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A 75-year-old man presented with recurrent pruritic eczema of the penis and scrotum that was refractory to medication of the local dermatologic clinic for one and a half years. The lesion consisted of an erythematous and indurated plaque with ulceration and exudation (). Review of the patient's history revealed that he underwent right hemicolectomy for adenocarcinoma in the ascending colon when he was 62 years old. He remained under regular follow-up for 13 years, during which no metastases were reported. Examination of skin biopsy from the inguinal folds revealed large cells with clear to eosinophilic cytoplasm that had infiltrated into the epidermis, singly and in clusters (). The initial histologic diagnosis of the skin biopsy was EMPD. The preoperative instrumental investigations showed no evidence of recurrence on the previous surgical site or other underlying internal malignancy. The patient underwent a mapping biopsy at multiple sites to accurately establish the boundary of the lesion, followed by wide excision and closure of the defect with a skin graft.\nThe resected perineum and penile shaft showed ill-defined indurated nodules with a firm consistency. The lesion in the overlying epidermis measured 6 cm, with a 1.5-cm-sized mass in the dermis. The cut surface was solid and gray-white with focal mucinous appearance. On histologic examination, the lowpower view showed a relatively well-defined mass occupying the dermis and subcutis (). The overlying epidermis showed irregular epidermal hyperplasia containing scattered large cells arranged singly or in groups, as in the previous skin biopsy, suggesting an epidermal pagetoid spread of underlying tumor cells (). The tumor showed two composite features in which solid nests of poorly differentiated carcinoma were juxtaposed with paucicellular mucinous lakes with floating tumor cell clusters (). The latter accounted for the majority of the tumor, about 70%, and the rest consisted of poorly differentiated components. Tumor cells in both the mucinous pool and more cellular area revealed the same histological features of abundant eosinophilic cytoplasm and large vesicular nuclei with frequent mitoses up to 7/10 high power field (, ). In situ lesions similar to ductal carcinoma in situ of the breast were also observed () with colonization of the hair follicles (). Overall histology suggested a mucinous carcinoma with minor poorly differentiated components.\nHistological differential diagnosis included PCMC and late metastasis of the previously diagnosed colon cancer. Histologic review of the patient’s previous colon cancer showed a 4.3-cm moderately differentiated adenocarcinoma with the assigned stage of T3N0M0. The tumor consisted of well-formed or cribriform patterns of tumor glands with frequently observed dirty necrosis (). There was no mucin production observed in the skin lesion.\nImmunohistochemical studies were performed. The Paget’s and dermal tumor cells of the skin lesion were positive for cytokeratin (CK) 7, CK20, gross cystic disease fluid protein-15 (GCDFP-15) (–), and carcinoembryonic antigen (CEA), but negative for caudal-related homeobox gene 2 (CDX-2). On the other hand, tumor cells of the colon cancer were positive for CK20, CDX-2, CEA, but not gross cystic disease fluid protein 15 or CK7. Additional staining of human epidermal growth factor receptor 2 and estrogen receptor (ER) was observed in the skin lesion (, ), but the lesion was negative for progesterone receptor (PR). Myoepithelial cells surrounding the carcinoma in situ were highlighted by CK5/6 immunostaining (). The overall immunohistochemical findings of the skin lesion were different from those of colon cancer but similar to those of breast cancer, but similar to those of breast cancer, indicating sweat gland origin. On the basis of these histologic and immunohistochemical findings, the two malignancies were considered to differ in origin, and the present case was a primary mucinous carcinoma of the skin.\nAnother challenge was to determine whether the minor poorly differentiated components were eccrine or apocrine in origin because there was no clear distinction in histologic and immunohistochemical features. We concluded apocrine differentiation of the lesion due to the location in the groin, where apocrine glands are many in number, and to the resemblance of apocrine carcinoma in the breast even though decapitation secretion was absent. In addition, close approximation and colonization of the hair follicle () favored the origin of the follicularapocrine unit.\nThe final pathologic diagnosis was PCMC with EMPD showing apocrine differentiation.\nThis case was approved by the institutional review board (IRB) of Kosin University Gospel Hospital, and informed consent was waived by the IRB (IRB reference number: 2017-10-010). |
A 20-year-old female was referred to our hospital, with a history of progressive sensory-motor paraplegia and a spinal magnetic resonance imaging (MRI) demonstrating conus medullaris edema as well as dilated vessels on the cord surface. Her history began two years prior to her admission to our hospital, while she was admitted to another hospital with acute abdomen and the suspicion of a ruptured ectopic pregnancy. For some reason, most likely related to the fact that she had eaten shortly before her admission, spinal anaesthesia was decided instead of general anesthesia. Several unsuccessful attempts for access were made. She described that during those attempts she felt a sharp electric current-like sensation in both the lower extremities followed by pins and needles-like sensation. She complained intensely and further attempts were aborted. Thereafter and during her hospitalisation she was complaining of disturbing sensory symptoms involving her legs. Over the following weeks, she started to have a progressive 'numbness' of her lower limbs followed by slowly progressive spastic paraplegia over the next twenty months. During that period and especially soon after her discharge, she visited her family doctor and described her problem, which was not properly evaluated and further investigation was not followed. She was getting worse in spite of physiotherapy, which was suggested. During the last six months she developed clear spasticity and paraparesis and was investigated by MRI, which revealed conus medullaris edema and dilated vessels on the surface of the spinal cord. A vascular lesion was suspected and the patient was referred to us for further investigation and treatment. On admission the general physical and systemic examination was unremarkable except for the neurological findings. No family history or sign of any genetic disease related to a central nervous system vascular lesion was discovered. Her neurological findings included severe spastic paraplegia-she came on a wheelchair-with hypoesthesia below the twelfth thoracic (T12) dermatome. Tone was markedly increased, and knee reflexes were exaggerated. Both the plantar reflexes were elicited with an up-going great toe and both her legs were affected by some atrophic changes. Bladder and intestinal sphincter function were preserved.\nAfter her admission she underwent a spinal angiogram that revealed a single, direct, moderate flow, single-hole type AVF at the left first lumbar (L1) level supplied by the anterior spinal artery (ASA), which presented a small dilatation just at the shunt site (). The draining vein and the superficial venous network were dilated with slow flow indicating venous congestion (). In the same session and under general anaesthesia we approached the lesion endovascularly using a Magic 1.2 Fr microcatheter (Balt, Montmorency, France) which was advanced over a Mirage 0.008-inch guidewire (ev3, Irvine, CA, USA). A single drop of N-butyl cyanoacrylate glue 50% was delivered just at the shunt site, which resulted to a complete occlusion of the fistula ().\nAfter awakening, she reported some immediate sensory improvement. Six months after the operation she was able to walk again with assistance. No complete motor recovery was achieved after one year despite of intensive rehabilitation. |
A 28-year-old female patient presented to a physician at the 33rd gestational week with symptoms of hypertension and accompanying edema. Laboratory tests showed nephrotic range proteinuria and the patient was hospitalized after being diagnosed as having preeclampsia. The pregnancy was terminated by cesarean section. She developed a fever and respiratory distress on postoperative day two. Antibiotic treatment was initiated with a diagnosis of pneumonia. The patient experienced increased respiratory distress during the follow-up period and was transferred to the intensive care unit with a suspected diagnosis of acute respiratory failure. The patient was connected to non-invasive mechanical ventilation (NIMV). A thorax CT scan showed symmetrical consolidated regions in the basal and perihilar segments of both lungs, with air bronchograms pronounced in the dependent regions, in addition to minimal pleural effusion in both lungs and a global increase in heart size. The upper lobes of both lungs and the middle lobe of the right lung were conserved, and the findings were consistent with pneumonia on the background of pulmonary edema. The patient was given bronchodilators and diuretic therapy, but a follow-up thorax CT showed an increase in ground-glass opacities so the patient was intubated due to worsening respiratory distress. Laboratory investigations performed at that stage indicated hypoalbuminemia and anemia.\nHer C-reactive protein (CRP) levels decreased under antibiotic treatment and respiratory parameters improved shortly after initiation of mechanical ventilation. She was therefore extubated and supported by NIMV. But her proteinuria was 18 g/day and she was transferred to another center to be followed up by the nephrology department. There, the patient once more experienced respiratory distress and developed peripheral cyanosis. She was re-intubated and monitored in the intensive care unit. A repeat thorax CT showed pneumothorax, which was minimal on the left side (less than 5%), and pneumomediastinum. The patient was extubated after the improvement of respiratory parameters and monitored under oxygen support provided using a nasal cannula. The pneumonia was not considered to be improving based on her ongoing need for oxygen and increases in leukocytosis and CRP levels. Consequently, the antibiotic regimen was changed and the patient, who had ongoing proteinuria and hypoalbuminemia during the entire follow-up period of almost one month, was transferred to our hospital to be monitored by the nephrology department.\nAt admission, the patient’s general condition was good and she was in need of 4 L/min oxygen support. Her chest radiograph showed bilateral extensive reticulonodular infiltrates and a previously obtained thorax CT scan was found consistent with hypervolemia accompanied by infective pathology. Subsequently, as the patient’s CRP levels decreased and fever resolved, the antibiotics were stopped after completing a ten-day course.\nThe patient’s protein level in a 24-hour urine sample was 3.5 g/day and urine sediment showed an average of 5-6 isomorphic erythrocytes, rare leukocytes, and an abundance of hyaline cylinders per field. Based on the recommendations of the Department of Nephrology, 1500 cc fluid restriction was started. The patient was given furosemide infusion because her physical examination indicated bilateral rales. At this time, cardiac evaluation was normal, and resolving renal condition was attributed to pregnancy, and no further evaluation was suggested. Her oxygen requirement decreased but did not resolve, thus a repeat thorax CT scan was obtained, which showed extensive bilateral traction bronchiectasis, adjacent to the regions of extensive ground-glass opacities, and thickening of the interlobular septa (Figure ).\nThese findings were considered to be consistent with interstitial pneumonia and 60mg/day methylprednisolone therapy was initiated. The patient’s need for oxygen ended on the second day of steroid therapy. Rheumatologic pathologies, cryptogenic organized pneumonia, and fibro-proliferative phases of ARDS were considered as differential diagnoses. Rheumatologic evaluations revealed no pathologies, and she was negative for ANA and anti-ds-DNA. Thus, bronchoscopy was performed with the aim of establishing a tissue diagnosis on the second day of steroid treatment. No endobronchial lesion was detected, bronchoalveolar lavage fluid revealed no microbiological pathogens and pathologic examination of the transbronchial biopsy obtained from the right lower lobe showed fibroblastic proliferation, type II pneumocyte hypertrophy, and hyperplasia of the alveolar septa (Figure ), which were consistent with the resolution period of diffuse alveolar damage.\nA thorax CT obtained at the end of the first month of steroid therapy showed regression in the previously observed regions of ground-glass opacity. However, as the patient described exertional dyspnea and her pulmonary function tests showed decreased forced vital capacity (FVC), it was planned to continue steroid therapy at a lower dose. The methylprednisolone dose was reduced to 24 mg at the end of 1 month by reducing the dose once a week and stopped after a period of six months, during which the patient experienced no adverse effects except for plethoric skin. The patient’s symptoms were completely resolved, her FVC increased from 55% to 78%, and almost all ground-glass opacities on thorax CT disappeared (Figure ); she is currently being followed up without any medical therapy. |
A 34-year-old Caucasian woman, gravida 1 para 0, presented to our hospital with repeated attacks of mild vaginal bleeding. Our patient, according to her sure reliable dates, was 16 weeks and three days pregnant. She had a history of primary infertility for seven years preceding this pregnancy, and she had sought medical advice for delayed conception one year after marriage. Male factor infertility was excluded by a single semen analysis and she was informed that her hysterosalpingography was quite normal; she was given medical treatment that she could not recall to improve her cycles (these were infrequent and irregular over the last five years). She used these medications for about four months after which she reported some improvement in her cycles but conception did not occur. A hormonal profile was ordered and our patient was examined transvaginally by ultrasound. Subsequently, she was informed she had bilateral polycystic ovarian syndrome. Her physician prescribed clomiphene citrate (Clomid, Global Napi, Egypt) 100 mg for five days beginning on the second day of her cycle. Our patient continued taking the drug without ovulation monitoring and the regimen was repeated with an increasing dose up to 200 mg daily for six successive months. Laparoscopic ovarian drilling was performed and our patient resumed using clomiphene citrate three months after the operation without prescription. Two months prior to admission, she took 250 mg of clomiphene citrate (five tablets per day) beginning from the second day onwards until the 13th day of the cycle.\nOur patient had a missed period immediately after this haphazard regimen. Pregnancy was confirmed by a urine pregnancy test then by a trans-vaginal ultrasonographic examination that was carried out six weeks and three days after her last menstrual period. According to this ultrasound report, the gestational sac corresponded to seven weeks of gestation. However, there was no comment regarding the presence of theca lutein ovarian cysts. She did not follow-up with her pregnancy until she reached the 16th week of gestation. At that time, she experienced recurrent attacks of vaginal bleeding that she described as mild and dark colored. Apart from pallor and tachycardia, our patient appeared quite normal on general examination; her pulse was 106 beats/minute, blood pressure was 125/85 and her temperature was 37.2°C. Abdominally, her uterine fundal level was equivalent to 28 weeks and the uterus was dewy in consistency in most of its mass. A transabdominal ultrasound examination revealed a huge complete hydatidiform mole occupying the lower pole of the uterus and a coexisting fetus with its placenta that were enclosed within a separate sac (Figure ). Our patient was admitted to our hospital and full laboratory investigations were ordered. Her blood test results revealed microcytic hypochromic anemia and her hemoglobin level was 9.6 g/dL. Other investigations were normal. In spite of her testing positive, her serum β-hCG level was relatively low for a patient with complete molar pregnancy (8354 mIU/mL and 7799 mIU/mL in two serum samples drawn two days apart). The technician did not suspect any technical error and he confirmed the accuracy of the result. However, we considered the possibility of falsely low results and accordingly, a senior specialist was consulted. She repeated the test with serial dilutions and β-hCG was found to be 1.876 million mIU/mL. Our patient was counseled about the risk of continuation of this pregnancy and the low possibility of fetal survival. However, our patient refused intervention and insisted on conservation.\nThe choice of conservative management was quite difficult; our patient was kept under strict observation and she was followed up using a four-hour interval chart for vital signs. Blood picture, renal chemistry (urea and creatinine), liver enzymes and thyroid function tests were ordered twice weekly, vaginal bleeding was observed and our patient was asked to report any pain, bleeding or other issues during the period of conservation. Our patient was offered genetic amniocentesis but she absolutely refused the procedure. On day 3, an increase in blood pressure above 140/90 mmHg was reported and it was found to be increasing (Figure ). However, dipstick testing for albumin in her urine gave a negative result. Anti-hypertensive drugs were not given in order not to mask her actual blood pressure. She experienced palpitation, flushing and excessive sweating from day five and the thyroid function test was repeated; the results indicated thyrotoxicosis (T4 = 3.26 ng/dL, free T3 = 5.95 pg/mL, thyroid stimulating hormone (TSH) = 0.022 μIU/mL). Two attacks of mild vaginal bleeding were reported on days five and nine. The dipstick testing for albumin in urine became positive (1 plus) on day seven and the results became worse over the next few days reaching 4 plus on day 10. Our patient was recounseled about these unacceptable complications (thyrotoxicosis and severe pre-eclampsia) and for the low possibility of fetal survival. Again, the patient refused termination. Two days later, the patient developed a severe attack of vaginal bleeding; a hysterotomy was inevitable. She delivered a 680 g viable boy with no apparent congenital anomalies; the placenta was complete, about 15 cm in diameter and adjacent but identifiable from the coexisting molar pregnancy. The baby died half an hour later in the neonatal intensive care unit. A histopathological study confirmed the diagnosis of benign complete hydatidiform mole. Unfortunately, karyotyping was not available.\nHer serum β-hCG level was followed up after termination; it dropped progressively until it became negative after 70 days and remained so for 12 successive months (Figure ). Serial dilution of the sample was no longer needed after termination. |
A 16-year-old male, presented with a Class II division 2 incisor relationship on a mild Class II skeletal base with average vertical proportions. This was complicated by a moderately crowded upper arch, buccally impacted UR3, and increased overbite, which was complete to soft tissue with no evidence of trauma (). The maxillary central incisors showed white and cream opacities. His dental history revealed delayed dental development, and also reported that his-MIH-affected FPMs were extracted at the age of 9. No orthodontic consultation had been sought at the time. His OPT moreover confirmed the presence of all third molars, apart from the lower right third molar. The upper standard occlusal radiograph showed no evidence of pathology associated with the upper right lateral incisor and upper right canine.\nThe FPMs in this case report were extracted around the recommended optimal age (8–11), which led to successful spontaneous eruption of the second permanent molars (). The space requirements in the upper arch, however, were deemed to be significant in this case; perhaps the temporization or restoration of the upper FPMs might have been a valid treatment alternative at the time. Additionally, the early extraction of the FPMs led to compromising the molar dentition in this case, due to the congenital absence of the lower right third molar (). It is important to take into consideration the third molar’s presence when treatment planning for the extraction of FPMs, to ensure the remaining molars erupt in a position that maintains good functional occlusion.\nIn contrast to Class I cases, the extraction of FPMs in growing Class II cases is more critical to plan, particularly with regard to the timing of upper FPMs extraction. This is due to the space requirements often needed in the upper arch for the correction of the incisor relationship and increased overjet. Whilst a favourable mesial eruptive position of second permanent molars was achieved in this case, the timely extraction predisposed the patient to a number of malocclusion features, including ():Round tipping of upper and lower second permanent molars; Distal tipping of lower second premolars; Spacing in the lower arch; Excessive retroclination of the lower labial segment that worsened an inherent deepbite.\nThe aforementioned features are a relatively common sequelae of the early extraction of FPMs in some Class II malocclusions, particularly the division 2 type, and they often present with a varying degree of severity. |
A 72-year-old Caucasian man was admitted to our department with a pain in the left posterior mandible and periodontal hyperplasia associated with the left mandibular second molar tooth. He also complained about the ongoing pain for 2 months and spontaneous hemorrhage within the lesion region.\nAccording to his medical history, the patient had suffered from coronary angioplasty 6 years ago. He also suffered from malaise and fatigue for last 1 year and also inappetence for last 6 months.\nExtraoral examination of the patient showed no visible swelling, tenderness or pus discharge. Skin color and temperature were normal. In the intraoral examination of the relevant region, oral hygiene level was not good and gingival tissue around the second molar was hyperplastic and had a tendency to spontaneous bleeding.\nOn the other hand, the panoramic radiograph (PANO) showed a radiolucent lesion with irregular margins located the periapical area and also extended coronally that led into the serious mobility of mandibular left second molar tooth (Figure ).\nConsidering the patient's medical history and after an exhaustively clinical and radiographical examination, we decided to perform an incisional biopsy under local anesthesia. As expected, the result of the pathological examination was peripheral giant cell granuloma (PGCG). We did not consider to take an initial photography before the surgical procedures, however, with regard to the pathological results, we decided to perform another surgery under local anesthesia 1 week later, including extraction of the tooth and a wide curettage of the lesion in the left posterior mandible. Despite the anesthetic procedures were performed properly and adequately, the patient was still suffering from pain but no severe hemorrhage during the curettage was observed from the surgical area. After pathological assessment of the second biopsy, the lesion was diagnosed as DLBCL (Figure ).\nEven though the patient was relieved and healing was uneventful, we did several consultations and asked for PET/CT scan of entire body because of metastatic nature of DLBCL. After all of these scanning procedures, we doubted the patient may also have had DLBCL in his thyroid gland, gastric system, and prostate either.\nOn the other hand, 2 weeks later from the second biopsy, our patient had satisfactory outcomes, such as; no pain, hemorrhage, or swelling in the operated area. He stated that he is totally relieved and he is ready for the prosthetic procedures.\nMandibular biopsy results showed sheets of medium to large lymphoid cells with hyperchromatic nuclei and scanty cytoplasm. These cells stained positive for CD3, CD20, LCA1, and LCA2 for Cyclin D1 (clone Polyclonal). Ki67 proliferation index was %90. The tumor was also positive for MUM-1 and BCL 2 and BCL 6 (Figure ). Other blood tests and bone marrow investigations did not reveal any abnormality. However, the gastrointestinal tract biopsy resulted in almost the same outcome, with a slight difference of %80 Ki67 proliferation index, positive CD5 (Clone 4C7), and CD138 (clone MI-15) and negative Cyclin D1 results. Attributed to these results, the lesion in the gastrointestinal tract was diagnosed with DLBCL (Figure ).\nEven though radiological findings were not satisfactory enough in our second and the third follow-up (Figure ) and intraoral healing of the patient was still uneventful after 3 months (Figure ), the patient was decided to have several courses of systemic chemotherapy by the department of oncology as further treatment protocol of DLBCL.\nNevertheless, the patient had a stroke after chemotherapy finished (6 months later) and he passed away within 2 years after diagnosis due to DLBCL. |
A twenty-five-year-old gravida 3 para 0111 had established limited prenatal care at our office at 9 weeks of gestation in conjunction with maternal fetal medicine for a known history of deep venous thrombosis (DVT) and pulmonary emboli (PE). The patient had multiple PEs and DVTs over the course of six years and was instructed to continue lifelong anticoagulation; however, the patient failed to maintain compliance until this pregnancy where she was placed on enoxaparin 100 mg twice daily. Her obstetrical history was significant for a preterm cesarean delivery at approximately 33 weeks of gestation, for arrest of dilation after failed induction of labor for preeclampsia two years before. This was followed by a missed abortion at 16 weeks of gestation requiring a dilation and extraction six months prior to the current gestation. She had no notable gynecologic or social history. Her family history included multiple family members with ischemic cerebrovascular accidents. The patient did not follow up again until 21 weeks and 3 days of gestation for a visit with maternal fetal medicine and was immediately sent to labor and delivery for prompt evaluation of her symptoms. This included headache, nausea, vomiting, syncopal episodes, right upper quadrant pain, and blurred vision. Her vital signs were stable and she remained normotensive; however, due to her history of preeclampsia, a 24-hour urine protein level was collected in addition to liver function panel, blood urea nitrogen, and creatinine for assessment of renal function. An EKG was also obtained due to complaints of syncopal episodes. Given her history of multiple PEs and DVTs, a thorough coagulopathy workup was done including antiphospholipid antibodies. Lab abnormalities included lupus anticoagulant antibody via Russell Viper Venom test in addition to anticardiolipin IgG titers > 112 and elevated IgM titers (74.5). The patient left against medical advice before completion of her workup and presented 10 days later to labor and delivery with complaints of worsening nausea, vomiting, chest pain, headache, and shortness of breath. On examination, vital signs remained stable including a blood pressure of 126/87 and pulse oximetry at 100% with her pulse at 56 beats per minute. She was noted to have significant right upper quadrant tenderness on superficial palpation. Her cervix was 0 cm dilated and 0% effaced, appropriate for gestational age. Fetal heart tones were noted to be 160 beats per minute. Lab evaluation revealed a platelet count rapidly declining within hours of presentation from 111,000/mcL to 58,000/mcL. SGOT and SGPT were noted to be 179 U/L and 194 U/L (from a baseline of 23 U/L and 21 U/L, resp.). EKG revealed normal sinus rhythm; additionally, troponins were negative; however lactate dehydrogenase remained as high as 480 U/L. Haptoglobin was also noted to be <10 mg/dL, well below the normal range suggestive of microangiopathic hemolytic anemia (MAHA), confirmed by peripheral smear. Anti-Xa was 0.7 IU/mL (within the therapeutic range) demonstrating patient compliance with anticoagulants. The remainder of her comprehensive lab workup was within normal limits. Due to significant and rapid decline in platelet count, conversely elevated liver function tests, and 24-hour urine protein of 329 mg, a preliminary diagnosis of HELLP was made and induction of labor was initiated. Given the patients' critical prognosis with rapidly worsening lab findings, immediate delivery via cesarean section was undertaken. A central line was placed prior to surgery and a Jackson-Pratt drain placed intraoperatively due to critical platelet levels. The patient was brought to the intensive care unit (ICU) postoperatively where she was continued on a magnesium drip since there was concern for HELLP. After minimal clinical improvement, hematology, critical care, and cardiology teams were consulted for a multidisciplinary approach. All teams reached a consensus for a diagnosis of probable CAPS and intravenous heparin infusion was initiated. Brain imaging was not performed since clinical improvement in neurologic manifestations drastically improved. Placental pathology reported focal fetal thrombotic vasculopathy characterized by microthrombi within villous vessels with decidual and adjacent placental infarct. She achieved clinical stability after postoperative day (POD) 2 and was transitioned to enoxaparin 100 mg twice daily. On POD 3 she was transferred out of the ICU and continued to meet all postoperative goals allowing for discharge in stable condition POD 4. The patient was instructed to follow-up in the office with plans to repeat lab workup for confirmation of APS. |
A 53-year-old woman came to our observation for persistent cough and dyspnea, increasing over the last 12 months. On physical examination, swelling and venous distention in the left side of the neck were noted, together with dilated vein collaterals in the upper left hemithorax. Chest x-ray detected a mass in the upper anterior mediastinum, causing narrowing and right-side deviation of the trachea. Blood tests were normal, including thyroid function tests. The patient medical history was unremarkable. Contrast-enhanced CT-scan of the neck and thorax showed a mass in contiguity with the left thyroid lobe and extending in the upper mediastinum, consistent with an intrathoracic ectopic goiter (A, B). An ultrasound-guided needle biopsy of the mass was performed through the neck, but histological examination found red blood cells. The echographic appearance of the mass was also consistent with a goiter.\nSurgical resection was indicated. Prior to surgery, arteriography was performed which showed a predominant blood supply from the neck and no significant feeding arteries coming from the mediastinum (A, B). Therefore, a cervical approach was preferred instead of a thoracic approach. UM and AS performed the procedure. A low transverse collar incision was performed. The mass appeared to be encapsulated, adherent to the surrounding structures but without signs of tissue infiltration. The thyroid gland was normal and the lesion appeared to be separated from the left thyroid lobe. The superior pole of the mass was clearly visible but the rest of the lesion extended deeply into the upper mediastinum. After ligation of the feeding vessels in the neck, gentle blunt dissection by finger and pledget was accomplished within the capsule, to achieve an adequate mobilization of the mass. Finally, the mass was delivered from the mediastinum and completely removed through the cervical incision. No significant bleeding occurred from the mediastinum. The left recurrent nerve was identified and preserved throughout the procedure. Frozen section examination found a mesenchymal tumor. The thyroid gland was not removed.\nThe post-operative course was uneventful and the patient was discharged on the fourth postoperative day. Histological examination showed a paraganglioma with a low mitotic index <5% (). The resection was complete. The patient is alive without recurrence 30 months after surgery. |
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.\nOn examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.\nMRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).\nIt showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Total resection of the lesion was done through only anterior knee portals without taking the risk of posterior portals preventing potential neurovascular injury. The pathology report confirmed the presence of PVNS. On 6-month MRI follow-up, the previously described soft tissue enhancement suggestive of residual inflammatory changes noted within the femoral notch along the cruciate ligaments as well as posterior to the distal metaphysis at the site of the previously present lesion has decreased (Figures and ). The synovial fluid had also decreased with no evidence of hemosiderin deposits. There was no evidence of interval appearance of new susceptibility artifacts or blooming effect on the T2 gradient sequence that could correspond to evident recurrence. The compressive effect previously present on the popliteal vessels has completely disappeared with no further tingling sensation and numbness over the calf region. Clinically, patient regained full ROM on flexion extension (0° to 135°) of the knee. The previously reported pain no longer exists, with no blocking upon flexion. Patient underwent physical therapy protocol and showed significant muscle strength and balancing improvement. She was scheduled to 1-year clinical follow-up. |
We present a case of a 70-year old Caucasian gentleman who underwent a living donor renal transplant 10 years ago following a diagnosis of glomerulonephritis aged 34. More recently, he had developed acute heart failure manifested by bilateral leg oedema, facial oedema and difficulty in breathing together with severe and difficult to control hypertension with wide pulse pressures. Biochemistry at the time of presentation revealed Cr 190 mmol/L and eGFR 27–32.\nThe patient had past history of several transplant biopsies performed to investigate repeated rise in serum creatinine level over the last 10 years. Clinically, there was audible bruit over the right side of the lower abdomen. Ultrasound, CT angiography scan and subsequently catheter angiography demonstrated very high flow arterial venous fistula within the transplanted organ (Fig. ), likely to be the cause of the patients symptoms of decompensated heart failure. The main transplant artery and veins, as well as all intra renal branches were aneurysmal with extreme tortuosity, especially in the intra renal vessels. The maximum diameter of the main transplant artery was 12 mm with relative narrowing at the origin. Other salient findings were ectatic and tortuous iliac vessels (Fig. ). Given the decompensated heart failure being caused as a result of the high flow AVF, patient planned for super-selective embolisation of the arterio-venous communication under interventional radiology.\nInformed consent was obtained and patient readmitted for elective super selective renal transplant embolization, to be performed under general anaesthesia in order to control the patient’s haemodynamic status. Given the knowledge of high flow through the AVM, plans were made to make both arterial and venous punctures. The contralateral left common femoral artery was punctured under ultrasound guidance and 6F sheath was inserted and positioned in the right common iliac artery. Through the sheath, the transplant artery was selected and 6mmx40mm angioplasty balloon was positioned and inflated at the origin of the transplant artery to reduce inflow and hence pressure into the AVM. The site of the AVM was approached via the venous side.\nSince the arterial side has a tight, almost 360°, backward bend to AV communication site and the venous channel has shorter and straighter path, a 6F sheath was inserted into the right common femoral vein, aiming to deliver the embolic device. Multiple attempts at cannulating the fistula from the venous side failed due to the predicted factors previously described. The tortuosity of the vessels led to difficult in reaching the exact site of the AVM, whilst the high flow from the arterial side continually forced the guide wires and catheters out of the transplant vein and back up into the common iliac vein as the inflated balloon at the origin of the artery failed to reduce the flow.\nTherefore, an additional 12F sheath and balloon (Medtronic ReliantM stent graft balloon catheter) were inserted into the venous ipsilateral side, coming from an insertion site just above the initial puncture. This balloon allowed transient occlusion of the common iliac vein (Fig. ), to ensure the guide wire remained in the transplant vein and not forced back into the host common iliac vein by the arterial pressure coming through the AVM. Once the wire was secured in situ, an occlusion plug (10mmx7mm) (AMPLATZER ™ Vascular Plug II, Abbott) was advanced through a 6F sheath and deployed across the fistula (Fig. ). This led to good embolic occlusive result with subsequent angiography showing no flow across the previous fistula (Fig. – (a) pre occlusion plug and (b&c) post occlusion plug).\nFollowing successful embolisation of the fistula, patient’s haemodynamic status remained stable. There was a transient rise in serum creatinine immediately after the procedure due to contrast nephrotoxicity from the procedure itself. In the proceeding weeks, the blood pressure decreased to around 130/85 systolic and serum creatinine improved to 138 on latest bloods. Of most importance, the patient is clinically significantly improved and has reported complete resolution of breathlessness and oedema – suggesting his symptoms were a direct result of the AVF causing high flow cardiac failure.\nUSS of the transplanted kidney performed 1 week after intervention showed good perfusion and no evidence of a residual or recurrent AV fistula. Follow up CT Angiogram performed 2 months after procedure confirmed good perfusion of transplanted kidney, stable position of the occlusion device at AVF site and resolution of the previous AVF (Fig. ). |
A 58-year-old male was referred to us for the evaluation of a possible percutaneous treatment for an adrenal metastasis from a previously resected lung cancer. The patient underwent 4 years before right upper lung lobe resection for a high-grade lung papillary adenocarcinoma. One year later, he developed a new lung lesion in the right lower lobe, and brain and left adrenal metastases, treated with repeated sessions of radiation therapy. The treatments achieved a good disease control at the brain level, meanwhile the adrenal lesion relapsed. The patient was referred to our Department of Interventional Radiology for local ablative treatment as radiation therapy was considered no more feasible. When the patient was evaluated for ablation, the adrenal lesion measured 31 mm (). The patient was considered suitable for a CT-guided microwave ablation. Percutaneous image-guided ablations have been reported to be feasible for the treatment of adrenal gland metastases [–].\nUnder general anaesthesia, the patient was placed in the prone position. As the adrenal lesion was very close to sensitive surrounding structures, such as the stomach, the colon and the pancreas (, ), percutaneous injection of carbon dioxide (CO2) was planned in order to displace the sensible structure from the adrenal gland. A protective manoeuver, such as the injection of fluid, gas or dedicated gel, has been successfully reported in order to displace the surrounding structure from the target of an image-guided ablation [–]. These techniques may increase the safety of image-guided procedures and help to enrol patients otherwise unsuitable for percutaneous treatment due to the high risk of complications. A 21 G needle was percutaneously placed under CT guidance medially and deeper to the lesion, in its close proximity (). Once the needle was in the planned position, a 20-ml syringe was filled with CO2, and manual gas injection was performed. CO2 is particularly helpful in some cases, as it displaces the surrounding structures and also allows the achievement of a thermal insulation between the sensitive structures and of the area to be treated, as, compared to fluid materials, gas conduces by far less the heating. On the contrary, gas is compressible and easily diffuses into the soft tissues following the less resistance plane and may not be sufficient to achieve the planned displacement. Thus, it is important to exactly understand where to place the small needle in order to reach the desired displacement. In our case, we planned to place the needle as close as possible to the adrenal gland, with the aim of achieving a gas distribution exactly around the gland. After the injection of CO2, we were able to achieve a good distribution of the gas around the gland and a good displacement of the surrounding structures (). At this point, the microwave antenna was inserted into the gland and the ablation was performed by using an energy of 60W for 6 min (). Microwaves represent a fast spreading technique for percutaneous ablation, as it allows the delivery of high energy in quite a short time, thus offering the possibility of achieving larger ablation volumes in a shorter time if compared to other techniques, such as radiofrequency [, ]. No complications occurred after the treatment and the patient had a regular clinical course and was discharged the day after treatment. The control performed with contrast enhanced CT 24 hours after the treatment demonstrated the complete devascularisation of the treated lesion (), which was considered to be completely ablated. |
A middle-aged female clinical doctor with no previous data of serious ill conditions had got over the chicken pox in early childhood (when she was five years old). She had no feeling of any health disorder but these days in the beginning of November of 2015 year she had too much work in her workplace in the hospital: in a short time several nights on duty with big number of seriously ill patients. In her private life she had a very big emotional stress–some financial problems of buying new apartment with neglecting proper nutrition in that period.\nAround 10th of November she began to feel fatigue, anorexia, general weakness, irritability, mild depression, which she explained that she was overworked. On the 12th of November when she went to sleep she felt the discomfort and mild pain beside the spine in the level of right scapula. She had difficulties in falling asleep with a number of awakenings during the night with feeling of discomfort and mild pain in the right shoulder, upper arm and right elbow. In the morning 13th of November she noticed the red skin indurated papules the size of a few millimeters to half a centimeter in diameter in the palmar side in the root of ring finger. During the day a few indurated papules appeared in the border between the palmary and dorsal side of the right hand in the area of innervations of the ulnar nerve. On the 14th of November a couple of the same indurations appeared in the palmary side of right hand in the root of forearm, and in the region of pinkie finger. In the next few days (4 to 5 days) skin of the ulnary side of the palm of the right hand became erythematous and grouped herpetiform vesicles developed hour by hour, day after day and almost complete clinical picture was developed on the 17th of November. The vesicles were cloudy, some of them with red border, some of them merged in blisters more than 2 centimeters in diameter. That day she went to doctor dermatologist who characterized the appearance as hemorrhagic form of herpes zoster and therapy was prescribed: Acyclovir tbl 5x 800mg two days and 5x600 mg 4 days four days, broad–spectrum antibiotic, vitamins B12 and B1, B6, analgesics and Acyclovir cream locally several times on day. The entire time patient felt fatigue, general weakness, discomfort and pain in most expressed in elbow and in ulnar side of forearm, ulnaro-carpal joint and in the palmary and dorsal side of the right hand all in projection of the branching of ulnar nerve. The vesicles were staggered and grouped also in the projection of ulnar nerve innervations. The pain may be described as burning but no narcotics were needed. It might be reduced by no steroidal anti-inflammatory drugs (ibuprofen) 3 to 4 tablets per day. During the first three days of therapy some new vesicles erupted. About 10 days after first eruption some vesicles started converting into crusts with no new vesicle eruption. After vesicular involution, there was slow resolution of the remaining erythematous plaques, but with visible squeals. On the control examination (10 day after first examination) the dermatologist characterized illness as gangrenous form of herpes zoster with recommendation to patient to examine her immune system and to use panthenol ointment–for epithelialization and skin regeneration long time and eozine (antiseptics) locally for five to six days. She has done blood testing (ESR-erythrocyte sedimentation rate, FBC–whole blood count, liver and kidney laboratory tests, rheumatic tests, OraQUICK HIV test, urine examinations, chest x- ray, ultrasound examination of abdomen and pelvis. All examinations were in normal rate. From day to day she felt better and better but 30 days after the begging of illness she still have crusts in the places of vesicles, the largest one on the ulnar side of the palm of right hand with mild pain in involved area. Two months after first vesicular eruption there are sequels in the form of the pink stains in the places of previous vesicles with mild hyperesthesia in involved area and very mild occasional pain in there especially in the evening.\nThe appearance of skin manifestations in first seven days is presented in the figures , , . |
A 35-year-old Caucasian female with extensive history of pelvic surgery but without prior urological history underwent robotic-assisted laparoscopic excision of endometriosis by gynecological surgery team secondary to chronic pelvic pain with suspected endometriosis. On initial laparoscopic evaluation of pelvic contents, visible vermiculation of bilateral ureters was noted as well as suspected findings of endometriosis-like lesions covering the pelvic peritoneum. The pelvic peritoneum was excised with sparing of the urinary bladder. Careful ureterolysis was performed bilaterally, during which the distal left ureter was found to be partially denuded, spanning 2 cm in length (). An intraoperative urologic consultation was requested, and denuded ureteral injury was confirmed by urology on laparoscopic evaluation. Given no evidence of ureteral laceration or obvious extravasation of urine from left ureter, no cystoscopy or contrast studies were performed. A 2 cm x 12 cm AmnioFix membrane was wrapped three times around the left ureter using laparoscopic robotic assistance (Figures and ). The procedure was completed without anesthesia complications and the patient was discharged on postoperative day one in stable condition.\nThe patient was seen by her gynecologist on postoperative day six after experiencing lower urinary tract symptoms and was subsequently started on PO antibiotic therapy. However, her symptoms did not improve, and she developed new left flank pain which brought her back to the hospital for further evaluation on postoperative day seven. She underwent noncontrast CT imaging of the abdomen and pelvis demonstrating moderate left hydroureteronephrosis to the level of the distal ureter. She underwent cystoscopy with left retrograde pyelogram demonstrating 1.5 cm distal ureteral stricture with moderate hydroureteronephrosis (). Continued contrast injection showed a small amount of extravasation from the vicinity of the narrowed ureteral segment (). However, the site of extravasation could not be delineated. A guidewire was passed through the left ureter and into left renal pelvis without resistance and a left ureteral stent was placed. Her pain improved, and she was discharged home.\nPatient was readmitted one month later secondary to nausea, vomiting, and lower urinary tract symptoms at which time she was found to have enterococcus urinary tract infection. Cross section imaging of the abdomen and pelvis was unremarkable without fluid collections. Left ureteral stent was noted to be in appropriate position. She was discharged home with antibiotic therapy with outpatient follow-up in two weeks at which time her ureteral stent was removed.\nThe patient did not report renal colic or abdominal pain following ureteral stent removal. A Lasix renal scan was performed three months following ureteral injury which demonstrated normal perfusion and excretion by 20 minutes without signs of left ureteral obstruction (Figures and ). Differential renal function was 45% left kidney and 55% right kidney. Repeat CT urogram performed 4 months after injury demonstrated no obstructive uropathy or contrast extravasation. Patient was recommended repeat Lasix renal scan in 1 year. The patient reported no symptoms during the interim. |
A 48-year-old man with a prior history of renal transplantation was admitted to our medical center with 2 weeks of fever, chills and left upper quadrant abdominal pain. His history was significant for end-stage renal disease due to congenital solitary kidney and reflux nephropathy which required cadaveric renal transplantation in 2008. His immunosuppressive regimen included mycophenolate mofetil and tacrolimus. Three months prior to his current presentation he was admitted with Salmonella enteritidis bacteremia. During that hospitalization he was found to have a splenic artery pseudoaneurysm measuring 4.9 × 5.1 × 7.8 cm on abdominal computed tomography. This was suspected to be a mycotic pseudoaneurysm related to the Salmonella infection. After undergoing antibiotic treatment he subsequently underwent interventional radiology-guided coil embolization of the splenic artery pseudoaneurysm without complication.\nAt the time of his current admission, the patient reported 2 weeks of subjective fevers, intermittent chills and abdominal pain. The pain was located in the left upper quadrant, dull in quality, and was not associated with eating. On presentation he was afebrile and had normal vital signs. There were surgical scars from his prior renal transplant surgery. His abdominal exam was notable for mild tenderness in the left upper quadrant with normal bowel sounds. There was no guarding or rebound tenderness. Laboratory tests were notable for a mild leukocytosis and stable renal function (table ). Blood and urine cultures were negative.\nThe patient had an abdominal X-ray revealing a fragment of embolization coil in the right lower quadrant (fig. ). Abdominal/pelvic computed tomography with oral contrast revealed a migrated coil within the right colon (fig. ). The remaining coils appeared to be within the splenic artery. There was no evidence of contrast extravasation or free intraperitoneal air. The patient subsequently underwent diagnostic upper endoscopy. This identified a large mucosal defect in the proximal stomach, with numerous coils extruding into the gastric lumen (fig. ), consistent with a gastrosplenic artery fistula. The patient subsequently underwent exploratory laparotomy with splenectomy, distal pancreatectomy, partial gastrectomy, resection of the splenic artery aneurysm and removal of the splenic aneurysm coils. He had an uneventful recovery and was discharged from hospital 9 days after surgery. |
A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical report\nOn physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.\nThe patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement denoting an abscess. There was diffuse anterior abdominal wall fat stranded with subcutaneous pockets of air denoting infection. Subcentemetric mesenteric lymphadenopathy was observed ().\nPatient was taken to the OR for exploratory laparotomy and drainage of the abscess. Upon internce to the abdomen a large pocket of pus in subcutaneous layer was opened and evacuated and a swab was sent for culture and sensitivity. A firm mass inclosing the pelvic was dissected and found to be a large diverticulum 10 cm from the ileocecal junction. The mass was attaching to the urinary bladder and was fistulating to the subcutaneous pus collection. Urology was called in at this point and the urinary bladder was checked by injecting methylene blue dye; there was no leak. Limited right hemicolectomy was performed with a primary iliocolic anastomosis ().\nHistopathology was consistent with diverticulum of the small bowel and serosal lipoma with a pocket containing multiple staghorn-type black stones, negative to tuberculosis (). Patient wound culture from OR showed E. coli which was sensitive to Tigacyclin. Treatment was started with this antibiotic and patient’s condition improved. Postoperative course was uneventful except for a small dehiscence at the lower part of the abdominal wound, which was treated conservatively with VAC dressing. Patient was discharged to travel to his country, and the wound was left for secondary closing. |
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.\nOn examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.\nMRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).\nIt showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Total resection of the lesion was done through only anterior knee portals without taking the risk of posterior portals preventing potential neurovascular injury. The pathology report confirmed the presence of PVNS. On 6-month MRI follow-up, the previously described soft tissue enhancement suggestive of residual inflammatory changes noted within the femoral notch along the cruciate ligaments as well as posterior to the distal metaphysis at the site of the previously present lesion has decreased (Figures and ). The synovial fluid had also decreased with no evidence of hemosiderin deposits. There was no evidence of interval appearance of new susceptibility artifacts or blooming effect on the T2 gradient sequence that could correspond to evident recurrence. The compressive effect previously present on the popliteal vessels has completely disappeared with no further tingling sensation and numbness over the calf region. Clinically, patient regained full ROM on flexion extension (0° to 135°) of the knee. The previously reported pain no longer exists, with no blocking upon flexion. Patient underwent physical therapy protocol and showed significant muscle strength and balancing improvement. She was scheduled to 1-year clinical follow-up. |
An 88-year-old male with severe diabetic peripheral neuropathy secondary to type 2 diabetes mellitus that had been diagnosed >20 years previous with complaints of exacerbation of dry mouth was admitted for further treatment. He was managed with blood glucose control by using insulin injections. However, a fever accompanied by increasing white blood cell and leucocyturia indicated an infection requiring antibiotics. A simple CXR revealed pneumonia and pleural effusion in both lower lung. Considering the aged patient also presented with edema with limbs and hypoproteinemia, a single-lumen CVC was introduced into the right subclavian vein to maintain robust and secure intravenous access, by an experienced physician.\nThe patient was placed in the supine position and the right subclavian vein was punctured, blood was easily aspirated, and the guide wire was inserted through the needle without any resistance up to 20 cm and the needle was removed. After dilating the skin and subcutaneous tissue, a one-lumen catheter was pushed in along the guide wire and inserted to a depth of 15 cm using the Seldinger technique. No resistances were felt during the initial insertion of both the guide and the catheter, and we confirmed aspiration of venous blood through the catheter. After insertion, the patient complained no obvious symptoms. Moreover, there was no noticeable resistance, arrhythmia, or changes in vital signs were observed during the initial insertion. No clinical manifestation was intensified by flushing the catheter with saline solution. Introduction of intravenous fluids resulted in corresponding clinical responses that further supported that the catheter was functioning.\nAfter the procedure, we arranged the bedside ultrasound to rule out pneumothorax and other complications. Vascular ultrasound of the jugular vessels detected the immediate appearance of venous tube in the right internal jugular vein from 2 parallel hyperechoic lines consistent with a portion of a catheter, thus establishing that the kinking tube forming a U-turn shape, eventually led the tip close to the junction between internal jugular vein and brachiocephalic vein (Fig. , Supplementary Appendix 1). It was concluded that the catheter had entered the right internal jugular vein directly, but its tip remained downward without causing severe complications and somehow partially functioned. Color ultrasonic Doppler ruled out extravascular effusion or vessel perforation.\nThe posteroanterior chest radiograph was obtained to confirm the position of the catheter tip, showing it ascending into the right internal jugular vein. The CXR definitely disclosed catheter tip positioning in the right internal jugular vein, the radiologist also reported catheter malposition. No signs of pneumothorax were present, and the patient had no chest pain or dyspnea.\nThe patient also had chest tube drainage on the right side. We next performed a bedside ultrasound at the anterior chest wall in the supine position and found out the presence of typical lung point (Fig. , Supplementary Appendix 2). In particular, abolished lung sliding, plus the A-line sign, which was a fundamental ultrasonographic sign highly specific for confirming pneumothorax. However, typical clinical manifestations such as dyspnea or decreasing of pulse oxygen saturation were still missing. Because some normal physiological conditions can be misdiagnosed for false lung points,[ we later perform the CXR to draw the conclusion (Fig. ). Once again, the diagnosis of CXR was consistent with bedside ultrasound.\nThe malpositioned catheter should always be removed due to the risks such as embolization, perforation, and consecutive pericardial tamponade.[ In the present patient, the catheter functioned properly, and there were no apparent adverse effects from the malpositioned CVC. As the patient was asymptomatic and the catheter was functioning normally, the catheter was used for the following 20 days without complications. Ultimately, we carefully performed the catheter removal. After the inserted catheter was removed, we attempted a new CVC through the left internal jugular vein. This time, we applied the ultrasound-guiding technique, paid attention to the direction of the guide wire to guarantee the catheter was located in the right place. After the procedure, bedside ultrasound was performed once again to reassure the intravenous placement and did not require further treatment. A routine CXR was reported as showing a left-sided CVC correctly terminating in the superior vena cava. After successful replacement of the central catheter, no further complications were observed. Malposition of central venous cannulation via the subclavian vein is a rare and hazardous event.[ The risk for this complication is increased if catheters are inserted in left-sided veins.[ |
A 58-year old Saudi female presented to the clinic for her routine follow-up appointment. The patient possessed a medical history of Bronchial Asthma and Chronic Rhinosinusitis with nasal polyps, for which she underwent Functional Endoscopic Sinus Surgery (FESS) on three separate occasions, the last of which was 7 years prior to the time of her current visit to the clinic. She had been prescribed Pulmicort nasal irrigations.\nHer chief complaint was a progressive left nasal obstruction and a noticeable mass in the left nostril over a duration of 2 months, which was associated with nasal discharge, facial fullness, and hyposmia.\nOn examination there was a Grade IV Nasal polyp in the left nasal cavity, while the right nasal cavity was patent and the sinuses were clear. On further advancement of the nasal endoscope within the left nasal cavity, between the polyp and the septum, clear ethmoid and sphenoid sinuses were seen, and it was determined that the polyp was originating out of the left maxillary sinus.\nThe treatment plan comprised of the excision of the polyp in entirety, in order to regain patency of the nasal airway. During the polypectomy under local anesthesia, a granulation tissue was found at the attachment of the polyp at the level of the Natural Ostium. The polyp along with the granulation tissue was completely removed and sent for histopathological assessment. Interestingly, the results showed an inflamed and ulcerated benign polyp with focal granulation tissue formation along with foreign body giant cell reaction around cholesterol clefts (). This established the definitive diagnosis of Cholesterol Granuloma of the left Maxillary Sinus. Based on this finding, a Computed Tomography (CT) scan of the paranasal sinuses was requested, which revealed mucosal thickening of only the maxillary sinuses and ruled out any residual lesion or bony destruction ().\nThe patient was recalled for 3 subsequent visits over a span of 6 months and was deemed to be doing very well with no recurrence of the granuloma or the polyp. |
A man, aged 67, was admitted to the Department of General and Vascular Surgery for an elective surgical procedure, due to clinical signs of abdominal aortic aneurysm, manifesting with periodical pain of changing intensity in the epigastric region (). The aneurysm had been diagnosed 3 months prior to the patient’s admission to the department. Before, the patient had suffered from episodes of stroke and undergone a bilateral trepanation of the skull, performed due to subacute subdural haematomas. His history also revealed long-lasting nicotine smoking and pharmacologically treated arterial hypertension. On admission, the patient was conscious and normally responsive. In a neurological examination, the patient was diagnosed with right hemiparesis, a consequence of previous strokes and neurosurgical procedures. In the epigastric region a mass, painless on palpation, resembling an aneurysm was revealed in a physical examination.\nThe patient was ordered an endovascular stent graft implantation procedure due to his clinical condition as well as due to the lower perioperative mortality and morbidity of this method in selected groups of patients in comparison to open surgery []. The approach to the abdominal aortic aneurysm was achieved by incising both the femoral arteries, through which a Zenith bifurcated stent graft was inserted. Systemic anticoagulation with 2500 IU of unfractionated heparin (UFH) was accomplished before catheter insertion and manipulation into the femoral arteries.\nBranches of an endovascular prosthesis were placed in the common iliac arteries. The stent graft body was placed in the abdominal aorta, below the place where the renal arteries arise, which allowed the aneurysm to be excluded from the circulation. A follow-up intra-operative angiography confirmed the proper placement and expansion of elements of the prosthesis (). It also revealed proper contrasting of renal arteries, iliac external and internal arteries and no traces of leak.\nOn the first day following the stent graft implantation, the patient’s condition dramatically deteriorated. He reported severe headaches, nausea and vomiting. He was periodically unresponsive and the verbal contact was impaired. The blood pressure was 200/90 mm Hg. Due to clinical symptoms and suspicion of another cerebral stroke, a single-phase computed tomography (CT) of the head was performed. The result of the examination allowed ischaemia to be excluded.\nOn the second day after the procedure, decreased muscle tone and decreased temperature in the lower extremities were observed. A neurological examination revealed bilateral flaccid paralysis as well as deep and superficial sensory disturbances of the lower limbs.\nAn magnetic resonance imaging (MRI) examination of the lumbosacral segment of the spine was performed urgently. It showed dilation of the whole distal segment of the spinal cord from the Th11 level to the mid L1 level, i.e. including its cone. Changes of signal intensity in T2-weighted images in the whole area of the cord at those levels, including the white and gray matter, were observed. The MRI results implied oedematous and ischaemic lesions ().\nResults of imaging examinations and clinical manifestations were the basis for diagnosing a stroke of the distal segment of the spinal cord, supplied by the Adamkiewicz artery. After 11 days of hospitalization, the patient, demonstrating flaccid paralysis and sensory disturbances of the lower extremities, was moved to the Ward of Internal Medicine for rehabilitation treatment. |
A 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The winged scapula did not emerge when the patient pushed on a wall at chest level. Radiographs showed a small bony fragment in the ventral side of the ISA, with a narrow space between the fragment and the scapular body (). Computed tomography revealed a bony protrusion extending from the medial scapular border to the bony fragment, with a narrow gap between the protrusion and the fragment (Figures –).\nThe patient was instructed to avoid elevating the left arm for 2 months and then performed reinforcement exercises of the SA such as the scapular push-up and the bear hug using an elastic band for 2 months. At examination 4 months later, the periscapular pain and the winging of the scapula with the arm at the side and in active flexion had resolved. The push-on-the-wall test at waist level was negative, and the range of motion of the left arm was the same as the unaffected side, except for a 15° limitation in external rotation. Although the radiographic findings were the same as at the first visit, computed tomography demonstrated bony union (Figures and ). The patient was permitted to use the left arm without restrictions.\nAt the time of the final follow-up 10 years of postinjury, the patient reported that there was an occasional painless click and a sporadic floating feeling of the scapula with initial active flexion of the arm. However, there was no pain or any disturbance to the patient's activities of daily life and work as a physical therapist. The patient's colleague confirmed the disappearance of the winged scapula associated with shoulder movement. The DASH score was 0, and the Constant score ratio compared with the right shoulder was 100% [, ]. |
This is the case of an 80-year old male without history of liver disease. His past medical history included hypertensive heart disease and chronic atrial fibrillation with cardioembolic cerebellar stroke in June 2009 for which he was assuming warfarin. In May 2010 the patient was admitted for severe anemia due to acute bleeding of a voluminous mass of the right liver lobe. Anticoagulant therapy was stopped and he underwent a contrast-enhanced liver CT that showed a radiologic pattern consistent with a malignant lesion. A percutaneous biopsy of the liver lesion revealed grade 2 HCC. AFP serum levels were normal. In December 2011 the patient was referred to our Unit and was staged with a contrast-enhanced CT scan that showed a lesion in segment VI of 111 mm x 95 mm with a small adjacent satellite lesion, and other three lesions with a maximum diameter of 22 mm (segment I), 25 mm (segment VIII), and 24 mm (segment IV) (, A, B, E, F). Due to the multifocal HCC with a high risk of bleeding and spontaneous rupture of the major lesion, we judged the patient not eligible for endovascular or sorafenib treatment (). Considering the absence of chronic liver disease, and the good clinical conditions (ECOG Performance status 0), we proposed an off label treatment with metronomic capecitabine at the dose of 500 mg thrice daily. The patient gave the informed consent and started treatment in January 2012. The contrast-enhanced CT scan, scheduled every three months, showed a progressive reduction in vascularity of all nodules with a global dimensional stability of the major lesion. The last control CT scan of January 2013 showed an increase of necrotic area within the largest lesion (, C and D). The lesion of the segment VIII (, G and H), after a reduction in size over the time, was no longer distinguishable from the surrounding tissue. The patient is still in treatment with a good quality of life, without side effects or laboratoristic alterations. |
A 29-year-old male patient was presented with the chief complaint of pain in and around the neck since 3 months with a metallic tracheostomy tube in situ. Furthermore, the patient is apprehensive of the rope tied around the neck for the retention of the metallic tracheostomal tube. No history of difficulty in swallowing was noted. On clinical examination, no scar or ulceration is seen around the stoma. The skin around the stoma is healthy. The patient had undergone for suicidal attempt 3 months before. Following a suicidal attempt with the patient complaining of breathing difficulty he underwent immediate video laryngoscopy examination, which reported as bilateral vocal cord movements were restricted, and the cords were in adducted position with minimal glottic chink. The recurrent laryngeal nerve was severely damaged, and the patient have undergone for gasping with the difficulty in breathing. Emergency tracheostomy was done, and the patient was with the metallic tracheostomy tube for the last 3 months. The patient was apprehended with the metallic tube and had a frequent history of pain and irritation around the tracheostomy site for the past 3 months. The patient was referred to the oral and maxillofacial Prosthodontics Department from Department of ENT to customize tracheal prosthesis for the stoma site instead of the metallic tracheostomy tube.\nOn physical examination, the patient was with a metal tracheostomy tube tied by a rope around his neck. Mild hoarseness of voice noted, and there was no difficulty in swallowing. There were no secretions, ulcerations and granulation around the stoma. The skin around the stomal tissue was healthy with a stomal diameter of 6–7 mm. Routine blood and relevant investigation reports were within the normal limits. The patient consent was obtained. A custom made tracheal button made of polyethylene urethane sheet was fabricated for the patient to maintain the airway patency of the mature stoma.\nPoly ethylene urethane sheet – 2 mm commonly used for bleaching the tray Patient's old tracheostomal tube Ruler scale for measurement Bunsen burner Sharp scissors or bard parker blade no 15 Cotton tip applicator Silicone burs Glutaraldehyde (1%) solution (Sporicidin Sterilizing Solution).\nA poly ethylene urethane sheet of 2 mm was selected [] The snug fit of the old metal tube was tested in all head movements. As custom impression was not done the width and length measurement of the old tube was taken as the guide and noted [Figures and ]. It was approximately of 6 mm × 10 mm dimensions With the informed consent of the patient, the tracheostomal diameter of 6.5mm was measured with a vernier caliper. The distance of 15mm from the anterior edge of the stoma to the posterior tracheal wall was determined with a cotton tip applicator. This measurement was done to cross verify whether the determined measurement of the old tube approximates the original measurements of the stoma. A difference of 5 mm from the original length of the stoma to the metal tube was noted. This 5 mm of difference in length compensates the posterior tracheal wall from the contact of the prosthesis to avoid irritation of the posterior tracheal wall The polyethylene sheet was cut for the above measurements (6 mm width × 10 mm length) with sharp scissors or BP blade. As the sheet is thermoplastic, it is easily flamed over the burner, rolled and fused, which forms the body or shaft [Figures and ]. This urethane tube was lukewarm and soft at this stage and inserted into the stoma with fingers to customize for stomal patency and check for fit Anterior retention was achieved by a 2 mm flange []. A 2 mm width × 10 mm length polyethylene sheet was cut, flamed and fused to the anterior region of the shaft to produce the flange. Now the body and flange were cooled to room temperature to make it semi-rigid Again, only the flange area was softened to the temperature that could be withstood by the patient and inserted into the patient's stoma. Now the flange would contact the anterior tissue surfaces, and the flange was kneaded over the peristomal skin surface to achieve better adaptation of the prosthesis Lipping was done by heating the posterior region of the shaft and rolled backward by finger manipulation. This lipping would aid in posterior retention of the prosthesis [] The finished product was thin, flexible with enhanced tear strength. The edges of the prosthesis were trimmed with silicone burs to allow for better accommodation to the tissue surface without distortion An ideal tracheostomal button with the body or shaft, anterior flange and posterior lip [] was ready for insertion After an acceptable prosthesis was obtained, it was cleaned, and cold sterilized in glutaraldehyde (2%) solution [Sporicidin Sterilizing Solution] for overnight. The prosthesis was checked and verified for the fit and inserted into the patient [Figures –] The insertion was done by flattening and folding the prosthesis with the fingers and then inserting the prosthesis at a 45° angle to the patient's stoma. After insertion, the fingers were released. Now the prosthesis would open and conform itself into the stoma. To remove the prosthesis simply grasp it on one side and gently pull toward the opposite side. When the prosthesis was in place inside the stoma, the prosthesis would fit snugly and require no tapes or adhesives The patient recalled the next day for initial follow-up and was instructed about the placement, removal and homecare of the button. The tubal patency was checked for every 2 weeks, and the initial gradual improvement of speech with reduction in hoarseness of voice was also noted. The intake of food and regular activity were noted and found to be normal The patient has been on regular follow-up in ENT OPD since 7 months after the placement of this prosthesis, and an excellent cure of his symptoms was noted []. |
A 32-year-old multipara presented to a large academic institution with a 20-week intrauterine pregnancy. She was diagnosed with polyarteritis nodosa as a child and was treated with both steroidal and nonsteroidal anti-inflammatory agents. After her teenage years, she had no relapses of her disease. However, in her previous pregnancy 3 years prior to this index presentation, the patient developed chest pain in the late mid-trimester. Evaluation at that time revealed aortic valve insufficiency and aortic dilation. She was intentionally delivered by preterm cesarean delivery at 30 weeks to avoid worsening hemodynamics should the pregnancy continue. The patient was placed on postpartum oral contraceptives but was again found to be pregnant.\nWhile receiving care by maternal fetal medicine specialists at an outside institution for this pregnancy, an MRI revealed worsening aortic dilatation that progressed from a 4 cm baseline up to 5.1 cm. The dilatation involved not only the aortic root, but also the level of the right pulmonary outflow tract, and a 15 cm segment of the descending aorta (). Transthoracic echocardiogram additionally revealed new moderate aortic insufficiency with normal ventricular function, normal atrial sizes, and a normal mitral valve. The patient developed progressively worsening chest pain and dyspnea to the point that she had symptoms with her activities of daily living. After also being diagnosed with hypertension she was started on a beta blocker. Due to her declining cardiac status and the concern for acute aortic dissection or rupture, she was referred to our medical center for further evaluation at 20-week gestation.\nThe patient and her husband were extensively counseled about the risks of continuing pregnancy versus termination of pregnancy (TOP) via induction of labor or dilation and evacuation (D&E), with subsequent aortic repair. Anesthesiology, cardiology, and cardiothoracic surgery services were involved in the discussion with the patient and her obstetrician. A general consensus was made to proceed with a D&E abortion in an operating room where cardiothoracic surgery would be available should the patient experience intraoperative cardiac decompensation.\nOn hospital day 1, the patient received an intrafetal digoxin injection and had cervical osmotic dilators placed. On hospital day 2, she received empiric antibiotics for spontaneous bacterial endocarditis prophylaxis and was taken to the operating room. General endotracheal anesthesia was administered in a similar fashion to a nonpregnant patient with an aortic aneurysm. Beta blockers, intravenous fluids, and a narcotic-based slow induction of anesthesia were performed to maintain hemodynamic stability and prevent sudden hypotension or reflex tachycardia []. Invasive lines were placed before the patient was asleep and blood products were in the room prior to the start of the case. With the cardiothoracic team on standby in the event of decompensation, routine D&E was performed under ultrasound guidance.\nPostoperatively, the patient was admitted for cardiac monitoring. She developed an isolated, transient episode of chest pain within hours after her operation, which resolved spontaneously without EKG changes. A calcium channel blocker was added to her regimen to optimize her blood pressure. The patient was discharged home on hospital day 4. Prior to discharge, she was again counseled on using a more effective and long-term contraceptive method, including an intrauterine device, to prevent future pregnancy.\nWithin the subsequent months after the D&E, the patient underwent two separate operations to replace her ascending and descending aorta as well as insert a mechanical aortic valve. Her postoperative course was complicated by development of chylothorax, splenic laceration, and clostridium difficile colitis. The pathology report of her aorta revealed burnt-out aortitis supporting a diagnosis of prior vasculitis (). |
A 59-year-old female presented to our outpatient clinic complaining of pain in the left knee, with decreased range of motion (ROM) for 1 year. When she visited our inpatient department on the next day, her ROM of the left knee was restricted from 0° to 15°. She had a history of left knee pain in the past 2 years with the absence of trauma. The pain was non-specific and significantly exacerbated by knee activity. She had no prior consultation for her symptoms but occasionally took diclofenac sodium capsules for pain relief. The pain became so severe that she could no longer walk. Her past history of illness revealed that she had atrial fibrillation and a 1-week history of swelling and pain in both legs 3 years ago. Therefore, she underwent ultrasound examination and was diagnosed with multiple thrombosis in the bilateral lower limb arteries, which was more serious in the right lower limb with complete thrombus occlusion occurring in the right popliteal artery. She underwent interventional right iliac artery thrombectomy with stent implantation and balloon dilatation of the right anterior tibial artery in our hospital 3 years ago. Since then, she has been taking anticoagulants (warfarin) for atrial fibrillation until she presented at our department. The patient had no history of endocrine and metabolic disorders such as diabetes, hyperthyroidism, and gout. During physical examination, obvious and unbearable pain upon movement was noted without any knee swelling and tenderness. Signs related to meniscus pathology or joint laxity were not found.\nBlood tests were performed while the patient was hospitalized. The results revealed normal range of calcium and glucose at 2.35 and 4.99 mmol/L, respectively; however, the patient’s blood uric acid was high (480 μmol/L). The patient had normal hemoglobin of approximately 130 g/L. Three days after arthroscopic debridement, the patient developed mild leukocytosis, which was believed to be a response to surgical stress. The results of biochemical and hematologic tests were within the normal range. Anteroposterior and lateral radiographs of the left knee demonstrated a high-density shadow within the intercondylar notch with mild osteoarthritic changes (Fig. ). The high-density mass on plain radiographs was so inconspicuous that our radiologist did not notice or report it. Multi-planar computed tomography (CT) positioned the lesion precisely and excluded any other intra-articular pathology that could cause limitation of joint movement. The mass appeared as a non-structural lesion in the intercondylar area by coronal CT (Fig. a). The sagittal CT image revealed the mass inside the PCL (Fig. b). CT showed the mass with heterogeneous density. In both X-ray and CT images, the mass was shown as high density, which made it difficult to determine whether it was an ossified or a calcified lesion. Although magnetic resonance imaging (MRI) is meaningful and necessary for a full evaluation of the ligaments in our patient, it was not recommended because of the presence of a stent of unknown material in the body.\nBecause we speculated that the patient’s discomfort resulted from mechanical locking and entrapment by the dense mass, we recommended surgery and performed arthroscopy accordingly. Intraoperatively, a hump of the PCL was revealed by arthroscopic examination, while other pathological changes were not found. The fiber fascicles of the PCL appeared after debridement of the synovial membrane covering the pathological site of the PCL. We slit open the fascicles and exposed the mass, which appeared grayish-white and seemed to be hard based on the macroscopic appearance (Fig. ). The mass was so closely adhered to the fibrous bundles of the ligament that debridement of the lesion was carefully performed. The pathological tissue obtained from surgery was sent for histopathology.\nPathologically, the tissues were calcified mature lamellar bone with completely fibrotic bone marrow, which was infiltrated by a few chronic inflammatory cells (Fig. ). The pathological tissue obtained from surgery was stained with hematoxylin–eosin. The finding of osteogenic components or lamellar bone and chondrogenic components or cartilage led to the diagnosis of HO. The hallmark of osteogenic components, which were stained clearly red, is lamellar characteristics. The chondrogenic components were stained light blue with a few chondroblasts.\nFollowing the surgery, the patient verbalized complete relief of her symptoms. Moreover, she was allowed full ROM and weight bearing with no assistance. No complications were observed during the postoperative course. The patient was discharged after wound healing 2 weeks later. At 1-year follow-up, clinical examination demonstrated no signs of recurrence, and the patient gained full ROM with no pain or instability. |
A 55-year-old gentleman with no history of abdominal surgery presented to the emergency department with a two-day history of sudden onset, colicky abdominal pain of increasing intensity and abdominal distention. He had nausea and vomiting but there was no history of fever, rectal bleeding, or melena. On examination there was tenderness in the lower left quadrant but no peritoneal signs, and he was clinically stable.\nHis history from another hospital reported trauma 14 months previously after being hit as a pedestrian by a car. He had sustained multiple facial and orthopedic injuries, which had been managed by the orthopedic team. Computed tomography (CT) of the abdomen at that time showed a small gastrocolic ligament hematoma, right adrenal hematoma, sub-capsular liver hematoma, and small sigmoid mesocolon contusions, which were managed conservatively. The patient was discharged after seven weeks in hospital. He had sought medical advice one month after discharge due symptoms and signs of bowel obstruction, with an abdominal CT performed at that time showing distal ileal obstruction with luminal narrowing and a transition zone suggestive of an adhesive band with surrounding fat stranding and mild intestinal wall thickening. The patient improved with conservative management and he was discharged after resolution of the obstructive symptoms.\nDuring his current admission, tumor markers were negative. Abdominal X-ray revealed dilated intestinal loops and multiple air-fluid levels, and an abdominal CT with oral contrast again showed luminal narrowing with a transition zone at the terminal ilium and proximal dilated bowel loops with contrast passing distally (). The patient underwent laparoscopic exploration, at which there was ileocecal mesenteric scarring and shortening with extensive adhesions involving the terminal ilium to cause a closed loop partial obstruction (, ). The procedure was converted to open laparotomy, and an ileocecal resection with primary anastomosis was performed. Histopathological examination of the resection specimen showed small bowel mucosa with active chronic inflammation with surface ulceration and granulation tissue formation, cryptitis and fissure formation, and serosal fibrosis. The patient was discharged after two weeks after an uneventful hospital course and was followed-up in clinic for two months without exhibiting any signs or symptoms of recurrent obstruction. |
A 22-year-old male reported with a chief complaint of pain and swelling in the upper left tooth region for 9 months. The swelling involved the orbital floor. There was no compromise in vision of the left eye. The swelling was initially small in size measuring around 3 cm, which then gradually increased to the present size []. Pain started 9 months back, and it was associated with mobility of tooth. Pain was dull and intermittent in nature, aggravated while sleeping on left side and relieved spontaneously. The patient gave a personal history of smoking two cigarettes per day for the past 3 years.\nIntraorally, the patient presented with a solitary, well-defined, sessile swelling on the left side of the palate measuring 5 cm × 3 cm in size extending from 23 up to 28 region, displacement of tooth to the buccal side was seen with respect to 27. There was grade II mobility with respect to 27 and 28 [].\nOn radiographic examination, orthopantomogram reveals displacement of 27 and 28, haziness of the left maxillary sinus along with loss of lamina dura; paranasal sinus view reveals break in continuity of superior wall of maxillary sinus. For determining the extent of the lesion, computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed.\nCT scan revealed a large destructive lesion involving maxillary sinus and maxilla on the left side. Lesion involved alveolar process of maxilla involving hard palate with thinning and elevation of the left orbital floor along with destruction of wall of the maxillary floor. Lesion showed moderate heterogeneously enhancing mass. Small necrotic areas were seen, extended into the left nasal cavity. There was partial destruction of nasal septum and destruction of pterygoid plate on the left side []. The mass was extending in the left ethmoid sinus. Intraoral extension with mild destruction of zygoma is seen. Mass measured around 6.8 cm × 5.5 cm × 7.5 cm. Mucosal thickening was seen in left frontal and left ethmoidal sinuses. The left orbital cavity was compromised with normal intraorbital contents []. |
A 24 year-old male with no significant past medical history and no history of smoking was transferred to our facility for evaluation of refractory colitis. Four weeks prior to transfer, the patient underwent a dental bone graft procedure and was administered antibiotics to include amoxicillin and clindamycin. Within 1 week the patient developed watery diarrhea up to 10–12 times daily. The patient was initially administered a 5-day course of metronidazole empirically, and initial Clostridium difficile PCR toxin assay while on metronidazole returned negative. The patient had no improvement in clinical symptoms on metronidazole.\nTwo weeks prior to transfer, the patient was evaluated by a gastroenterologist and second C. difficile PCR toxin assay returned positive. Treatment was initiated with vancomycin without clinical improvement. The patient was subsequently admitted to an outside facility 1 week prior to transfer with a CT scan of the abdomen demonstrating pancolitis (). The patient had no clinical improvement with oral vancomycin and intravenous metronidazole. He further described persistent abdominal pain, night sweats and a 11 kg weight loss.\nOn transfer to our facility, the patient had persistent bloody diarrhea. On physical examination the patient was afebrile and had diffuse abdominal discomfort. Initial laboratory studies revealed an elevated CRP, 41 mg/L, with a decreased albumin, 2.5 g/dL. Flexible sigmoidoscopy was performed demonstrating active colitis, without rectal sparing, and containing granular mucosa with a complete loss of vascular pattern (). Pathology revealed active colitis without changes of chronic colitis and without evidence for cytomegalovirus infection (). Stool culture on admission returned positive for Klebsiella oxytoca while repeat C. difficile PCR toxin assay following transfer was negative.\nGiven the presence of acute colitis and concern for antibiotic-associated hemorrhagic colitis secondary to K. oxytoca, antibiotics were withdrawn with clinical improvement in stool frequency. The patient was discharged with 1-week follow-up, at which time he continued to report symptoms of persistent colitis and weight loss. Repeat stool studies were performed to include a negative stool culture and positive C. difficile PCR toxin assay. Without formal diagnostic criteria present for UC, and in concern for recurrent C. difficile infection (CDI), the patient underwent a fecal microbiota transplantation (FMT) utilizing a third party source and instillation via colonoscopy, although no demonstrated clinical benefit was achieved. Colonoscopy at the time of FMT demonstrated persistent active colitis with a Mayo endoscopic subscore of 2 extending from the anal verge to the cecum (). Biopsies revealed moderately active chronic colitis, now consistent with a diagnosis of UC.\nGiven lack of response to therapies for antibiotic-associated hemorrhagic colitis and CDI, and with biopsies now favoring UC 3 weeks after initial presentation, the patient was hospitalized due to persistent colitis, weight loss and abdominal discomfort. Therapy was initiated for severe UC to include intravenous corticosteroids and cyclosporine. The patient was discharged on oral tapering doses of prednisone and cyclosporine with transition to oral azathioprine. Subsequently, salvage therapies to include infliximab, vedolizumab and tofacitinib were trialed without clinical or endoscopic response despite targeting recommended drug levels resulting in the performance of a total colectomy fifteen months after initial presentation. Pathology from the colectomy specimen was consistent with severely active chronic colitis consistent with a final diagnosis of UC (). Informed consent was obtained from the patient for description of this case. |
A 68-year-old man, with an established left anterior descending coronary artery disease, had initially declined surgical revascularization, citing his asymptomatic status.\nThe patient subsequently presented at a remote hospital as an emergency case, having collapsed at home after complaining of sudden onset of back pain. He was resuscitated and the initial assessment demonstrated electrocardiographic and biochemical evidence of posterior myocardial infarction.\nGiven the new symptom of back pain, the patient underwent a nongated computed tomography (CT) scan to exclude any acute aortic pathology. There was no evidence of dissection, but the CT scan demonstrated a voluminous aneurysm of the aortic root and the patient was transferred to a cardiothoracic center for consideration of urgent cardiac surgical intervention.\nThe patient underwent subsequently a gated CT aortogram and CT coronary angiography, and this clarified the size and nature of the aortic root aneurysm (\n). The aneurysm involved the right sinus of Valsalva at the 12 o'clock position; it was separate from the origin of the right coronary artery which was stretched over the aneurysm. The aneurysm measured 31 mm × 33 mm × 29 mm and was fully opacified with contrast. There was no mural thickening of the aortic wall, no obvious flow-limiting disease of the right coronary artery and no acute aortic pathology.\nTransthoracic echocardiography demonstrated significant turbulence in the right ventricular outflow tract but no other abnormality, and the cardiac function was preserved.\nThe patient was taken to the operating room, where the imaging findings were confirmed. The aneurysm arose just below the ostium of the right coronary artery, the course of which was stretched over the aneurysm with slit-like compromise of the lumen. There was also partial compression of the right ventricular outflow tract.\nThe repair began by transecting the ascending aorta just above the sinotubular junction. The right sinus was excised and a right coronary button was fashioned. A neosinus was tailored using a Dacron patch that was cut to the size of the excised sinus. The neosinus was sutured in place using 5–0 Prolene and this was then used as a running suture to reapproximate the ascending aorta. The right coronary button was reimplanted into the neosinus and the operation was completed with a bypass graft to the left anterior descending coronary artery using a pedicled left internal mammary.\nThe patient had an uncomplicated postoperative course. A predischarge gated CT aortogram demonstrated satisfactory repair with the aortic root, assuming normal appearance and dimensions (\n). |
RC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.\nOn postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with hyalinization of the lamina propria and atherosclerotic changes in the adjacent vessels. After the second revision, the patient progressed as expected with return of bowel function and tolerance of diet and was later discharged on hospital day 38. Our presented patient continues to do well on the outpatient follow-up. |
A 41-year-old woman presented with intermittent pharyngeal obstruction and repeated vomiting after meals. Concerning her previous history, she had undergone the resection of a fibroma in the right side of her neck 7 years earlier, and complained of a voice change over the past 3 months. The family history was not contributory. The physical and nutritional status were good. There were no abnormal physical findings in the thoracic or abdominal regions. Palpation did not reveal any abnormalities in the superficial lymph nodes or neck. The blood biohistochemistry showed no abnormal findings. Neck and chest computed tomography (CT) revealed an 3.6 cm oval mass with slightly low attenuation in the upper esophagus, and a 7 mm nodule in the left lobe of the thyroid gland (). Esophagogastroscopy showed a 3.5 cm smooth, soft, dark purple, mobile mass which was located just beneath the upper esophageal sphincter with a possibility of airway obstruction (). The thyroid nodule was diagnosed as thyroid papillary carcinoma through sonography guided fine-needle aspiration cytology. We decided to perform a combined operation for total thyroidectomy with dissection of the central neck nodes followed by resection of the esophageal tumor through cervical esophagotomy.\nUnder general anesthesia with a single lumen endotracheal tube, a 6 cm transverse neck skin incision just above the clavicle was performed. After meticulous dissection, total thyroidectomy with central neck node dissection was completed by a head and neck surgeon. Esophageal dissection was performed to the level of the hypopharynx. In palpation, there was no mass in the cervical esophagus even after direct visualization of the intraluminal space through cervical esophagotomy. With a laryngoscope, the mass was seen at the level of the arytenoid cartilage in the hypopharynx. After a gentle push of the mass with a long Kelly in the direction of the esophagus, it could be extracted through the esophagotomy opening (). Mucosal resection was performed around the stalk, and the mass was removed without any complication such as hemorrhage or perforation. The esophageal mucosa and muscle were repaired with 4-0 vicryl interrupted sutures.\nThe histopathological findings showed irregularly dilated vascular lumens in the submucosa, suggesting cavernous hemangioma (). On the seventh post-operative day, an esophagogram was performed. There was no leakage or stricture. After 1 day of oral feeding, the neck drain tube was removed. The patient was discharged on the ninth post-operative day, and underwent follow-up care without incident for 1 month. |
A 28-year-old female patient came to the Department of Periodontics, Bengaluru, India, with a chief complaint of swelling on the right mandibular front tooth region for 3 weeks. The lesion at the initial stage was of poppy seed in size which gradually increased within 3-week time as a size of dumbbell. The lesion was painless but caused discomfort and often bled on slight provocation. She stated that a similar type of growth in the same area was present for 2 years. The patient's past history revealed the appearance of the lesion during the third trimester of pregnancy which was excised after parturition. The lesion reappeared in the same area approximately 7 months later following the excision. The lesions were excised by scalpel method as mentioned by the patient, and the histopathological examination was performed for the excised lesion which confirmed the diagnosis of PG. The patient stated that the present recurrence of the lesion occurred after approximately 8 months from the last excision performed.\nNo relevant medical and family history was reported by the patient. On intraoral examination, the lesion was present around the right labial mandibular anterior tooth region extending from the distal aspect of incisor to the mesial aspect of the canine region. It measured approximately 3 mm × 4 mm in dimension. On visual examination, it appeared reddish pink as observed in . It was large and lobulated with a sessile base. On palpation, the lesion was firm and resilient with bleeding on slight provocation. Periodontal examination revealed good plaque index score of < 1 as per Silness and Loe in 1964[] and mild gingival inflammation as per gingival index score of < 1 by Loe and Silness in 1963.[] Intraoral periapical radiograph showed no horizontal or vertical bone loss in the region as contemplated in . The differential diagnosis of peripheral giant cell granuloma, peripheral ossifying fibroma, hemangioma, and hyperplastic gingival inflammation was ruled out based on the recurrence of the lesion and similar growth. Following the previous histological findings and clinical examination, the lesion was diagnosed as a recurrent PG.\nThe patient was explained about the nature and etiology of the lesion and also the possible reasons for the frequent recurrence of the lesion. Conventional surgical procedure by scalpel method was chosen for the excision of the lesion. A complete excision of the lesion could expose the underlying bone leading to resorption. An autologous PRF membrane was placed on the excised area. A written signed informed consent was taken from the patient before the commencement of the surgical procedure.\nThe area of interest was anesthetized with local anesthesia with a solution of 2% lignocaine with 1:200,000 adrenaline. A circumferential full-thickness incision was given. The incision extended from the distal aspect of incisor to the mesial aspect of the canine region circumferentially including 2 mm of an adjacent gingival region. Scalpel excision was performed from the base of the lesion exposing the bony surface as observed in Figures and . The excised lesion as shown in was then transferred to a bottle of 10% formalin solution and was sent for histopathological evaluation. The denuded bone surface was then covered with PRF membrane. The PRF was prepared as per Choukron et al's. protocol in 2001[] as shown in . 10 ml of the patient's blood was withdrawn from the antecubital vein and was immediately transferred to REMI-4C centrifugation machine within 30 s. It was centrifuged at 2700 rpm for 12 min.\nThe clot was then squeezed between a sterile gauze, and a PRF membrane was placed into the exposed bone surface.[] The membrane was further stabilized by suturing it with direct interrupted suture on the mesial and distal aspects as shown in . The periodontal dressing was placed. Postoperative instruction was given to the patient and chlorhexidine mouthwash (0.12%) was prescribed to the patient.\nThe histopathological evaluation showed a large ulcerated area covered with fibrin exudate. The epithelium appeared to be hyperplastic, edematous, and was infiltrated with inflammatory cells. Underneath the epithelium, numerous small endothelial lined channels in the lobular structure were seen, suggestive of perivascular inflammation. The lesion had a fibrous appearance with neutrophils, plasma cells, and lymphocyte inflammatory cell infiltrate. The histopathological slide at ×20 and ×40 magnification confirmed the diagnosis of PG as shown in . The patient was recalled at 2-week follow-up period where a complete epithelialization over the denuded bwone surface was seen as contemplated in . At 12-month follow-up period, recurrence of the lesion was not observed as shown in . |
A 52-year-old Han Chinese woman was admitted to the Department of Thoracic Surgery of Beijing Friendship Hospital on 20 November 2017 after multiple nodules were detected in the right lung. The patient had a five-year history of hypertension, denied any history of smoking and drinking, and had a family history of lung disease. On 2 November 2017, she had undergone reserved mastectomy for right breast cancer followed by axillary lymph node dissection at the Department of General Surgery of Beijing Friendship Hospital. Postoperative pathology showed infiltrating ductal carcinoma in the right breast and metastases in 1–20 right axillary lymph nodes. The chest computed tomography (CT) examination showed multiple nodules in both lungs; metastasis was not excluded. The nodule in the apical segment of the upper lobe of the right lung was larger but was not confirmed as malignant. Whole-body positron emission tomography (PET)-CT examination further showed that the nodule in the apical segment of the upper lobe of the right lung was larger; the lesion was considered to be malignant, thus indicating a strong possibility of peripheral lung cancer. No abnormal increase in F18 fluorodeoxyglucose (FDG) metabolism was found in the other pulmonary nodules and mediastinal and hilar lymph nodes. Follow-up observation was recommended. It was difficult to preoperatively diagnose whether the multiple nodules of both lungs were primary lung cancer with intrapulmonary metastasis, or lung metastasis of breast cancer. The following two surgical programs were recommended after general discussion among the whole department:\nProgram 1: Video-assisted thoracoscopic wedge resection of the nodule in the upper lobe of the right lung and wedge-shaped resection of the nodule in the lower lobe of the right lung, followed by resection of the nodule in the upper lobe of the right lung and lymph node dissection, depending on the results of the intraoperative frozen section.\nProgram 2: Thoracoscopic excision of the nodule in the upper lobe of the right lung, mediastinal lymph node dissection, and dynamic observation of the remaining nodules.\nPreoperative CT-guided microcoil localization was conducted on the small nodules of the upper lobe of the right lung, and Program 1 was implemented on 24 November 2017. A total of four nodules were resected during the surgery: (i) a nodule in the apical segment of the upper lobe of the right lung, measuring 2.1 × 1.2 × 1.1 cm3; (ii) a nodule in the anterior segment of the upper lobe of the right lung approximately 0.4 cm in diameter; (iii) a subpleural nodule in the lower lobe of the right lung approximately 0.4 cm in diameter; and (iv) a paravertebral nodule in the lower lobe of the right lung approximately 0.6 cm in diameter (Fig ). Postoperative pathology showed that the nodules in the apical and anterior segments of the upper lobe of the right lung and the paravertebral nodule in the lower lobe of the right lung were all primary lung adenocarcinoma. The subpleural nodule in the lower lobe of the right lung was infiltrated with inflammatory cells. The choice of surgical procedure was reasonable based on the postoperative pathological results.\nHematoxylin and eosin (HE) staining and immunohistochemistry were performed. HE staining of the three surgically resected pulmonary nodules showed adenocarcinoma infiltration in the lung tissue, and acinar was the dominant type (Fig a,b,d). The results of immunohistochemical detection showed aspartic proteinase A (Napsin A) (+), cytokeratin (CK) 7 (+), and thyroid transcription factor 1 (TTF-1)(+). The positive Ki-67 rate in the nodules of the apical segment of the upper lobe of the right lung (20%), the anterior segment of the upper lobe of the right lung (15%), and the paravertebral nodule in the lower lobe of the right lung (15%) indicated primary lung adenocarcinoma (Table ). HE staining of the breast cancer specimen showed a glandular tubular structure and the lesion was ductal carcinoma in situ (Fig e,f). The results of immunohistochemical detection showed that estrogen receptor (ER) was approximately 80% strong (+), progesterone receptor (PR) approximately 30% strong (−) medium (+), Ki-67 approximately 25% (+), E-cadherin (+), CK8 (+), and CerbB-2 (1+), which indicated breast infiltrating ductal carcinoma (Table ). HE staining of the pulmonary inflammatory nodules showed benign micronodular hyperplasia in the stromal spindle cells (Fig c), and immunohistochemistry showed CK7 alveolar epithelium (+), CD31 blood vessel (+), Syn (−), CgA (−), and actin (−).\nExon sequencing was conducted in the resected tissue samples and blood specimens, and the relationships among their somatic mutations were compared. Both TP53 and EGFR gene mutations were found in all three surgically resected pulmonary nodules, and their base alterations, amino acid alterations, and functional areas were the same. Although TP53 gene mutation existed in both the breast cancer lesion and the nodule in the upper lobe of the right lung, their base alterations, amino acid alterations, and functional areas were different. The frequencies of TP53 and EGFR mutations in the apical segment of the upper lobe of the right lung were 39.3% and 20%, respectively, which were significantly higher than in the other two nodules. Moreover, rare nucleophosmin (NPM1) mutation existed in both the subpleural nodule in the lower lobe of the right lung and the paravertebral nodule in the lower lobe of the right lung. On the first day after surgery, blood samples were collected for gene detection (Table ). |
The patient is a 38-year-old Caucasian female, who presented with right flank pain. She denied any gross hematuria or history of urinary tract infections. Her past medical history was significant for hypertension and polycystic ovarian syndrome on metformin. She was a nonsmoker and had no family history of genitourinary diseases. She had no history of hormonal therapy. A computed tomography (CT) scan of the abdomen and pelvis renal mass protocol showed a 9 cm mass with fluid density and very thin intracystic septations representing a Bosniak II cyst in her right kidney []. Due to flank pain resulting in multiple visits to the emergency room, the patient elected surgical treatment. She underwent robotic-assisted renal cyst marsupialization via transperitoneal approach and tolerated the procedure well with an uneventful postoperative course. Her surgical pathology showed mixed epithelial stromal tumor (MEST) measuring 6 cm in maximum dimension and focally present at the cauterized edge. She was seen at a 3-week postoperative visit. Although she had a positive margin, the plan was to return in 1 year with repeat imaging owing to the benign nature of this disease. However, she was lost to follow-up and presented 3 years later with a CT scan showing an 11 cm × 8 cm right renal cystic lesion with few thin internal septations and focal punctate calcifications along the walls of the cyst. Interestingly, she was also found to have multiple cystic lesions near the ascending colon with similar radiologic features as the renal cyst suspicious for MEST deposits []. She was referred to colorectal surgery, and a colonoscopy was performed that did not show any intraluminal abnormalities. Due to recurrence and fear of malignancy, the patient underwent a hand-assisted laparoscopic radical nephrectomy by urology team. Then she underwent an excision of cystic multiloculated mesenteric lesion that was attached to the ascending colon [] by the colorectal team using Endo GIA™ stapler. Final surgical pathology showed MEST in the right kidney and also in the paracolonic mass. The patient was discharged on postoperative day 2 with no issues.\nThe multiloculated cystic lesion showed epithelial and stromal components. Most cysts were lined by flat to cuboidal and in some areas with hobnailed epithelium. No atypia is present in the epithelial component. The stroma was composed of areas of dense fibrous, loose, smooth muscle, hypercellular spindled, and ovarian stroma-like elements []. No mitotic activity or atypia was observed in those stromal components either. The septae did not contain any normal renal parenchyma.\nStromal cells showed diffuse nuclear estrogen and progesterone positivity, consistent with MEST or also known as cystic nephroma []. |
This patient was a 26-year-old female with a past medical history of catastrophic antiphospholipid syndrome secondary to newly diagnosed SLE, acute on chronic ITP, hypertension, and hyperlipidemia who presented from an outside facility with shortness of breath and chest pain. She reported to her primary care physician that morning with worsening cough over the last year that became productive within the last 3 months and became painful within the last day. She described parasternal chest pain that radiated to her throat that was exacerbated by cold and smoking and a non-radiating parasternal chest pain worsened with cough. She also stated she had increasing shortness of breath upon ambulation and while lying flat. Her primary care physician sent her to her local hospital for further evaluation. Laboratory studies from the outside facility were notable for a D-dimer of 3.4 mcg/mL, hemoglobin of 18.9 g/dL, and platelet count of 130,000/uL. Chest radiograph () was initially reported as no acute cardiopulmonary process. Further evaluation by computed tomography (CT) chest pulmonary embolism protocol was performed (), which demonstrated a large intracavitary heterogeneous, irregular, calcified mass extending into the right atrium, across the tricuspid valve, and into the right ventricle and pulmonary outflow tract. Additionally, a small to moderate pericardial effusion was noted, with reflux of contrast in the collateral veins, suggestive of restrictive cardiac dysfunction. With concern for cardiac tamponade, the patient was transferred to our institution for further evaluation by cardiology.\nAfter transfer from her local hospital to our tertiary University hospital emergency department, a transthoracic echocardiogram confirmed the presence of a large pericardial effusion and noted significant clot burden and possible intracavitary right ventricular mass which was incompletely characterized (). Normal heart rate and blood pressure in the emergency department suggested that the patient was not in cardiac tamponade, but cardiology recommended a pericardiocentesis and cardiac CT and cardiac magnetic resonance imaging (MRI).\nCT heart morphology ( and ) revealed a heterogeneous irregular calcified mass extending into the right atrium, across the tricuspid valve, and into the right ventricle and pulmonary outflow tract. This mass had characteristics suggestive of an organized chronic thrombus, as webs of thrombus were extending throughout the right atrium and almost completely occluding the distal superior vena cava. An extensive network of collateral vessels was also demonstrated around the nearly occluded superior vena cava extending through the mediastinum, chest wall, and abdomen. A small pericardial effusion was shown, which was consistent with previous TTE findings in the emergency department.\nCardiac MRI () further confirmed the presence of a large intracavitary right atrial mass extending into the right ventricle. This mass demonstrated a diffusely hypointense signal on long T1 sequence (A), and no post contrast enhancement suggesting bland thrombus, rather than a tumor thrombus. On the first pass post contrast imaging (B) it was difficult to differentiate tumor enhancement from intervening blood pool, but there was no contrast enhancement on delayed contrast enhanced sequences (C).\nFurther evaluation with CT of the abdomen and pelvis was unremarkable other than presence of ascites, which we attribute to cardiac dysfunction.\nThe patient had a complicated hospital course, as she continued to be managed at our facility for her hematological and rheumatological diseases. A successful pericardiocentesis removed 440 cc of serosanguinous fluid. Cardiothoracic surgery was consulted for surgical management of the patient's intracavitary mass. They emergently resected the 8.7 × 7.5 × 3.0 cm multi-lobulated mass that was adherent to the endocardium throughout. The differential diagnosis of the mass included thrombus versus cardiac tumor of unknown origin. Due to the extensive nature of this mass, a tricuspid valve replacement was indicated for this patient and was successfully performed using a 31 mm St. Jude Epic porcine bioprosthesis. The pathology report confirmed that the specimen was consistent with an organized thrombus with valve leaflets diffusely covered by friable, loosely adherent calcifications ().\nUnfortunately, the patient clinically declined after cardiac surgery. She continued to have respiratory failure eventually requiring tracheostomy and had wound complications. She then had failure to thrive secondary to candida fungemia and vancomycin resistant enterococcus bacteremia, acute kidney injury requiring continuous renal replacement therapy, anemia, continued thrombocytopenia, marginally controlled diabetes mellitus, and cytomegalovirus viremia. After a complicated 72-day hospital course, she succumbed to her illnesses surrounded by her family. |
After taking written informed consent and informing the patient about possibility of reporting this case in a medical journal, a 45-year-old, 70 kg, 172 cm man with a history of episodic cluster headache was admitted to the hospital for pain management. He had periodic sharp excruciating pain on the left side of his face radiating from the back of his left eyeball. Lacrimation, conjunctival congestion, and nasal discharge were present on the left side. The present cluster was started one day ago. He experienced two severe episodes the day before; each lasted about 60 minutes with a six-hour pain relief between them. On the day of admission, he came with the same severe hemifacial pain initiated less than five minutes ago (he worked in the same hospital that researchers practiced). He was otherwise healthy and had no past medical history except some orthopaedic surgeries (due to an accident). He was not an alcohol or drug abuser. He had the same abrupt pain every three to six months that lasted about 15 days (the shortest and the longest clusters he remembered were five and 17 days, respectively). His symptoms started since five years ago and each year he experienced two to four clusters of headache on average, albeit he remembered a year with only a seven-day episode. The pain was not always completely improved with oral nonsteroidal anti-inflammatory drugs and very often, he was admitted to the hospital to receive oxygen therapy and intravenous painkillers. He mentioned that his first headache lasted six hours without any medication, as he was reluctant to receive any medication at first; however, he took painkillers for his following headaches. By taking medication, disabling episode of headaches lasted between 15 to 180 minutes; however, some mild to moderate pain remained for the same episode or following days of that cluster for which, he received trivial medication. He noted that he took just few hours sick leave and usually tolerated the pain. Once he received opioid (20 mg of intravenous meperidine) for his pain; however, it just added dizziness and nausea with no pain relief. He was reluctant to receive any prophylactic medication for his headaches. In his recent episode, he was admitted and hemodynamic and respiratory monitoring was utilized. Intravenous line was prepared and fluid was infused. He did not receive any supplemental oxygen. He received 20 mg of propofol (propofol 1% MCT/LCT, Fresenius, Germany) every four minutes () and simultaneous titrated dose of alfentanil (100 μg) every ten minutes. After the third injection of propofol and second prescription of alfentanil (about 15 minutes from the initiation of therapy), he reported acceptable pain relief with a mild remaining pain. He received a total dose of 120 mg of propofol (with the same protocol, however, as we encountered some drowsiness with no desaturation, we extended the interval for injection to every ten minutes and overall, it took about 50 minutes). Moreover, a total of 500 μg of alfentanil was infused (about 50 minutes). At this time he reported complete recovery with no remaining pain. He was just monitored and was discharged after two hours with no medication. He had no more episodes in the following days. In a four-month follow up, he did not experience any cluster headache. |
A one year and four months old male child presented with preaxial polydactyly of the right foot and dysplastic tibia associated with shortening and varus deformity in the right leg and foot. On examination the child was found to have normal mental and physical milestones. Obstetric history of the mother revealed no previous history of abortion. No history of any previous pregnancy. She was a primigravida with the first child being the present one with no siblings. The child was born from a full term pregnancy with caesarean for pregnancy induced hypertension. There was no history of consanguineous marriage in the family. On examination the child had a varus deformity in the right leg with a shortening of 5cm (). The right leg as maintained in an attitude of flexion at the knee. Extension was possible actively with grade 3+ power in the right knee. Active flexion was possible up to 100 degrees. Complete range of movements possible at the hip however the ankle was fixed in a rigid equinovarus position. No instability was associated at the knee or ankle. Radiographs relevealed a trapezoid tibia with preaxial polydactyl (, ). At the time of presentation the child was 1 year 3 months but unable to walk. Since the other milestones both physical and mental had progressed well, the child’s inability to walk was attributed to the deformity in the left foot and tibia associated with shortening. Other associated anomalies included a preaxial polydactyly at the right hand with an additional right thumb. The child had an undescended testis on the left side with an absent kidney on the right side as well as no testes on the right side.\nProblem faced by the child at the time of presentation were mainly: shortening, severe varus deformity of the tibia and foot which were not passively correctible, preaxial polydactyly causing inability to wear footwear and also giving the foot a grotesque cosmetic deformity. Aim of surgery at this stage was to provide the child with a plantigrade foot, improve cosmosis and enable child to wear footwear.\nSurgical procedure: Surgery was performed under general anesthesia with intubation. Surgery involved two stages. The first part was removal of the preaxial polydactyly in the foot. This was performed with a racquet shaped incision in which the toes were removed with the metatarsals. This procedure did not include excision of the duplicated talus. Thus 2 metatarsals and 2 sets of phalanges were excised. The wound was then closed over the medial aspect. The second part of the surgery was correction of the varus deformity in the trapezoid tibia. This varus deformity was corrected by a lateral incision over the leg on the most prominent part of the tibia. This was also marked by a small dimple in the skin. The tibia was dissected out subperiostialy. Two guide wires were used to mark out a lateral closed wedge osteotomy. A fibular osteotomy was done with excision of 1 cm of fibula to allow correction to occur at the osteotomy site. Correction was achieved with a lateral closed wedge osteotomy held in place with a pair of K wires. Closure of the wound was done. Cast maintained for a period of 2 months till the osteotomy site healed completely. K wires removed at 4 weeks of cast change when check x-ray showed good healing at osteotomy site. Post operatively the child was given a supportive clam shell brace extending up to the thigh with a shoe raise. This facilitated the child’s ability to walk and run. It also was expected to maintain the correction achieved.\nAt 2 years follow up there was recurrence of varus deformity (, , ). There was overgrowth of the fibula with prominence of the fibular head. However the child was walking and running with help of orthosis and parents refused to undergo corrective surgery. The patient was lost to follow and finally was traced back 5 years after corrective surgery. At this time the tibia vara had increased with ankle inversion and overgrowth of fibula, however ankle dorsiflexion was 90° and plantar flexion was 30°. There was a limb length discrepancy of 9 cm, however the child was able to walk and run with shoe raise (, , ). Knee quadriceps was grade 5 with no flexion deformity and full range of knee movements. At present again the child’s parents are not ready for corrective surgeries but promise to keep regular follow up.\nContemplated surgeries for the future are a repeat osteotomy of the tibia and epiphysiodesis of the fibular head to prevent further growth at the fibula from causing recurrence of the deformity. |
A 30-year-old male with no past medical history was instructed by his nephrologist to present to the emergency department (ED). However, before the presentation here, the patient went to his primary care physician with a complaint of chronic dry intermittent cough for the last four weeks and pain in his right eye associated with changes in his vision. His outpatient labs revealed that the patient had high levels of serum calcium as well as an acute kidney injury (AKI). He was hence referred to an ophthalmologist and a nephrologist by his primary care physician. The ophthalmologist diagnosed him with iritis, which was prominent in his right eye and progressed to his left eye. His outpatient workup by the nephrologist revealed high calcium and low parathyroid hormone. The laboratory testing for multiple myeloma, HIV, and hepatitis all came back negative. Furthermore, several imaging studies were performed to screen for a malignancy considering high calcium in the setting of low parathyroid hormone. An ultrasound of the abdomen and bladder were negative for any masses; the CT scans of the chest, abdomen, and pelvis performed were negative for any masses or lymphadenopathy. Considering all these findings, the patient was instructed to go to the ED for an elective kidney biopsy. On initial presentation to the ED, he endorsed being completely asymptomatic and his vital signs were within normal limits. His initial laboratory studies (Table ) were significant for AKI and mild hypercalcemia, whereas the urinary analysis revealed proteinuria (100 mg/dL) (Table ). Sarcoidosis was high on the list of differential diagnoses due to the combination of iritis, chronic dry cough, and laboratory findings. The nephrology and pulmonology teams consulted in the hospital both recommended a kidney biopsy. We also sent in laboratory studies for other possible causes of these symptoms such as systemic lupus erythematosus or scleroderma. The following day a kidney biopsy was performed. The 25-hydroxy vitamin D levels were found to be low. Results for antinuclear antibody (ANA), antineutrophil cytoplasmic antibody (ANCA), complement, thyroid stimulating hormone (TSH), angiotensin-converting enzyme (ACE) were all found to be within normal limits. The ferritin level was high in the setting of anemia, which suggested the presence of chronic disease. On hospital day 2, the preliminary results from the biopsy revealed diffuse tubulointerstitial disease with early fibrosis, widespread moderate inflammation, multifocal tubulitis, and focal aggregate of epithelioid cells suggestive of granuloma. These findings were all consistent with a high suspicion for sarcoidosis. The patient was subsequently started on a prednisone taper. He was discharged and then referred to follow up with a multidisciplinary team for long-term care involving nephrology, pulmonology, and hematology. A few days later the official report of the kidney biopsy confirmed sarcoidosis. |
A 55-year-old female presented to our musculoskeletal oncology clinic with a chief complaint of a growing, painless posterior thigh mass for approximately 6 months. We obtained radiographs of the femur, which demonstrated a soft tissue shadow in the posterior thigh with some apparent calcifications within the mass (). We then ordered a magnetic resonance imaging (MRI), which showed a large, heterogeneous soft tissue tumor abutting the neurovascular structures of the posterior thigh ( and ). Based on the concerning imaging, we moved forward by obtaining a core needle biopsy of the mass. The biopsy findings suggested the mass to be a hyalinizing tenosynovial giant cell tumor. Because the imaging and clinical history did not match well with our suspicion that his was a soft tissue sarcoma, we decided to move forward with a wide excision of the tumor, prepared for the possibility that final pathology would prove this mass to be a sarcoma. On the day of the procedure, a preoperative pregnancy test was ordered as is routine and the serum β-hCG was positive at 1122 IU/L. The patient reported that she was in menopause and had not had sexual activity in nearly a year. She denied any symptoms of pregnancy. The decision was made to proceed with surgery, understanding that there was a possibility that the tumor was secreting this hormone. The tumor was resected with a wide margin and sent for histopathologic evaluation (). Sections from the resection specimen showed a proliferation of spindle cells and pleomorphic nuclei. By immunohistochemistry, there was strong staining of tumor cells for β-hCG. The morphologic and immunophenotypic features were consistent with an unclassified pleomorphic sarcoma with ectopic β-hCG production ( and ). Unfortunately, no molecular analysis is available for the specimen. Postoperatively, the patient’s wound healed without complication, she received postoperative radiotherapy, and at 2 weeks postoperatively her β-hCG test was negative. At 1 year postoperatively, she was without evidence of local or metastatic disease and her β-hCG continued to be negative. |
A 44-year-old male reported with a chief complaint of food impaction and bleeding while brushing in relation to his right lower back teeth for the past three months. On clinical examination, there were clinical signs of gingival inflammation with generalized bleeding on probing. Periodontal pockets were detected using a William's periodontal probe; pocket depth of 7 mm and clinical loss of attachment of 5 mm was noticed on the mesial aspect of 36 the loss of attachment was calculated by using the crown margin as a fixed reference point, and furcation involvement Gr-II in 17 and Gr-I in 47 were noticed and the oral hygiene status was fair. A provisional diagnosis of chronic generalized periodontitis (mild) was made. Nodular bilateral tori was seen on the lingual side of the mandible, above mylohyoid line at the level of premolars. Excision of the tori was planned, to be used as autogenous bone graft in relation to 36.\nConservative incisions were done to provide soft tissue cover over the graft material at the end of the procedure. The soft tissue cover prevents the material from being washed away. Full thickness flap reflection was done to expose the recipient area. A relatively thick flap was preferred over a thin flap to prevent tissue necrosis and possible washing away of the graft material. Full thickness flap was reflected on the lingual side to expose the mandibular tori which extended from distal aspect of the canine to the mesial aspect of second premolar [Figures –].\nThe defect between 35-36 and 36-37 were prepared by soft tissue debridement by using a combination of hand curettes and ultrasonic scalers. Root conditioning was done with tetracycline hydrochloride to decontaminate the root surface and increase the compatibility of the root surface with cell attachment. As the defect was lined by a cortical wall of bone, which can limit blood flow to the graft area, intra marrow penetrations were done using a micromotor hand piece with a round bur to encourage blood supply from the underlying cancellous bone, and provide graft with sufficient nutrients for survival.\nThe tori from the lingual side was excised with rotary instruments and chisel and mallet and placed in a sterile dappen dish with saline. The graft material was condensed in the defect area tightly. Care was taken for grafts not to be overfilled to avoid exposure due to soft tissue shortage [Figures –]. The flap margins were coapted and sutured. Figures and show the radiograph of the bone defect taken before and after the placement of the graft and shows the radiograph of the bone fill in the defect area taken one year post-operatively. The long-cone paralleling technique was used to take all the radiographs. Note the bone fill between 35-36 and 36-37 were angular defects were present. Clinically the treated lesions were evaluated in terms of pocket depth and clinical attachment levels. Post-operative clinical measurements taken one year after the treatment revealed a significant reduction in probing pocket depth to 3 mm from 7 mm at baseline and reduction in loss of attachment to 2 mm from 5 mm at baseline. A previous pocket which does not probe after treatment and the bone fill seen in the radiograph indicates the success of the treatment.\nAll efforts to minimize bacterial build-up in the grafted area were emphasized. This included 0.2% chlorhexidine rinses 2-3 times per day for 2-3 weeks. Systemic antibiotic and analgesics were given (amoxicillin 500 mg 3 times daily and aceclofenac 100 mg 2 times daily were prescribed).\nSuture removal was done. After one week the patient was instructed to initiate oral hygiene in the area and was examined every 15 days for the next 3 months. During these examination, light debridement of the area was performed. No probing or vigorous scaling of the grafted area were performed for 3 months following surgery. Radiographs were taken at periodic intervals to assess regeneration. |
A 72-year-old Caucasian man was admitted to our department with a pain in the left posterior mandible and periodontal hyperplasia associated with the left mandibular second molar tooth. He also complained about the ongoing pain for 2 months and spontaneous hemorrhage within the lesion region.\nAccording to his medical history, the patient had suffered from coronary angioplasty 6 years ago. He also suffered from malaise and fatigue for last 1 year and also inappetence for last 6 months.\nExtraoral examination of the patient showed no visible swelling, tenderness or pus discharge. Skin color and temperature were normal. In the intraoral examination of the relevant region, oral hygiene level was not good and gingival tissue around the second molar was hyperplastic and had a tendency to spontaneous bleeding.\nOn the other hand, the panoramic radiograph (PANO) showed a radiolucent lesion with irregular margins located the periapical area and also extended coronally that led into the serious mobility of mandibular left second molar tooth (Figure ).\nConsidering the patient's medical history and after an exhaustively clinical and radiographical examination, we decided to perform an incisional biopsy under local anesthesia. As expected, the result of the pathological examination was peripheral giant cell granuloma (PGCG). We did not consider to take an initial photography before the surgical procedures, however, with regard to the pathological results, we decided to perform another surgery under local anesthesia 1 week later, including extraction of the tooth and a wide curettage of the lesion in the left posterior mandible. Despite the anesthetic procedures were performed properly and adequately, the patient was still suffering from pain but no severe hemorrhage during the curettage was observed from the surgical area. After pathological assessment of the second biopsy, the lesion was diagnosed as DLBCL (Figure ).\nEven though the patient was relieved and healing was uneventful, we did several consultations and asked for PET/CT scan of entire body because of metastatic nature of DLBCL. After all of these scanning procedures, we doubted the patient may also have had DLBCL in his thyroid gland, gastric system, and prostate either.\nOn the other hand, 2 weeks later from the second biopsy, our patient had satisfactory outcomes, such as; no pain, hemorrhage, or swelling in the operated area. He stated that he is totally relieved and he is ready for the prosthetic procedures.\nMandibular biopsy results showed sheets of medium to large lymphoid cells with hyperchromatic nuclei and scanty cytoplasm. These cells stained positive for CD3, CD20, LCA1, and LCA2 for Cyclin D1 (clone Polyclonal). Ki67 proliferation index was %90. The tumor was also positive for MUM-1 and BCL 2 and BCL 6 (Figure ). Other blood tests and bone marrow investigations did not reveal any abnormality. However, the gastrointestinal tract biopsy resulted in almost the same outcome, with a slight difference of %80 Ki67 proliferation index, positive CD5 (Clone 4C7), and CD138 (clone MI-15) and negative Cyclin D1 results. Attributed to these results, the lesion in the gastrointestinal tract was diagnosed with DLBCL (Figure ).\nEven though radiological findings were not satisfactory enough in our second and the third follow-up (Figure ) and intraoral healing of the patient was still uneventful after 3 months (Figure ), the patient was decided to have several courses of systemic chemotherapy by the department of oncology as further treatment protocol of DLBCL.\nNevertheless, the patient had a stroke after chemotherapy finished (6 months later) and he passed away within 2 years after diagnosis due to DLBCL. |
A one-day-old male Nigerian neonate of Igbo ethnicity was referred from a private hospital with complaints of bleeding from the mouth and vomiting of blood shortly after delivery. Frank bleeding started about an hour after delivery. There was no bleeding from any other site. He had vomited nine times on the first day of life and three times on the day of presentation.\nHe had received some antibiotic injections from the referring clinic but bleeding had persisted. A diagnosis of neonatal sepsis with disseminated intravascular coagulopathy was made and he was referred to our hospital.\nThe pregnancy had been supervised in a maternity home and had been uneventful. Delivery was at term by a traditional birth attendant (TBA). Further history revealed that the lingual frenulum had been clipped by the TBA about an hour after birth, after which bleeding had commenced. The indication for frenotomy could not be ascertained.\nThe baby was the last of five children, four girls and a boy. All the other children had undergone the same procedure, performed by the same TBA, within the first few hours of birth, with minimal complications. The family was of a low socioeconomic background.\nOn examination, our patient was in respiratory distress, severely pale and had cool extremities. He was noted to have a bleeding severed frenulum. His peripheral pulses were weak and thready and his systolic blood pressure was unrecordable. His heart rate was 180 beats per minute with normal heart sounds. His respiratory rate was 94 cycles per minute and breath sounds were vesicular. His abdomen was flat and soft with no palpable organs. He was conscious but lethargic, with a depressed anterior fontanelle. His primitive reflexes were depressed but he had normal tone in the limbs. A review of his systems showed that he was very weak, had poor suck and had not passed urine in the last eight hours.\nA diagnosis was made of severe anemia and hypovolemic shock secondary to acute blood loss, occurring after the clipping of the frenulum. An adrenaline pack was applied to the bleeding site and bleeding was controlled within a few minutes. His urgent packed cell volume (PCV) was 15%.\nHe was rehydrated with normal saline until blood was available for transfusion. He received whole blood transfusion and a single volume exchange blood transfusion. He was commenced on broad spectrum antibiotics (ceftazidime). Vitamin K injections were also given and his vital signs were monitored. His post-transfusion PCV was 45%. His electrolytes, urea and creatinine results were normal except for elevated urea; his clotting profile was also within normal limits. He also developed jaundice which responded to phototherapy. He was discharged five days after admission. |
A 75-year-old female with symptomatic paroxysmal atrial fibrillation (PAF), statuspost atrial fibrillation ablation, and prior history of breast cancer, statuspost bilateral mastectomy and left lymphadenectomy, presented with diziness and near syncope and was found to have sinus bradycardia. Given her symptomatic sick sinus syndrome (SSS), she was planned for a dual chamber pacemaker implantation.\nThe placement of a dual chamber pacemaker insertion was attempted from the right side as the patient previously underwent left-sided lymphadenectomy. The right subclavian vein access was obtained and cannulated under fluoroscopy. The right ventricular (RV) lead was advanced attempting to access the right superior vena cava (SVC). While attempting to advance the lead, resistance was encountered and the lead was withdrawn. A venogram was performed revealing the absence of a right SVC with the presence of a persistent left superior vena cava draining into a massively dilated coronary sinus (Figures and ).\nThe lead could not be advanced into the right ventricle, and as a result, the procedure was aborted and cardiothoracic surgery was consulted for possible epicardial lead placement.\nAfter discussing the potential need for cardiothoracic surgery with the patient, she considered another attempt at transvenous placement of a dual chamber pacemaker with us. After repeated attempts, left subclavian vein access could not be obtained. The venogram revealed stenosis of the left subclavian vein. The decision was made to make an additional attempt from the right subclavian vein utilizing the previous pocket. After successful cannulation of the right subclavian vein, an active fixation lead was advanced through the subclavian vein into the PLSVC through the coronary sinus and then through the tricuspid valve into the right ventricular septum. Following successful right ventricular lead placement, an active fixation bipolar pacing lead was advanced into the right atrium using a straight stylet and secured to the right atrial wall.\nStimulation and sensing thresholds were determined to be satisfactory in both leads. A St. Jude Medical generator was connected to the leads, and the pocket was closed. |
A 32-year-old man fell from a high place and sustained a comminuted fracture in the right distal radius (AO classification type C1). He underwent open reduction and internal fixation using a volar plate at an emergency hospital. He visited the outpatient clinic of our department 24 months after the initial surgery because wrist pain had increased during his work. Radiographs showed an irregular articular surface of the distal radius due to poor reduction in the initial surgery (). An examination revealed a restricted range of motion of the wrist joint (flexion/extension 40°/30°) and grip strength had decreased to 20% of the healthy side.\nRemoval of the plate and radiolunate arthrodesis with a free iliac bone graft was performed in our department (). The radiolunate fusion was done through a dorsal approach. However, the pain was still present at 6 months postoperatively, and radiography showed nonunion and loosening around the screws (). The patient was then treated with a vascularized bone graft from a medial femoral condyle bone flap (). First, an external fixation device was used for the purpose of load reduction on the radiocarpal joint. Next, after exposing the radiocarpal joint, the fibrous damaged tissue including the iliac crest and screws at the nonunion site were removed. The damaged articular cartilage and subchondral bone were sufficiently excised to expose the underlying cancellous bone. The descending genicular vessels as the vascular pedicle were elevated with the periosteum and bone cortex and cancellous bone at the right medial femoral condyle bone (pedicle length 50 mm, vascularized graft segment 30 × 10 × 10 mm). The size of vascularized graft segment was decided considering intraoperative measurement of the bone defect. The bone graft was tailored to fit the radiocarpal joint and was placed between the lunate and distal radius with a slight distraction of the lunate, decompressing the scaphoid (). Then, the bone graft was fixed with two headless compression screws at both the lunate and distal radius sites. End to end anastomosis into the dorsal branch of the radial artery and concomitant veins at the snuff box was performed.\nAn external fixation device was used for 4 weeks. This was due to a concern regarding the poor strength of femoral condyle bone with a thin cortex. The reason why we chose the external fixation instead of the dorsal spanning plate was to avoid worsening the blood circulation in the vascularized bone. There was no additional procedure performed at the donor site after harvesting the bone flap. A short arm cast was used for immobilization for 2 weeks after removal of the external fixation device. After cast removal, wrist and hand therapy was started, with the aim of regaining wrist and thumb mobilization. Ambulation was permitted starting on the first postoperative day. Complete bone union was achieved 8 weeks after the third surgery. At final follow up of 12 months postoperatively, the grip strength was restored to 92% of the healthy side, and the range of motion of the wrist and the VAS and DASH scores were improved (flexion/extension: 45°/50°, VAS: 85 to 5, DASH: 52 to 13). There was no morbidity such as pain at the donor site. The patient returned to unrestricted daily activity and his work 4 months after the third surgery. |
A 50-year-old female patient was referred to the Department of Oral and Maxillofacial Surgery of the VU University Medical Center in Amsterdam with complaints of a long ongoing unpleasant altered nasal airflow after the placement of eight dental implants in the maxilla. Four months prior to implant surgery, a bony augmentation of the atrophic edentulous alveolar crest and a bilateral maxillary sinus floor elevation using autogenous bone harvested from the anterior iliac crest had been performed. Shortly after implant placement, one of the implants placed in the area of the left first incisor had to be removed due to an oronasal fistula and subsequent lack of osseointegration. No further complications such as rhino-sinusitis, nasal discharge, pain, recurrent epistaxis, or headaches were reported.\nHowever, anterior rhinoscopic examination revealed that the apical part of the dental implant placed in the upper right first incisor region had perforated the nasal floor close to the nasal septum and partially extended into the right nasal cavity (Fig. ). The mucosa of the left nasal cavity was intact and demonstrated no signs of inflammation. Radiological examination (dental and panoramic radiographs and computer tomography) confirmed that the implant placed in the right first incisor region had perforated the cortical bone of the nasal floor (Fig. ).\nAfter a discussion with the patient regarding the risks and benefits of surgery, transnasal resection of the apical part of the titanium dental implant in general anesthesia was opted for. During surgery, the floor of the nasal cavity was locally anesthetized and the nasal mucosa surrounding the dental implant was incised and meticulously elevated exposing the nasal floor and the apical part of the perforating dental implant. Under direct vision and adequate sterile saline cooling, the perforating implant was resected to the level of the nasal bone initially using a hard steel fissure burr. The titanium surface was further smoothened with a round diamond burr. All metal debris were carefully removed from the operating site, and the nasal mucosal flap was realigned and sutured using 4-0 Vicryl to provide a watertight mucosal seal. The patient was postoperatively instructed to avoid sneezing and nose blowing and received a broad-spectrum antibiotic (amoxicillin-clavulan acid 500/125 mg three times daily for 5 days).\nNo complications were apparent during the surgical procedure. Postoperative clinical and radiological examinations demonstrated an intact nasal mucosa and an adequate resection of the dental implant to the level of the nasal floor (Fig. ). The patient had an uneventful recovery and at 2-, 6-, and 12-month follow-up, she reported having no altered nasal airflow.\nInsertion of endosseous dental implants is usually associated with a low incidence of complications and excellent prognosis [, ]. However, physiologic changes following tooth loss may complicate or even impede insertion of dental implants in the upper jaw. Furthermore dental implants can only be inserted if there is sufficient bone for adequate stabilization [–]. Therefore, in severely atrophied bone conditions, augmentation procedures using autogenous bone grafts or bone substitutes are often required [–].\nVarious short- and long-term complications such as maxillary sinusitis, oroantral fistula, and extrusion of graft material have been reported after implant placement [–]. Particularly, dental implants that partially extend into the maxillary sinus or nasal cavity are known to cause complications [–]. Furthermore, patients with a predisposition to develop sinusitis are prone for complications after dental implant placement in the maxillary sinus area []. Interestingly dental implants that partially extend into the nasal cavity are often asymptomatic and may reside in the nose for many years. However, when complications do occur, unilateral mucopurulent and fetid nasal discharge are the most prevalent symptoms, which can be accompanied by pain, discomfort, headache, or congestion of the affected side. Therefore, patients complaining of nasal discharge after dental implant placement should be thoroughly checked for foreign bodies in their nasal cavities. Differential diagnosis of a unilateral nasal obstruction may also include nasal tumors, nasal polyps, septal deviations, hematomas, and various infections [].\nMinimal invasive treatment strategies for dental implants residing in the nasal cavity as described in this study have to the best of our knowledge not often been described. A more invasive removal of the complete dental implant in the presented case would have had a negative effect on the load bearing during mastication because of its strategic position in the maxilla supporting the fixed bridge construction. Furthermore, an explantation through the oral cavity could have created an oronasal communication and compromised mucosal blood supply resulting in mucosal recession with a negative outcome on esthetics and peri-implant supporting tissue. Therefore, a partial removal of the apical part of the dental implant using a transnasal approach was opted for. |
The male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of “hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemorrhage (Fig. a). Craniotomy and clipping of intracranial aneurysm were performed the next day after admission. During the operation, the aneurysm was found to be located in M1 bifurcation of the left middle cerebral artery, which was in cystic bulging. An asci formation with the size of 3 × 4 × 5 mm was located on the upper side of the aneurysm, and the aneurysm neck measured 4.2 mm, which was clipped successfully. There was no significant hematoma in the subarachnoid space, and the arachnoid around the aneurysm showed no obvious adhesion during the surgery. The patient successfully recovered from anesthesia after the surgery, without any significant neurological deficits. The patient was discharged after 2 weeks and Glasgow Outcome Scale (GOS) scored 5 points. Follow-up was performed for 4 months at the Outpatient Department. Head CTA (Fig. b) demonstrated that aneurysm did not relapse and GOS score was 5 points. |
A 70-yr-old right-handed man with nine years of education developed sudden memory loss three days before admission to Kyung Hee University Hospital. Past medical history was remarkable for hypertension for three years and two episodes of stroke. The first episode of stroke developed 11 yr earlier when he was admitted because of transient confusion. About 40 days prior to admission, he was admitted to another hospital for evaluation of dizziness. Despite the absence of focal neurological or cognitive deficits at this time, diffusion-weighted (DWI) and T2-weighted images (T2WI) showed an acute infarction in the right cerebellar hemisphere. The scan also identified an old infarct in the left lingual gyrus, as well as another slit-like lesion in the right anterior thalamus on T2WI with signal characteristics consistent with a previous thalamic hemorrhage ().\nThree days before admission, his family suddenly noticed him asking the same questions repeatedly. On the forth day after onset (the second hospital day), the patient was alert and cooperative but recalled none of the previous day's events and failed to recognize the attending physician who had been introduced to the patient several times on the previous day. On the Mini-Mental Status Examination, he did not even recall being given three words that he had registered only a few minutes before, scoring 20/30 due to additional problems with orientation to time, place, and naming. The patient was aware of his memory loss. No abnormalities were found on the rest of the neurological examination.\nHigh-resolution DWIs taken four days after onset showed a new focal infarct, which proved to be localized to the left MTT according to an atlas () (). T2WI and fluid attenuated inversion recovery imaging obtained three days later showed the MTT lesion with no additional lesions except the aforementioned lesions (). Single photon emission computed tomography (SPECT) performed on the same day showed decreased cerebral blood flow in the right cerebellar hemisphere and the left occipital lobe, but no flow reduction in other cortical regions.\nDetailed neuropsychological tests using a standardized battery called Seoul Neuropsychological Screening Battery () and Wechsler Adult Intelligence Scale were performed four days after onset. His verbal and performance IQ were 92 and 93 with a full-scale IQ of 92, consistent with expected premorbid function. Forward digit span was 6 (64th percentile). His performances on spoken and written language were normal as were on 10 items of praxis and on tasks for Gerstmann syndrome. However, the patient had impaired confrontation naming as assessed by the Korean version of the Boston Naming Test (29/60, 1st percentile). Copying ability tested with the Rey-Osterrieth Complex Figure was intact (30/36, 32nd percentile), but immediate recall (7.5/36, 12th percentile), 20-min delayed recall (10/36, 17th percentile), and recognition ability (true positive-false positive=3-2, <1 percentile) were impaired. Verbal memory as assessed by the Seoul Verbal Learning test was also impaired, showing defective new learning (3-trial immediate free recall: 8/36, 1st percentile), delayed recall (0/12, <1 percentile), and recognition (1/12, <1 percentile). Frontal/executive functions including go-no-go test, controlled oral word association, motor set shifting, and Stroop color test (101/112, 72nd percentile) were intact. In addition to anterograde amnesia, he also had impaired recalling of remote events. He believed the current president to be the one in office 10 yr ago, and he failed to recall 2002 FIFA WORLD CUP KOREA/JAPAN. Retrograde memory impairment was most profound for incidents during the past one year, including the deaths of two close friends, moving to a new house, and even his hospital admission 40 days before our evaluation. To further substantiate his retrograde amnesia, we performed the autobiographical memory interview, which showed that his retrograde amnesia was limited almost exclusively to the events during the past one year.\nA repeat evaluation using the same neuropsychological tests four months after onset showed persistent amnesia. He could not even remember his mother's death two months previously. |
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.\nOn examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.\nMRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).\nIt showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Total resection of the lesion was done through only anterior knee portals without taking the risk of posterior portals preventing potential neurovascular injury. The pathology report confirmed the presence of PVNS. On 6-month MRI follow-up, the previously described soft tissue enhancement suggestive of residual inflammatory changes noted within the femoral notch along the cruciate ligaments as well as posterior to the distal metaphysis at the site of the previously present lesion has decreased (Figures and ). The synovial fluid had also decreased with no evidence of hemosiderin deposits. There was no evidence of interval appearance of new susceptibility artifacts or blooming effect on the T2 gradient sequence that could correspond to evident recurrence. The compressive effect previously present on the popliteal vessels has completely disappeared with no further tingling sensation and numbness over the calf region. Clinically, patient regained full ROM on flexion extension (0° to 135°) of the knee. The previously reported pain no longer exists, with no blocking upon flexion. Patient underwent physical therapy protocol and showed significant muscle strength and balancing improvement. She was scheduled to 1-year clinical follow-up. |
A 30-year-old Japanese woman presented to our hospital with chronic cough and had a workup in the internal medicine department. She had a past history of hyperlipidemia. A chest computed tomography scan showed a cystic lesion attached to the body of her pancreas, and a diagnosis of cystic pancreatic tumor was made. Blood tests showed neither inflammation nor anemia. Her serum amylase, lipase, aminotransferase, and bilirubin levels were within normal limits. Tumor markers including CEA, CA19-9, and AFP were not elevated. A contrast-enhanced computed tomography scan of her abdomen showed a 5 cm tumor (Fig. ). The lesion was attached to and compressing the body of the pancreas, the left gastric artery, the body of the stomach, and the abdominal part of the esophagus superiorly. The wall of the mass was thin and not enhanced. Magnetic resonance images showed a multilocular tumor. Neither an internal nodule nor septations were noted. There was no abnormality in the pancreatic duct, and the main pancreatic duct was not in communication with the lesion. Endoscopic ultrasonography showed that the cyst content had iso- and hypoechoic density with a thin wall and no mural nodules. A fine-needle aspiration biopsy was not performed. Differential diagnosis included a mucinous cystic neoplasm, a pancreatic cyst, or a retroperitoneal cystic lymphangioma. She was thus referred to the surgical department for evaluation. At this stage, we could not determine whether a pancreatectomy was necessary, thus we proceeded with a diagnostic laparoscopy.\nThe surgery was performed 1 month after the first visit to our hospital. Under general anesthesia, the operation was started laparoscopically with five ports (5 mm × 3 and 12 mm × 2). The tumor was within the lesser sac, which was incised and a window created. Because the left lateral segment of the liver was large and obscured the surgical view, we added a 5-mm port to elevate the lateral segment. The tumor was located in the retroperitoneal space and was attached to the body of the pancreas. We began the dissection of the tumor from the opposite side of the pancreas using laparoscopic coagulation shears (LCS, Harmonic ACE®; Ethicon Endo-Surgery, Cincinnati, OH, USA) and scissors. Branch vessels from the left gastric artery and vein were divided and the compressed left gastric vessels were preserved. The dissection was done easily and bluntly. We dissected the tumor from the pancreas gently using a lymph node dissection technique similar to that in gastric cancer, and were able to separate the mass from the pancreas. Eventually, the tumor was connected only to retroperitoneal lymphatic tissue around the celiac axis. At this stage it became clear that this was a case of cystic lymphangioma; as such, we finished the operation with cystectomy only. The specimen was extracted using a plastic bag (Endo-pouch®; Ethicon Endo-Surgery). An additional movie file shows this image in more detail (see Additional file ). The postoperative course was uneventful and our patient was discharged on the sixth postoperative day. As the postoperative follow-up, our patient received an abdominal computed tomography examination at 3 months after surgery and then every 6 months. Our patient had no signs of recurrence for a 2-year period after the surgery.\nA histopathological examination showed that the cyst was lined by flattened endothelium. Immunostaining was positive for CD31, D2-40, AE1/AE3, and SMA. Other markers including CD34 and calretinin were negative. The diagnosis was made of a retroperitoneal cystic lymphangioma (Figs. and ). |
This is the case of a 51-year-old female with a past medical history of IPAH. This had been diagnosed by right heart catheterization 16 years previously when the patient collapsed at home shortly after childbirth. The patient’s condition was stable for many years, being medically managed with intravenous iloprost at 1300 μg once daily. This allowed the patient an acceptable quality of life maintaining a WHO functional class II.\nA computed tomography pulmonary angiogram in 2013 diagnosed a 5.5 cm PAA, worst affecting the main and left pulmonary arteries. Right heart catheter performed at this time demonstrated pulmonary artery pressure of 90/39 mmHg (mean 31 mmHg), right ventricular pressure of 93/10, end diastolic diastolic pressure of 20 mmHg and a mean right atrial pressure of 13 mmHg. Due to the progression of the underlying pathology additional pulmonary antihypertensives were added to the treatment plan (sildenafil and ambrisentan). The patient was considered for bilateral orthotopic lung transplantation but after assessment was deemed too clinically well to list for transplant at that time and the patient continued to be monitored by their local hospital.\nClinical deterioration prompted review at our centre in 2019, which identified worsening symptoms of shortness of breath, causing severe limitation of daily function (WHO functional class III-IV), and left shoulder pain. Echocardiography revealed marked progression of the PAA causing dilatation of the pulmonary valve annulus and subsequent severe pulmonary regurgitation. There was also severe right ventricular impairment, moderate tricuspid regurgitation and a 4 cm pericardial effusion lateral to the left ventricular wall. Pulmonary artery pressure was estimated at > 65 mmHg.\nComputed tomography pulmonary angiography confirmed a 12 cm aneurysm of the pulmonary artery mainly affecting the main and left pulmonary arteries. There was also a 6 cm aneurysm of the right pulmonary artery (Fig. ). Cardiac magnetic resonance imaging confirmed a right ventricular ejection fraction of 23% (this had been 40% at the previous assessment). A chest x-ray demonstrated marked cardiomegaly, tracheal deviation, and an extremely widened mediastinum extending into the left hemi-thorax (Fig. ).\nDue to the presence of a giant PAA, severe pulmonary regurgitation and a 4 cm pericardial effusion, it was decided to list the patient for heart-lung transplantation. Episodes of right heart failure were managed with inotropes and the patient was maintained on pulmonary antihypertensive medications and diuretics whilst awaiting transplantation.\nApproach via median sternotomy revealed the large aneurysm sac which was translucent to blood. The space occupying effect caused lateral deviation of the aorta, as well as inferior displacement of the heart into the diaphragm (Fig. ). It also extended well into the left hemi-thorax, severely compromising the left lung. Cardiopulmonary bypass was established via aortic and bi-caval cannulation and the patient cooled to 34 °C. Dissection of the pulmonary artery allowed identification of the ligamentum arteriosus and safe dissection of the left recurrent laryngeal nerve (Fig. ). Following dissection and preservation of the phrenic nerves the recipient heart and lungs were explanted. The donor heart-lung block was prepared and implanted and after haemostasis was confirmed, primary chest closure was performed. The patient was started on an induction immunosuppressive regime and transferred to the cardiac intensive care unit in a stable condition. A post-operative chest x-ray was performed which was normal (Fig. ). The only significant post-operative complication was a below-knee deep vein thrombosis which was easily managed with enoxaparin. The patient was discharged 34d post-operatively and follow-up for 13 months since discharge has confirmed good progress. |
We present the case of a 61-year-old man who presented to the emergency department with a two-day history of severe abdominal pain. The pain was generalized and non-radiating. He described the pain as burning in character and was constant. The pain was aggravated by food intake and was not relieved by over-the-counter medications. He rated the pain as 8 out of 10 in severity and he could not sleep because of the pain. The pain was associated with nausea and recurrent episodes of vomiting. The patient reported that he had been having abdominal pain that was similar in quality but much milder in severity than the current episode. He reported that he usually developed abdominal pain following meal intake. He visited several outpatient clinics for his pain. He was diagnosed as having indigestion. He has been on a proton pump therapy for two years and it has provided moderate relief to his pain. He underwent upper gastrointestinal endoscopy and revealed normal findings. He reported that because of the chronic abdominal pain, he had reduced appetite and lost more than 15 kg.\nIn addition to the chronic abdominal pain, the past medical history was remarkable for a longstanding history of hypertension, dyslipidemia, diabetes mellitus, and chronic obstructive pulmonary disease. The patient had a history of Helicobacter pylori gastritis 15 years back that was successfully eradicated by triple therapy. The patient was on several medications for his comorbidities, including metformin 1000 mg, amlodipine 5 mg, omeprazole 40 mg, atorvastatin 20 mg, and aspirin 75 mg. His surgical history included a remote history of tonsillectomy. He was not known to have any drug or food allergies. He was a heavy smoker with a 30 pack-years smoking history. He never consumed alcohol. He was a retired school teacher. The family history was remarkable for inflammatory bowel disease.\nUpon examination, the patient appeared in pain. His vital signs showed tachycardia (115 bpm), normal respiratory rate (14 bpm), normal temperature (36.8℃), and maintained blood pressure (124/91 mmHg). His oxygen saturation was normal on the room air. Abdominal examination revealed a soft abdomen with generalized tenderness. However, there was no guarding or rigidity. The bowel sounds were present and had normal intensity and frequency. Cardiovascular examination revealed a loud S2 sound with no added sounds or murmurs. The peripheral pulses were normal. The respiratory and neurological examination findings were normal. The initial laboratory findings, including hematological and biochemical investigations, were within the normal range (Table ).\nConsidering the cardiovascular risk factors for atherosclerosis and the severity of the pain, the initial differential diagnosis was acute mesenteric ischemia. Hence, the patient underwent a contrast-enhanced computed tomography scan of the abdomen. The scan demonstrated an acute angulation and indentation upon the celiac trunk with thickening of the median arcuate ligament (Figure ). The bowel loops had normal wall thickness and enhancement. In light of the clinical and radiological findings, the diagnosis of celiac artery compression syndrome was made.\nSubsequently, the patient was prepared for surgical intervention for decompression. He underwent laparoscopic surgery. The operation was done under general anesthesia and the patient was placed in a supine position. After establishing pneumoperitoneum, diagnostic exploration was made. The thickened median arcuate ligament was appreciated. Careful dissection of the ligament was performed and the celiac artery was decompressed successfully. No complications occurred during the operation. The patient had an uneventful recovery. Postoperatively, the patient was able to tolerate oral feeding with no postprandial pain. He was discharged on the fifth postoperative day. After one year of regular follow-up visits, the patient had major satisfaction and his symptoms showed complete resolution. |
A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical report\nOn physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.\nThe patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement denoting an abscess. There was diffuse anterior abdominal wall fat stranded with subcutaneous pockets of air denoting infection. Subcentemetric mesenteric lymphadenopathy was observed ().\nPatient was taken to the OR for exploratory laparotomy and drainage of the abscess. Upon internce to the abdomen a large pocket of pus in subcutaneous layer was opened and evacuated and a swab was sent for culture and sensitivity. A firm mass inclosing the pelvic was dissected and found to be a large diverticulum 10 cm from the ileocecal junction. The mass was attaching to the urinary bladder and was fistulating to the subcutaneous pus collection. Urology was called in at this point and the urinary bladder was checked by injecting methylene blue dye; there was no leak. Limited right hemicolectomy was performed with a primary iliocolic anastomosis ().\nHistopathology was consistent with diverticulum of the small bowel and serosal lipoma with a pocket containing multiple staghorn-type black stones, negative to tuberculosis (). Patient wound culture from OR showed E. coli which was sensitive to Tigacyclin. Treatment was started with this antibiotic and patient’s condition improved. Postoperative course was uneventful except for a small dehiscence at the lower part of the abdominal wound, which was treated conservatively with VAC dressing. Patient was discharged to travel to his country, and the wound was left for secondary closing. |
The present case report is about a 73-year-old man who was referred to I.T.S College of Dental Studies and Research Murad Nagar with the chief complaint of difficulty in eating and speaking. He gave a history of a tobacco smoking habit since 50 years. He was diagnosed with squamous cell carcinoma of the right buccal mucosa about 14 years back. His medical history revealed that he had undergone hemimandibulectomy of the right side with modified radical neck dissection 14 years back []. Intraoral examination revealed thick, freely movable soft-tissue with scar formation, the loss of the alveolar ridge and the obliteration of the buccal and the lingual sulcus in the entire right half of the mandibular region. The patient was completely edentulous present on the left half of the mandible. The scarring of the tissue after surgery caused severe deviation of the mandible to the resected side. The patient complained of inability to eat and wanted restoration of the missing teeth. Rehabilitation was planned with fabrication of an implant supported denture to aid in retention and stability of the denture on the resected mandible.\nTotal three implants were placed, in which two were anterior to the mental foramen and one was posterior. Amongst the two anterior implants, the 1st was placed 5 mm from the resected site on the right side and the 2nd was placed 5 mm from the mental foramen toward the midline on the left side. The 3rd posterior implant was placed near 2nd premolar. At the time of prosthetic rehabilitation, it was noted that the patient required a mandibular labial vestibuloplasty procedure as his labial sulcular depth was not adequate []. A mucosal incision was made 3-5 mm away from the mucobuccal fold []. A lip-cheek mucosal flap and a mucosal alveolar flap were raised and muscles and fibrous tissues were dissected to the required depth []. The lip-cheek mucosal flap and the muscles were then sutured and reattached to the periosteum at the inferior border. The alveolar mucosa was fenestrated by 4-5 oblique full-thickness incisions, stretched to cover most of the labial raw periosteum and fixed to it. Finally, a pre-operatively prepared stent [] with overextended flanges was lined with soft-liner and secured in place []. Adequate sulcus depth was obtained post-operatively and the patient was referred to the Department of Prosthodontics for rehabilitation and was provided with interim denture []. |
A 59-year old obese man presented to the emergency department with a long standing history of lower urinary tract symptoms and a subsequent appearance of a right groin swelling of nine months duration. His symptoms of difficulty of urination, increased urinary frequency, nocturia and urgency became worse when the groin swelling increased in size. The patient used to reduce the swelling manually to improve the symptoms. Six hours prior to the emergency room visit, the pain became intolerable and the swelling was tender and irreducible. The patient has essential hypertension and benign prostatic hypertrophy for the last 5 years.\nPhysical examination revealed that the patient had stable vital signs and controlled blood pressure. Body mass index (BMI) was 32 kg/m2. Abdominal examination showed the presence of a tender right groin swelling which was difficult to assess because of tenderness and obesity. Digital rectal examination showed a clinically benign enlarged prostate about 80 grams in volume.\nAbdominal ultrasound showed 11 × 5 cm bladder diverticulum herniated into the right groin region. The size of the prostate was estimated to be 60 grams and the post residual urine volume about 150 ml. Pelvic CT scan was requested but the patient refused to do it because of its cost. Cystogram was done to confirm the diagnosis and showed a bladder diverticulum herniated into the right femoral canal (Figures and ).\nOn planning for an emergency surgery, urine analysis, CBC, serum creatinine and urea, serum electrolytes, chest x-ray and ECG were all done and were within normal limits. The patient gave an informed consent only for diverticulectomy and hernia repair and preferred to try medical treatment for the benign prostatic hypertrophy.\nPfannenstiel incision was done, retroperitoneal space was opened, and dissection around the right side of the bladder revealed a congested urinary bladder diverticulum entrapped through the femoral ring which was dissected and reduced back with difficulty. Diverticulectomy was then performed and the femoral hernia was repaired using a polypropylene rolled plug mesh placement. During closure of the wound, a bulge was noticed in the right inguinal area. By palpation, it was proved to be reducible right inguinal hernia. Extension of the pfannenstiel incision to the right side, inguinal canal approached anteriorly opened, indirect inguinal hernia was found, hernia sac was dissected and excised. Hernia was repaired using a tensio and on free mesh technique. Prophylactic antibiotic (ceftriaxone) was given for 3 days. Foley’s catheter removed after 4 days and the patient was discharged.\nSix months after surgery, none of the hernias recurred, but his lower urinary symptoms were only partially relieved by the medical treatment. |
A 64-year-old man presented to the general surgery outpatient clinic with a 3 months' history of anal bleeding and pain during the defecation. Anal examination revealed the presence of hemorrhoids and subsequently the patient was treated by hemorrhoidectomy. Unfortunately, radiological studies, tumor marker blood tests and colonoscopy were not performed prior to hemorrhoidectomy. Postoperatively, the patient continued to suffer from constipation and severe pain during defecation. Therefore, he visited another hospital 1.5 1½ months later, where physical examination revealed the presence of an anal stricture. Colonoscopy could not be performed at this time either, because of pain, but he underwent operative dilation of the stricture. The patient returned to the general surgery clinic 1 month after the procedure because of persistent pain and a rectoscopy was performed. This procedure revealed a fragile, fungating tumor at the posterior wall of the rectum 5 to 7 cm above the dentate line and obstructing the lumen. Histologic examination of a biopsy from this tumor demonstrated a well differentiated adenocarcinoma. The patient had laparoscopic low anterior resection (LAR), followed by radiotherapy and chemotherapy. Pathologic examination of the resected tumor revealed a 4 × 4 × 3 cm well differentiated adenocarcinoma, invading the muscularis, and extending into rectal subserosa. All surgical margins were free of disease and there was no evidence of metastasis in the regional lymph nodes.\nRectal bleeding recurred 18 months after the operation and the patient returned to the clinic. At this time, an anorectal smear was procured as the initial procedure, using an endocervical brush. The smears were fixed in 95% ethanol and stained with Papanicolaou stain. Cytologic examination of the smears revealed a mucinous and necrotic background in which numerous neutrophils, squamous, and glandular cells were identified. Many of the glandular cells were in the form of sheets of reactive columnar cells with thin cytoplasm and uniform oval to round nuclei. In addition, there were several atypical glandular cells with large hyperchromatic nuclei and thick cytoplasm []. These cells were either single or in the form of three dimensional clusters, straps, and glands. Cellular strips with nuclear pseudostratification, reminiscent of short “bird tail like” arrangements were also seen [].[] Some tumor cells were spindle shaped similar to a high-grade anal intraepithelial neoplasia or squamous cell carcinoma []. These cytologic findings were interpreted as diagnostic of adenocarcinoma.\nRectoscopy was performed following the procurement of the smear. This revealed a 3 cm ulcero-papillary mass at the level of dentate line. Microscopic examination of the biopsy showed a well differentiated adenocarcinoma, and an abdominoperineal resection was performed. Histologic examination of the resected material demonstrated invasion of the muscularis propria by neoplastic glands []. Some dysplastic, but not frankly malignant, glands were seen in the mucosa adjacent to the adenocarcinoma. The tumor did not have any continuity with the area of the initial anastomosis, thus hindering the ability to determine if it was a recurrence or a new primary. There was no evidence of involvement of any lymph nodes or perianal soft tissue by the tumor. The patient received postoperative chemotherapy and has been living with no evidence of disease for 17 months after the second operation. |
A 35-year old female with chronic hepatitis B infection and liver cirrhosis was referred to our hospital due to severe mitral valve regurgitation and atrial fibrillation. A decision was made to first treat the hepatitis infection and initiate liver protection therapy with a combination of Entecavir, the antiviral agent, polyene phosphatidyl choline and then operate on the heart defects. Once normal liver function was regained, she returned to our center for surgery. After all presurgery examinations had been carried out, we performed a mechanical mitral valve replacement and radiofrequency ablation. On day 5 postoperation the mediastinum and pericardium drainage tubes were removed. A routine echocardiogram found moderate fluid accumulation in the pericardium and fluid in the left pleural cavity. An arrow chest drainage tube was placed to treat the latter, however only 180 mL of a light yellow fluid was successfully drained. A computed tomography (CT) scan on day 9 showed a reduction in fluid in both the pericardium and the pleural cavity, so the patient was discharged on day 13.\nAt the time of discharge, an excessive amount of leachate (non-infection, non-bloody) was seen around the drainage wound, so the patient was instructed to attend her local hospital for further dressing and inspection of the wound. Ten days later, the patient went to the local hospital complaining of fatigue and chillness, physical examination revealed the wound had already self-healed and a CT examination showed moderate-to-severe pericardial effusion. A pericardial puncture was performed immediately and 500 mL of yellow liquid was drained. Approximately 1000 mL of yellow fluid was then drained daily for a total of 5 days. As there was no reduction in the volume of fluid being drained, the patient was readmitted to our hospital for further treatment. At admission, the patient complained of no obvious discomfort, her vital signs were stable, and no abnormal heart murmurs were found upon physical examination. The pericardial drainage tube place in the local hospital was still patent, and the characteristic of the drainage fluid remained liquid yellow. The volume of liquid drained daily remained at around 1000 mL.\nOn day 30 drainage liquid was sent for laboratory examination and was negative for chyle and no bacteria was found after a 10 day culture, and blood biochemical tests showed a total protein of 43.4 g/L, albumin 26.2 g/L, globulin 17.2 g/L, triglyceride 0.64 mmol/L, white blood cells 3.3×109 /L and a C-reactive protein of 2.52 mg/L. Echocardiography revealed a pericardial effusion (Fig. A) and a normal mechanical valve at the mitral position with no obvious perivalvular leakage. On day 31, a CT scan showed a massive pericardial effusion, right sided pleural diffusion and partial pulmonary atelectasis (Fig. B).\nThe chyle analysis test was repeated on day 41, after the patient had been given food with a high fat content, and found to be positive. In the intervening period of the two chyle tests differential diagnoses for the pericardial effusion were ruled out, for example low osmotic pressure as a result of decreased liver function, low hydrostatic pressure due to decreased cardiac function post surgery, inflammation of the pericardium or an adverse drug reaction.\nOn the 43rd day postsurgery the decision was made to carry out an exploratory resternotomy during which an open lymphatic fistula with a continuous flow of yellow liquid was found immediately inferior to the position of the initial mediastinal drainage tube on the surface of the diaphragm (Fig. C and D). Thus a primary diagnosis of supradiaphragmatic lymphatic fistula was made. The fistula was closed with a continuous suture and no other fistulas were found after a thorough exploration. The sternum was not closed until a complete sternal hemostasis had been performed. The patient was extubated with 8 hours after surgery and discharged home on postoperative day 5. Recovery was uneventful. |
A 4-month-old girl visited our clinic with the diagnosis of right CMT and right brachial plexus injury. The ultrasonogram done at the previous hospital showed diffuse thickening and heterogenous hyperechogenicity in the right SCM compared with the left SCM, suggesting right CMT (). She was born through a vaginal delivery at full term with a birth weight of 3,640 g. The delivery was complicated with cephalhematoma and right brachial plexus injury. On the first visit, clinical examination revealed tight and thick right SCM. She received physical therapy for 3 months in the previous hospital, but there was no improvement in the range of neck motion. We measured her neck rotation with an arthrodial protractor. For that, she lay supine with the shoulders stabilized and the examiner supported the head and neck in the neutral position. Lateral flexion was measured with a large protractor. There were 50° of neck rotation toward right side and 40° of neck lateral flexion toward left side, ending up with right torticollis. She also showed weakness of right shoulder girdle muscles and elbow flexors, showing grade 2 on pediatric functional muscle testing. By inducing the patient's developmental reflexes, we observed the reaction and evaluated to grade 2 that only partial movement was possible []. She showed shortening of the left leg in comparison to the right, and was diagnosed with developmental dysplasia of the left hip by an ultrasonogram. The alpha angle of the left hip was 45° and the beta angle was 62°. She was treated with a Pavlik harness for 4 months. With the diagnosis of right CMT and brachial plexus injury, she received physical therapy for CMT and brachial plexus injury. After 3 months of treatment, the strength of shoulder girdle muscles and elbow flexors was improved from grade 2 to grade 4, which can tolerate resistance without breaking the test position on the pediatric functional muscle testing []. However, she did not show any significant improvement in the range of neck motion. The patient showed too much resistance to continue the stretching exercise, so she did not respond to physical therapy for 7 months. Therefore, the neck magnetic resonance imaging (MRI) was performed at the age of 8 months in order to determine whether surgical release was required. The neck MRI showed diffuse thickening of the right SCM with low signal intensity within right SCM on both T1- and T2-weighted images, suggestive of right CMT (). In addition, a mass with diameter of 1.5 cm with low signal intensity on T1-weighted image and high-signal intensity on T2-weighted image was found in the superior portion of the right SCM, unlike typical findings of CMT ().\nAt the age of 9 months, unipolar release of both the sternal and clavicular head of the right SCM was performed just above right clavicle for management of CMT to prevent musculoskeletal complications secondary to CMT. A needle biopsy was also performed on the mass in the superior portion of the right SCM. Microscopic examination of a hematoxylin and eosin stained biopsy specimen revealed diffuse spindle cell proliferation with fibrosis, consistent with CMT. As the pathologic findings appeared to be compatible with CMT, she received postoperational physical therapy without considering surgical treatment for the mass lesion in the superior portion and was followed up in the outpatient clinic.\nFour months after surgery, she had gained full range of neck motion, but the mass in the superior portion of the right SCM had been growing. Neck MRI was performed to confirm the possibility of malignant neoplasm in the rapidly growing mass. Because the neck MRI of CMT patients can demonstrate high signal intensity on T2-weighted images caused by edematous condition for 1 year, we additionally conducted gadolinium-enhanced imaging. The mass in the superior portion of the right SCM on the follow-up MRI showed iso- to low-signal intensity on T1-weighted image and high signal intensity on coronal T2-weighted image and gadoliniumenhanced T1-weighted image, along with increased size of the mass from 2.1×2.8×2.5 cm3 to 2.8×4.1×4.2 cm3 (). A multidisciplinary team including a pediatric oncologist, otolaryngologist, and radiation oncologist concluded that the possibility of low-grade malignant tumor indicating rapid growing could not be excluded, and so radical excision of the mass was performed.\nThe surgical specimen revealed a circumscribed yellow to gray solid mass with focal myxoid change (). Microscopically, the tumor showed myxoid and fibrous areas composed of spindle cells (). In areas of hypercellularity, it showed positive immunohistochemical staining for Ki-67, which is a marker of proliferating cells (). Tumor cells were negative for CD34, which is one of the markers of solitary fibrous tumor. Tumor invasion to surrounding soft tissue was present but there was no involvement of resection margin. On the basis of these findings, the excised mass was proven to be LGFMS. G-banding karyotyping using the primary-cultured cells from the surgical specimen showed 47,XX,t(4;18) (q27;q23),+14[3]/46,XX[27] (). Positron emission tomography-computed tomography performed at the age of 15 months revealed no evidence of metastasis. On monthly follow-ups without adjuvant radiotherapy over 19 months, there was no evidence of recurrence on MRI. |
A 48-year-old man presented to the emergency department (ED) with progressive chest pain which intensified with inspiration. Earlier that day for the first time, he had had an episode of impaction of a fish oil tablet which was resolved by inducing vomiting. This is when the chest pain started and progressively increased. In the ED, he was initially worked up for a cardiac event and pulmonary embolus, both of which were negative. A computed tomographic (CT) scan of his chest revealed thickening of the esophageal wall as well as evidence of air/gas that appeared to dissect a plane of the esophagus. The CT also revealed extraluminal air suggestive of esophageal perforation. An upper endoscopy with stent placement was performed. The esophageal biopsy taken at this time showed inflammation with increased eosinophils in both the upper and lower esophagus parts. Histological sections of the esophagus showed basal cell hyperplasia, interstitial edema, and intraepithelial eosinophils up to 30 eosinophils per high power field (HPF) in the proximal and distal esophagus. The patient was discharged on a liquid diet, antibiotics, and a proton pump inhibitor. The stent was left in situ for 17 days and then was removed without difficulty. A repeat endoscopy three months later showed basal cell thickening, intercellular edema, and up to 20 eosinophils/HPF in the proximal and distal esophagus. This endoscopy also revealed stricture in the total esophagus and a ringed esophagus consistent with EoE. He was then referred to the allergy/immunology clinic for further evaluation. The clinical picture along with pathological findings was consistent with a diagnosis of EoE. Following the diagnosis of EoE, the patient began treatment with topical fluticasone propionate with complete symptom resolution. Repeat endoscopy on topical steroid for several months showed up to 3 eosinophils/HPF and mild inflammation and the patient had resolution of his symptoms.\nThe patient had a long standing history of dysphagia for the past 20–25 years predominantly with solid foods. He usually needed to chew his food for extended duration to swallow it with ease. He also reported intermittent symptoms of gastroesophageal reflux in the past which were neither evaluated nor treated. He has had no history of food allergies, asthma, or allergic rhinitis. His past medical history was significant only for hypercholesterolemia. There was no family history of atopic diseases. He consumes alcohol occasionally and does not smoke. A skin prick test done as part of the allergy workup was mildly positive to shellfish. |
A 48-year-old Caucasian male with recurrent left tonsillar bed cancer was referred for Port-A-Cath placement for anticipated chemotherapy. The right subclavian vein was selected for placement. A percutaneous gastrostomy tube under general anesthesia was also planned to be placed as a combined procedure.\nAfter induction of general anesthesia, the right subclavian vein was accessed at first attempt as noted by the return of dark nonpulsatile blood. Patient's oxygen saturation at that time was 100% as displayed on the monitor screen. Mild resistance was initially encountered at advancing the guidewire which seemed to take a wide course before reaching the right side of the mediastinum as seen under fluoroscopy. An 8 Fr Peel-Apart sheath introducer with a dilator was then inserted. Some technical difficulties were encountered upon passing the catheter which was described as the catheter getting buckled as seen under fluoroscopy, which was eventually overcome with catheter manipulation.\nUpon completion of the procedure, poor blood return from the port was noted. Under fluoroscopy, the catheter appeared to take an irregular course, crossing the mediastinum to the left of the midline [], before descending inferiorly to the right side of the mediastinum. Arterial placement was suspected and confirmed with arterial blood gas analysis of a blood sample drawn from the port. The catheter and port were removed intact. Firm pressure was applied around the clavicle for several minutes. No visible or palpable hematoma was noticed after the pressure was released.\nAnother attempt at placement, again at right subclavian vein, was undertaken and the vein was ultimately cannulated uneventfully.\nVascular surgery was consulted and a chest radiograph was obtained which revealed mild widening of the mediastinum. Computed tomographic (CT) angiography of the chest with and without contrast was then undertaken for further delineation which revealed mild intimal irregularity of the right subclavian artery [] with central dissection of the right subclavian and innominate arteries extending as intramural hematoma of the ascending aorta [] up to the aortic valve. Also present was moderate mediastinal hematoma without active bleeding. The patient remained hemodynamically stable and neurologically intact.\nCardiothoracic surgery was consulted, and the pros and cons of surgical versus conservative management options were discussed with the patient. The decision was made to proceed with surgical repair of the aortic injury, which was accomplished by replacing the ascending aorta with an interposition graft under deep hypothermic circulatory arrest. Reportedly, no intimal tear was found during surgery, though the presence of an aortic wall thrombus was described. The patient recovered uneventfully and was discharged home to follow up as scheduled. |
A 1-yr-old girl presented with a salivary discharge at the facial skin of her right cheek. CT sialography was done and a sialo-cutaneous fistula from an accessory parotid gland was diagnosed (). She also had a skin tag on the tragus of the right ear. At that time, surgical excision was considered at a later age. At the age of five, she visited the outpatient clinic for definitive treatment. The clinical examination demonstrated a 1 mm-sized opening located at the facial skin 1 cm lateral to the angle of mouth. The salivary discharge was clear and serous. The salivary flow rate was calculated by a cotton ball test. It revealed that the flow from the accessory gland was about 10% of the total flow of a parotid gland. According to our previous experience (), fistulectomy was scheduled, but aesthetic considerations for the young girl made the surgical plan change to more conservative management. Under general anesthesia, the 6 cm-long fistula tract was identified with a lacrimal probe. Intraoperative ultrasonography was done to demarcate the accessory parotid gland. Although the accessory gland was too small to be clearly identified, 16 IU of botulinum toxin was injected to the accessory gland under ultrasound guidance. After thin adhesive film was attached on the buccal skin around the fistula opening to prevent spillage of corrosive agent from unwanted skin injury, about 2 mL of 40% TCA solution was injected into the tract with a small metal suction tip (). Thirty seconds later, all the solution was removed with suction and squeezing. This procedure of TCA cauterization was repeated twice. There was no immediate complication postoperatively.\nAfter several days, a tensely inflated sialocele formed and the opening was found to be completely closed up. Aspiration was done with long subcutaneous tunneling from behind so as not to make an iatrogenic sialo-cutaneous fistula. After 4 sessions of weekly aspiration, the sialocele did not recur. During one year follow-up, there was no more salivary leakage or sialocele. Moreover, the aesthetic result was very satisfactory. |
A 32-year-old gentleman had inversion injury to his left ankle on 2007 resulting in persistent medial ankle pain. He was treated with physiotherapy without improvement. Radiographs and magnetic resonance imaging (MRI) of his left ankle showed the presence of osteochondral lesion (OCL) of the medial talar dome (). Ankle arthroscopy and microfracture of the osteochondral lesion were performed on May 2008. His left ankle pain persisted after the operation and MRI of his left ankle was repeated and showed no interval change as compared to the previous MRI. Ankle arthroscopy was repeated on March 2009. Intraoperative findings showed that the medial talar OCL was covered with fibrocartilage and the other articular cartilage of the ankle joint was normal. However, his left ankle pain deteriorated afterwards as that he needed to walk with crutches. He complained of medial ankle pain and there was no rest pain or systemic upset. He was referred to our clinic for further management. Clinical examination showed that his left ankle was stiff with tenderness at the medial talar dome. Standing radiographs and MRI of his left ankle showed decreased ankle joint space without significant osteophytes formation, subchondral cyst, or subchondral sclerosis (). Blood tests and gallium scan did not suggest any underlying infection. Ankle arthroscopy and distraction arthroplasty with Universal Compress Hinge were performed on May 2010. Arthroscopic findings showed marked fibrosis of the capsule with minimal synovitis. Most of the articular cartilage of the ankle joint was gone with exposure of the subchondral bone. There was an osseous defect at the medial talar dome. The patient was advised on active ankle mobilization exercise and weight bearing walking as pain was tolerated. The external fixator was removed three months later and his left ankle pain persisted with weight bearing. His left ankle pain started to improve 12 months after the distraction arthroplasty. During the latest followup on May 2012, he did not experience left ankle pain on walking although the ankle motion was still limited. Radiographs of his left ankle showed that the joint space remained decreased after removal of the external fixator (). |
A 72-year-old Caucasian man was admitted to our department with a pain in the left posterior mandible and periodontal hyperplasia associated with the left mandibular second molar tooth. He also complained about the ongoing pain for 2 months and spontaneous hemorrhage within the lesion region.\nAccording to his medical history, the patient had suffered from coronary angioplasty 6 years ago. He also suffered from malaise and fatigue for last 1 year and also inappetence for last 6 months.\nExtraoral examination of the patient showed no visible swelling, tenderness or pus discharge. Skin color and temperature were normal. In the intraoral examination of the relevant region, oral hygiene level was not good and gingival tissue around the second molar was hyperplastic and had a tendency to spontaneous bleeding.\nOn the other hand, the panoramic radiograph (PANO) showed a radiolucent lesion with irregular margins located the periapical area and also extended coronally that led into the serious mobility of mandibular left second molar tooth (Figure ).\nConsidering the patient's medical history and after an exhaustively clinical and radiographical examination, we decided to perform an incisional biopsy under local anesthesia. As expected, the result of the pathological examination was peripheral giant cell granuloma (PGCG). We did not consider to take an initial photography before the surgical procedures, however, with regard to the pathological results, we decided to perform another surgery under local anesthesia 1 week later, including extraction of the tooth and a wide curettage of the lesion in the left posterior mandible. Despite the anesthetic procedures were performed properly and adequately, the patient was still suffering from pain but no severe hemorrhage during the curettage was observed from the surgical area. After pathological assessment of the second biopsy, the lesion was diagnosed as DLBCL (Figure ).\nEven though the patient was relieved and healing was uneventful, we did several consultations and asked for PET/CT scan of entire body because of metastatic nature of DLBCL. After all of these scanning procedures, we doubted the patient may also have had DLBCL in his thyroid gland, gastric system, and prostate either.\nOn the other hand, 2 weeks later from the second biopsy, our patient had satisfactory outcomes, such as; no pain, hemorrhage, or swelling in the operated area. He stated that he is totally relieved and he is ready for the prosthetic procedures.\nMandibular biopsy results showed sheets of medium to large lymphoid cells with hyperchromatic nuclei and scanty cytoplasm. These cells stained positive for CD3, CD20, LCA1, and LCA2 for Cyclin D1 (clone Polyclonal). Ki67 proliferation index was %90. The tumor was also positive for MUM-1 and BCL 2 and BCL 6 (Figure ). Other blood tests and bone marrow investigations did not reveal any abnormality. However, the gastrointestinal tract biopsy resulted in almost the same outcome, with a slight difference of %80 Ki67 proliferation index, positive CD5 (Clone 4C7), and CD138 (clone MI-15) and negative Cyclin D1 results. Attributed to these results, the lesion in the gastrointestinal tract was diagnosed with DLBCL (Figure ).\nEven though radiological findings were not satisfactory enough in our second and the third follow-up (Figure ) and intraoral healing of the patient was still uneventful after 3 months (Figure ), the patient was decided to have several courses of systemic chemotherapy by the department of oncology as further treatment protocol of DLBCL.\nNevertheless, the patient had a stroke after chemotherapy finished (6 months later) and he passed away within 2 years after diagnosis due to DLBCL. |
We present a case of a 58-year-old female patient with a large recurrent ventral hernia. Six years before, the patient had been operated on for the umbilical hernia, with the simple repair without a mesh. The patient was an active smoker who suffered from morbid obesity with a body mass index of 43 kg/m2 and COPD as comorbidities relevant for this case report.\nThe patient was introduced to the surgeon during hospitalization at the gastroenterology department where a diagnostic workup due to a clinical picture of chronic small bowel obstruction was conducted. While taking the anamnesis, the patient reported frequent abdominal cramps, swelling, and pain in the area of the hernia that had intensified in the last few weeks. The physical examination revealed a large irreducible ventral hernia in the lower abdomen that was quite painful on palpation, but soft and, at that time, without signs of incarceration or strangulation. Taking into account the clinical picture with threatening hernia incarceration, the surgeon did not opt for preoperative optimization of the patient in terms of smoking cessation and starting a weight loss program but made an indication for semielective surgery.\nOn operative procedure, greater omentum, part of the transverse colon, and a cluster of small bowel loops with signs of chronic obstruction were found as hernial content. After adhesiolysis hernial content was reduced into the abdominal cavity. Hernial defect measuring about 7 cm in diameter and about 15 cm in the vertical line with significant rectus diastase in the supraumbilical part of the abdomen was revealed. Using the Rives-Stoppa technique a wide retromuscular space was created. Lateral dissection boundaries of this space were perforating neurovascular bundles in the area of the lateral edges of the rectus muscle on both sides. The posterior fascia was easily closed using also a portion of the hernia sac to bridge the defect between the posterior rectus sheaths. A 30 × 25 cm polypropylene mesh was placed in the retromuscular space ensuring adequate mesh overlap over the edges of the hernia defect of a minimum of 5 cm in all directions.\nWhen we observed that the anterior fascia, due to the size of the defect and decreased abdominal wall elasticity, would not close entirely and cover the mesh, we opted for rectus mobilization by the ACS method to avoid bridging. Upon extensive dissection of the anterior abdominal wall subcutaneous space without preservation of the rectus perforator vessels, relaxing incisions of the external oblique muscle aponeurosis were performed. Using the Ramirez technique, long longitudinal incisions of aponeurosis were made bilaterally, adjacently to the semilunar line, extending from the costal arch to the groin. This procedure resulted in the considerable mobilization of the vital musculofascial flap medially, and the hernial defect was closed at the midline without tension. Then, four redon drains were placed, i.e., 2 in the retrorectus space and another 2 in the subcutaneous space.\nThe postoperative course was complicated by skin ischemia. Ischemic lesions of the abdominal wall skin on the right with signs of necrosis along the midline were observed already on day 8 (). On postoperative day 11, multi-slice computed tomography (MSCT) of the abdomen was performed because of the ever more abundant wound discharge. MSCT findings showed a large subcutaneous seroma, a normal musculofascial component of the abdominal wall, appropriate mesh position, and normal intra-abdominal status. Percutaneous puncture of seroma was performed and about 800 ml of clear seroma was evacuated. During the next 10 days, ischemia progressed, along with the development of another two full-thickness skin necrotic foci paramedially (). Considering the relatively strict demarcation area of necrosis, we opted for the operative procedure of necrosectomy.\nFollowing abdominal wall necrosectomy with a safety margin of healthy tissue and considering an appropriate amount of vital residual abdominal skin, as well as the absence of signs of local tissue infection or mesh infection, primary wound closure was performed in consultation with a plastic surgeon (). As early as day 4 of the second operation, increased wound discharge and signs of skin wound dehiscence occurred, which required removal of skin sutures (). Then, a wound dressing with a hypertonic solution was applied for a week.\nWhen inflammation subsided, negative pressure wound therapy (NPWT) with the “Renasis Ez Max VAC® system” (Smith & Nephew, Mississauga, Canada) was initiated (). NPWT was delivered in continuous mode with negative pressure maintained at −100 mm Hg. Dressing in the form of a sponge of polyurethane black hydrophobic foam was changed every third day. After 2 weeks of NPWT administration, considerable improvement was recorded in wound cleaning and formation of healthy granulation tissue (). NPWT was continued for the next 2 months, which resulted in further improvement of condition of the patient, along with decreased wound discharge and cavity reduction. The wound swab obtained twice during dressing change was sterile. The patient was discharged from the hospital and regular changing of silver-impregnated antimicrobial wound dressing (Aquacel Ag, ConvaTec, Reading, United Kingdom) was continued in ambulatory care that led to complete wound closure in 7 months (). |
A 49-year-old male was working at a mine unrestrained was involved in a serious tramcar accident. He was admitted to the local emergency department with an open injury of the left lower limb, bilateral hip pain and deformity combined with and abdominal injury 5 h after the accident. Bilateral supracondylar traction of the femur and debridement and suture of the left thigh were performed immediately at the local hospital. Due to the concomitant visceral injury, an exploratory laparotomy was performed and, one day later, the patient was transferred to the emergency department of our hospital after hemodynamic stability was achieved.\nIn our hospital, the left lower extremity was adducted, flexed, and internally rotated, with 20 cm infectious wound on the back of his thigh. The right lower extremity was abducted, flexed and externally rotated (Figure 1). In the emergency department, pelvis computed tomography (CT) revealed asymmetrical bilateral hip dislocation (left posterior, right anterior) and fractures of the left acetabulum and bilateral pubis (Figure 2). Other injures included fractures lumbar 1-5 transverse processes, liver, kidney, and lung dysfunction. The patient was transferred to the operating room where manual reduction was performed under general anesthesia. The anterior dislocation of the right hip joint was successfully reduced. Manual reduction of the posterior dislocation of the left hip joint was also attempted; however, reduction failed after the second attempt. Due to hemodynamic instability, manual reduction was not attempted and open reduction was not considered. Meanwhile, the patient was transferred to the monitoring room of the trauma center to maintain its hemodynamic stability. Postoperative three-dimensional CT scan showed that the right femoral head was in place and the left femoral head was located behind and above the acetabulum. After the evaluation of the anesthesiology department, emergency operation was performed on the second day. Open reduction and internal fixation of the left acetabular posterior wall were performed combined with open reduction of the left hip joint and debridement of the left thigh.\nAfter surgery, deformities of both lower limbs were corrected. Due to severe systemic symptoms and multiple injuries, the patient was transferred to the surgical intensive care unit for the supportive treatment. Postoperative CT scan revealed that the fracture fragment in the posterior wall of left acetabular was successfully reduced. Three weeks after the injury, the left acetabular anterior wall fracture was treated with open reduction and internal fixation (Figure 3). After the operation, the patient received physical therapy in bed including quadriceps strengthening exercises and active range of motion. The left hip pain was relieved successfully after surgery.\nFive months after the injury, the patient was usually in a good condition. The quadriceps muscle strength of both lower limbs at level V, the posterior muscle group of the lower leg at level IV+, and the anterior muscle group at level IV+ with a good range of motion was achieved. The flexion of the left knee joint was slightly impaired due to tissue necrosis at the back of the left thigh and partial removal of the biceps femoris. Radiological evaluation showed that both hips, pelvis, and acetabulum were in a good shape. However, heterotopic ossification of the left hip joint was observed. No osteonecrosis of the femoral head in bilateral hip joints was observed. The patient was lost-to-follow-up due to noncompliance to scheduled visits. A written informed consent was obtained from the patient. |
A 17-year-old male presented in June 1995 with left hip pain for 2-month duration. The patient was a high school student, and he had this pain on and off which was tolerable. At that time, he was active with his high school extracurricular activities. But he went to see his general practitioner as the pain was disturbing his school activities for 1 month. He took oral analgesia for the pain, and he came to our hospital as the pain worsened the last 10 days. There were no constitutional symptoms and no history of trauma.\nOn physical examination, the range of motion of the left hip was reduced due to pain. There was no lymphadenopathy or neurovascular deficit. The plain radiograph showed osteolytic lesion over the superior aspect neck of left femur with scalloping of medullary canal (). CT scan reported a 4 cm destruction involving the metaphysis and neck of left femur with calcification and joint effusion and no sequestrum (). MRI findings revealed a 4 cm well-circumscribed eccentric mass at neck of femur with abnormal marrow signals (). The erythrocyte sedimentation rate (ESR) was slightly elevated (40 mm for the 1st hour), and the C-reactive protein (CRP) and total white cell count level were within normal range. Based on the history, clinical examination, and imaging, a diagnosis of benign bone tumor involving the neck of left femur was made.\nOn anterior exploration of left hip joint, the capsule was intact; we opened up the capsule to reach the lesion. There was friable bone tissue of 4 × 3 cm over the anterior cortex of neck of femur which was breached, but the other cortices were intact. Curettage and autologous iliac crest bone grafting was carried out, as the frozen section confirmed the diagnosis of EG. Two cannulated screws were used to pin the neck of left femur prophylactically against pathological fracture. The histopathologic examination revealed a mixed cellular infiltrate consisting of eosinophilic polymorphs with plasma cells and Langerhans histiocytes. He had an uneventful postoperative period and was on non-weight-bearing crutches for 3 months. On the 4th month postoperatively the lesion showed a sign of healing, and partial weight bearing was commenced. He went back to high school after 6 months when he was on full weight bearing without any walking aid (see ).\nNow, it has been 14 years since the surgery and his EG of neck of femur has healed (). He has no symptoms of recurrence or fracture, and the radiograph shows obliteration of the lesion with good trabeculae formation of the femoral neck which is visible clearly as the femoral neck screws have been removed. |
A 50-year-old woman was admitted to a county hospital in the suburb of Shanghai in August 2003 with acute colonic obstruction due to cancer of the sigmoid colon confirmed by colonoscopy. She underwent an emergency surgical resection of the tumor followed by end sigmoid colostomy and closure of the rectal stump at 10 cm above the anal verge (Hartmann procedure). The pathology was reported as well differentiated adenocarcinoma of the sigmoid without lymph node metastasis. Her postoperative course was uneventful. Asking for a restorative surgery four months later she was readmitted to the same hospital and operated by the same surgeon. There was no much adhesion in the pelvis and an end-to-end anastomosis was made using a circular stapler (Proximate® 29 mm, Ethicon). She was discharged from the hospital after three weeks. After her return to home she noticed passage of gas and later feces from vagina. She visited the surgeon's clinic again and had a check-up by the gynecologist. The gynecologist did not find her cervix uteri but a defect was found on her posterior vaginal wall five centimeter above the vaginal orifice with feces coming out. The surgeon denied any possibility of removal of her uterus during the surgery. At that point no treatment for rectovaginal fistula was given to the patient. Her case was presented to the medical malpractice committee for evaluation and she came to us to seek further treatment five months after her second operation.\nDigital examination of the rectum revealed a 1.5 cm defect on the anterior anal wall 5 centimeters above the anal verge. Vaginal inspection showed three metal clips stapled both the anterior and posterior vaginal wall with small cleavages between the clips. Stool discharged from the vagina. The cervix uteri was not found. Magnetic resonance imaging (MRI) showed that the uterus was present closed to the sacrum. Before this admission she had had a colonoscopy undertaken in a university hospital in Shanghai which reported that the whole colon and the anastomotic site were otherwise normal but a fistula on the anterior rectal wall. The diagnosis of rectovaginal fistula was established and she was operated under epidural anesthesia. Transvaginal repair of rectovaginal fistula was performed. The patient was uneventful until the sixth postoperative day when she passed flatus and stool per vagina but not the rectum. Failure of repair was highly suspected and she was taken into the operation room and had an examination under anesthesia. A blind rectal remnant was found about ten centimeters above the anal orifice and the repaired rectovaginal fistula was all right. Vaginal examination found that after removal of the residual metal clips there was an opening at the anterior fornix of vagina which was three centimeters above the original rectovaginal fistula. The diagnosis of an inadvertent colovaginal anastomosis was established then and a laparotomy was undertaken. After dissection of dense adhesion in the low abdominal cavity and pelvis the uterus was found to be adhered to the sacropromotory and the sigmoid colon was located anteriorly across the left appendix uteri and ended in the anterior cul-de-sac. There was dense adhesion in this area indicating that there has been dissected during the previous surgery. The colovaginal anastomosis was identified by insertion of finger within the vagina. After detachment of the colovaginal anastomosis and repair of the anterior wall of vagina the sigmoid colon was anastomosed to the rectal remnant by a circular stapler (Proximate® 29 mm, Ethicon). Postoperative period was uneventful and the patient was discharged from the hospital eight days after the final operation. She was followed up nine months later with satisfactory result. |
An 80-year-old woman presented to the authors' hospital emergency department complaining of right hip pain after sustaining a fall in her own home. Prior to injury she could walk normally. She had a normal body mass index and did not suffer from any other comorbidities. Clinical and radiographic evaluation of the right hip demonstrated an AO type 31.A2 intertrochanteric fracture.\nThe femur fracture was treated with intramedullary fixation the following day (). The patient tolerated the procedure well and the immediate postoperative period was completely uneventful. She was instructed not to bear weight for two weeks, but a range of motion exercises were started on postoperative day one. After an unremarkable hospital stay she was transferred to a rehabilitation facility on postoperative day four. Two weeks following surgical fixation of the femur fracture the patient started progressive weight-bearing and gait training. However, on postoperative day 20 the patient complained of a sudden onset pain at the right groin, over the femoral triangle of Scarpa. On physical examination the patient presented with a palpable and visible mass of about 3 × 3 cm, hard and tender to palpation (). Arterial pulses, strength, and sensation of the right lower extremity were unaffected. The pain was poorly controlled by rest and pain medication.\nOn postoperative day 40 anteroposterior and lateral X-rays were obtained demonstrating cephalad migration of the lesser trochanter (). For such reason an angio-computed tomography (CT) was obtained to assess fragment location and femoral vascular involvement (). The study demonstrated the migration of the lesser trochanter over the femoral triangle of Scarpa with no apparent neurovascular injury. On postoperative day 45 the patient underwent surgery for removal of the dislocated lesser trochanter. Intraoperatively the ascending branch of the lateral circumflex artery was isolated and retracted to access and remove the bony fragment. The apex of the fragment was medial to the deep femoral artery and distal to the lateral circumflex artery, both being completely intact. Further, there was no lesion/compression of the superficial femoral nerve, which has been described as the source of pain in a previous report []. It is likely that the complaint of pain was therefore caused by skin tension rather than nerve injury.\nThe patient tolerated the procedure well and the immediate postoperative period was uneventful. She was allowed immediate weight-bearing and was completely asymptomatic at four weeks postoperatively. |
A 21-year-old Caucasian female gravida two parity one at 28 weeks presented to the dermatology clinic for evaluation of a large mass on her left lateral thigh (Figure ). The patient had an existing diagnosis of NF One, but no other medical conditions. Denied any use of regular medication besides prenatal vitamins. The mass had been present since early childhood and had been stable in size since 11 to 12 years of age.\nPer the patient, the mass started to grow early in her first trimester and was noted to be more painful than in the past. The patient reported pain with minor trauma that lasted for days. No change in consistency of the mass was noted. No reported weakness or altered sensation in the leg, night sweats, fevers, chills, or weight loss by the patient. In her past pregnancy, the patient denied any change to the size of the mass or increase in pain like she was currently experiencing.\nThe physical exam was notable for multiple 2-3 mm hyperpigmented macules in the bilateral axilla. The upper extremities and back had large hyperpigmented tan macules and patches in various sizes consistent with Cafe au lait spots. The left thigh had a large 18 x 9 cm boggy hyperpigmented mass on the lateral side. It was pendulous and had multinodular consistency. The mass was moderately tender on palpation. The patient was noted to be able to ambulate without difficulty and had equal sensation and strength in both lower extremities.\nAfter discussion with the patient, she was prepped for punch biopsy of the mass. Multiple biopsies were taken from different areas of the mass to ensure adequate sampling. The results of the biopsy revealed plexiform neurofibroma without any indications of malignant changes in any of the sites. The patient returned to the clinic a week later for suture removal and was informed that the mass was a plexiform neurofibroma, but did not appear to be malignant at the time of biopsy.\nThe patient was educated about the risk of malignant transformation of the plexiform tumor and told to return if the mass changed in size again or became more painful. There were no indications of weakness in the extremity that would need to be evaluated further. The patient was advised to follow up with her obstetrician for routine pregnancy care. The patient was counseled to seek follow-up with an ophthalmologist for a full eye exam and to maintain regular follow-ups with her primary care physician. |
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.\nOn examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.\nMRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).\nIt showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Total resection of the lesion was done through only anterior knee portals without taking the risk of posterior portals preventing potential neurovascular injury. The pathology report confirmed the presence of PVNS. On 6-month MRI follow-up, the previously described soft tissue enhancement suggestive of residual inflammatory changes noted within the femoral notch along the cruciate ligaments as well as posterior to the distal metaphysis at the site of the previously present lesion has decreased (Figures and ). The synovial fluid had also decreased with no evidence of hemosiderin deposits. There was no evidence of interval appearance of new susceptibility artifacts or blooming effect on the T2 gradient sequence that could correspond to evident recurrence. The compressive effect previously present on the popliteal vessels has completely disappeared with no further tingling sensation and numbness over the calf region. Clinically, patient regained full ROM on flexion extension (0° to 135°) of the knee. The previously reported pain no longer exists, with no blocking upon flexion. Patient underwent physical therapy protocol and showed significant muscle strength and balancing improvement. She was scheduled to 1-year clinical follow-up. |
A 75-year-old woman presented initially to an outside hospital with left upper quadrant pain 5 days following diagnostic colonoscopy. The indication for endoscopy was surveillance of colonic polyps and the colonoscopy itself was deemed uncomplicated by report. Specifically, no patient repositioning or use of externally applied abdominal pressure was required to aid passage of the endoscope. No biopsies were performed.\nHer past medical history was significant for remote laparoscopic cholecystectomy, hysterectomy, bilateral hernia repair, and two previous uncomplicated diagnostic colonoscopies. Of note, there was no history of hematological malignancy or other known cause of splenomegaly and no history of anticoagulant medication use. The patient had mild generalized abdominal discomfort immediately following endoscopy but this resolved and she was discharged in stable condition following 4 h of standard observation. Five days later the patient presented to the emergency department at an outside hospital with a 4-day history of slowly worsening left upper quadrant pain, which had become more acute that morning. She denied interval abdominal trauma but had increased her level of physical activity the preceding day. She was hemodynamically stable with a serum hematocrit on arrival to the ED of 38%. Multidetector contrast-enhanced computed tomography (CT) was performed demonstrating a lower pole splenic laceration with active extravasation of contrast and high density perisplenic and perihepatic fluid (). Of note, the spleen was normal in size measuring 9 cm in maximal craniocaudal dimension. The patient was transferred to our institution where she remained hemodynamically stable with a heart rate of 84 beats per minute, blood pressure of 141/74 mmHg and a repeat hematocrit of 35.7%. Following joint assessment of the imaging and clinical findings by the surgical and interventional radiology services a decision was made to proceed to angiography and embolization.\nThe procedure was performed under conscious sedation within 90 min of arrival at the ED. Briefly, standard right common femoral arterial access was obtained with placement of a 5F vascular sheath (Avanti Sheath Set, Cordis, Bridgewater, NJ, USA). The celiac trunk ostium was stenotic but was successfully cannulated using a Simmons 1 catheter (Merit Medical, South Jordan, UT, USA). Digital subtraction angiography confirmed active contrast extravasation from the inferior splenic pole (). A microcatheter (Renegade STC, Boston Scientific, Natick, MA, USA) was used to selectively cannulate the bleeding lower pole splenic artery branch. Four 2 × 4 mm microcoils (Hilal Embo coil, Cook Medical, Bloomington, IN, USA) were placed and hemostasis achieved (). Subsequent selective DSA images confirmed cessation of extravasation with normal enhancement of the remaining splenic parenchyma (). The patient remained hemodynamically stable but described new right inguinal and lower back pain 24 h following the procedure. Given concern for a possible retroperitoneal hematoma, she underwent a repeat abdominal multidetector CT of the abdomen. This showed no evidence of a retroperitoneal hematoma and a stable perisplenic hematoma with no active contrast extravasation. No blood transfusions were administered before, during or after the embolization procedure. Of note, the patient did not develop symptoms or signs of post-embolization syndrome following the procedure. The patient was discharged on the third postprocedural day with a stable hematocrit of 35% and resolution of symptoms. She remained asymptomatic on outpatient clinic review 3 months later. |
Our case is a 68-year-old female with a past medical history of hyperlipidemia and insulin-controlled type 2 diabetes mellitus who presented with right knee pain and swelling. She denied any history of trauma. Radiograph and magnetic resonance imaging were concerning for GCTB. She underwent curettage and cementation of the right distal femur lesion and histological examination confirmed the suspected diagnosis of GCTB. Approximately one year later, she developed local recurrence of the tumor, which was also curetted with additional use of cement. One year after the second surgery, a routine chest radiograph showed lung lesions suspicious of metastatic disease (). At the time she was feeling well, with only mild pain in her right knee. Computed tomography (CT) imaging verified the presence of several pulmonary nodules including a large right lower lobe (RLL) mass measuring 5.6 cm (). CT-guided core needle biopsy of the largest lung mass confirmed metastatic GCTB ().\nAfter discussion at a tertiary center musculoskeletal tumor board the patient was started on denosumab therapy. Treatment was initiated with a loading dose of 120 mg every week for three weeks. She was then transitioned to receive a dose of 120 mg every four weeks. She was also placed on daily calcium and vitamin D supplements.\nAt 3 months after the initiation of treatment she had repeat CT imaging of her chest. The scan showed the RLL mass had decreased considerably in size, now measuring 2.6 cm in its greatest dimension. There was also a decrease in size of the other pulmonary lesions (). No new pulmonary nodules were seen. Since then she has had CT imaging of her chest every three months and radiographs of her right knee every six months. She has been without subjective complaint at each follow-up visit. After 16 months of denosumab therapy, q cardiothoracic surgery consultation was obtained and, due to the location and stability of disease, no surgery was recommended. The patient also was adamantly opposed to surgery. She continued to tolerate the denosumab without any evidence of side effects or complications.\nForty-eight months after initiating treatment, CT imaging showed the stable RLL mass as well as the smaller pulmonary lesions to be unchanged in size (). |
A 64-year-old, well built, tall (height 182 cm, weight 90 kg) African male cadaver showed a pronounced unilateral variation in the length (elongation) and course (kinking) of the highest portion of the cervical part of his left ICA. The history of this cadaver was not available, but during dissection of his abdominal cavity massive adhesions between the visceral peritoneal lining of the adjacent abdominal organs, between the visceral and parietal peritoneum and the perforated peptic ulcer of the duodenal bulb were found. These findings were interpreted as signs of the acute peritonitis – the most obvious cause for the death of this patient. No signs of any other diseases or pathological conditions were detected during the process of anatomical dissection of this cadaver.\nThe left ICA of this patient arose from the CB of the left CCA at the level of the middle third of C3 vertebra (symmetrical to the right ICA). The cervical part of the left ICA (diameter 8 mm) ascended 52 mm by a spiral course from its origin marked by the CS (width 16 mm) to the cranial base. Being posterolateral to the ECA, the ICA turned during its ascend first posteromedially then anteromedially toward the lateral pharyngeal wall and, when approaching the base of the skull in the area of the pharyngeal recess, anterolaterally. It came into the direct contact with the petrous part of the temporal bone just anteromedial to the base of the styloid process and it was located there between the jugular process of the occipital bone posteriorly and the lower edge of the tympanic part of the temporal bone anteriorly, occupying an area about 9 mm wide just laterally to the external opening of the carotid canal (CC).\nAt the base of the skull the upper end of the ICA started a sinuous (kinking) course (Fig. ) thus making the descending and ascending limbs of an extracranial siphon (ECS) of the ICA. From the inferior surface of the petrous bone the ICA sharply turned inferomedially and descended 13 mm along the medial surface of the upper end of this artery from the site of its curving. The site of the arterial bending was suspended to the base of the skull by a fibrous band, which had its ends attached to the inferior surface of the petrous bone just laterally to the fossula petrosa with the external opening of the canaliculus tympanicus. The fibrous band and petrous bone were forming a rigid fibroosseous ring through which the ICA was passing. There was a noticeable constriction of the ICA at this ring. The descending portion (limb) of the ECS of the ICA made a sharp bend turning medially and upward and ascended 13 mm as an ascending limb of the ECS toward the external opening of the CC. Because of anterolateral direction of the ICA approaching the external opening of the CC, it entered this canal obliquely making with the plane of the inferior surface of the cranial base a sharp angle open posteromedially. In the first portion of the CC the petrous part of the ICA ascended anterolaterally and then, after its sharp bend in the genu, it curved to become horizontal and pointed anteromedially towards the foramen lacerum (Fig. ).\nBoth, the descending and ascending limbs of the ECS had rigid attachments to the petrous bone of the cranial base at two places, a kinking area was suspended by the fibrous band and the point of entry of the end of the cervical part of the ICA into the external opening of the CC also was attached to the rim of CC. Anteriorly, the ECS was related to the upper parts of the ascending pharyngeal artery and the pharyngeal venous plexus, the lateral end of the auditory tube and the tensor tympani muscle. Posterior to the ECS there were the upper part of the superior cervical sympathetic ganglion (SCSG), the glossopharyngeal nerve, the inferior vagal ganglion, the accessory nerve the hypoglossal nerve and the upper bulb of the IJV. The glossopharyngeal nerve had close relation and connection to the fibrous band, which suspended the curved (kinked) upper end of the ICA to the petrous bone. The inferior vagal ganglion was connected to the hypoglossal nerve. The SCSG had connections with the inferior ganglia of the glossopharyngeal and the VN and with the hypoglossal nerves.\nThe total length of all portions of the cervical (extracranial) part of the ICA constituted 78 mm. The course of the petrous, cavernous and cerebral parts of the left ICA was identical to the course of the right ICA and it corresponded to the common standard. The right ICA had its width at the beginning 16 mm, length of the cervical part 53 mm and diameter 8 mm.\nExamination of the removed brain with its meninges revealed a significant asymmetry in the diameter of the fourth parts of the vertebral arteries (Fig. ). The diameter of the left vertebral artery was 4.5 mm, which is almost in tree times more than the diameter of the right vertebral artery – 1.7 mm. |
An ambulance brought in a female patient aged 25 years to the ED of a public, teaching hospital. She was assaulted in the face with a rock. Full examination was performed and she was kept in a hard-collar until a spinal injury could be ruled out with a head and cervical computerised tomography (CT) scan. Her facial wound was cleaned and left open. The CT scan was performed just before the morning medical shift handover and results had not been processed at the time of handover.\nHandover was conducted at the bedside comprising a multidisciplinary team of clinicians. A senior medical consultant conducted the handover, and junior clinicians positioned themselves at the peripheries. The junior doctor taking over patient care from the night-time doctor could not hear the handover clearly and did not attempt to clarify information. Instead, he read the medical notes and assumed that the wound had been explored and cleaned. He also believed that the wound could be safely sutured if the CT scan was reported as normal. Unfortunately, the medical consultant stated that the wound was explored only superficially and recommended careful exploration and possible referral to the plastics team. After the junior doctor obtained a verbal report of the CT scan over the phone, he removed the hard-collar and cleared the patient of a spinal injury. He then cleaned and sutured the wound.\nIn preparing for discharge, the junior doctor wrote the discharge letter for the patient’s general practitioner (GP), detailing the plan of care. He told the patient to see her GP in 3 days and then again in 7 days for wound review, suture removal and confirmation that the formal CT report was normal. He gave a copy of the letter to the patient, faxed a copy to the GP and placed another copy in the medical record. The letter requested that the GP seek out the formal CT report. The fax was not received by the GP and the GP did not have access to the patient’s medical record. The patient forgot the advice she was given, and aside from the discharge letter, she was not provided with any additional written discharge instructions. In addition, the patient did not give her discharge letter to her GP. Nevertheless, the patient managed to see her GP on three occasions over the next 10 days.\nIn reviewing the wound, the GP observed that it appeared red, slightly swollen and painful to touch. There was also some tissue discolouration at the wound margins. As a result, she believed that it may have become infected and she prescribed a course of antibiotics. No wound culture was taken of the wound. The GP also removed the sutures. Unfortunately, the GP did not request the formal CT report, nor was it sent to the GP. As the GP did not receive the letter from the patient, she saw no reason to check the CT report. On the day following the patient’s discharge, a consultant radiologist reviewed the CT scan. He amended the original report to indicate that he located a foreign body in one of the jaw muscles. He noted that it looked like a piece of rock, but he could not see a fracture. The amended report was sent to the senior ED consultant, but it was misplaced once the report arrived in the department.\nAfter the senior ED consultant eventually received the amended report 2 weeks later, he spoke to the junior doctor involved with the patient’s care. They attempted to clarify whether the GP knew about the results of the CT report by checking with the patient and the GP. The senior consultant rang the GP and the GP informed the consultant that she was unaware of the situation relating to the CT scan. Furthermore, after the senior consultant called the patient at home, the patient stated that she had been off work for 2 weeks, was unable to eat, had lost 6 kg since the incident and was taking opioid analgesics, which had been prescribed by her GP. In addition, the patient had chronic facial inflammation, leading to problems with salivation, facial numbness and severe pain. The amended results of the CT were discussed with the patient, and she was asked to attend the ED.\nAs the senior ED consultant was about to finish his shift, he informed the oncoming ED doctor about the patient, and he called the plastics registrar to organise a review. He wrote a detailed entry in the medical record, requesting an admission under plastic surgery for removal of the rock. The second ED doctor examined the patient’s cheek with a bedside ultrasound machine. She easily recognised a piece of rock in the masseter muscle with a collection of fluid involving the parotid gland and facial nerves just below the well-healing scar. She wrote this observation in the patient’s notes and told the triage nurse who called the plastics registrar.\nAn oncoming plastics registrar had just commenced his shift and was not informed about the patient at his handover meeting. The oncoming plastics registrar saw the patient 6 h after the patient’s arrival. By this time, the patient was angry, in pain and wanted to go home. The plastics registrar was also unwilling to admit the patient without a formal ultrasound. The patient was sent home.\nSubsequently, the patient visited her GP 1 week later, who organised the formal ultrasound to be performed. The patient underwent surgery where the rock was removed from her masseter muscle. It took several weeks before she was able to eat normally and have normal facial sensation. |
A 36-year old woman was admitted acutely to our institution with a four week history of increasingly intrusive palpitations associated with pre-syncope. She was 31 weeks into her second pregnancy having experienced no problems during the first or second trimester or at all during her previous pregnancy 6 years earlier. Ambulatory monitoring organised prior to her admission had demonstrated frequent unifocal premature ventricular contractions (PVC) including couplets and triplets, and short salvos of non-sustained ventricular tachycardia (VT) corresponding with symptoms. The initial physical examination, electrolytes and laboratory investigations were unremarkable. Obstetric assessment revealed a healthy fetus consistent with 31 weeks of gestation.\nHer electrocardiogram during a typical episode revealed a monomorphic wide-complex tachycardia of left bundle branch block morphology consistent with an origin from the right ventricular outflow tract (). Echocardiography demonstrated a mildly dilated left ventricle with normal function and an ejection fraction of 63%. Initial attempts to control her arrhythmia medically with oral and intravenous metoprolol were unsuccessful. The patient was subsequently treated with oral verapamil therapy but, despite initial benefit, suffered with recurrent and increasingly sustained episodes of VT associated with hypotension and pre-syncope. Following obstetric consultation, the option of catheter ablation was offered as a therapeutic option. After discussion of the potential risks to the mother and foetus, both of the procedure and of potential radiation exposure, informed consent was obtained.\nThe patient was brought to the electrophysiology laboratory in the postabsorptive state and placed in the left lateral position using a wedge to decompress the inferior vena cava. A midwife was present to monitor the foetal heart rate. Lead shielding of the abdomen and pelvis was used to shield the fetus as much as possible if any fluoroscopic radiation was needed. Venous access was obtained from the right femoral vein. Although we intended to perform the procedure with zero fluoroscopy, owing to the distortion of the pelvic anatomy by the gravid uterus and the tilt from the wedge, minimal fluoroscopy (60 seconds, 9.9mGy) was utilised to position the catheters in the heart. Catheters were placed in the right ventricular apex and coronary sinus.\nThe remainder of the procedure was performed with zero-fluoroscopy using a 3-dimensional mapping system to create a geometrical shell of the right ventricular outflow tract (NavX, St. Jude Medical, St Paul, Minneapolis, USA). During frequent periods of non-sustained VT earliest endocardial activation was localised to the high outflow tract (). At this location the local electrogram on the ablation catheter preceded the onset of the QRS complex by 33ms (). Catheter tip pressure at this site induced sustained VT with subsequent radiofrequency ablation terminating VT. There was no recurrence during a 30-minute period of observation. The procedure was uncomplicated and no further PVCs or VT were observed on telemetry over the following 48-hours.\nThe patient remained asymptomatic and interim ambulatory monitoring after 8 weeks demonstrated no evidence of recurrent arrhythmia. She delivered a healthy child at term by elective caesarean section without complication. |
A 21-year-old Caucasian female gravida two parity one at 28 weeks presented to the dermatology clinic for evaluation of a large mass on her left lateral thigh (Figure ). The patient had an existing diagnosis of NF One, but no other medical conditions. Denied any use of regular medication besides prenatal vitamins. The mass had been present since early childhood and had been stable in size since 11 to 12 years of age.\nPer the patient, the mass started to grow early in her first trimester and was noted to be more painful than in the past. The patient reported pain with minor trauma that lasted for days. No change in consistency of the mass was noted. No reported weakness or altered sensation in the leg, night sweats, fevers, chills, or weight loss by the patient. In her past pregnancy, the patient denied any change to the size of the mass or increase in pain like she was currently experiencing.\nThe physical exam was notable for multiple 2-3 mm hyperpigmented macules in the bilateral axilla. The upper extremities and back had large hyperpigmented tan macules and patches in various sizes consistent with Cafe au lait spots. The left thigh had a large 18 x 9 cm boggy hyperpigmented mass on the lateral side. It was pendulous and had multinodular consistency. The mass was moderately tender on palpation. The patient was noted to be able to ambulate without difficulty and had equal sensation and strength in both lower extremities.\nAfter discussion with the patient, she was prepped for punch biopsy of the mass. Multiple biopsies were taken from different areas of the mass to ensure adequate sampling. The results of the biopsy revealed plexiform neurofibroma without any indications of malignant changes in any of the sites. The patient returned to the clinic a week later for suture removal and was informed that the mass was a plexiform neurofibroma, but did not appear to be malignant at the time of biopsy.\nThe patient was educated about the risk of malignant transformation of the plexiform tumor and told to return if the mass changed in size again or became more painful. There were no indications of weakness in the extremity that would need to be evaluated further. The patient was advised to follow up with her obstetrician for routine pregnancy care. The patient was counseled to seek follow-up with an ophthalmologist for a full eye exam and to maintain regular follow-ups with her primary care physician. |
A 30-year-old male patient reported to our institution with a huge swelling of the left side of his face and neck for almost 10 years. He was unable to close his mouth, had difficulty in breathing and his chin was deviated to the opposite side. His head was weighed down by the immense weight of the mass and it had to be supported with his hand while sitting or standing. When asked why he turned up so late, he reported that the swelling caused no problems in his daily life until only a few days back when he suffered from difficulty in breathing and spontaneous intraoral bleeding. On examination, a gigantic extraoral swelling measuring around 28 cm × 24 cm × 20 cm was seen on the left side of his face and neck []. The lips were wide apart at rest and he was unable to bring them together. Extensive engorged blood vessels and areas of superficial erosion and crustation were visible []. On palpation, the mass was firm in consistency with some fluctuant areas. No pulsations or thrills were felt. The solid bone of the mandible could be felt posterior to the second premolar area on the right side. Intra orally, a lobulated, erythematous swelling was present on the entire alveolar ridge of the left side including the floor of the mouth, elevating the tongue. The swelling was soft and fleshy in consistency. On mild provocation, oozing of blood was observed which regressed after application of firm pressure. The aspiration test was negative. Computed tomography scan of the face revealed a well-circumscribed, multilobular lesion involving the maxilla and the mandible, compressing against the adjacent structures and crossing the midline []. The individual locules were enhanced homogenous areas arranged circumferentially, pointing toward an ill-defined and hazy central radiolucent area. Incisional biopsy was performed from an anterior intraoral site, but severe intraoperative hemorrhage was encountered which was arrested by application of a local hemostatic agent and firm digital pressure. Histopathological report revealed the presence of nondescript epithelium backed by myxoid connective tissue stroma and numerous vessels of varying shapes and sizes, some of which showed perivascular hyalinization. Few areas of myoid differentiation were also noted. All the features were suggestive of aggressive angiomyxoma []. The patient was advised to undergo a digital subtraction angiography (DSA) to determine the presence of feeder vessels. Unfortunately, the patient expired during the procedure (DSA) due to a massive cardiac arrest caused most probably by high output cardiac failure. |
A 53-year-old man presented to our institution with a 3-year history of pain in the left throat and trismus caused by pain. Magnetic resonance imaging in the Department of Neurology revealed an abnormal shadow above the hyoid bone. The patient was referred to the Department of Otorhinolaryngology, where no abnormal signs other than trismus were found. Computed tomography (CT) revealed that the left styloid process was connected to the hyoid bone, had a total length of 70 mm, and was approximately 10 mm thick along almost its entire length (Figures and ). Five years earlier, the patient had been transferred to our emergency clinic with a facial injury, and cervical CT images taken also revealed elongation of the styloid process. At that time, the styloid process had been approximately 5–7 mm thick, and its enlargement in the subsequent 5 years was evident ().\nThe patient was diagnosed with Eagle syndrome and treated initially with analgesics. However, the treatment with analgesics had not improved his pain, so he underwent transcervical resection of the styloid process under general anesthesia. A horizontal skin incision was made in the upper part of the neck, and the submandibular gland was removed to ensure a wide surgical field (). The styloid process was firmly connected to the hyoid bone on the dorsal side of the hypoglossal nerve, and a 40 mm portion was resected from the attachment to the hyoid bone. No invasion of the surrounding tissue was found intraoperatively, and it was easy to separate and resect the bone. Pathologic examination revealed that the lesion consisted of bony tissue with a bone marrow component and a cartilaginous component in contact with the trabecular bone. There were no signs of active inflammation or malignancy. The symptoms such as pain and trismus disappeared completely. Preoperatively, the patient scored pain on opening his mouth and pain on swallowing as 8 on a visual analog scale, and both scores improved to 0 postoperatively. The patient had no recurrence of subjective symptoms at the most recent follow-up 19 months postoperatively. Postoperative CT revealed that a good portion of the left styloid process was resected (). The stylohyoid ligament on the right side was partially calcified and requires ongoing observation in the future. |
A 64-year-old male was examined in the cataract clinic of the Tel Aviv Medical Center for the possible removal of a densely mature cataract in his right eye. His past medical history included heavy smoking, hypertension, hyperlipidemia, and noninsulin-dependent diabetes mellitus, and he did not have any past ocular history. Visual acuity (VA) in the right eye was hand movement and in the left eye 20/50. There was no relative afferent pupillary defect (RAPD). Visual loss in the right eye was consistent with the degree of maturity of the cataract. Since it was impossible to view the posterior pole through the dense cataract, ultrasonography was performed and found to be normal. The left eye had a nuclear sclerotic cataract and a normal dilated fundus examination. Subsequently, the patient underwent a cataract extraction in the right eye by phacoemulsification with an implantation of a posterior chamber intraocular lens. Surgery was performed under topical anesthesia and was uneventful. On the first day after surgery, corneal edema was seen, attributed to the high energy required to aspirate the dense cataract; however, it resolved rapidly during the following days. Intraocular pressure on the first postoperative visit was 15 mm Hg. One month after surgery, VA was 20/50 and the ocular examination was normal.\nTwo months after surgery, the patient experienced a sudden loss of vision in the right eye. Upon examination, VA was 20/120 and a positive right RAPD was found. The optic disc was swollen with surrounding flame-shaped hemorrhages. He was diagnosed with NAION and was started on aspirin 100 mg daily.\nFour months later, the patient complained of decreased vision in his left eye. VA in the left eye was 20/400 and was consistent with progression of the cataract. Following a detailed explanation of the risks involved with cataract surgery in these circumstances, including a 50% risk for NAION after surgery [], the patient expressed his desire to undergo the procedure in order to improve his vision. Surgery in the left eye was uneventful, and 1 week after surgery VA in the left eye was 20/25. The early postoperative course during the first several months was entirely normal; however, 5 months after surgery the patient developed an abrupt loss of vision in his left eye. VA was reduced to finger counting, the pupils’ reaction to light was sluggish, and the left optic disc was swollen with surrounding flame-shaped hemorrhages. Therefore, the visual loss was again attributed to the development of NAION.\nOn the patient's last follow-up examination 6 months after NAION had developed in the left eye and 10 months after its occurrence in the right eye, VA was 20/100 in the right eye and 20/200 in the left eye, with reduced color vision in both eyes. Anterior segment examination was normal bilaterally. Right-trace RAPD was observed, and the optic nerves were atrophied and pale in both eyes (fig. ). A 30-2 Humphrey visual field test revealed a severe depression with remnants of only the inferotemporal quadrant in the right eye and the superotemporal quadrant in the left eye (fig. ). Optical coherence tomography of the optic discs demonstrated bilateral thinning of the retinal nerve fiber layer (fig. ). |
An 18-year-old healthy female patient presented with the complaint of discolored left upper front tooth. She had a history of fall 10 years back, which resulted in slight fracture of crown of the tooth but the patient was otherwise asymptomatic.\nThe clinical examination revealed Ellis class II fracture and discoloration in the crown of tooth 21 (). A sinus opening was also seen in the apical region of 21. Thermal and electric pulp vitality tests revealed that the tooth was non-vital. IOPA radiographic examination revealed presence of a blunderbuss canal having open apex in tooth 21 (). CBCT examination was also done, which revealed perforation present on the mesial side of tooth apex in coronal plane indicating presence of a periapical lesion (). CBCT image in sagittal plane revealed perforation of the tooth structure and buccal cortex in the apical region (). The 3D CBCT image revealed the presence of a periapical lesion associated with tooth 21 (). CBCT images in axial plane done at coronal, middle and apical third of the root revealed considerable increase in the diameter of the root canal at middle third and disruption of the buccal cortex at apical third region of the root (Figure -). The extent of the periapical lesion apico-occlusally and mesio-distally toward the buccal cortex and radiolucent area at the lesional site was also noted in the coronal plane of the CBCT image ().\nBased on these findings, a diagnosis of periapical abscess and pulp necrosis associated with an open apex in tooth 21 was established. Its management by endodontic therapy with MTA obturation was planned to enable closure of the open root apex and healing of the periapical lesion. It was to be followed by non-vital bleaching and final restoration with a direct composite veneer on tooth 21.\nAfter placing the rubber dam, an access opening was done in 21 (). It was followed by working length determination using IOPA radiograph (). Cleaning and shaping were done by circumferential filing and ultrasonic activation of 3% sodium hypochlorite. A calcium hydroxide dressing mixed with saline was placed in the canal using absorbent paper points (). IOPA radiograph revealed increase in the radiopacity of the canal space following calcium hydroxide placement in 21 (). The patient was recalled after a week, rubber dam was placed, the dressing was removed and the canal was thoroughly dried with absorbent paper points. For obturation, the white ProRoot MTA wMTA was mixed to a paste consistency with distilled water and delivered to the canal up to the apex using Messing gun and a hand plugger. The access cavity was temporarily sealed and post-operative IOPA radiograph revealed a homogenous compaction of the wMTA into the canal space of 21 (). Post-operative CBCT image in coronal, sagittal and axial plane at coronal, middle, and apical third of root showed a homogenous wMTA obturation (Figure -). A slight inadvertent extrusion wMTA was seen into the lesional space in post-operative CBCT image in coronal plane and the 3D CBCT image immediately after wMTA obturation (Figure and ).\nAfter wMTA obturation, an intra-orifice glass ionomer cement barrier was placed followed by placement of sodium perborate mixed with saline in the access cavity for intracoronal non-vital bleaching (Figure and ). Temporization of the access cavity was done () and patient was recalled after 1 week to replace the bleaching material for adequate lightening of the tooth. When desired lightening of color tooth was achieved and the tooth was clinically asymptomatic with healed sinus opening (), tooth preparation was done on 21 for direct composite veneer (). Then, etchant 37% phosphoric acid gel was applied for 15 s, rinsed thoroughly and dried with absorbent paper. Then, bonding agent was applied and cured for 20 s. Final restoration was done with a layer of composite, which was cured for 45 s (). The occlusion was carefully checked and adjusted. The patient was recalled regularly for follow-ups.\nThe IOPA radiographs taken at 1 month and 3 months showed that the periapical radiolucency had reduced in size indicating progressive periapical healing (Figure and ). CBCT examination was done at the end of 3 months in all the three planes - coronal, sagittal and axial taken at coronal, middle and apical third of the root, which again revealed healing of the periapical lesion seen as increased radiopacity (bone density) in the lesional site around the wMTA filling (Figure -). The 3D CBCT reconstruction image showed an unchanged morphology of the extruded MTA at the lesional site (). The status of wMTA obturation as evaluated with IOPA radiograph revealed a well compacted filling up to the apex with no voids, even after 6 months and a healed periapical area (). The patient was clinically asymptomatic throughout this time period. The patient is now scheduled to come for routine yearly follow-ups. |
The patient is an 86-year-old right-handed female who presents for evaluation of tremor and episodic stiffness. She had attacks of muscle stiffness since about age 9. Attacks have a prodrome of tongue heaviness and difficulty in speaking, followed by abnormal sensation in bilateral upper extremities. She remains fully conscious during the episodes. The actual episodes consist of dystonia of trunk associated with unilateral or bilateral upper and lower extremity chorea. About a quarter of the attacks are unilateral. There is complete resolution of symptoms between attacks except for persistent mild horizontal and vertical head tremor as well as action tremor of both extremities, also with onset at age 9. Hence she was able to play baseball and basketball at this age. There is an extensive family history of similar episodes but not tremor inherited in autosomal dominant fashion.\nPsychological stress can trigger episodes, as a few have occurred just after medical appointments and phlebotomy. Caffeine exacerbates her condition. She refuses to drink coffee and only rarely drinks tea, both of which can cause attacks. She is able to handle a half a cup of hot chocolate with milk each morning. She does not drink alcohol. Surprisingly, evening diazepam did not prevent episodes and daytime as needed diazepam did not abort episodes. She will try clonazepam as that was reported to be more effective in PNKD [].\nThe frequency of attacks was about once a month, but two and a half years ago it has escalated to once a day. Duration of attacks increased from half an hour to two hours. In addition, amplitude of action tremor of the hands as well as persistent horizontal and vertical head tremor worsened at that time. Two years ago she was diagnosed with breast cancer (3.3 cm Grade III infiltrative ductal carcinoma, Her2Neu positive, negative lymph node biopsy), which was treated with excision and localized radiation. Her episode frequency and length slowly returned towards baseline after treatment was completed.\nIn addition, she believes that her current exercise regimen utilizing 1 kg weights helps reduce frequency of attacks. This is in stark contrast to paroxysmal exercise induced dystonia (PED) and paroxysmal kinesigenic choreoathetosis/dyskinesia (PKC/PKD), which are episodic disorders triggered by exercise and sudden movements, respectively []. |
A 29-year-old pregnant woman was referred at 22 weeks of gestation because the fetal heart was suspected to be abnormal in a routine ultrasound examination. The fetus was appropriate for age, and no other malformation was found. A high-resolution ultrasound device (Voluson E8 Expert, GE Healthcare, Munich) was used for ultrasound examination of the fetal heart. The fetal heart rate was within normal range. The right ventricle was dilated due to an apical aneurysm, and the contractility of the right ventricle was reduced. The function of the left ventricle seemed to be slightly reduced. Objective measurement of fractional shortening was not possible due to the disturbed right ventricular morphology. A left CAF (diameter 2.9 mm) draining into the aneurysmatic part of the right ventricle was visualized by color Doppler ultrasound. Pulsed Doppler recordings revealed characteristic bidirectional flow in the fistula. Turbulent diastolic reversed flow was detected in the aortic arch resulting from the blood steal phenomenon via CAF into the right ventricular aneurysm (). Genetic testing was normal. The poor prognosis and likelihood of intrauterine or perinatal death were discussed with the parents; however, they decided to continue pregnancy. During pregnancy, there was an increase in the size of the fistula, and it became dilated up to 11.5 mm at 37 weeks of gestation (). The size of the aneurysmatic right ventricle area became larger, and cardiomegaly developed at 35 weeks of gestation. The remaining functional right ventricle became smaller and was difficult to differentiate from the aneurysmatic part of the right ventricle, resulting in a bizzare formation of the right ventricular entity. No tricuspid regurgitation, pericardial effusion, or hydrops developed. The proportion of the aorta and pulmonary artery was normal and remained balanced. Brain-sparing physiology on middle cerebral arterial Doppler was not found. But there was a steal phenomenon, within the aortic arch and head-neck vessels due to the massive filling of the coronary arterial fistula draining blood away from the aortic root. Birth was planned in a center closely related to a major pediatric cardiac center. At 37 3/7 weeks of gestation, induction of labor was performed due to the obvious progression of the disease. Due to less fetal well-being, the child was born by cesarean section at 37 3/7 weeks of gestation in a tertiary obstetric center with standby of pediatricians specialized in pediatric cardiology. The birth weight was 3350 g, length 51 cm, Apgar score 1/3/2, and umbilical artery birth pH 7.29. Despite extremely prolonged resuscitation, the newborn died at 3 hours of life. Postmortem pathology was refused by the parents. |
A 65-year-old woman with severe, symptomatic aortic stenosis was admitted to a hospital for a TAVI. Her past medical history included type 2 diabetes mellitus, hypertension, diabetic chronic kidney disease, and dyslipidemia. The patient was well known to have a bicuspid aortic valve and had been followed up by echocardiography for 20 years. She complained of exertional dyspnea for the last three months and was admitted with severe pulmonary edema. Following careful assessment, it did appear that the primary precipitant for refractory pulmonary edema is severe aortic stenosis. The aortic valve area of a heavily calcified valve was only 0.3 cm2. Aortic valve replacement was a necessary therapeutic strategy to achieve hemodynamic stability and reduce in-hospital mortality.\nContrast-enhanced computed tomography (CT) scan was contraindicated because of her renal impairment. Noncontrast computed tomography would not have added significant diagnostic information to influence the treatment plan. Catheterization with limited contrast injections for coronaries, aortic root, and peripheral bed had provided the required details to plan the procedure with less contrast than computed tomography with contrast. In addition, noninvasive imaging with echocardiography has been used pre and postprocedure.\nCoronary angiography was normal but revealed a single right coronary artery, with the left main coronary artery arising from the proximal right coronary artery (). This is a very rare congenital malformation which can be a lethal obstruction of the orifice of the right coronary artery occurring secondary to stenosis or because of coronary emboli during the deployment of a new aortic valve.\nThe distance of the single coronary artery to the bicuspid aortic valve was >12 mm and to the annulus of the valve was >20 mm, and to S5 was 25 mm ().\nEchocardiography showed a severe bicuspid aortic valve stenosis with a gradient of 80/50 and a valve area of 0.3 cm (). Mild mitral regurgitation was observed, but there is no aortic regurgitation.\nAn electrocardiogram showed a normal sinus rhythm.\nThe patient was informed by the cardiac team, and it was agreed to proceed with an urgent TAVI procedure.\nA direct implantation of Evolut Pro, 26 mm valve from Medtronic, was performed using a right femoral artery approach. Close monitoring of the single coronary artery with coronary angiography revealed no complications (). The left main coronary artery took its origin from the proximal right coronary artery. 2Proglide was used on the right-hand side, with 6F Angioseal on the left side; a hundred mL contrast medium was used.\nThe procedure was performed in the cardiac catheter laboratory under local anaesthesia plus sedation, and the patient remained hemodynamically stable throughout.\nThe patient was then transferred to the intensive care unit for observation and was discharged to the ward the following day. The patient remained in sinus rhythm and did not require a pacemaker postoperatively.\nThe post TAVI echocardiography showed a well-functioning aortic valve with trivial paravalvular leakage and no pericardial effusion. Ejection fraction was 70% with a peak and mean gradient after TAVI of 10/4. The mild mitral valve regurgitation apparent before the procedure remained unchanged.\nThe patient was asymptomatic and consequently discharged home after 3 days. The two-week follow-up showed a well-functioning valve with similar echocardiography. The electrocardiogram confirmed normal sinus rhythm, and the patient remained asymptomatic. |
A healthy 21-year old male patient was diagnosed with hypohidrotic ED. Extra-oral examination revealed prominent forehead, large and low set ears, sparse hair, dry skin and abnormal nails [Figures and ]. Patient had been wearing upper and lower acrylic complete dentures laid over five maxillary and six mandibular teeth since a young age. The teeth supporting the overdenture were root canal treated and prepared to receive the overdenture []. This prosthesis restored his vertical dimension. Due to the social drawbacks associated with dentures, patient insisted on getting a fixed prosthesis. Family history revealed that his elder sibling was also diagnosed with ED and he was rehabilitated with tooth-supported maxillary and mandibular FPDs.\nA series of radiographic evaluation was carried out to know the status of teeth and bone. Panoramic radiograph revealed an underdeveloped alveolar bone, two impacted teeth in the right maxillary canine region, one impacted tooth in the left maxillary canine region and a tooth with resorbed root in the right mandibular canine region which showed 3° mobility clinically. Roots of remaining teeth were surrounded by healthy bone []. Hand wrist radiograph was taken to confirm skeletal maturation [].\nA sequential treatment plan was formulated. The two impacted teeth in the right canine region of maxilla were horizontal and highly placed, and disturbing it would result in loss of the large amount of bone and hence was left untouched. The impacted tooth in the left maxillary canine region was in a favorable position, so surgical exposure and orthodontic eruption of that tooth was planned. Starting with discontinuation of dentures, posts were inserted in the overdenture abutments and their cores build up with composite resin to resemble a prepared abutment tooth of a FPD. Orthodontic brackets were fixed on the maxillary teeth and the impacted tooth was surgically exposed. It took six months to bring impacted tooth in arch position by fixed orthodontic treatment []. Clinical and radiographic evaluation indicated mandibular anterior region as an appropriate site for implant placement. During the initial phase of orthodontic treatment, three implants (Tatum Surgical Tapered, USA) were placed in the anterior mandible between the mental foramina. One implant of 4.0 mm × 14 mm was placed in left mandibular canine region, 2nd implant of 3.5 mm × 11 mm was placed in right mandibular lateral region and a 3rd implant of 3.5 mm × 11 mm was placed in the socket of right mandibular canine immediately after extraction. Cover screws were placed over the implants. After through irrigation, the surgical site was closed with sutures. Patient followed a standard regimen of antibiotic (Tablet- Cephadroxyl 500 mg) and analgesics (Tablet-Ibuprofen 400 mg). A period of four months was allowed for the implant osseointegration prior to the stage two surgeries. Straight abutments were attached to the implants and remaining natural teeth were prepared to receive a FPD []. Meanwhile, the orthodontic extrusion brought the left maxillary impacted tooth to an appropriate arch position, which was also prepared to serve as a FPD abutment. All acrylic temporary FPDs were fabricated followed by porcelain fused-to-metal maxillary FPD and three mandibular segmental permanent FPDs [Figures and ]. |
A 78 year old man with a history of atrial fibrillation, significant weight loss, and hypertension sustained a posterior dislocation of his right shoulder following a fall whilst getting off a bus. He did not have a history of any previous injury or symptoms regarding his shoulders. Following unsuccessful attempts to reduce his shoulder under sedation in the accident and emergency department, he underwent a closed reduction under general anesthesia. The shoulder joint, on examination, was found to be unstable on internal rotation beyond 10 degrees. Two weeks following a closed reduction, he sustained a recurrence of dislocation whilst putting on his shirt. X-rays demonstrated the presence of a large reverse Hill Sachs defect (Fig. , ). While performing a closed reduction under general anaesthesia with fluoroscopic screening, this defect was seen engaging the glenoid on internal rotation beyond 10 degrees. Screening was performed in all degrees of rotation, both in the reduced and unreduced positions to assess the maximum volume of this defect. A decision was taken to surgically repair the defect over the anteromedial humeral head without the need for further CT scans as fluoroscopic screening suggested the defect to be of sufficient size to contribute to a recurrent dislocation. Pre-operative x-rays and intraoperative screening confirmed an arthritic acromioclavicular joint. Excision of the lateral 1cm of the clavicle is a well described procedure in the management of acromioclavicular joint arthritis []. The size of the excised fragment was estimated to be of sufficient size to cover the reverse Hill Sachs defect as determined using fluoroscopy. An open reduction, bone grafting and shoulder stabilization was performed.\nWith the patient in a beach chair position, the shoulder joint was approached anteriorly through a standard deltopectoral approach. The subscapularis was divided in Z-lengthening pattern, and carefully dissected medial to the glenoid neck. A 3 cm X 4 cm defect was identified over the anteriomedial aspect of the head of humerus, caused by impingement of the posterior glenoid rim. The defect was debrided to reveal a bony bed and prepared for grafting. The antero-inferior aspect of the lateral clavicle was approached through the same incision, without the need for an extension or a separate incision. The curved shape and size of this section of the clavicle appeared well suited to fill the humeral head defect. A 1cm length of the lateral clavicle was excised, without disruption to the coracoclavicular ligaments and superior joint capsule. The acromioclavicular relationship under direct loading was confirmed to be maintained following excision of this fragment. The reverse Hill Sachs defect was filled with the correctly sized clavicle graft and fixed in place with a 4mm partially threaded cancellous screw and washer. The screw placement was determined to be anterior to the site of engagement of the defect and hence would not impinge upon the glenoid articular surface. Subscapularis was repaired with the shoulder maintained in 25 degrees of external rotation, to prevent over-tightening, with a No.5 non-absorbable Ethibond®. As the shoulder joint was found to be stable on internal rotation exploration of the rotator cuff was not performed. Other authors have described a very low incidence of rotator cuff injuries with posterior dislocation of shoulder [,]. Following wound closure, with layered Vicryl®, the shoulder joint was braced in neutral rotation for 6 weeks.\nAt follow up, 2 months after surgery, the patient was able to actively externally rotate to 30 degrees, abduct to 90 degrees, and forward flex to 90 degrees. The shoulder and acromioclavicular joints were clinically and radiologically stable (Fig. , ). At the final follow up 18 months following surgery, there were no reports of further dislocations. The patient had a clinically stable joint with a range of movements of 140 degree of forward flexion, 120 degrees of abduction and 60 degrees of external rotation. Internal rotation was restricted to L2 (up to T10 on the contralateral normal side). |
In January 2014, a 72-year-old gentleman with a history of chronic obstructive pulmonary disease attended an emergency department following a fall while intoxicated. He presented with left hip pain and decreased mobility. Radiographs demonstrated a left intertrochanteric neck of femur fracture. He underwent operative fixation with a dynamic hip screw (DHS) []. There were no immediate complications; however, postoperatively, he reported pain in his medial thigh. Further radiographs were reported as unremarkable and the patient was discharged home without significant delay.\nIn April 2015, due to a persistent pain and swelling in his left thigh, the patient represented to the emergency department and was referred to fracture clinic. Since his initial surgery, the thigh swelling had been gradually increasing in size and he frequently took dihydrocodeine to manage the pain. Further questioning revealed that the patient presented to the emergency department 2 weeks following surgery; however, a pelvic radiograph was reported as normal and he was discharged without followup. On examination, there was a large, fixed mass in the left anteromedial aspect of his thigh. Distal pulses were palpable and distal sensation was intact. A pelvic radiograph showed arthrosis of the left hip and union of the proximal femur fracture, with a DHS present in a satisfactory position. There was scalloping of the medial femoral cortex and extrusion of the screws past the medial femoral cortex []. Ultrasound was inconclusive. A magnetic resonance image was performed to exclude sarcoma, which demonstrated an asymmetric expansion of the left proximal thigh and an 11 cm × 11 cm × 12 cm heterogeneous lesion that was likely to be impinging upon the neurovascular bundle. Differential diagnosis at this stage included vascular aneurysm formation, osteomyelitis with abscess formation, or a neoplastic process.\nA computed tomographic angiogram of the lower limb confirmed a large hematoma and pseudoaneurysm measuring 24.2 mm from a branch of the left profunda femoris artery. The patient underwent coil embolization of the pseudoaneurysm with an uneventful recovery [Figure and ]. At 3-month followup, the patient's symptoms had completely resolved. At 2½-year telephonic followup, the patient continues to report no further symptoms. |
A frail 77-year-old multiparous Caucasian female with a history of aspirin and naproxen use, presented to an outside hospital with epigastric pain and an episode of hematemesis. She had no prior history of peptic ulcer disease, alcoholism or pancreatitis. The patient was hemodynamically stable with an acute anemia (hemoglobin of 7.7 g/dl), which prompted transfusion of 2 units of PRBC and transfer to a tertiary care facility. Upon transfer, she underwent an emergent upper endoscopy, which revealed a large amount of blood with clots in the lumen of the stomach. However, sufficient suctioning of the large intra-gastric clots was not possible; hence, an underlying etiology was not obtainable. The patient subsequently underwent a diagnostic angiography, which revealed a 4 cm mid-SA pseudoaneurysm with active contrast extravasation into the stomach which can be seen in Figs and . The radiologist decided to perform a transcatheter arterial coil embolization of the artery to halt the active bleeding. A post procedure angiography revealed no further contrast extravasation. A planned upper endoscopy was repeated the following day that revealed some residual clotted blood in the stomach, no active bleeding and a deep 4 cm gastric ulcer. Due to the high risk of re-bleeding, the patient was optimized physiologically and consented and prepared for exploration. Intraoperatively we observed that the SA pseudoaneurysm was densely adherent to the posterior wall of the stomach, and coursing through an inflamed distal pancreas. We decided to proceed with an en bloc resection of SA pseudoaneurysm, distal pancreatectomy, partial gastrectomy and splenectomy. After the celiac axis was surgically defined, proximal and distal SA controls were obtained and a circumferential posterior gastrotomy was made. There was a visible posterior gastric mucosa to splenic arterial fistula, with the radiologically inserted embolic coils clearly visible. This can be seen in surgical specimen (Figs and ). Once the stomach was reflected, the splenic vessels and the pancreas were divided and the specimen removed. The pathology reports indicated active gastritis with transmural ulceration into the splenic artery (SA) and adjacent pancreatic tissue. No malignant cells were identified in the gastric or pancreatic tissue and the SA was not aneurysmal (Fig. ). During the postoperative period, the patient had an uncomplicated recovery and was discharged on day 5. |
The male patient aged 60 years was hospitalized due to sudden dizziness for 3 h combined with slurred speech on May, 16, 2017. The patient had nausea, but he did not have vomiting, incontinence and unconsciousness. The patient was immediately referred to China-Japan Union Hospital of Jilin University. Head CT performed within 3 h of onset of symptoms (Fig. a) showed hemorrhage in the left temporal lobe, and the patient was admitted in our department with a clinically confirmed diagnosis of “hemorrhage in the left temporal lobe”. The patient had a previous history of hypertension for more than 10 years, and was under medication to control and maintain the blood pressure to be around 130/80 mmHg. The patient denied the history of diabetes and had no bad habits, such as smoking and drinking alcohol. Physical examination at admission revealed that his body temperature was 36.2 °C and blood pressure was 196/119 mmHg. The patient was conscious and suffered from incomplete aphemia. Bilateral pupils were of the size and round, the diameter of pupils was 3 mm, and pupils were sensitive to light reflexes. Muscular strength of the limbs was about grade 4. Bilateral pathological signs were negative, and there was no significant abnormality noticed during nervous system examination. Head MRI conducted the next day after admission indicated no significant vascular malformations (Fig. b). General consultation evaluated that bleeding sites of the patient were slightly different from hypertensive intracerebral hemorrhage. The hematoma sites were close to the middle cerebral artery and the walking areas of its branches, mainly in the temporal lobes. Therefore, cerebral vascular hemorrhage and other causes could not be excluded, and head CTA was further suggested. Head CTA performed on 17th May 2017 showed that the patient suffered from intracerebral hematoma caused by aneurysm rupture at the M1 bifurcation of the left middle cerebral artery, without any significant subarachnoid hemorrhage (Fig. a). Craniotomy and clipping of intracranial aneurysm were performed the next day after admission. During the operation, the aneurysm was found to be located in M1 bifurcation of the left middle cerebral artery, which was in cystic bulging. An asci formation with the size of 3 × 4 × 5 mm was located on the upper side of the aneurysm, and the aneurysm neck measured 4.2 mm, which was clipped successfully. There was no significant hematoma in the subarachnoid space, and the arachnoid around the aneurysm showed no obvious adhesion during the surgery. The patient successfully recovered from anesthesia after the surgery, without any significant neurological deficits. The patient was discharged after 2 weeks and Glasgow Outcome Scale (GOS) scored 5 points. Follow-up was performed for 4 months at the Outpatient Department. Head CTA (Fig. b) demonstrated that aneurysm did not relapse and GOS score was 5 points. |
A 30-year-old man presented to the emergency trauma room following a motor vehicle collision in which he was the front-seat unrestrained passenger. At the time of presentation, the patient was vitally stable, conscious, alert, oriented with a Glasgow Coma Scale 15/15 []. A cervical collar and spinal board were applied by the paramedics at the scene. The trauma surgery team assessed the patient initially and implemented the advanced trauma life support protocol []; he was deemed to be hemodynamically stable with no other systemic injuries. The patient was, however, complaining of moderate left hip and thigh sharp pain as well as left shoulder pain. On examination, he was noted to have abducted, shortened and internally rotated left lower limb. Active and passive movements of the left thigh were not possible due to pain with no neurovascular deficits detected distally. There were no significant examination findings of the left shoulder and upper limb. X-rays of the pelvis and left femur revealed a posterior fracture dislocation of left femoral head with an ipsilateral femoral mid-shaft fracture and a computed tomography (CT) scan of the pelvis showed large and small fracture fragments within the acetabulum originating from the medial aspect of the femoral head (). A shoulder X-ray also revealed a non-displaced left scapular body fracture. An attempt of left hip closed reduction was made while the patient was still in the emergency department and it was, however, unsuccessful.\nAfter being cleared by the trauma team, the patient was admitted to the orthopedic service with a working diagnosis of left posterior hip dislocation with a Pipkin Type 1 ipsilateral femoral head fracture [] and an ipsilateral femoral shaft fracture. The patient was taken to the operating theater for closed versus open reduction and intramedullary nailing of the left femur. Within 5 h of his injury, the patient underwent closed reduction of the left hip with the aid of a temporary external fixator applied on the femoral shaft proximal to the fracture (). The external fixator rod was used as a handle, and the reduction was successful after the first attempt, as confirmed by the C-arm and CT reconstruction (). Subsequently, the external fixator was removed, and intramedullary nailing of the left femur was carried out. After completion of the procedure, the left hip was examined and found to be stable with the femoral head fragment not affecting the movement. The patient was discharged after 3 days with a clean, dry wound and full weight bearing ambulation as tolerated. Unfortunately, he was lost to follow-up and attempts to contact the patient were unsuccessful. |
A 52-year old female patient was admitted to our hospital with complaints of intermittent dysphagia and chest pain for 1 year. She had symptoms on the lower substernal area when swallowing a large amount of water, which were accompanied by chest pain. Chest pain was a sharp and non-radiating and was relieved by transports of swallowed water to the stomach. These symptoms only occurred when guzzling water and not by taking a sip of water or eating. The temperature of water did not show any correlation with her symptoms. Her past history was unremarkable. There was no family history of similar symptoms. She was of normal body weight and had no abnormalities on chest and abdominal physical examination.\nEndoscopy of the upper digestive tract was performed in other hospitals, but there were no abnormal mucosal lesions. Then she was referred to our hospital for further investigation on dysphagia and chest pain. The barium esophagogram showed no abnormalities. 24 hour esophageal impedance-pH monitoring was performed and there were no pathologic regurgitation.\nHRM was performed to access the esophageal motility (). On sitting position, 14 times of water swallowing in total was performed. The interval between each swallow was 30 seconds. The patient swallowed 5 mL of water from the first swallow to the seventh swallow, 10 mL from the eighth swallow to the 10th swallow, 15 mL on the 11th swallow, 20 mL on the 12th swallow and 50 mL on the 13th swallow. On the 14th swallow she tried to drink 100 mL water, but could swallow only 25 mL. She did not have symptoms from the first to the 10th swallow, but started to complain chest pain and dysphasia when swallowing more than 15 mL. The more water she swallowed, the worse her symptoms got. She complained the most severe symptoms when swallowing 50 mL of water. Rapid propagated pressurizations were observed at the second, fourth, sixth and seventh swallows, in which pressurization front velocity was measured as 19.1, 8.4, 42.7 and 32.4 cm/s, respectively. Impaired deglutitive inhibition was observed at the 13th swallow, but peristalsis was normal (). Except for the 13th swallow, all of the swallows were associated with normal deglutitive inhibitions. The mean gastroesophageal junction pressure was 12.7 mmHg. We diagnosed her with DES because more than 20% of total swallows induced symptomatic esophageal spasms. She was advised to drink water little by little and to take diltiazem 30 mg 3 times a day. Thereafter, her symptoms have improved. |
A 17-year-old girl with a history of SLE who had received treatment with regular azathioprine for at least one year presented to rheumatology clinic with a one-week history of a rash. On examination the patient had a malar rash and oral mucosal ulceration. Neurological examination was unremarkable. The patient reported a recent history of hypomanic symptoms that had ceased without treatment immediately prior to the onset of the rash.\nShe reported a week-long history of poor sleep, racing thoughts, irritability, and grandiose overvalued ideas. She had held the belief that she was destined to open a French language school and to start a clothing line, both of which were certain to be a worldwide success. When challenged on these ideas by her mother she would become markedly irritable. She had spent time through the nights making collages and mood boards for the fashion line. Her mother confirmed that these ideas were totally out of character and far beyond her capabilities despite her interest in the fashion industry. She had become irritable with several friends both in person and on social media. The onset and termination of these symptoms was acute, though she remained mildly irritable.\nThe patient had had three previous flares. The first flare occurred when the patient was thirteen. The first two flares had cutaneous and renal involvement but no psychiatric symptoms. The third flare had occurred one year previously when she presented with a malar rash and an acute depressive episode of moderate severity, which was exacerbated by treatment with pulsed steroids. During this episode the patient complained of low mood and low energy and had thoughts to jump out a high storey window of the hospital. These thoughts were not acted upon. This depressive episode gradually resolved once the oral steroid dose was reduced to 15–20 mg prednisolone daily.\nThere was no family history of mental illness.\nBloods tests revealed a raised DsDNA and low C3. Lumbar puncture showed normal protein, white cell count, and microscopy. CSF oligoclonal bands were negative.\nMRI brain was reported as follows.\n“The intracranial appearances are normal. A few punctate foci of contrast uptake, most conspicuous within the posterior fossa, appear related to normal vessels. There is no convincing pathological parenchymal or meningeal enhancement.”\nDifferential diagnosis included SLE, a viral or bacterial encephalitis including the possibility of an atypical infection given the patient's immunosuppression, a primary psychiatric disorder, normal adolescent behaviour, adverse effects of medications, illicit drug use, and lymphoma.\nThe diagnosis of a lupus flare with cutaneous and neuropsychiatric involvement was made and steroid treatment was initiated.\nSeveral hours following the first dose of methylprednisolone, the patient's mental state deteriorated. She experienced sleep disturbance, disorientation, and agitation and expressed paranoid delusions. She held the belief that the family were being monitored by an unknown agency who were convinced her parents had stolen medical devices from the ward. She was suspicious and hypervigilant around staff whom she believed were constantly talking about her. She denied that she was unwell and made attempts to leave the ward against advice complaining that she needed to get back to school or attend the gym. There was no perceptual abnormality and she was fully orientated.\nThe patient was initially commenced on a three-day course of intravenous methylprednisolone 250 mg, followed by a switch to oral prednisolone which was gradually reduced and stopped over six weeks. She received six infusions every four weeks of cyclophosphamide 750 mg, the first of which was given during the admission described.\nHer cutaneous symptoms improved rapidly. Following the pulsed steroid treatment and subsequent deterioration in her mental state, there was a period of watchful waiting for several days, followed by treatment with olanzapine titrated up to a dose of 7.5 mg once daily. This resulted in an improvement in her psychotic symptoms. The patient was discharged from hospital.\nThe patient's mental state was followed up closely over the following month and olanzapine gradually reduced and discontinued. At three-month follow up the patient's cutaneous and psychiatric symptoms remained in remission. |
A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical report\nOn physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.\nThe patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement denoting an abscess. There was diffuse anterior abdominal wall fat stranded with subcutaneous pockets of air denoting infection. Subcentemetric mesenteric lymphadenopathy was observed ().\nPatient was taken to the OR for exploratory laparotomy and drainage of the abscess. Upon internce to the abdomen a large pocket of pus in subcutaneous layer was opened and evacuated and a swab was sent for culture and sensitivity. A firm mass inclosing the pelvic was dissected and found to be a large diverticulum 10 cm from the ileocecal junction. The mass was attaching to the urinary bladder and was fistulating to the subcutaneous pus collection. Urology was called in at this point and the urinary bladder was checked by injecting methylene blue dye; there was no leak. Limited right hemicolectomy was performed with a primary iliocolic anastomosis ().\nHistopathology was consistent with diverticulum of the small bowel and serosal lipoma with a pocket containing multiple staghorn-type black stones, negative to tuberculosis (). Patient wound culture from OR showed E. coli which was sensitive to Tigacyclin. Treatment was started with this antibiotic and patient’s condition improved. Postoperative course was uneventful except for a small dehiscence at the lower part of the abdominal wound, which was treated conservatively with VAC dressing. Patient was discharged to travel to his country, and the wound was left for secondary closing. |
A 16-year-old high-school dropout, unmarried girl belonging to a joint family of lower socioeconomic status from rural background was referred from the Department of Surgery for the evaluation of her problem of recurrent spontaneous release of glass pieces from her body parts (upper and lower limbs) for the past 1 year. The patient had initially reported pain and development of abrasions due to the extrusion of glass pieces from her limbs in succession, which started from the left foot, and then from the left hand and forearm followed by the right foot and hand. As informed by the family members, every day, about 10–15 glass pieces of size ranging up to approximately 6 mm × 3 mm were taken out from patient's body parts by a doctor in the village. The glass pieces extracted from the patient would be given to the family members. Patient and family members sought treatment at many places in nearby towns. As per the patient and her family members, there was cessation in the release of glass pieces for about 3 months, after she had received some homeopathic treatment. However, when homeopathic treatment was stopped, again her symptoms reappeared. Family members had also visited many faith healers for her problems.\nPatient and her family members denied about any obvious psychosocial stressors. Premorbid temperament did not reveal any abnormality.\nThe patient was initially guarded, so attempts were made to engage her in an interview by establishing rapport. She was sent to the recreational therapist regularly. Sessions were taken by the clinical psychologist. Later during the sessions, she had expressed about some interpersonal conflicts with her elder brother's wife. She was also disappointed by the denial of her marriage proposal in an influential family of her village. Physical examination of the patient revealed multiple abrasion of the skin of both hands and feet, predominantly on the left side suggestive of dermatitis artefacta []. On palpation of her forearm, some impacted glass pieces were felt under the abraded skin and patient used to take out the impacted glass pieces with her own hand. However, no abrasions were present in any inaccessible areas of the body or face. Her hematological investigations were within normal limits, except hemoglobin level of 10.6 g%.\nX-ray of the upper and lower limbs revealed radio-opaque foreign bodies (glass pieces) underneath the skin of her left forearm and at the heel of left foot []. Psychometric assessment (Rorschach inkblot test)[] revealed intact human empathy, increased form-based responses indicative of rigidity and concrete thinking. The presence of dysphoric emotion, anxiety and negative self-worth, and feelings of inferiority were also evident from the psychometric assessment. A wide range of contact indicated that she showed wide range of interests in her environment. Assessment on Structured Clinical Interview for DSM-IV Axis II Personality Disorders[] for personality disorder was noncontributory.\nDuring ward behavior observation, once, it was found that she was hiding something by putting her hands across her chest. During physical examination, glass pieces were recovered from patient's clothes.\nThe diagnosis of factitious disorder was made due to the presentation of repeated healthcare seeking for glass pieces extruding from the body parts. Malingering was ruled out due to the absence of definite external motive/incentive. Old, impacted glass pieces were removed surgically from patient's body. Patient and family members were psycho-educated about the nature of illness. The patient stopped reporting the release of glass pieces from her body parts and remained symptom free for three months following discharge.\nOne pharmacist from the patient's village had maintained her fear by suggesting that this clinical presentation might be possible in some rare clinical disorder which caused lot of difficulty in convincing the patient and her family members about it, which was subsequently taken up in the sessions and was addressed by the treating team. |
A 53-year-old man presented with a sudden onset of severe diffuse headache followed by dizziness. The patient had no remarkable medical history, except for hypertension, and had not suffered from any recent head trauma. On clinical examination, there was no focal neurological deficit. The systemic blood pressure was normal. Soon after arrival, the patient showed a confused mental status.\nA noncontrast CT scan of the head revealed a large amount of SAH in the basal cisterns and left sylvian cistern () with a small amount of subdural hemorrhage in the left frontal convexity. On the CT scan, there was also a small hyperdense mass-like lesion seen in the left sphenoid ridge, which showed bony destruction of the left sphenoid ridge with extension into the left anterior middle cranial fossa () and the sphenoid paranasal sinus. This lesion showed mild enhancement and was suspected to be in contact with the left MCA as seen on a contrast-enhanced CT scan (). The possibility of an SAH originating from the ruptured aneurysm was suggested; therefore, cerebral digital subtraction angiography was performed. Cerebral angiography showed no evidence of aneurysms or arteriovenous malformations, but demonstrated a mild focal dilatation at the proximal M2 portion of the left MCA () and a small tumor blush from the left middle meningeal artery. Since the possibility of an aneurysm was eliminated, an SAH originating from the malignant tumor with vascular invasion was suspected. MR imaging revealed an extraaxial mass lesion in the left sphenoid greater wing with slightly high signal intensity on T2-weighted images and enhancement on contrast-enhanced T1-weighted images (). This lesion showed no definite uptake on a PET scan, suggesting a benign or low-grade tumor ().\nA left frontotemporoparietal craniectomy was performed. There was a soft tissue mass lesion adjacent to the left MCA. The mass was tightly adhered to the left MCA, and resulted in perforation at the MCA bifurcation area (). The perforated area seemed to be analogous to the focal dilatation at the cerebral angiography. Tumor removal together with primary repair for the perforated MCA was performed.\nA pathological examination revealed a white-gray and hemorrhagic myxoid soft tissue mass, which was demonstrated to be a meningotheliomatous meningioma without atypical or malignant features. |
A 29 days old Pakistani female infant was brought by parents to our outpatient department with two weeks history of a rapidly progressing purplish color, raised cutaneous lesion with bosselated surface involving most of the right cheek and right eyelids with associated inability to open the right eye. (). The parents were particularly concerned about the explosive progression of the lesion on the face, recurrent bleeding episodes from ulcerations and complete occlusion of the eye on the affected side. Clinical examination of the infant revealed features suggestive of a large hemangioma on the right face (), three similar hemangiomas on the right side of the palate and adjoining buccogingival surfaces (), and a small hemangioma on the right third toe (). Ulcerated areas were noticed on the hemangioma of the cheek. The right eye could not be opened.\nThe systemic physical examination of the infant, laboratory work up, chest x-ray, and ultrasonography of the abdomen were all unremarkable. Ophthalmology colleagues were consulted to rule out any associated eye abnormalities. The infant did not have any features suggestive of the PHACES syndrome (i.e. posterior fossa malformations, hemangioma of the cervicofacial region, arterial anomalies, cardiac anomalies, eye abnormalities and sterna defects). Family history of atopy or any history of recurrent wheezing in the infant was sought to rule out any possible contraindications to propranolol treatment.\nWritten informed consent was taken from the parents of the infant for instituting propranolol treatment and taking serial photographs through the course of the therapy. Prior to initiating propranolol therapy, pretreatment cardiovascular evaluation of the infant was undertaken to rule out any contraindications to propranolol therapy. The evaluation was performed by our cardiology colleagues and included baseline clinical observation of pulse, blood pressure and respiratory rate, ECG recording and echocardiographic assessment of the infant. All these were within normal limits in our infant.\nFor oral administration of the first dose of propranolol, we kept the infant under observation/monitoring for four hours in the hospital. The initial loading dose we employed was one third of the calculated 2 mg/kg/ day dose of propranolol. The mother was encouraged to continue breast feeding. The post dose pulse and blood pressure measurements were carried out every 15-20 minutes for the first four hours, and they were all stable in our infant. The infant was subsequently sent home with advice to mother regarding adherence to appropriate dosage regimen and a follow up visit after 72 hours ().\nFrom then on, the infant was followed up on outdoor basis every fortnightly and response to therapy was recorded through serial photographs. The mother was educated to notice and report any side effects of the therapy. The treatment was stopped after four weeks when there was a sustained halt in the growth of the hemangiomas (). |
The patient is a 54-year-old man who first presented to our department in 1988 with an adenocarcinoma of the right mandible. He underwent a right hemimandibulectomy, neck dissection, and reconstruction using iliac bone and pectoralis major flap, with postoperative chemotherapy and 70Gy radiotherapy. He did well until 2006 when he was found to have a right internal carotid artery near total occlusion, most probably post radiation in origin, with a 40% contralateral stenosis. He underwent consequently a right carotid artery angiography and endovascular stenting, and was started on anticoagulation.\nOn his last follow up in our clinic, he was found to have a nonhealing 5 × 3 cm necrotic mass occupying the right oropharyngeal space. Biopsies were taken from the ulcer and were inconclusive, favoring necrotic tissue. Attempts of hyperbaric oxygen therapy were unsuccessful. Therefore, he was scheduled for debridement of the ulcer and biopsy of the mass in the operating room to rule out the possibility of tumor recurrence. Preoperative Computed Tomography scanning (CT) showed the irregular ulcer at the right oropharyngeal space, with the right carotid artery stent completely occluded with no distal perfusion (), and it was encased in the mass of necrotic tissue. In the operating room, under general anesthesia, the oropharyngeal lesion was inspected endoscopically transorally (). Using a punch biopsy forceps, a specimen was taken from the ulcer for pathological examination. However, the mass was so rubbery and consistent that a large piece was excised, with a net-shaped cribriform metallic object encased within. On inspection, the carotid endovascular stent was identified, invaded, and surrounded by the mass of necrosis that was filling the lateral oropharyngeal wall (). The patient had no bleeding. The vascular surgery team was consulted into the operating room, to assess the possibility of any secondary bleeding. They recommended close surveillance of the patient for 72 hours since there was no evidence of bleeding and since the ICA was already completely obstructed, with practically a very minimal risk of vessel rupture. The patient was discharged home a few days later in a good condition. Pathology revealed necrotic tissue with absence of tumor cells. |
The patient is an 18-year-old woman. When she was 13 years old, she visited a doctor because of primary amenorrhea. Chromosome analysis revealed 46, XY karyotype (), and she had an artificial menstrual cycle for 2 years. On June 1, 2016, the then 16-year-old woman visited the emergency room following a complaint of acute abdominal pain. A computed tomography (CT) scan revealed a pelvic mass, and the initial AFP level was >3,000 ng/mL. Laparoscopic pelvic tumor resection was performed at a local hospital. Intraoperative observation showed that the patient had typical female external genitalia with sparse pubic hair and a normal clitoris. The mass was approximately 10 cm in diameter and was not connected to the vagina, and the fallopian tubes were discovered on the side of the mass. No other tumors were observed after a comprehensive intraoperative exploration was performed. The mass was completely resected, and the pathology report confirmed that the histological type of the gonadal tumor was YST without other GCT or SM components after extensive sampling. Smooth muscle tissue lined with the endometrium was also observed from certain sections, which indicated that both the uterus and pelvic tumor had been resected. After the surgery, seven cycles of chemotherapy were performed: four cycles with PEB and three cycles with PE. The AFP level was within the normal limits after the second cycle. However, a CT scan after the seventh cycle revealed abdominal and pelvic metastases including liver metastases. Furthermore, continuous vaginal bleeding occurred after the surgery. Hysteroscopic exploration was performed to search for the cause of vaginal bleeding. According to the local operation recording, a 3 cm neoplasm in the vagina, which was not connected to the pelvic cavity, was noted. The symptom of vaginal bleeding was still observed after the surgery, and she received hemostatic drugs as the symptomatic treatment.\nAfter almost 1 year since the last chemotherapy was performed, the patient was referred to our hospital because of vaginal bleeding and abdominal distension. A whole-body tomography-computed tomography (PET-CT) scan revealed multiple metastases in the abdominal wall and pelvic cavity, and on the surface of the liver and intestine. All tumor markers including AFP were within normal ranges. Consultant pathology reports revealed YST in the first surgery, but SMs derived from YST for the second surgery.\nOwing to the different pathology reports and continuous vaginal bleeding, we performed laparoscopic exploration and examination under anesthesia. Intraoperative findings included the following: 1,500 mL bloody ascitic fluid, multiple gray solid tumor nodules on the omentum majus and liver surface, and an approximately 3 cm bleeding nodule on the anterior abdominal wall (). There was a bleeding neoplasm in the vagina, and after its resection, ulcer tissues could be seen at the deep end of the vagina. After exploratory surgery, the platelet level gradually declined for an unknown reason and decreased to 30×109/L on the third day after the surgery. The patient presented with symptoms of hemorrhagic shock, and we had to perform emergency exploratory laparotomy on that day owing to acute intraperitoneal hemorrhage. The operation (right streak gonad resection, omentectomy, and tumor resection) was performed after obtaining informed consent from the patient. The primary purpose of the second surgery in our hospital was hemostasis, and it was impossible to perform satisfactory tumor reduction at that time (remaining tumor >1 cm).\nThe pathology report confirmed SMs derived from YST, and the specific histological type of SM was sarcoma. His-topathological analysis of liver metastatic tumors revealed a lacunar, microcystic, or reticular pattern. Irregular or fusiform tumor cells were variably sized with severe nuclear atypia. Mitotic figures were observed. Pleomorphic tumor giant cells could be seen and had a scattered distribution. The stroma was edematous with multifocal hemorrhage (). IHC staining showed that tumor cells were focally positive for AE1/AE3 (), but negative for GPC3 and Sal-like protein 4 (SALL4) (), and the Ki-67 labeling index was approximately 10% (). Histopathological analysis of the vaginal tumor revealed the same pattern (). IHC staining showed that tumor cells were negative for AE1/AE3, GPC3, and SALL4 (). Histopathological analysis from the right gonad sections revealed fibrous tissue with no germ cells, which indicated PGD (), and IHC staining was negative for octamer-binding transcription factor 3/4 (OCT3/4) (). All micrographs were taken using an Olympus Camera U-TV0.5×C.\nConsidering the sarcomatous components of the tumor, we performed three cycles of PEI (cisplatin, etoposide and ifosfamide) chemotherapy. However, pelvic ultrasound revealed that the pelvic residual lesions did not reduce and vaginal bleeding was still observed, while all the tumor markers were within normal ranges. We also performed whole exome sequencing, and the germline mutation results demonstrated copy-number variations of FGF9 gene (chr13:21948488-25914325)×1 and frameshift mutation of MAP3K1 gene c.2822_2827delCAACAA (p.Thr941_943del); somatic gene mutation of samples from the primary gonadal tumor and metastatic tumors revealed a non-synonymous mutation of KRAS (c.182A>G). There was no indication for currently targeted drugs.\nAfter communicating with the patient, she refused to undergo further treatment. At the time of this writing this report, the patient has been alive with the disease 7 months after the final PEI chemotherapy was administered. |
In March 2018, a 60-year-old man presented to a private dental clinic with a history of painful swelling in the right angle of the mandible. The patient reported that in December 2017, he had visited another local dental clinic with a chief complaint related to pain in the right posterior mandibular region. His past medical history included controlled type 2 diabetes. The dentist requested a panoramic radiograph, and the diagnosis was a periapical infection related to the right third molar and badly decayed right second molar, and an extraction was performed based on the patient's history. After extraction, the patient reported continuous pain with an unhealed socket, and an antibiotic regime was initiated. As a result of the unresolved pain, and without a prescription from his physician, he packed the unhealed wound with diclofenac sodium daily.\nA panoramic radiograph was acquired from his first visit (), and it revealed an ill-defined radiolucent lesion posterior to the right third molar, as well as an abnormally irregular inferior border of the mandible. The clinical examination record did not mention any observation of an intraoral soft tissue mass or ulceration at that time. An extraoral examination revealed a swelling with paresthesia in the right mandibular angle (). A panoramic radiograph was requested and showed complete erosion of the right ramus, with the lesion extending to the body of the mandible (). The radiographic signs were highly suggestive of aggressive neoplastic changes, and advanced imaging was therefore recommended. Multi-slice computed tomography without contrast revealed a large soft-tissue mass lesion occupying the right side of the parapharyngeal region, extending from the inferior orbital margin to the lower neck region, resulting in a prominent right anterolateral contour bulge (). The lesion had infiltrated the masseter muscle. A complete absence of the right mandibular ramus and temporomandibular joint (TMJ) was observed, as well as erosion of the distal mandibular body. The right maxillary sinus showed erosion of its posterolateral boundary, mild mucosal thickening, and a large cyst with a calcific margin and fluid content. The left TMJ was intact, and no osteoarthritic changes were noticed. These imaging features suggested a large, osteolytic, neoplastic lesion.\nMagnetic resonance imaging (MRI) was performed in the head and neck region to reveal the soft-tissue extent of the lesion mass (). A large irregular heterogenous soft tissue mass involving the right hemi-mandible was observed, including the condylar and coronoid processes and the mandibular ramus, and most of the mandibular body had been replaced by a broad, ill-defined, soft-tissue mass lesion measuring 8.8×4.5×5 cm. The lesion was seen extending superiorly into the mandibular fossa of the temporal bone, inferiorly to the level of the C3 vertebra, and medially involving the medial and lateral pterygoid muscles. Laterally, the lesion had invaded the masseter muscle and extended into the right subcutaneous facial fat planes, with an indistinct line of cleavage from the parotid gland. Posteriorly, it was seen to be intimately related to the right maxillary artery. The mass displayed a low signal in T1 imaging, and an intermediate signal in T2 imaging, with hyperintense foci. In post-contrast T1 imaging, the lesion showed intense post-contrast enhancement and was seen to have infiltrated the adjacent muscles.\nAnother well-defined rounded lesion, measuring 2×2.2×2.3 cm with a similar imaging pattern, was observed inferior to the neoplasm. It was closely related to the right submandibular gland, with a vague line of cleavage. In the right maxillary sinus, a soft-tissue mass (predominantly low-signal in T1 imaging and high-signal with a low-signal area in the center in T2 imaging) was seen, measuring 2×2.5 cm, along with an obliterated osteomeatal complex and invasion of the inferomedial maxillary wall with significant post-contrast enhancement (). These MRI features of the maxillary lesion indicated that the content was an inflammatory process not consistent with the main lesion. This excluded the possibility that the main lesion extended to the sinus, and the lesion in that area was diagnosed as sinusitis. Multiple bilateral enhancing submandibular and upper cervical enlarged lymph nodes were noticed, with the most significant measuring 1.4 cm on the right side. The differential diagnoses were odontogenic carcinoma, metastatic carcinoma, and sarcoma.\nTwo specimens were taken for histopathological examination (). The first specimen was obtained from the soft tissue mass around the angle of the mandible by an extraoral approach. The second sample was obtained from the maxillary sinus by enucleation of the cyst using Caldwell-Luc antrostomy (). For the first specimen, the microscopic examination revealed fibro-fatty tissue infiltrated by a tumor mass of large pleomorphic atypical squamous cells with a high nucleoplasm ratio and focal intracytoplasmic keratin formation (). The intervening stroma was heavily infiltrated by mixed inflammatory cells with numerous mitotic figures. Histopathological examination of hematoxylin and eosin-stained slides showed plentiful irregular-shaped solid epithelial islands of differing sizes in the connective tissue (). The basal cells vwere arranged in a plexiform pattern with palisading of the peripheral cells (). Microscopic examination of the maxillary sinus specimen revealed soft tissue infiltrated by lymphocytes, plasma cells, and fragments of necrotic bony spicules. Based on the microscopic findings, a final diagnosis of solid-type PIOSCC was made. |
A 23-year-old female attended the OPD, Faculty of Dental Science, with the chief complaint of swelling in the floor of the mouth, difficulty in chewing, and inability to move the tongue and open her mouth fully. She also complained of malaise, pain in the floor of the mouth loss of appetite and loss of weight. She had observed the swelling about 6 months ago with the subsequent difficulty in moving her tongue. There was no history of trauma or illness preceding the swelling. No alteration in the taste or paraesthesia was complained. No relevant medical history was present. On examination, the patient appeared ill looking. Extraoral scarring was not present. A diffused smooth swelling extending from right cheek to the floor of the mouth, obliterating the angle of the mandible, was noted. Asymmetry of the face was very conspicuous (). Enlarged lymph nodes were palpated in the submandibular region. On examination of the mouth cavity, the diffused swelling occupied the floor of the mouth on the right side; the oedema of the lower right gingiva and vestibule of the lower jaw were also observed. The tongue was coated, and constant fibrillation of the right side of the tongue was observed. She felt extreme difficulty in protruding her tongue, and on extreme effort to protrude the tongue, it showed deviation to the right side, almost to a right angle (). Examination of other cranial nerves was found to be normal and intact. Routine examination of the total count, differential leucocytic count, and immunological and serological examination showed no viral infection or autoimmune disease. Blood glucose and the liver function test were normal. The chest X-ray was clear with no lung pathology. An oral pantogram and CT scan of head and neck were advised to evaluate the possible cause of the hypoglossal nerve palsy. The radiograph and the CT scan revealed the right third molar tooth impacted lying horizontally, deep within the mandibular bone (). A diffused swelling confined to the right side of the floor of the mouth, which extended into the oropharynx and retropharyngeal space, was observed (Figures , , and ). No abnormality of the hypoglossal nerve or its sheath itself could be seen in CT scan. The impacted tooth was extracted (, Binbox). The patient was put on multivitamins, analgesics, and antibiotics. After two weeks the patient showed tremendous recovery in the hypoglossal nerve function, not only the tongue deviation to the right had lessened but also she could push it to the left side too (). |
A 49-year-old previously healthy female presented with a 1-week posterior-region knee pain post direct fall from a standing position on her left knee. This was directly followed by knee joint blockage with a limited range of motion of only 30 to 60 degrees of flexion. The patient started taking NSAID and had minimal pain relief. She reported increased pain upon standing from a sitting position and vice versa with associated tingling and numbness at the level of the calf region especially upon standing.\nOn examination, she showed good lower-limb alignment, no pain was provoked on meniscal and ligament testing, and there was an absence of muscular atrophy. Her range of motion was limited to only 30 to 60 degrees of flexion, and the patient had pain on the active range of motion. She also had pain upon active and passive extension of the knee joint with tingling and numbness over the calf region extending from the knee posteriorly. She was found to have a nonpitting edema posteriorly with moderate anterior joint effusion. On patellar examination, she felt pain originating from the posterior region of her left knee joint. To note, the patient has never had any symptoms related to her knee up until the direct fall from the standing position.\nMRI revealed a multiloculated structure arising from the synovium around the cruciate ligaments within the femoral notch extending beyond the joint capsule posteriorly with significant displacement of the popliteal vessels (Figures and ).\nIt showed evidence of synovial thickening, and on gradient echography, it showed spotty and irregular hyposignals compatible with the presence of hemosiderin. There also was associated soft tissue edema around the above-described lesion. The patient underwent arthroscopic intervention in the left knee under spinal anesthesia. The posterior compartment of the knee was reached arthroscopically through the triangular space formed by the ACL laterally, PCL medially, and the femoral notch superiorly. Total resection of the lesion was done through only anterior knee portals without taking the risk of posterior portals preventing potential neurovascular injury. The pathology report confirmed the presence of PVNS. On 6-month MRI follow-up, the previously described soft tissue enhancement suggestive of residual inflammatory changes noted within the femoral notch along the cruciate ligaments as well as posterior to the distal metaphysis at the site of the previously present lesion has decreased (Figures and ). The synovial fluid had also decreased with no evidence of hemosiderin deposits. There was no evidence of interval appearance of new susceptibility artifacts or blooming effect on the T2 gradient sequence that could correspond to evident recurrence. The compressive effect previously present on the popliteal vessels has completely disappeared with no further tingling sensation and numbness over the calf region. Clinically, patient regained full ROM on flexion extension (0° to 135°) of the knee. The previously reported pain no longer exists, with no blocking upon flexion. Patient underwent physical therapy protocol and showed significant muscle strength and balancing improvement. She was scheduled to 1-year clinical follow-up. |
In 2008, a 24-year-old non-smoking female was admitted to the hospital for right upper limb pain. On examination, she appeared to have a tender fusiform bony-hard swelling of the right upper arm. An X-ray scan showed an extraosseous tumour on the periosteal surface mainly in the mid humerus. A biopsy of the lesion was performed, with the histological result confirming periosteal osteosarcoma diagnosis. Computed tomography (CT) of her thorax and emission computed tomography (ECT) scan demonstrated no metastases. Segmental resection of the proximal periosteal osteosarcoma with internal fixation grafting was performed. The histology report demonstrated the presence of periosteal osteosarcoma. The report indicated that the local excision was complete with wide excision margins. She received adjuvant therapy postoperatively with 4 cycles of a cisplatin and doxorubicin regimen.\nWe followed the patient every 6 months with routine complete blood counts and liver function, serum alkaline phosphatase, and lactate dehydrogenase level tests, along with X-rays of the right humerus. ECT and CT scans of the chest were performed annually. No signs of recurrence were found through these examinations. However, chest CT found a mass in her left chest for the first time in December 2018. The mass was 5.5 cm, and the mass increased to 6.1 cm half a year later (Fig. a). The patient underwent thoracotomy in June 2019. We found a solitary mass on her diaphragm during the operation. The mass partially involved the left lower lung without involving any other organs, including the oesophagus or chest wall (Fig. b). We removed the tumour that was partially on the left lower lung with sufficient tumour resection margins and repaired the diaphragm defect. The patient was discharged 4 days after surgery. Postoperative histopathology showed a tumour measuring 6 cm. Postoperative pathology revealed that the tumour was mainly distributed in the diaphragm muscle tissue, and the pulmonary membrane of the left lower lung was not invaded (Fig. ). The tumour showed an intermediate grade periosteal osteosarcoma, the same characteristic as the original tumour in the right humerus. Genetic analysis of the tumour sample showed a tumor protein 53 (TP53) (exon 8) p.R280K point mutation and Cyclin E1 (CCNE1) gene copy number variants (CNVs). The patient received chemotherapy after surgery. No severe adverse effects appeared, and no signs of recurrence were found at the 6-month follow-up visit. |
In September 1999, a previously healthy 47-year-old Caucasian male patient presented to the outpatient clinic with a bilateral temporal headache and feeling of pressure around his eyes. The patient was diagnosed with a tension headache at that time and was prescribed analgesics. Few weeks later, he started to develop changes in smell perception in addition to headaches. These symptoms progressed for two months during which the patient did not seek medical attention. In mid-January 2000, the patient had an episode of syncope and was brought to the emergency department. The patient underwent a brain CT scan and was found to have increased intracranial pressure and a lesion on the right side. Brain magnetic resonance imaging (MRI) was performed and revealed a contrast-enhancing lesion in the right parieto-occipital region. The patient underwent craniotomy, and the lesion was resected without complications. Histopathological examination of the resected tumor revealed grade IV glioma (GBM) which was confirmed at multiple pathology laboratories. After that, the patient received external beam radiotherapy treatment given in 30 fractions with 2 Gy per fraction over six weeks and chemotherapy (temozolomide) for 26 months. Later, in 2001, the patient noticed a small skin lesion in his right arm which was found to be melanoma. The lesion was removed without any complications. In 2002, the patient developed a seizure, and was transported to the hospital. Imaging showed that the patient had a scar/necrotic tissue in the previously resected GBM tumor area which was then removed.\nThree years ago, in 2018, the patient had sudden weakness in his left leg and seizure. Imaging findings were consistent with chronic subdural hematoma with no evidence of tumor recurrence. The most recent follow up of the patient after 20 years of tumor removal re-affirmed that the patient was generally in a good status and free of the tumor. He was oriented to place, time and person, and his neurological examination showed some degree of psychomotor slowing, left-sided homonymous hemianopia, and difficulty in hearing. The patient’s words while speaking were comprehended and appropriate, but he has a short-term memory deficit and some difficulty with executive functioning. The patient reported a blank-out seizure once a year although he was on anti-epilepsy medications. Other neurological investigations including cranial nerves, muscle strength, and gait were normal. Brain MRI showed encephalomalacia, mild cortical volume loss, and stable chronic microvascular ischemic changes (Figure ). MRI did not show any evidence of tumor recurrence.\nThe patient is 67 years old now, 20 years after the initial diagnosis of GBM which is considered a rare long survival in GBM cases. Thus, the case was further analyzed for more details that could reveal factors that may be associated with such long survival. The patient's past medical history showed that he had a history of chickenpox infection and shingles when he was in his early thirties which was before developing his initial symptoms. |
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