walls collapsed inward and further resection was carried out cautiously because of tumor invasion into the ependymal walls of the left lateral ventricle. The deep venous drainage of the brain was embedded within the caudal aspect of the tumor extending into the third ventricle. These vessels were carefully preserved. On conclusion of the resection, an external ventricular drain (EVD) was left behind in the left lateral ventricle. The EVD was weaned and removed a couple of days after surgery. Immediate postoperative noncontrast CT and T1 with contrast MRI showed sub-total resection (STR) of tumor with resolution of mass effect and no postoperative hydrocephalus [ and ].\nThe patient was ultimately discharged home within a week and toward the end of his stay, was ambulating freely without any complaints and possessed an intact neurological exam as assessed by the discharge physician. He was seen in clinic at 3- and 6-months follow-up postsurgery. He had complete resolution of his headaches and remained neurologically intact without any deficits. His 6-month postoperative MRI showed stable to slightly decreased size of residual tumor with minimal enhancement, markedly decreased from prior []. Long-term care plan called for MRI surveillance and possibly repeat surgery in the event of tumor progression.\nPathology showed a solid-appearing, glioneuronal neoplasm composed of monotonous cells with round nuclei, punctate chromatin, and cytoplasmic clearing in a neuropil-like background. The tumor cells were arranged in vague neurocytic rosettes and loose perivascular pseudorosettes in a lightly myxoid background. Vessels within the tumor were seen to be thickly hyalinized and there were focal piloid areas with eosinophilic granular bodies and Rosenthal fibers [-]. Active mitoses were difficult to find, although there was microvascular proliferation with slightly hypertrophic endothelial cells and patchy infarct-like necrosis. The tumor stained strongly positive for GFAP, S-100, OLIG2, and SOX10, and weakly patchy positive for epithelial membrane antigen (EMA), D2-40, and CD99 (patchy cytoplasmic positivity). Scattered cells showed positive p16 staining. A synaptophysin stain highlighted scattered neurocytic roesettes and perivascular structures. It was concluded that the pathology was diagnostic of RGNT, WHO Grade I.
A 22-year-old man was admitted to the hospital for 2 days because of left knee joint pain and limited movement caused by a traffic accident. Physical examination on admission showed that the left knee joint was swollen with local tenderness, but no open wounds were present. The floating patella test was positive, and the muscle strength of the left lower extremity was normal. Preoperative imaging revealed a comminuted fracture of the left patella (), determined to be type 34-C3 according to the AO/OTA classification.\nBefore the operation, both sides of the patella were scanned by computed tomography (CT) with a scanning thickness of 1 mm. The collected CT data were imported into Digital Imaging and Communications in Medicine format, and a 3D model was established by Mimics 19.0 software (Siemens, Berlin, Germany). Next, a mirror-image model of the healthy patella was used as a template to virtually reset the affected patella. This allowed us to further design and print the complete patella and the distal and proximal fractured patellar reduction guide plates with the cartilage surface as the mask. The patella model after virtual resetting and the data for the three corresponding reset guide plates were imported into the 3D printer in stereolithography format, and the model and guide plates were then printed out ().\nThe patient underwent spinal anesthesia and was placed in the supine position, and an anterior median incision was made in the left knee joint. First, the local reduction guide plate of the proximal patella was placed behind the articular surface of the patella, and the large pieces adjacent to the cartilage surface were identified. The proximal patellar reduction guide plate was used for splicing, and a 1-mm fine Kirschner wire was used for temporary fixation in the coronal direction. All bone fragments with the cartilage surface at the proximal end of the patella were assembled together and temporarily fixed with a fine Kirschner wire, allowing the proximal patellar cartilage surface bone fragments to be restored to a whole. The other pieces of the proximal patella separated in the coronal position were then assembled together on the proximal patella, which had been anatomically reduced on the cartilage surface, and were also temporarily fixed with a fine Kirschner wire. Reduction and temporary fixation of the distal patellar comminuted fracture were completed using the same method. The patella was reinforced with a steel wire tension band, and all temporary fine Kirschner wires were removed for completion of precise reduction and fixation of the entire patella ().\nAfter the operation, the patient’s incision healed well. Reexamination of the left knee joint 1 week postoperatively showed that the patella was positioned well and that the internal fixation had not loosened. Six weeks after the operation, the patient was fully weight-bearing, and the fracture had healed completely at 3 months postoperatively (). At the last follow-up (2 years after the operation), the patient’s visual analog scale score was 1, the range of motion of the left knee joint was 130°, and the Böstman score of the knee joint was 28.8 points.
A 71-year-old Caucasian female presented with a chief complaint of acutely worsened lower back pain. The pain had come on over the previous two months and was localized over the upper lumbar spine. She reported an increase in intensity of the pain when lying flat. The patient had a longstanding history of chronic back pain, and two previous surgeries for adult tethered cord syndrome, but reported this pain to be significantly worse than what she had experienced before.\nNotably, her past medical history included a diagnosis 13 months prior of infiltrating ductal adenocarcinoma of the breast, which had been identified on routine screening mammogram. The tumor was determined on core needle biopsy to be ER (90%), PR (95%), and Her2 (3+) positive, with a Ki67 of 13%. She had undergone a left breast lumpectomy and sentinel lymph node biopsy with negative surgical margins. Final pathology from lumpectomy demonstrated the tumor was grade 2 and 1.2 cm in greatest dimension. Focal DCIS was present with high nuclear grade. The sample was without lymphovascular invasion. Pathology showed one of six sentinel nodes was positive for macrometastatic disease with associated extracapsular extension. Final pathological staging after lumpectomy and sentinel lymph node biopsy was pT1N1aMx.\nAfter lumpectomy, the patient had been treated with adjuvant chemotherapy followed by radiation therapy and hormonal therapy. Her chemotherapy regimen consisted of dose dense paclitaxel, cyclophosphamide, and trastuzumab for a total of six cycles, which was complicated by neutropenic fever following the first dose as well as a persistently infected wound of the toe prompting a dose reduction of paclitaxel and cyclophosphamide for the remaining five cycles, with plans to continue trastuzumab therapy for one year. Her radiation treatment was initiated five weeks following completion of her cyclophosphamide and paclitaxel treatment. Radiation treatment was delivered to the whole breast with high tangents using a hypofractionated course to a total dose of 4256 cGy delivered over 16 fractions followed by a 1000 cGy boost to the tumor bed delivered over five fractions. Given the ER-positive status of her tumor, the patient was also started on anastrozole at the conclusion of her radiation therapy. Ten months after initial diagnosis and three months after the completion of radiation therapy, a diagnostic mammogram showed no evidence of disease in either breast. The patient was continued on trastuzumab and anastrozole.\nHer presentation with acutely worsened back pain occurred one week after completion of the one-year of adjuvant trastuzumab therapy, and approximately 13 months after breast cancer diagnosis. A review of systems was negative for constitutional symptoms. Physical examination at the time of presentation showed tenderness to palpation midline in the upper lumbar spine, with limited range of motion bidirectionally due to pain. Neurological examination, including assessment of strength and gait, was normal. No laboratories were drawn at this time.\nAn MRI of the spine was ordered, which showed an abnormal signal and enhancement at L2, L4, and S1 in addition to iliac and sacral lesions consistent with metastatic disease (Figure ). A follow-up PET scan demonstrated multifocal hypermetabolic lesions in the mediastinum, hila, spleen, liver, abdominal and inguinal lymph nodes, as well as in multiple bones (SUVmax(range): 3-5.75) suggestive of widespread and distant metastatic involvement (Figure ). A biopsy of a liver lesion was planned for confirmation of metastatic disease but results from this failed to confirm the diagnosis of metastasis and showed no signs of malignancy, instead unexpectedly showing granulomatous hepatitis with multiple non-caseating epithelioid granulomas.\nDue to these non-confirmatory findings on biopsy, the case was reviewed by a multidisciplinary tumor board comprising diagnostic radiology, pathology, oncology, and radiation oncology. The consensus from this session was that, despite the nondiagnostic biopsy results, the patient's imaging findings, clinical findings, and history of breast cancer were most consistent with metastatic disease and palliative radiation therapy with repeat biopsy of a separate site was recommended.\nTwo weeks later, the patient underwent a CT-guided biopsy of the left iliac and right side of the L4 vertebral body. These biopsies again failed to demonstrate any evidence of malignancy but instead consistently demonstrated a non-necrotizing granulomatous pattern of disease. Therefore, metastatic disease was no longer considered the likely diagnosis due to the biopsies of multiple sites failing to demonstrate any evidence of metastatic disease.\nA comprehensive workup was performed to evaluate for a possible infectious source for the lesions. A quantiferon test as well as urine and serum Ag/Ab tests for histoplasma, blastomycosis, coccidiomycosis, and treponema was completed with all tests coming back negative. PCR testing of the liver was also negative for acid-fast bacilli and fungi. On further evaluation, it was noted that one year prior to her breast cancer diagnosis, the patient had complained of a persistent cough with evaluation demonstrating imaging evidence of possible sarcoidosis. She did not receive treatment for sarcoidosis at the time, and instead was instructed to return if her cough worsened. As a result of this additional information and her recent biopsy results demonstrating non-necrotizing granulomas, the patient was referred to a rheumatologist, and her imaging findings were evaluated for their potential to represent widespread sarcoidosis. However, she still refrained from initiating steroid treatment for sarcoidosis as her back pain was thought to be more consistent with worsening osteoarthritis after consultation with a rheumatologist. A repeat MRI of the lumbar spine four months later demonstrated that the PET-avid bone and soft tissue lesions were stable and comparable in size with what was seen in the previous MRI, providing further reassurance against a metastatic etiology for these lesions.
A 60 year old Caucasian male patient was referred to general surgery for multiple unrelated complaints including umbilical hernia and left arm lipoma. The patient also had an additional complaint of a fast-growing right leg mass located on upper lateral right calf distal to the knee. The patient had no other suspicious skin lesions and admitted to having the lesion shave biopsied two years prior by dermatologist with benign findings. No picture was taken of the lesion prior to surgical intervention as it was expected to be benign based upon prior dermatological findings. The patient stated that the leg lesion was non-painful in nature but was concerned that it may have increased in size over the previous 2 months and had a brown-gray discoloration. No prior imaging was obtained for the leg lesion. A wide margin elliptical excision was performed with a minimum goal of 1 cm margins on all sides of the lesion and the depth was resected to the muscle layer. The full specimen was marked for orientation and submitted to pathology. The excised elliptical portion measured 4.3 cm in length and 2.5 cm in width at widest points. The nodular lesion measured 2.4 × 1.8 × 0.9 cm. Ancillary studies showed that the lesion was CD31 positive, CD34 positive, and negative for cytokeratin markers. The pathology report confirmed EHE with tumor close to circumferential margins and present at the deep margin. The lesion was staged as pT1a pNX in accordance with AJCC staging. Given the deep margin extending to the thin layer of muscle just distal to the knee, the patient was referred to orthopedic surgery for further evaluation and operative intervention. The mainstay of treatment for invasive sarcoma is surgery often coupled with radiation and/or chemotherapy. A second surgical excision 19 days later following the original surgery was performed into deeper tissue. The second lenticular ellipse measured 8.1 cm in length and 2.1 cm in width at widest points at a depth of 1.4 cm. Multiple frozen sections were examined and clean margins of a minimum of 1 cm was determined in all directions.\nDue to the diagnosis of EHE, it was prudent to obtain additional imaging to determine if the malignancy had metastasized. Although incredibly rare, there have been documented cases of pulmonary epithelioid hemangioendotheliomas, as well as cases of tumors found on the liver. A CT scan was performed with IV and oral contrast of the chest and abdomen. The findings were unremarkable for the chest but multiple hepatic cysts and an enhancing lesion in the right lobe of the liver were identified. A follow up MRI with and without gadolinium confirmed a 2 cm well-defined focal area of delayed enhancement within the posterior segment of the right lobe of the liver corresponding to the CT findings, likely representing a cyst and not a metastatic lesion. These findings suggest that no metastasis had occurred and that the leg skin lesion appeared to be the primary site of EHE.
A 49-year-old male experienced recurrent obstructive ileus, counting two admissions in our department within three months, treated conservatively. The third time he underwent an exploratory laparotomy when all conservative measures failed.\nThe patient's previous medical history included only hyperlipidemia, treated with an oral agent. One month before the first episode of intestinal obstruction he underwent emergency surgery in another institution for acute appendicitis and appendectomy was performed. The surgeon noticed an abnormal membrane covering part of the ileus, and a sample of the tissue was sent for histological examination. The findings were non-specific, indicating a membrane formed of connective tissue.\nThe diagnostic workup during his second admission included an upper GI endoscopy and a barium-contrast examination. A CT scan with oral and intravenous contrast was scheduled in the last admission. The endoscopy revealed gastritis, caused by helicobacter pylori, while the barium study showed no abnormalities. The CT scan revealed a distended stomach and upper jejunum, especially near the ligament of Treitz (Figures , ). It also revealed an area of the jejunum with thickened wall and narrowed lumen.\nThe patient experienced incapacity of feeding properly and was malnourished. During hospitalization he was supported with parenteral nutrition and a decision of laparotomy was made, as no amelioration of his condition was observed with conservative measures.\nHe underwent laparotomy through a midline incision. By entering the abdominal cavity, a dense membrane was found encapsulating the stomach, the small intestine and part of the large intestine (transverse colon and the front of the ascending and descending colon) (Figures , ). The whole membrane was excised and extended adhesiolysis was performed, releasing the small bowel loops (Figure ). The entire small intestine was viable, without serosal tears. The patient had an uncomplicated postoperative period and left hospital the 12th postoperative day.\nThe membrane was sent for histological examination. The pathology report of the membrane revealed connective tissue with the presence of inflammatory cells.\nOne week after he was discharged, the patient experienced retching and vomiting when consuming liquids, while surprisingly he could tolerate eating solid food. He was advised to be hospitalized again with food restriction and Levin catheter. There was a high suspicion of cocoon syndrome and the histological results would confirm the diagnosis. He denied admission and visited another institution, where he underwent another laparotomy.
An 80-year-old male patient was referred to the abdominal surgery department due to incarcerated ventral hernia and ileus. In the past he was operated due to perforated gastric ulcer. He also had arterial hypertension, chronic pulmonary obstructive disease and pulmonary hypertension, a history of smoking, he suffered an ishemic stroke in the past. He was urgently operated on the same day. Segmental resection of small bowel with end-to-end anastomosis was performed and the hernia defect was closed with direct sutures, without prosthetic mesh because the bowel was resected. There were no surgical or other complications after surgery and he was discharged from hospital after 8 days. 5 days later he was admitted to the hospital again due to early recurrence of ventral hernia. The content in hernia sac could however be reduced back to his abdomen. Laboratory findings showed leucocytosis and elevated C-reactive protein (CRP - 148 mg/l). Intestinal winding with a thickened wall up to 5 mm was found at the location of the ventral hernia by ultrasound examination. The patient underwent a second surgery 22 days after the first surgery due to obstructive ileus, which was seen on the abdominal computed tomography (CT) a day earlier. Due to additional diseases and disorders (ischemic stroke and insertion of stent in his left internal carotid artery in 2011, arterial hypertension, asthma, pulmonary fibrosis and hypertension, which were not properly treated, because the patient did not follow the prescribed treatment) the anaesthesiologist decided for the spinal anaesthesia, because the general anaesthesia would be to risky. The surgery was performed by an abdominal surgeon with 5 years experiences as a specialist and he performed more than 30 Rives-Stoppa ventral hernia repairs. The skin incision was made along the previous skin incision. In the subcutaneous tissue the small intestine was tightly adhered on to the skin. We managed to release it but unfortunately, a segment of the small intestine was damaged during adhesyolisis. Segmental resection of the damaged small bowel with end-to-end anastomosis was performed (). The small intestine was reduced back in to the abdominal cavity. Ventral hernia was repaired according to Rives-Stoppa technique with prosthetic mesh (). Other than postoperative tachycardia there were no reported issues. A couple of hours after the procedure apnoeic episodes appeared followed by unconsciousness. A computed tomographic angiography (CTA) of the brain vascular system was made and it showed a stenotic left vertebral artery (90% stenosis). Because of respiratory insufficiency and haemodynamic instability, the patient was transferred to the intensive care unit. Due to a worsening clinical condition, a CTA of the abdomen was preformed and an occlusion of superior mesenteric artery (SMA) was discovered. Interventional radiologist preformed an embolectomy and thrombus aspiration from the SMA with an insertion of a stent. The patient's condition continued to worsen so the abdominal surgeon decided for a “second look” abdominal exploration. At surgical revision we found a small intestinal and sigmoid colon gangrene. Because of the patients age, several other comorbidities and gangrene of the entire small bowel, the multidisciplinary team (abdominal surgeon, anaesthesiologist, intensivist) decided for conservative treatment. The patient died the day after surgery.
An 18-year-old male presented after a motor vehicle rollover accident. He was taken to the emergency where standard X-ray revealed odontoid fracture. He was transferred to the tertiary care center for further management in a rigid cervical collar. Physical examination revealed significant tenderness in the upper cervical spine. He had restricted neck flexion up to 30 degrees and extended to neutral. He had minimal lateral bending motion and refused to turn head from side to side because of pain. His neurological examination was normal. Anteroposterior (AP), lateral and open mouth odontoid films were obtained followed by computed tomography (CT) scan. CT scan confirmed the diagnosis of Type II odontoid fracture with a gap of 2.5 mm and anterior displacement of the dens by 4 mm. The fracture angulation was 27 degrees with an associated anterior and posterior arch of atlas fracture leading to unstable left lateral mass of C1 (). Magnetic resonance imaging (MRI) showed intact transverse ligament. Possible treatment options were nonsurgical management in a halo vest as well as surgical management. Both were discussed with the patient. The patient denied a conservative treatment with halo vest because of the long duration of treatment and high incidence of associated complications.\nSince the fracture had angulation of 27 degrees, the surgeon felt that it would be difficult to get appropriate trajectory for screw fixation and in turn adequate reduction. Hence, anterior odontoid screw fixation was not considered. Considering the patient's young age and the limitations of C1-C2 fusion including significant loss of cervical rotation, temporary internal fixation with a lateral mass fixation of C1 and pedicle fixation of C2 without fusion was planned. The intention was to remove the internal fixation after radiological healing of odontoid fracture to maintain the rotational motion of the cervical spine. As a part of the preoperative work-up, CT angiogram was done which showed the vertebral artery in an abnormal position and closer to C2 pedicle (). Hence, the surgeon planned unilateral internal fixation of C1-C2 segment without fusion. Accordingly, internal fixation of left C1-C2 segment was done with left C1 lateral mass screw and left C2 pedicle screw with technique as described in the literature () []. He had an uneventful recovery and was discharged on postoperative day 3. Patient was immobilized in a rigid collar postoperatively for 2 weeks. Collar was discontinued in 2 weeks and patient was followed up in the office at 6 weeks, 3 months, and 6 months. CT scan was repeated at 6-month follow-up visit which showed healed odontoid fracture and excellent C1-C2 alignment (). At 9-month postoperative visit, patient was admitted for removal of internal fixation and discharged on postoperative day 1. Patient had normal flexion/extension and rotation of cervical spine at 1-year follow-up ().
A 34-year-old female presented to the Department of Oral and Maxillofacial surgery with a complaint of swelling on the left side of the face which initiated 8 months back, was small in size and gradually increased to the present size. The patient also complained of dull pain in the region of lower left back teeth region for 8 months for which consultation from a dental practitioner was sought, but did not subside. The patient also complained of burning sensation of the mouth and pain during night time with a history of difficulty in mouth opening, mastication, and speech. The medical history and family history were not contributory. However, the patient had deleterious habit of chewing pan since 1 year with a frequency of four times a day. The patient was examined at an institution in Chennai before she reported to our institution. In the previous institution, the biopsy and computed tomography neck were performed.\nOn inspection, a gross solitary swelling was noted on the left side of the face involving upper, middle, and lower one-third of the face approximately 15 cm × 20 cm in size superiorly extending from the lower eyelid to inferiorly beyond the lower border of mandible approximately 4 cm, crossing midline up to the right lower border of the mandible medially, and laterally 5 cm posterior to the ear lobe with deviation of nose to the right side and elevation of the left ear lobe. Skin over the swelling was stretched and shiny with prominent vasculature, and erythematous region noted below the lower border of the mandible.\nOn palpation, there was local rise in temperature and swelling was firm to hard in consistency. Tenderness noted on the left zygomatic region.\nMouth opening was limited (10 mm). Intraoral swelling was present extending from left premolar to posteriorly up to the retromolar region. Mucosa over the swelling was pale with ulceration and pseudomembranous area approximately measuring 6 cm × 8 cm.\nOn palpitation, tenderness was present over the mucosa in relation to left premolar to posteriorly up to the retromolar region. Vestibular tenderness and obliteration noted in relation to 34, 35, and 36.\nA diagnosis of high-grade NHL Stage III was made based on the clinical, radiographic, and histopathological examination.\nAs an investigation, orthopantomogram was advised that did not show any significant changes in the bone. Incisional biopsy was performed from the left buccal mucosa for investigation which gave a report of diffuse large B-cell lymphoma. The report also mentioned about mildly hypercellular marrow with no evidence of lymphoma. Trephine biopsy was performed which mentioned about the high-grade NHL.\nA large ill-defined heterogeneously enhancing soft tissue lesion noted in the left side with adjacent subcutaneous fat stranding (inflammation). Loss of fat plane with the left masseter, medial and lateral pterygoid and suspicious involvement of the deep lobe of parotid and the left submandibular gland. Few nonenhancing area showing necrosis and intratumoral neovascularity. Underlying mild cortical erosion of the body and ramus of the mandible with mild periosteal reactions. Inferiorly loss of fat plane with the left floor of mouth and anterior belly of left digastric. Anteriorly extending up to the angle of mouth with loss of fat plane with the left buccinator. Superiorly, the component lateral to the ramus extends up to the left zygomatic arch, and the component medial to the ramus extends up to the skull base with no obvious intracranial extension. Hypodense lesion in the superficial lobe of the left parotid.\nLevel 1A – few small nodes, largest node ~10 mm shows necrosis Level 1B – left and right multiple necrotic nodes largest ~16.5 mm Level 2A – multiple nodes bilaterally (closely spread on the left), largest left node ~23 mm, and right largest ~10 mm Level 2B – left up to 7.5 mm, right −6.5 mm Level 3 – left – 8.5 mm, right nil significant Level 4 – left – nil significant, right −10 mm Level 5 – nil significant Left lateral pharyngeal ~10.5 mm Supraclavicular nil significant The level 2 nodes compress the left internal jugular vein causes complete collapse of the lumen.\nChemotherapy was advised by the oncologist, and a total of 14 cycles were suggested at the gap of every 2 weeks. The treatment protocol followed was Classical CHOP therapy comprising of -\nInjection cyclophosphamide 1150 mg intravenous (IV) in 500 ml normal saline (NS) over 2 h Injection doxorubicin hydrodaunorubicin 75 mg IV in 500 ml NS over 2 h Injection vincristine (oncovin) 2 mg diluted in 10 ml NS IV push.\nAt the end of 2 cycles, the swelling started regressing in size with healed intraoral ulcerated lesion.
An 81-year-old gentleman presented acutely to the surgical assessment unit with a painful, diffuse swelling in the left popliteal fossa. The swelling, which was first noticed 6 weeks prior to admission, came on suddenly and was associated with pain and tenderness. Over the following weeks, it had progressed in size and become increasingly painful. The patient had a background history of hypertension, but was not on any regular medication.\nA provisional diagnosis of a Baker’s cyst had been made by the patient’s primary health care provider and he had subsequently been awaiting an Orthopaedic clinic appointment for this. The swelling continued to increase in size, restricting the range of movement at the knee. The patient subsequently attended the emergency department where a pulsatile popliteal fossa mass was found. The impression was still of a Baker’s cyst and the patient was sent home. In the weeks to follow, the patient struggled to bear weight on the left leg. The 24 hours leading up to his present admission was accompanied by a sudden onset diffuse swelling in the entire left lower leg. An urgent ultrasound was arranged to exclude a deep venous thrombosis which instead revealed a large, 8 cm, popliteal aneurysm in the popliteal fossa, the outer wall of which was not well defined. There was a 5 cm patent channel noted within the centre of this structure with extensive intramural thrombus noted at the periphery. No obvious abdominal aortic aneurysm was seen.\nOn initial surgical evaluation, the patient was haemodynamically stable and apyrexial. The left leg was grossly oedematous from below the knee, with a pulsatile firm tender mass in the popliteal fossa. The pedal pulses were all palpable with good range of movement in the feet; however, there was marked reduction of movement at the knee joint. Initial blood tests including white cell count and C-reactive protein were normal. To get a more detailed image of the aneurysm and arterial tree in the left leg, an urgent magnetic resonance (MR) arteriogram was arranged, which showed a false aneurysm of the popliteal artery measuring 8.8 cm coronally and 7.4 cm axially (). Approximately 50% of the false aneurysm was thrombosed and distal runoff was well preserved. No other aneurysm or stenosis was found elsewhere in the vasculature of the lower limbs. A decision was made to immediately perform an emergency open repair due to rapid clinical deterioration, possibly due to an acute bleed.\nPer-operatively, the aneurysm was approached posteriorly and the sac dissected. Bleeding was controlled and clamps applied at either end of the aneurysm. The appearance of the aneurysm was very much indicative of a mycotic aneurysm, and a tissue sample was sent to the microbiology laboratory for microscopy and culture. A 5 cm vein graft was used to repair the aneurysm and the wound was closed. After the procedure, a strong flow signal was detected distal to the aneurysm repair. In the days to follow the patient recovered very well and the oedema in the leg slowly started to settle.\nThe aneurysm tissue was processed using the local Microbiology Laboratory Standard Operating Procedure for sterile tissues. It was emulsified in sterile saline using sterile glass beads, then plated onto 5% sheep blood (BA), chocolate (CA), CLED and anaerobic (ABA) agar plates and into cooked meat broth (CMB) (bioMérieux), which were incubated in appropriate atmospheres at 37 °C for 48 h (5 days for the anaerobic plate and CMB). The culture on CMB was sub-cultured after 5 days onto BA, CA and ABA, which were then incubated as above. The isolate was identified as Streptococcus sanguinis by API 20 Strep (bioMérieux) – a member of the viridans group streptococci. These results were available on the seventh day post-operatively, confirming the suspicion of a mycotic aneurysm. Intravenous benzylpenicillin and flucloxacillin were commenced for 2 weeks, as recommended by the microbiologist.\nDespite these findings, the patient remained afebrile and serial blood cultures taken all came back negative. As the organism is commonly part of the oral flora, an orthopantomogram and transthoracic echocardiogram (TTE) were requested to exclude infective endocarditis. Both of these tests were inconclusive and the patient subsequently refused to have a trans-oesophageal echocardiogram (TOE) to evaluate his heart further. The patient regularly visited his dentist and had reasonable dental hygiene. In the absence of any focal source of sepsis, a conclusion was made that the mycotic aneurysm was secondary to transient Streptococcus sanguinis bacteraemia through the oral mucosa. The patient continued to show significant improvement in mobility in the weeks to follow.
The patient, a 16.3 year-old girl, was in excellent health, both physically and emotionally, with no known adverse drug reactions or allergies and good oral hygiene. The major concern of both the patient and the referring general dentist was the persistence of several deciduous teeth. Possible systemic, endocrine, metabolic or genetic-syndromal disorders as possible etiologic factors could not be detected by a physician and endocrinologist, to which the patient was referred prior to orthodontic examination. In addition, there was no family history of eruption failure of permanent and persistence of deciduous teeth. The first deciduous upper molar on the right side (tooth 54) was extracted 1 year earlier by the referring general dentist, but no spontaneous eruption of the permanent first premolar could be achieved within this timeframe (Table ). Thus and due to no previous referral by the general dentist or presentation of the patient for orthodontic planning, treatment was started quite late.\nThe clinical examination and study model analysis (Figs. and ) in conjunction with the panoramic radiograph (Fig. ), taken by the referring general dentist, showed initially nine persisting deciduous teeth – all deciduous canines and molars of the upper jaw and those on the right side of the mandible, minus the already extracted upper right deciduous molar. All upper permanent canines and premolars were impacted and malpositioned. The lower right canine, which was severely rotated, was also impacted to a higher and the lower right first and second premolars to a lesser degree, whereas the corresponding teeth on the lower left side were in good occlusion and showed no signs of impaction. No adequate root resorption of the deciduous teeth could be detected radiologically with exception of the lower deciduous molars on the right side. Radiographically the impacted teeth showed no evident signs of ankylosis. Some physiological spacing of the incisors was present and both the first permanent molars as well as the deciduous canines were in good occlusion and had a class I relationship with a shallow curve of Spee in both jaws. The second permanent molars were also in occlusion and all four third permanent molars present radiologically within their germ stage. No reduction of the extraction space due to a mesial or distal drifting of the neighboring teeth was evident. The patient also showed a lower alveolar midline deviation to the right side (about 2 mm), most likely due to the unilateral failure of eruption at the lower right side, which caused a more mesial eruption and inclination of the lower left permanent canine and the lower incisors, as evidenced by the gap formed between the canine and lower left premolar.\n3D CBCT diagnostic imaging was declined by the patient and her guardian due to concerns about a potential health risk by the radiation exposure. The cephalometric analysis according to Ricketts (Table , Fig. ) revealed a vertical dolichocephalic growth type, hyperdivergent jaws and a large mandibular plane angle, thus a further vertical development had to be avoided during treatment. In addition, the mandible was found to be prognathic with an ortho- to retrognathic upper jaw, resulting in a slight skeletal class III, which was dentally compensated (class I molar relation). Both approximately normally inclined upper and lower incisors were distinctly protruded, whereas Ricketts’ E-line indicated a retrusion of the upper lip due to the proganthic lower jaw. Furthermore, overjet and overbite were increased.\nThe radiologically evident complete root development of all permanent impacted teeth with closed apices in conjunction with the persisting deciduous teeth without distinct signs of root resorption in absence of genetic-systemic causes formed the basis for our diagnosis of idiopathic multiple bilateral impactions, confirmed by the failure of spontaneous eruption of the first upper left premolar after extraction of the corresponding deciduous predecessor.\nThe main treatment objective was to align the nine impacted teeth at the occlusal level by means of controlled guided traction after their surgical exposition and ligation and after extraction of the preceding deciduous teeth. Secondary objectives were a levelling of the arches, a correction of the lower dental midline shift, establishing a physiological overjet and overbite and achieving a stable and functional occlusion. We opted for treatment with a fixed multi-bracket appliance in conjunction with the Easy-Way-Coil System™ (EWC) []. To minimize treatment time, a simultaneous alignment of all impacted upper six permanent teeth was planned (4 weeks discrepancy in start of treatment between right/left side). Vertical and horizontal relations as well as dental class I were to be kept stable during treatment and the risk of root resorption at the second incisors was minimized by excluding them from the appliance. Due to the higher treatment complexity of the maxilla, treatment within the mandible was started at a later date.\nThe patient and her legal guardians were informed and motivated about the necessity of good oral hygiene and compliance during the treatment as well as about the expected duration of treatment and the risks involved - particularly root resorptions and failure of eruption, which would necessitate a later implant and restorative treatment. Informed consent was obtained and ethical regulations according to the Declaration of Helsinki (1964) and its later amendments were observed at all times.\nThe best choice of treatment was discussed and considered both with the patient and an oral surgeon and a combined surgical-orthodontic approach with simultaneous traction of the impacted teeth by means of an Easy-Way-Coil™ was deemed to be most promising and time-efficient.\nThe most simple approach to treat multiple impactions would have been to just extract the persisting deciduous teeth and wait for a spontaneous eruption. However, the advanced age of the patient, the complete root development and the already failed attempt by the general dentist made a success of this approach seem unlikely.\nAn alternative method described by Schmidt and Kokich [] to extract the deciduous teeth and only expose the impacted teeth surgically without traction to facilitate spontaneous eruption, which for canines usually occurs after 6–8 months [], was rejected by the patient for cosmetic reasons. This also excluded the possibility of a surgical luxation of the impacted teeth to facilitate tooth movement. In addition, the impactions were considered to be too deep for an exposure without traction to be successful. For this reason, we also opted for a closed instead of an open eruption technique in this case [, ].\nIf the impacted teeth were ankylosed, an extraction and consecutively implant-restorative treatment would be indicated. This option was considered as potential alternative, if the primary therapy failed in case of confirmed or developing ankylosis or invasive cervical root resorption during treatment, whereas at baseline no ankylosis of the impacted teeth could be confirmed. In this case a mesialisation of the upper permanent molars by means of skeletal anchorage and a mesial sliding appliance [] could have been used to reduce the resulting gaps, enable an occlusal alignment of the third molars and reduce the number and extent of necessary implants and restorative treatment.\nA sequential extraction of persisting deciduous teeth [] and also sequential traction of the impacted teeth individually as described by Krey et al. [] could have reduced the risk of extensive tooth loss in case of alignment failure. This approach, however, was rejected due to the unwillingness of the patient to accept prolonged treatment times, her already advanced age for treatment and a persisting deciduous dentition. The patient rather preferred implant-restorative treatment in case of treatment failure.\nAt the beginning of treatment brackets (slot 0.018”) were bonded only to the upper central incisors and bands were placed on the first molars. These were connected by a transpalatinal arch (Burstone, 0.032” × 0.032” stainless-steel) for anchorage. Second molars were stabilized by connecting them with the first molars with a passively bonded partial arch-bow (0.017” × 0.025” stainless-steel) (Fig. ).\nAt the level of the second transversal palatal ridges one mini-screw of the BENEfit™ system (2.0 × 11 mm, dental line, Birkenfeld, Germany) [] was inserted into the palate to carry a screwed standard abutment with a welded 1.1 mm stainless-steel wire. This wire was shortened, bent to the upper central incisors in shape of a U and bonded to their palatal surface (Fig. ). The upper central incisors and first molars were then connected with a 0.017” × 0.025” stainless-steel arch-wire (straight-wire technique) within a passive closed coil spring (Fig. ). The lateral incisors were intentionally left out of the fixed appliance to avoid any root movement and contact with the impacted canines.\nTreatment was started at the upper right quadrant. After extraction of the persisting deciduous teeth a mucoperiosteal flap was raised and the impacted permanent teeth were surgically exposed up to the assumed cemento-enamel junction. Three EWC™ appliances were bonded to the individual teeth at the palatal surface (canine) and at the buccal surfaces (premolars) and directed towards the arch-bow used for anchorage (Fig. ). The mucoperiosteal flap was then repositioned and fixated with surgical sutures (closed eruption technique).\nAfter 1 week the sutures were removed and the EWC™ springs activated. The direction of traction was chosen to be disto-buccal for the canines and buccal for the premolars. A suitable anchorage spot was chosen on the circular arch-bow and a gap introduced into the passive closed coil spring by gently closing a ligature cutter at this location. This way a displacement of the ligature wire used for connecting the EWC™ spring with the arch-bow was effectively prevented. The correctly aligned EWC™ springs were then shortened to create a gap of exactly 2 mm (canine) and 1 mm (premolars) between arch-bow and the spring. By gently closing the ligature cutter 1 mm proximal to the shortened end of the EWC™ spring, an eyelet consisting of the terminal three coils was formed, which was connected seamlessly to the gap formed at the arch-bow coil spring by means of a ligature wire (Fig. ). The EWC™ spring activation of 2 and 1 mm ensured a predictable force level of 0.32 N and 0.16 N, respectively.\nFour weeks later the same procedure was performed at the contralateral upper left jaw side (Fig. ). At the same time the EWC™ springs at the right side were reactivated by clipping 2 mm (canine) and 1 mm (premolars) off the springs at their anchorage point and re-fixating them with a ligature wire (Fig. ). This procedure was repeated every 4 weeks at both upper jaw sides until the impacted teeth erupted. Then the EWC™ springs were removed and lingual buttons attached to the occlusal surfaces of the premolars (Fig. ) and buccal surfaces of the canines (Fig. ). The teeth were then further moved in buccal direction by means of a PowerTube™25 (Ormco B.V., Netherlands) until brackets could be bonded to the labial surfaces (Fig. ). Final extrusion and levelling of all impacted teeth was achieved by a superelastic Nickel-Titanium (NiTi) arch-wire initially (Fig. ) and subsequent rigid TMA (Titan-Molybdenum-Alloy) arch wires.\nAfter the deciduous teeth had been extracted in the lower jaw, the permanent premolars at the lower right side erupted spontaneously (Fig. ). A fixed multi-bracket appliance was bonded in preparation for aligning the impacted lower right canine, which was performed in analogy to the technique used in the upper jaw (surgical exposure, 0.017” × 0.025” stainless steel anchorage arch-bow with passive closed coil spring, EWC™ system and 2 mm activation). To prevent intrusion and tipping of the incisors at the lower right side, the continuous arch-wire was separated and only the lateral tooth segment used for anchorage (Figs. and ).\nAfter removing the upper skeletal anchorage, remaining spaces in the upper dental arch were closed and incisors slightly re- and intruded with a T-loop bow (0.017” × 0.025” TMA, Fig. /i) to achieve physiological overjet and overbite. The lower alveolar midline deviation was corrected during levelling by uprighting the mesially inclined lower right canine into the gap to the first premolar with consequent distalisation of incisors aided by a buccal power chain placed on top of the arch-bow from the lower right second incisor to the left first premolar (Fig. ).\nTotal treatment time was 22.8 months. The required time for aligning the upper jaw from surgical exposure to finishing with a 0.017” × 0.025” TMA arch-bow was 19.6 months with a total 26 sessions in the office. The corresponding treatment time for the lower jaw was 20 months with a total of 19 office visits.\nAll impacted teeth could be successfully aligned within the levelled dental arches. Class I canine and molar relation were maintained at both sides (Figs. and ) and the patient (19.7 years) was happy with the treatment result. The cephalometric analysis after the end of treatment (Table , Fig. ) as well as the superimposition of pre- and posttreatment tracings (Fig. ) showed a slight intensification of the mesial skeletal tendency to a skeletal class III jaw relation (dentally compensated), caused by anterior rotation of the mandible, whereas the vertical hyperdivergence of the upper and lower jaw decreased by posterior rotation of the maxilla and anterior rotation of the mandible. The protrusion of the upper, but not lower incisors, both normally inclined, was reduced during treatment. Upper incisors were intruded. The lower alveolar midline deviation could be successfully corrected and a physiological overjet of 2.5 mm and overbite of 2.2 mm was achieved. The retrusion of the upper lip remained unchanged during treatment due to the still prognathic mandible.\nFor retention purposes, the patient was instructed to wear a removable Hawley-retainer for 24 h a day within the first 6 months and then to gradually reduce wear time (only at night, every second night etc.). In addition, a coaxial annealed retainer wire (Penta-One™ 0.0215”, Masel Orthodontics, Carlsbad, USA) was bonded to the palatinal surfaces of the lower incisors and canines due to the severe rotation of the aligned lower right canine and thus increased risk of rotational relapse [].\nA total of nine deciduous teeth were extracted and seven permanent teeth surgically exposed, ligated and aligned. The two initially impacted permanent premolars at the lower right side erupted spontaneously after extraction of the deciduous molars and did not require additional traction. Post-treatment clinical examinations and radiographs (Fig. ) showed no indications of avital or traumatized teeth, root resorption, periodontal problems (probing depths < 3 mm for all teeth and locations) or other iatrogenic damages. At the end of treatment the patient was referred to the oral surgeon for possible extraction of the third molars, since proper eruption of the lower right molar seemed unlikely due to the radiographically evident lack of space and problematic angulation.
A 39-year-old man with a history of severe stump pain and phantom limb pain of his right upper limb for over 26 years was referred to our department. He had undergone a right below-elbow amputation when he was 13 years old because of severe avulsion injury of his forearm. Six years later, he developed phantom limb pain and stump pain. The pain was diagnosed as neuroma-related pain and he underwent excision of the stump neuromas of the radial, ulnar, and median nerve three times. Despite repeated surgeries, the pain was only relieved partially and temporarily and became more intense after the surgeries. After the last surgery, the pain was treated by nerve blocks but the effect transient.\nAt first assessment in our unit, he presented with increased and intolerable phantom pain and stump pain. He described the pain as stabbing with an intensity of 9/10 on the visual analogue scale. The pain lasted for a few minutes and reoccurred at 30–60 minute intervals. It was accentuated when pressure was applied to the medial side of the limb stump () and the Tinel's sign was confirmed by pressing on the point. He experienced phantom pain and sensations on his small and ring fingers. Oral administration of pregabalin, opioids, and non-steroidal anti-inflammatory drugs and a stellate ganglion block injection were ineffective. He could no longer use his upper limb prosthesis because of this severe stump pain.\nAn ultrasound examination showed that the stump of the ulnar nerve was around the point of pressure-induced pain. Infiltration of local anaesthetic of 1% lidocaine around the ulnar nerve stump with ultrasound guidance produced significant pain relief. This suggested that the pain was possibly related to the problem around the stump of the ulnar nerve.\nSurgical exploration around the medial side of the upper limb was performed. Two large stump neuromas originating from the medial cutaneous nerve of the forearm were found (). The tight scar tissue had formed around the stump neuromas making dissection very difficult. The nerve stump of the ulnar nerve was found close to the stump neuromas of the medial cutaneous nerve of the forearm but had not developed into a stump neuroma. The nerve stumps of median and radial nerves were also explored but none had developed neuromas and all were free of scarring. Neuromas that had developed in the stumps of the medial cutaneous nerves of the forearm were considered to be the main cause of his pain and both resected (). After confirming that the cut ends of the medial cutaneous nerves were healthy and with clear fascicles and no scar tissue, the ends were coapted together in an end-to-end fashion using #9-0 nylon without any tension ().\nAfter surgery, the patient's stump pain and phantom pain diminished dramatically. Four years after the surgery, the patient has only occasional episodes of stump or phantom pain with symptoms only when it rained, describing the intensity of pain as 3/10 on the visual analogue scale and with a duration of only a few minutes. There was no longer a need for oral analgesics or nerve blocks and the patient has been using his upper limb prosthesis without problems.
A 64-year-old man, who had suffered from right hip pain after jumping on the floor from 15 cm height two months ago, was seen at the orthopaedic outpatient department of a local hospital. As his pain persisted despite treatment, he was admitted to our hospital. The patient was 68 kg, 170 cm tall with a calculated body mass of 23.53 kg/cm2. He had undergone right hip cemented hemiarthroplasty after displaced femoral neck fracture caused by a motor vehicle accident eight years ago, when he was 56 years old. After the surgery, he had been controlled regularly every year for three years, and then he was lost to follow-up.\nTwo months earlier, he experienced a significant pain in his right hip and an analgesic drug was prescribed to him at a local hospital. As his pain increased with time, he was admitted to our hospital; radiographs taken shortly thereafter revealed a fractured femoral prosthesis (). Physical examination revealed a healthy-appearing elder man in no acute distress with normal examination of the lower extremities. There was a well-healed posterior incision over the right hip without any evidence of skin infection. Active and passive movements of the hip caused pain. C-reactive protein, erythrocyte sedimentation rate and the other laboratory parameters were in normal range.\nFour days later, he underwent a revision arthroplasty of the right hip. A modified Watson-Jones approach was used and the proximal part of the fractured Thompson’s prosthesis (51 mm sized) was extracted while the hip was dislocated. In order to extract the distal part of the femoral stem and cement, an anterior window was created at the distal part of the femur to the tip of the femoral stem, and cement mantle and the distal part of the fractured stem was extracted. The breakage occurred in the middle part of the femoral stem (). Both parts of the femoral stem were found to be poorly fixed and easily extracted. A fully porous coated femoral stem (70 mm proximal body and 12/200 mm distal) was implanted (). There was no post-operative complication and the patient was ambulated with partial weight-bearing on the second day after surgery. Patient was administered analgesics to reduce pain and first generation cephalosporin to prevent infection. Low molecular weight heparin was administered for 6 weeks postoperatively to prevent deep vein thrombosis Muscle strength training was commenced on 3rd day postoperatively alker use was initiated in the hospital and discontinued in the 3rd week following surgery. Patient underwent regular sessions of outpatient or home-based physical therapy. Follow-up visits were performed at 6 weeks; at 3, 6, and 12 months after surgery. The Harris hip score of the patient at 1-year follow-up was 88 and there was no complication during first year follow-up.
A 59 year-old female patient, who has been employed as rehabilitation worker, has observed gradually enlarging formations under both her right and left scapula for approximately eight months. In anteflexion, elevation of the upper extremities and when stretching the arms forward, swellings reaching up to the rear axillary lines appear bilaterally subscapularly. They were of soft consistency at palpation. The patient also described pain in the upper extremities, and in the region of arms. She had no recollection of any accident or fall. However, she had undergone neurosurgical operating procedures of disc extrusion in the cervical and thoracic spine, and the findings of bilateral resistances were present already pre-operatively. In the another surgical workplace repeated punctures and partial resection of the swelling on the right side were implemented 5 months ago, and it came to its subsequent recurrence.\nThe magnetic resonance ((b) and (c)) on thoracic wall showed in dorsolateral parts in subscapular regions in the level of 3rd to 7th rib symmetrical limited fluid collections with dimensions of 120 × 37 x 115 mm on the right side with a volume of 250 ml and on the left side 120 × 24 x 90 mm with a volume of 130 ml. The collections were localised in the intermuscular spaces between the external intercostal muscles and the heads of the muscle serratus anterior. The contents of collections were moderately heterogeneous with sporadic internal septa. Cystic formations had slightly distinct signal, native image in T1 weighing displayed hypersensitive contents on the right side. It could be a case of chronic post haemorrhagic changes. Postcontrastly the collections were without amplification of signal intensity. On the left side postcontrastly there was present a moderate reinforcement of capsule of fluid collection. In diffuse weighing the lesions were without marks of diffusion restriction. Axillary lymphatic nodes were of physiological size, the displayed pulmonary parenchyma was without inflammatory and focal changes, without mediastinal and hilar lymphadenopathy, the pleural cavities without effusion, the pleura was without hypertrophy, the recorded skeleton was without traumatic change.\nOwing to progressing swelling and increasing difficulties a surgical resection was indicated in the female patient. She was operated on under general anaesthesia, and a resection of the encapsulated collections of fluid was implemented bilaterally ((d)), two Redon drains were introduced. In the left collection serous fluid was present, on the right side also serous fluid with admixture of old blood was present. A histological examination of cystic collections proved that it concerned pseudocystic lesions with relation to subscapular bursa without marks of malignancy. Their walls were created by collagenous, hyalinised and vascularised connective tissue with predominately perivascular nonspecific chronic inflammatory cellulation ((a)), the internal surface of which was lined by a layer of fibrin and by a nonspecific granulation tissue with a focally accentuated xanthogranulomatous, siderophagous and giant-cell reaction without epithelium ((b)). In the lumen of the cysts there were remnants of blood clots with fibrinous or fibrinoid substances with dispersive admixture of siderophages, lymphocytes, neutrophils and giant polynuclear cells ((c)). The proof of amyloid by Congo red was negative. On the lesion periphery soft-tissue structures were caught, including striated muscularis. The drains were removed the 10th postoperative day due to higher production, the surgical wounds were healed-up per primam intentionem. After the operation the female patient had a full range of movements and was without trouble and pains.
A 60 year old lady was referred to the Princess Alexandra Hospital Head and Neck Clinic in July 2009 following a biopsy taken from a suspected tumour at the base of the tongue (BOT). The patient was referred to our unit for ongoing investigation and management. She had noted a one year history of dysphagia and difficulty in moving her tongue. Our patient also noted an unintended a 25 kg weight loss over the past year and had had a PEG feeding tube inserted in the interim before being referred to our department. The patient confirmed that she was an ex-smoker with a 30 pack year history but denied alcohol consumption.\nOn examination there was limited movement of her tongue with significant tethering (Figure and ). A large mass was palpable predominantly on the right side of the base of the tongue and there were no masses palpable in the neck.\nAn MRI taken shows an extensive BOT tumour across the midline which extends to involve the right faucial tonsil. The tumour has an intermediate T2 signal with foci of bright T2 fluid within (Figure ). The intermediate T1 signal tumour shows irregular enhancement following Gadolinium (Figure , ). The tumour appears exophytic. The tumour extended inferiorly to the level of the epiglottis which it displaced posteriorly. The vertical length of the tumour was 3.7 cm. Small (approx 1 cm) lymphadenopathy was noted bilaterally in level 2 but this was thought to be clinically unlikely to be involved with tumour in view of the size, morphological appearance and clinical nature of the disease. The appearances of the BOT tumour are not typical for the more common SCC in this location with the irregular bright T2 signal. However an unusual SCC appearance is still be more likely than a minor salivary gland rare tumour based a review of the literature.\nA panendoscopy was performed which revealed a 4 cm submucosal lesion with a firm, posterior tongue (Figure ). The mass extended over the midline, into the inferior half of the tonsil and into the vallecula but the glossal epiglottis was clear of tumour. The mass was not fixed to the mandible. Histological examination of the biopsy samples demonstrated epithelial-myoepithelial carcinoma of the tongue base. The morphology and the pattern of immunoreacitivity are typical for Epithelial-Myoepithelial carcinoma (Table and Figures , , and ). The results of the panendoscopy and the biopsy were discussed with the patient and a thorough literature review enabled the multidisciplinary Head and Neck team to realistically discuss potential treatment options.\nPlanning by the Radiation Oncology team was undertaken with a view to a 60 Gy treatment over 30 fractions with a 2 cm margin around the primary tumour. Her treatment was well tolerated although she did require daily hyoscine injections to dry up excessive secretions. She has had a complete clinical response and will be followed with a new MRI in 6 months.
A 87-year-old male patient was transferred to the emergency department after an episode of sudden upper abdominal pain and vomiting. On arrival, the patient was pale, tachycardic with a heart rate of 103 beats per minute, and tachypnoeic with a blood pressure of 110/60 mmHg. Physical examination revealed guarding of the right upper quadrant with tenderness. Laboratory examination revealed a hemoglobin level of 10.2 g/dL, normal platelets count, prolonged INR = 1.41, normal liver enzymes, and slightly elevated γGT = 70 U/I (normal values < 50). Past medical history included coronary artery disease with coronary artery bypass surgery and carotid artery stenting. However, electrocardiogram and cardiac enzymes were within normal values. Abdominal ultrasound showed a hepatic lesion with free intraperitoneal fluid. A contrast enhanced abdominal CT was ordered which demonstrated a heterogenous mass of 7.5 cm diameter occupying the right lobe of the liver, thrombosis of the right portal vein, and free quantity of blood in the peritoneal cavity (). These findings indicated a spontaneous rupture of a possible HCC since there was no past history of HCC disease. During the examination, the patient became hemodynamically unstable, with loss of consciousness. He was intubated and transferred to the operating room for an emergency exploratory laparotomy since TAE was not feasible at that time. During surgery, there was a notable amount of fresh and clotted blood in the abdomen and a large hepatic ruptured mass was detected, located in the right hepatic lobe. Although a right hepatectomy was technically feasible, this was not performed due to critical patient's situation. Under these circumstances, it was decided to perform damage control surgery with enucleation of the tumor, ligation of the hepatic artery, and perihepatic packing. Patient's condition did not permit us to check intraoperatively the patency of the main portal vein, but the CT had shown that the left portal vein was patent and there was also a collateral circulation due to cirrhosis. The haemorrhage was successfully controlled and the patient was transferred to the intensive care unit (ICU) for further supportive treatment. Forty-eight hours later, a second laparotomy was performed to remove the packing and apply RF ablation to the tumor's bed. After 4 days in the ICU, the patient was transferred to surgical ward and he was discharged on the 18th postoperative day. The histopathological examination showed HCC, while serological tests were positive for hepatitis B virus infection. One year after the operation, he is still alive, in good condition living at his village.
A 29-year-old primigravida (now 34 years), an undergraduate at 40 weeks gestation, had emergency caesarean section for cephalopelvic disproportion under subarachnoid block in 2005 in a low-resource setting. There was no prior bleeding diastasis or neurological deficit. There was no intercurrent illness. Her weight was 80 kg and height 1.62 m. The spinal anaesthesia was administered with the patient in the sitting position and was technically difficult. A live female baby was delivered (who is now five years old). She was unable to move both lower limbs 24 hours after surgery and had a swelling on her back. There was loss of sensation in the both lower limbs with power 0. Power was normal in the upper limbs. She had urinary and faecal incontinence. Magnetic resonance imaging, computed tomography, and myelography was not available at the centre and the nearest tertiary health facility. A diagnosis of spinal haematoma following spinal anaesthesia was made. Patient was counselled for surgical evacuation of the hematoma, but she declined that she was sure of the outcome and scared. She was placed on conservative management. She spent thirteen weeks in hospital and was discharged home on request but to continue physiotherapy. She was unable to sit up at that time. Five years after, she is no longer incontinent of urine and faeces. She can now sit up but unable to walk. She is now confined to a wheel chair. There is full recovery of sensory function of the lower limbs but no motor function. There is loss of muscle bulk of the lower limbs.\nShe was a final-year university student when this incident occurred. She had to stay away from school for one year because of the long in-hospital stay. She is now a sales girl at her sister's dress shop.\nNo one in the family is happy about her situation, because she is the first female in her family to have a caesarean section as the other females in family all had spontaneous vaginal delivery. Since she comes from an island in Nigeria, she encounters some difficulty visiting her hometown, which is only accessible by air and water from the city where she resides.
A 82-year-old woman presented to Emergency Department (ED) with 24 hours of nausea, vomiting and worsening right sided abdominal pain. Patient reported that her bowels were last open 2 days ago and has since been unable to pass any flatus with increasing abdominal bloating. Her medical history included well controlled type 2 diabetes mellitus, hypercholesterolemia and hypertension. Her surgical history was significant for a hysterectomy 25 years prior for uterine cancer for which she also received pelvic radiation. Her blood tests on presentation revealed a white cell count of 8.46 109/L and a C-reactive protein of 3 mg/L with haemoglobin, platelets, electrolytes and liver enzymes all being within normal limits, as were her vitals.\nAn abdominal examination revealed a focal tenderness over her right lower quadrant and right pelvis and generalised abdominal distention. Computed tomography (CT) scan ( and ) showed small bowel faecalisation in the distal small bowel with a focal bowel loop in the right iliac fossa displaying engorgement of its mesentery with moderate volume of free fluid in the right paracolic gutter and Morison’s pouch. Findings were highly suspicious for a closed loop bowel obstruction with bowel wall compromise.\nThe patient was taken to theatre for an exploratory laparotomy where the proximal jejunum was dilated and serous fluid in the peritoneal cavity was noted. There was herniation of 30 cm of jejunum through a defect created by a tight band adhesion traversing the lower abdomen between an appendage epiploicae on the lower sigmoid colon and its attachment to the right pelvic wall ( and ). The strangulated loop of small bowel was ischemic and necrotic at the time of operation with no macroscopic evidence of perforation. The band was released and the bowel was run and no other areas of compromise were noted. The patient underwent segmental jejunal resection with a side to side double layered hand sewn anastomosis and made an uneventful post-operative recovery. Histology confirmed ischemic enteritis in the resected small bowel segment with adjacent acute serositis without evidence of perforation.\nWe deduce that a combination of pelvic radiation and subsequent hysterectomy had contributed to the formation of the adhesive band.
A 34-year-old female was transferred from an outside hospital with a sudden onset of diffuse abdominal pain. Her history is significant for malrotation with subsequent volvulus, small bowel resection done for ischemic bowel, carcinoid tumor of the stomach, multiple gastric ulcers, and a tubular adenoma of the colon. She first presented in 2005 with suspected ischemic bowel, which was resected and repaired with an ileocolic anastomosis. Her next presentation was in January of 2013 at which time she had severe anemia with a hemoglobin of 4.2 mg/dL. An EGD revealed a carcinoid tumor in the lesser curvature of the stomach that was endoscopically removed. A polyp removed during colonoscopy was identified as a tubular adenoma. She presented again the next month and an abdominal CT revealed two lesions in the liver, a left adrenal nodule, and an umbilical hernia. The liver nodules prompted a workup carcinoid syndrome, but the urine was negative for 5-HIAA.\nUpon her arrival to our hospital in August of 2013, she was noted to have moderate generalized tenderness on physical exam and her last bowel movement was earlier that day. An abdominal CT scan done prior to her arrival was suggestive of new marked mechanical traction of the distal small bowel. There were also three target signs present on imaging, a classic representation of intussuscepted bowel (). The patient consequently underwent an exploratory laparotomy. The operation was initiated using a midline incision, and an area of intussusception was revealed in the proximal jejunum () and multiple fibrotic implants were present throughout the bowel and mesentery. The lead point of intussusception was identified (). The compromised portion of bowel was resected and a jejunojejunal anastomosis was created. The bowel was then run from the Ligament of Treitz to the ileocecal anastomosis. An area of narrowed bowel was seen in the distal ileum near the site of the patient's previous ileocolic anastomosis (). An ileoileal anastomosis was created to bypass this site given the presence of shortened bowel. In addition, there was mesenteric foreshortening throughout the small bowel, which is significant due to its tendency to cause twisting and obstruction of the bowel. An internal hernia and an umbilical hernia were also found but did not appear to be as lead points for the intussusception and were subsequently reduced.

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