text
stringlengths 746
31k
|
|---|
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 62-year-old man was beginning to run a short distance race when he felt a pop in his calf while coming off the starting block. He felt a short intense pain and did not finish the race. He went home to ice and rest his leg, but his pain and swelling continued to increase. He presented to the emergency department but left due to long wait. He returned 2–3 hours later when the pain became “unbearable.” His physical exam revealed firm swelling of the posterior leg, with taut skin and significant pain with palpation. His foot was held in resting plantarflexion and he demonstrated pain with passive movement of the ankle but no significant increase in pain with flexion or extension of the toes. He had no neurological deficits and distal pulses were intact. He had no history of injury to that leg previously, no history of coagulopathy, and was not taking any anticoagulants.\nClinical suspicion for ACS was high despite the lack of high energy mechanism or fracture. Compartment pressures were measured and found to be significantly elevated in all four compartments of the leg, with a diastolic BP 95 mmHg, anterior compartment 58 mmHg (Δp = 37 mmHg), lateral compartment 63 mmHg (Δp = 32 mmHg), superficial posterior compartment 70 mmHg (Δp = 25 mmHg), and deep posterior compartment 86 mmHg (Δp = 9 mmHg). He was promptly brought to the operating room for exploration and four-compartment fasciotomies.\nBased on clinical presentation, the superficial posterior compartment released first. After incising the superficial fascia and releasing the compartment, there was evacuation of approximately 400–500 cc of hematoma proximally between the gastrocnemius and the soleus ( and ). After decompression of the hematoma, the tension in the leg compartments was significantly improved to palpation. The deep posterior, anterior, and lateral compartments were then released. All muscles were noted to be contractile and viable; however, there was contusion noted of the soleus and gastrocnemius. The medial and lateral wounds were left open with vacuum-assisted closure (VAC) device. He returned to the operating room 2 days later for irrigation and debridement, at which time there was a visible medial soleus tear noted. Both medial and lateral wounds were closed primarily, and incisional wound VACs were placed. On post-operative day four from fasciotomies, the incisional VACs were taken down and the patient was discharged home. At his 8-week post-op appointment, he was doing well with no functional deficit when compared to contralateral side. At his 1-year follow-up, he continued to do well. He reported little to no pain and was only bothered by a mild persistent swelling of the leg and ankle that would occur after a full day of being on his feet. He is back to all of his previous activities, although he now mountain bikes instead of running as his main exercise as it is easier on his joints. He reported no functional limitations and is overall very pleased with the outcome of his operation. |
A 45-year-old male presented with painless and progressive swelling on the right frontal region over 2 years prior to examination. According to patient history, the “swelling” started over his eyebrow and progressively increased in size. He underwent a biopsy at an outside facility and the pathology report diagnosed neurofibroma but patient failed to follow-up. He was later referred to our hospital after the lesion enlarged in size and he had developed difficulties opening his eyes. He had no history of trauma, bone pain, systemic disease, or neurological symptoms. Physical examination found an extensive scalp lesion that measured 30 × 20 cm in size, extending from the right orbital rim toward the contralateral side and the parietal region. Upon palpation the lesion was firm but without any tenderness []. The skin on the tumorous area was adherent to the underlying soft tissue and the lesion was immobile. There was no visible venous dilatation or any audible bruit over the lesion. A small post biopsy scar was present at the middle of the lump. Neurological examination was unremarkable and the patient did not bear any signs of NF-1 as well as in their family tree.\nComputed tomography (CT) scan of the head revealed a calvarial soft tissue mass predominantly located in right frontoparietal with infiltrating mass on the frontal region and associated right frontal bone defect [Figure and ]. Magnetic resonance imaging (MRI) of the brain revealed a soft tissue mass that was iso-hypointense on T1 showing lobulated mass at frontal region [], which enhanced homogenously after contrast administration []. The mass extends to the frontal base viewed by coronal plane [] and various intensity on T2 imaging []. The tumor showed extension from extracranial compartment through the bony defect into the right frontal lobe and frontal base. The decision was made to pursue resection.\nThe patient was positioned supine with back slightly elevated 20° and without any head fixation. A wide marginal excision with 4 cm distance from neoplasm margin was performed. At surgery, tumor tissue was found to be soft, fleshy, moderately vascular, and mostly encapsulated with some areas displaying ill-defined margins. The mass was eroding through the internal table of the bone and infiltrated the dura mater as well as the intradural compartment. The mass was highly vascular and bled easily when touched. The bone at the right frontal region appeared moth-eaten and was removed with rongeurs until a normal hard and thick border was identified. A wide intracranial portion of the lesion was removed without any involvement of brain parenchyma, and a fascia lata graft was used for duroplasty. The postoperative bone defect measuring 10 × 10 cm was closed using a titanium mesh. A vascularized free flap was raised from anterolateral thigh and sewn in by the plastic surgeon to close the skin defect. The patient's neurological status remained intact postoperatively. He was discharged from the hospital uneventfully.\nOver a period of 6 months, the patient was seen in regular follow-up when a recurrence was seen on routine imaging and also new complaint of ptosis on left side. The images show local recurrence on right frontal lobe; interestingly, a new lesion was prominent on contralateral cavernous sinus []. Patient underwent surgery for the right frontal lobe mass and 20 gray external beam radiosurgery for cavernous sinus lesion. There was partial response as the ptosis complaint got better and mass shrink nearly 50% of its size. After 2 years the tumor recurred again on both right frontal and also cavernous sinus, but the patient refused any other medical intervention. Patient died two-and-a-half years after initial diagnosis of this disease. |
We describe the case of a premature Bahraini girl born at 29 weeks of gestation by spontaneous vaginal delivery, to a 39-year-old gravida 6 para 5 mother. She was born “flat” with an APGAR score of 4 and 9 at 1 and 5 minutes respectively and a birth weight of 910 g. Ventilatory support was required during her first 6 days of life, with a dose of surfactant. She had an uneventful Neonatal Intensive care stay, tolerating breast milk and was gaining weight at a steady pace. On her 47th day of life she developed sepsis and required repeated ventilator support for 3 days. At day 51 she weighed 1400 g, but developed abdominal distension and feed intolerance. She was referred to the pediatric surgeon on day 54 when pneumoperitoneum was detected by a shoot-through lateral plain abdominal film (Fig. ). Our examination showed her abdomen to be distended but soft with mild diffuse tenderness and no signs of peritonitis. There was no abdominal wall erythema or visible bowel loops. We did not find any hernias or abdominal masses. Her C-reactive protein (CRP) was 37 mg/L which is 12 times higher than the normal range. In view of pneumoperitoneum, she was taken for exploratory laparotomy. A classic right transverse upper abdominal incision was used to open her abdomen as the diagnosis was NEC. Her entire small and large bowel was healthy and normal in appearance (Fig. ). Her appendix measured approximately 2 cm in length and was acutely inflamed with a perforation at the tip. Except for the site of perforation, there was no other evidence of gangrene (Fig. ). The findings were consistent with a perforated appendix with no evidence of peritonitis or NEC. An appendectomy was performed. She had a smooth postoperative recovery where she was started on breast milk on the second postoperative day and her CRP was normal on the eighth postoperative day. Histology demonstrated mucosal ulceration of her appendiceal wall, marked acute transmural inflammation, and necrotic wall at the perforated end (Fig. ) but the rest had intact mucosal lining (Fig. ). A neuron-specific enolase (NSE) immunohistochemical stain showed positive staining for nerve fibers (Fig. ) which excluded Hirschsprung’s disease. She was discharged home at day 120 of life and was thriving at 2-year follow-up. |
A 47-year-old man presented at our dermatology outpatient department with multiple painful reddish raised nodular lesions over the chest and upper abdomen for the last four months. A year and a half back, he first noted a small single nodular lesion in the middle of the chest, gradually increasing in size with a rough surface overlying it which later became painful, but was not associated with any discharge. The lesion was subsequently excised in a medical college in September 2008. The site took a long time to heal. Within 3-4 months post surgery, he noticed multiple groups of raised lesions of skin close to the suture site and draining site in the abdomen. These lesions gradually increased in size within another 3-4 months, with no associated discharge or pain. Now for the past four months, he had noticed multiple crops of lesions on the chest and abdomen suddenly increasing in size and number. They were associated with pruritus, bleeds on scratch, and pain, associated with discharge. He complained of painful swelling in bilateral axilla and thickening of skin underneath and surrounding the existing lesion.\nPhysical examination revealed multiple grouped nodular erythematous to skin-colored translucent papules and nodules, a few of them hyperkeratotic, brownish to black in color of varying sizes ranging from less than 1 cm to about 10 × 8 cm distributed over the anterior chest wall and upper abdomen []. There were also ulceroproliferative lesions with pus discharge rising from the excision scar overlying the epigastric region. The lesions were painful and there was purulent yellowish discharge from the lesions. The skin around the nodular masses was infiltrated and tender. Examination of the axilla revealed bilateral hard, tender, and mobile lymphadenopathies (single, about 8 × 6 cm in the right axilla, and single, about 3 × 4 cm in the left axilla). The initial cytopathological report before the first excision was consistent with benign adnexal tumor and histopathology of the excised lesion revealed it to be eccrine poroma. Based on the clinical and pathological features of a repeat biopsy, done after two years, a provisional diagnosis of cutaneous malignancy/malignant adnexal tumor was made. The repeat histopathology revealed a tumor arising within the lower portion of the epidermis with extension downward into the dermis. The tumor was present in lobules and broad anastomosing bands. The border between the epidermis and the tumor was readily apparent.\nThe tumor was predominantly solid []; however, narrow ductal lumina could be seen focally. The cells were oval to cuboidal with a deeply basophilic nucleus and a clear-to-eosinophilic cytoplasm. Focally large hyperchromatic nuclei were seen. The mitotic rate was very high (10 per 10 high power field) with atypical mitosis []. No cytoplasmic keratinization, intracytoplasmic pigment, or peripheral palisading of nuclei was noted. Necrosis was also not visible. The tumor displayed an infiltrative growth [] and reached up to the subcutaneous plane. Focal surface ulceration was noted. The margins of resection were free. Histochemically, the cells were PAS-positive (PAS; periodic acid-Schiff) indicating the presence of glycogen. The cells were positive for pancytokeratin and negative for HMB-45 (HMB: Human Melanoma Black) and S-100. A final diagnosis of malignant eccrine acrospiroma or acrospirocarcinoma was made on histopathology, based on these findings.\nA computed tomography (CT) evaluation of the abdomen and thorax revealed multiple heterogeneous, hyperdense nodular lesions of varying sizes with irregular margins rising from the skin of the anterior abdominal wall and anterior chest wall []. Some were continuous and others rose as discrete exophytic nodules. The lesions could be grouped into three types, those rising from the skin and growing exophytically with little or no deeper component, some that were primarily rising deep to the epidermis in the subcutaneous fatty tissue as discrete nodules, and other bigger lesions extending from the surface of the skin across subcutaneous fatty tissue and invading into the underlying muscles of the anterior abdominal wall and thorax. The largest nodule measured around 6.2 × 6.0 cm rising from the epidermis. There was no extension into the abdominal cavity. There was also the presence of bilateral multiple enlarged lymph nodes, of around 5 × 6 cm on the right and around 1.3 × 2.5 cm on the left []. A radiological diagnosis of dermal appendage tumor (?malignant) with infiltration into the subcutaneous tissue and underlying muscle over the upper anterior abdominal wall and upper anterior chest wall with bilateral axillary nodal involvement was made.\nThe patient was treated with systemic chemotherapy, as wide local excision was not deemed feasible by the surgeon citing widespread and disseminated nature of the lesions. He was initially treated with a combination chemotherapy regimen consisting of adriamycin 50 mg/m2 Day 1, vincristine 1 mg/m2 Day 1 and Day 5, 5-fluorouracil (5FU) 500 mg D1–D5, cisplatin 20 mg/m2 and bleomycin 5 IU/m2 from Day15–Day19, a 28-day cycle for two cycles with no significant clinical response. Thereafter, the chemotherapy regimen was changed to paclitaxel 175 mg/m2 D1, a 21-day cycle which showed minimal clinical response with the appearance of new lesions. However, there was significant amelioration of pain. The patient subsequently received two more cycles of paclitaxel, with sustained pain relief but minimal or no regression of the lesions. He was planned for locoregional radiation using electron beam but defaulted and was lost to follow-up thereafter. |
A 58-year-old man was referred for patent foramen ovale closure following a presumed cryptogenic stroke. The patient presented with transient hemiparesis, with MR imaging suggesting a previous additional, unrecognized cerebellar infarction. CT angiography of the neck and intracranial vessels was unremarkable. Ambulatory ECG monitoring did not detect any atrial fibrillation. Contrast transthoracic echocardiography suggested the presence of a patent foramen ovale with subsequent transoesophageal echocardiography confirming the presence of a PFO with an aneurysmal interatrial septum. In view of the absence of alternative mechanisms of stroke, MR imaging suggesting previous embolic events, and the desire to avoid lifelong anticoagulation, the patient was referred for percutaneous device closure.\nUnder general anaesthesia and transoesophageal echocardiography guidance, a 30 mm Amplatzer fenestrated atrial septal occluder was delivered using a 9 Fr delivery system. The device was released uneventfully () and the final appearance on fluoroscopy () and transoesophageal echocardiography was excellent; device position was confirmed with a “push-pull” maneuver prior to device release. A transthoracic echocardiogram was performed the following day demonstrating satisfactory device position with no evidence of pericardial effusion. The patient was then discharged on aspirin and clopidogrel. The patient remained asymptomatic. Routine repeat transthoracic echocardiography was undertaken six months following device implantation to assess for any residual shunt. The Amplatzer occlusion device was not visualized on transthoracic imaging with strongly positive right to left shunt noted. Subsequent transoesophageal imaging demonstrated absence of the occluder across the interatrial septum consistent with device embolization; the device could not be visualized in the main or branch pulmonary arteries. CT angiogram of the thoracic and abdominal aorta was performed and the device was located in the visceral abdominal aorta. There was no compromise of flow noted to either the visceral vessels or distal aorta.\nArrangements were then made for percutaneous device retrieval. The right common femoral artery was exposed using a transverse incision and a 20 Fr Cook sheath was advanced through the right common femoral artery. Heparin was administered intravenously. The device was located in the abdominal aorta () with no compromise of mesenteric vessels observed. The device was initially snared with a 20 mm gooseneck snare; however the device could not be retrieved into the sheath due to lack of compressibility when withdrawal into the 20 Fr sheath was attempted. The gooseneck snare was then substituted for an ANL retriever; despite multiple attempts the device would not deform to allow passage into the 20 F sheath (). The device was partially distorted and could be retracted into the right common iliac artery. Once positioned into the common iliac artery, the patient underwent open retrieval via a right sided Rutherford Morris incision.\nPeripheral pulses were present at the end of the retrieval and no distal angiogram was performed. However, the postsurgical course was complicated by bilateral lower limb claudication. This was the result of nonocclusive embolism to the tibial vessels requiring surgical thrombectomy after attempted percutaneous aspiration. No metal was present in the retrieved tissue which was thought to be chronic thrombus and fibrin detached off the device during attempted withdrawal into the sheath.\nThe patient was subsequently commenced on apixaban with no recurrent thromboembolic complications during 12 months' follow-up. |
A 10 year-old girl was referred to the Prosthodontic Department, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran by her parents who were in search of a prosthesis that could prevent injuries to her oral mucosa, and improve her function and appearance. Medical history revealed that the girl was the second child of consanguineous parents whose first child was normal. When the patient was a few months old, her parents began to suspect that there was something wrong with the child since she failed to cry during painful stimuli, did not sweat and suffered from episodes of unexplained fever that decreased with physical activity. By the time she was 12 months old, deep ulcers developed in the patient’s fingers, lips, tongue and oral mucosa due to bites, with premature loss of a number of teeth due to biting hard toys. At that time, the child was diagnosed with CIPA however, the parents did not seek dental management until she was 10 years old.\nOral examination of the child showed mixed dentition. The left and right permanent canines were present in the mandible; however other teeth were lost due to biting hard items and self-tooth extraction. The remaining mandibular teeth had mild cervical caries.\nIn the maxilla, both the right and left permanent first molars were in good condition and only occlusal caries were noted. The other remaining maxillary teeth and roots were primary teeth with extensive caries (). Necrotic ulcers were apparent on the left side of the tongue and buccal mucosa which resulted from the child's biting habit (). The patient had a decreased ability to open her mouth that was attributed to a fibrous band of scar tissue in the cheeks. The hands and fingers also showed signs of biting ().\nAlthough the patient had mild mental retardation, she was very cooperative and eager to have teeth that could improve her appearance and function. After extraction of her maxillary primary teeth and roots under anesthesia (due to the vasoconstrictor role of epinephrine), an esthetic-functional acrylic removable partial prosthesis was provided. In the mandible, the cervical caries of the canines were removed and restored with tooth-colored composite resins. After removal of the canine teeth undercuts, a mandibular overdenture was constructed ().\nThe parents were instructed to remove both prostheses at night. Prophylactic daily use of fluoride gel inside the overdenture was recommended to prevent caries. During the first visit (24 hours after prosthesis insertion), the mucosa was checked carefully for any signs of tissue inflammation and ulcers due to the prosthesis. After one week, the mother reported that her daughter had managed well with artificial teeth and that she had been able to chew soft food.\nAt one month recall, the patient could chew tough food with her prosthesis. An improvement in ulcerations was noted and no new lesions were seen. The prosthesis improved the patient's appearance and psychosocial adjustments. After a six month follow-up, the girl was in good condition and was satisfied with her prosthesis. There was no weight loss and she could chew well. Her oral hygiene improved due to her care and the parents’ cooperation. The remaining teeth were also in good condition and no gingivitis around the canine teeth was observed. |
The patient was a 19-year-old male with a ten-year history of epilepsy, as well as transient episodes of severe morning headaches with nausea, vomiting, and dizziness. At age nine during a workup for severe headaches, he was found to have a presumed right insular vascular abnormality on imaging. A month later, the patient began having seizures. He was managed medically for ten years; however, during this time, his seizures progressed in frequency from occurring approximately once every six to nine months to almost daily simple or complex partial seizures and rare generalized tonic-clonic seizures despite maintenance on high-dose antiepileptic therapy. Given his refractory and progressive disease, he eventually presented to clinic for consultation about possible surgical management. The only finding on physical examination was distal left upper extremity weakness and hand muscle atrophy resulting from an injury in a motor vehicle accident sustained at the time of a seizure.\nA magnetic resonance imaging (MRI) scan performed one year prior to surgery showed a suspected single right posterior frontal flow void with adjacent cortical foci of susceptibility artifact compatible with calcification or hemosiderin from remote, small hemorrhages suggesting an atypical vascular lesion (Figures and ). The flow void itself had the appearance of a developmental venous anomaly (DVA), but the pattern of adjacent hemosiderin deposition was noted to be unusual for DVA or an associated cavernous malformation. There were no imaging features specific for parenchymal arterial venous malformation (AVM) or dural AV fistula. The vascular abnormality identified in the right frontal operculum was not demonstrated on MRA images. Imaging was repeated and showed the same lesion again felt to likely represent an atypical vascular malformation (Figures and ).\nThe patient was elected to undergo intracranial seizure monitoring with subdural grid and depth electrode placement in order to determine the location of all epileptogenic foci.\nPostoperatively, the patient had some left-sided weakness, dysarthria, and left facial weakness. At one month postoperatively, he was almost completely back to his baseline with only minimal residual left facial weakness. The patient did not experience further complex partial seizures. In the immediate postoperative period, he had occasional auras every two to three days, but at one month postoperatively, this had decreased to once every four to six days. At his 20 month visit, he had no auras and his previously almost daily seizures had been eliminated. He was continued on his antiepileptic medications; however, a few days prior to his one year postoperative visit, he stopped taking his seizure medications for two days and suffered a generalized tonic-clonic seizure. A surveillance MRI performed at this visit showed encephalomalacia and no change in the size of the residual lesion (Figures and ). The patient's seizure medications were resumed, and he has not had any seizures or auras since on dual antiepileptic therapy. |
A two-year-old male patient was admitted for open heart surgery with preliminary diagnosis of a partial anomalous connection of the middle and inferior right pulmonary veins to the right atrium and 9 mm atrial septal defect (ASD), based on ultrasound and computed tomography (CT) scan evaluation. The transthoracic echocardiography performed in our department found posterior rotation of the right margin of the intraatrial septum resulting in PAPVD, but did not confirm the presence of ASD. The left pulmonary veins as well as right superior pulmonary vein were found to drain in a normal way to the left atrium.\nDuring surgery, while dissecting the inferior vena cava for direct bi-caval cannulation, we found a 5 mm diameter vein passing through the diaphragm and draining into the coronary sinus. It was located leftward and parallel to the inferior vena cava (IVC) within the distance of 1.5 cm. Any major tension applied to the vein resulted in cardiac rhythm disturbances and drop in blood pressure.\nAfter commencing moderate hypothermic cardiopulmonary bypass (CPB) (31°C), the aorta was cross-clamped for a single period of 21 minutes, and the right atrium was opened and inspected. The anomalous vein was controlled with a tourniquet (released every ten minutes). The intracardiac findings consisted of two right pulmonary vein orifices within the right atrium and no atrial septal defect. Ostium of the coronary sinus was markedly enlarged, whereas the orifice of the anomalous (left hepatic) vein was clearly visible in the most distal part of the coronary sinus, close to the right atrial chamber. A large part of the atrial septum was resected and a patch of autogenous pericardium was then used to re-direct the right pulmonary veins to return to the left atrium. The postoperative period was uneventful and the patient was discharged home on the 9th day after surgery.\nConsidering the intraoperative findings and possible surgical consequences of unrecognized anomalous connection of the hepatic vein into the coronary sinus, we decided to reevaluate the patient and look for the morphological evidence of the left hepatic vein to the coronary sinus connection. The purpose of this procedure was to determine whether it was possible to make the proper diagnosis prior to surgery. The analysis of preoperative echocardiographic recordings carried out anew did not show the vein directly. It could not be suspected from apparent hemodynamic consequences either. It was most likely due to the markedly increased, turbulent flow caused by an abnormal connection of the right pulmonary veins joining the lowermost part of the right atrium close to the IVC-RA junction and CS ostium. We expected that redirecting the flow from both right pulmonary veins to the left atrium with the patch would diminish blood turbulence within the area of interest and make the task easier. Indeed, the four-chamber apical view revealed the dilatation of the distal (closest to the ostium) part of the coronary sinus, whereas more proximal parts of the CS were normally narrow (). The thorough, gradual inspection of the CS, seen in transverse cut with modified parasternal short axis views, revealed the ostium of the abnormal vein joining the dilated part of the coronary sinus. The 3 mm diameter vein that originated from the liver, was passing the diaphragm, and joined the coronary sinus perpendicularly ( and ) (). |
A 38-year-old man admitted to hospital with the complaint of swelling in the left testis for the last 3 months. Scrotal ultrasonography revealed heterogeneous and hypoechogenic solid mass lesion in the left testis with 9 x 6 cm dimensions. Normal testicular tissue was not observed and it was considered to be testicular tumor.\nThoracic computed tomography (CT) showed many bilateral parenchymal metastatic lesions in the lungs, the biggest one was 7 x 9 x 11 cm in dimensions and located in the left upper paramediastinal region (). Serum β-HCG was 89.7 IU/ml and AFP was 1050 ng/dl.\nWhile the patient had been followed up by the medical oncology department, a cerebrovascular accident (CVA) developed and symptoms of NYHA class 4 heart failure were detected. Then, an echocardiography was performed. Echocardiography revealed a mass attached to the mitral valve with 18 x 52 mm in dimensions and filling two thirds of the left atrium. It was tufted with irregular borders and prolapsing into the left ventricle (). The patient underwent the surgery following our examination.\nUnder general anesthesia, after median sternotomy, cardiopulmonary bypass was started with bicaval cannulation. Left atriotomy was performed following cross clamp placement. Left atrium was explored and a 5 x 3 cm pedunculated fragile mass was seen in the left atrium. It was free of the atrial wall and mitral valve. The pedicle was extending to the left lower pulmonary vein and was probably a part of metastatic mass in the left lung. The mass was excised totally (). The left atrial space was irrigated by saline after excision and there was no residual mass. There was a slight mitral valve insufficiency which required no additional intervention. Cardiopulmonary bypass was terminated without any complication or problem.\nThe patient was taken to the postoperative intensive care unit for 1 day and discharged on the 6th postoperative day. He was taken to the medical oncology department for therapy. Symptoms of the patient declined to NYHA class 1 postoperatively. Postoperative echocardiography revealed first degree mitral insufficiency and no residual mass.\nPathologic examination of the left atrial mass with a large amount of polypoid tissue revealed hypocellular mesenchymal tissue consistent with a non-seminomatous germ cell tumor metastasis. Microscopically teratoid glandular and ductular structures lined by columnar or squamous epithelial cells were seen in an edematous and hemorrhagic fibrous stroma. Epithelial areas were very scanty and focal. The small foci of choriocarcinoma component were located in hemorrhagic areas. Immunohistochemically, while teratoid areas were stained with pankeratin, choriocarcinoma areas were stained with HCG ().\nMetastatic testicular germ cell tumor was diagnosed and BEP (bleomycin, etoposide, cisplatin) chemotherapy protocol was started 15 days after the surgery. The patient did not have any problem in wound healing during the follow-up. The thoracic CT at sixth month's control showed regression in the pulmonary mass and no recurrence in the cardiac cavity (). |
A 27-year-old, right-hand-dominant south Asian man sustained a road traffic accident and presented to our emergency department four hours after the accident. He was walking along the road, when he was hit by a motor vehicle (a truck) from behind. He fell by the side of the road and landed with his left limb trapped under his body.\nOn arrival, he was conscious and well oriented with stable vital signs but complained of breathing difficulty. He also complained of pain in his left shoulder and arm. On examination, the air entry was found to be decreased on the left side of his chest. Radiography of his chest was done and a diagnosis of hemopneumothorax was made by the emergency physician. A chest tube was inserted in his left hemithorax and 150ml of blood was drained. There was relief in his breathing difficulty and air entry was found to be equal on both sides of his chest. There was visible deformity of the left humerus, with abrasions over the left scapular region, and no distal neurovascular deficit in the left upper limb. Local examination revealed a positive sulcus sign and anteriorly displaced humeral head along with unnatural mobility at the humeral shaft. A radiographic examination confirmed an anterior dislocation of the shoulder, with transverse fracture of the shaft humerus at the proximal one-third and distal two-third junction, along with fracture of the ipsilateral scapula and left-sided third, fourth and fifth rib fractures (Figure ). A computed tomography scan was done to outline the scapular fracture pattern, and decide its management (Figure ). A magnetic resonance imaging scan of the shoulder revealed a tear in the anteroinferior and superior labrum, a partial bicipital tear and no injury to the rotator cuff (Figures and ).\nA closed reduction of the shoulder dislocation was not attempted due to the concomitant humeral shaft fracture, with high risk of failure and iatrogenic neurovascular damage []. The fracture fixation should be carried out prior to joint reduction to avoid neurovascular traction injury. Following a secondary survey, our patient was transferred to the operating room and general anesthesia was administered. The humerus was approached through an extended deltopectoral approach. The humeral shaft fracture was reduced and fixed with a proximal humerus locking plate. The shoulder was subsequently reduced by gentle manipulation, under direct vision. The rotator cuff was examined for its integrity and was found to be intact, which reinforced the magnetic resonance findings. The labral repair was deferred due to the prolonged anesthesia time. The scapular fracture was managed conservatively as the fracture pattern did not warrant a surgical intervention. Postoperative radiographs confirmed a concentric reduction of the shoulder joint and good fracture fixation (Figure ). Our patient did not have any neurovascular deficit post surgery.\nOur patient was given an arm sling and pendulum exercises for the involved shoulder along with a range of motion exercises at the elbow joint that were initiated in the immediate postoperative period. The recovery of our patient was uneventful and the chest drain was removed on the third postoperative day. Our patient was discharged on the fourth postoperative day. After three weeks, active assisted flexion and external rotation to neutral were allowed. At six weeks, further movements at the shoulder were encouraged. Radiological union at the fracture site was noticed at 16 weeks (Figure ) with a good range of movements at the shoulder at six months (Figure ). A follow-up computed tomography scan (Figure ) of the shoulder revealed union at the fracture site with the humeral head well placed into the glenoid cavity and union at the medial border of the scapula. |
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 19 year old male patient presented with a swelling involving left side of the lower face for more than 6 months []. The swelling had rapidly grown in last 2 months and was also associated with pain at the left mandibular angle region. Patient had visited a dental surgeon for the above complaint 4 months back following which he underwent an intraoral procedure with extraction of his left lower third molar tooth under general anesthesia. One month after the procedure the swelling did not resolve and began to increase in size and was associated with pain. On examination there were no extraoral or intraoral draining sinuses or suppuration and patient was in good health with no medical problems except for the pain and swelling which extended from left angle region to the premolar-canine region []. The lesion was firm on palpation, slightly tender. The skin over the swelling was normal.\nIntraorally, the buccal vestibule was obliterated due to the expansion of the buccal cortical plate extending from the retro-molar region to the premolar-canine region. Overlying mucosa was pink and smooth. The teeth were not mobile.\nPanoramic radiograph showed a lytic and expansive lesion showing a ‘honeycomb’ and soap bubble like appearance with defined margins []. Lytic lesion measured 7 cm × 5 cm in its greatest dimension with destruction of buccal and lingual cortical plates but maintaining continuity of the lower border.\nAn incisional biopsy under local anesthesia was carried out and was suggestive of aneurysmal bone cyst.\nSurgical treatment for resection of the mandible followed by immediate reconstruction with a vascularised fibula flap was planned as we concluded it to be a recurrence. Under general anesthesia, through an extraoral submandibular approach the tumor was exposed. The mandible was resected 1 cm beyond the radiographic margins both at the ramus and the premolar-canine regions []. The jaw cortex was ballooned out and thinned having an egg shell appearance, but without loss of continuity. There was infiltration into the soft tissues at areas of perforation of the buccal cortex, which was cleared. Primary reconstruction of the defect was carried out with a vascularised fibula flap [Figures and ] harvested from the right leg and secured with a titanium reconstruction plate []. There was no significant blood loss during surgery. Patient was put on intermaxillary fixation for three weeks.\nThe histopathological examination of the surgical specimen revealed capsule of a cystic lesion with many dilated blood filled cavernous spaces and extravasated RBCs. These spaces were separated by fibrous septa with osteoid tissues, multinucleated giant cells and macrophages []. The diagnosis of an aneurysmal bone cyst was made.\nThe patient had a good postoperative recovery, with good healing. He was on constant follow up for 12 months without any signs of local recurrence. Patient is yet to be dentally rehabilitated on the affected site. |
This is a report of a previously active and healthy 13-year-old Trinidadian boy of African descent with no past medical history, significant history of trauma or travel abroad. He suddenly presented with flu-like symptoms, vomiting and diarrhea of four days duration at a community health center. There was no history of known contact with S. aureus infection either at school or with family. He was assessed as a case of viral illness, possibly gastroenteritis, and was treated symptomatically with anti-emetic and analgesic intramuscular injections. Laboratory tests were not pursued and he was discharged with instructions for home care and, if necessary, oral rehydration therapy. About two weeks later he was admitted to the hospital complaining of fever, increasing pain, weakness and inability to lift or to move his left leg where he received an intramuscular injection of the anti-emetic drug.\nOn admission, his physical examination revealed tender and warm erythematous swelling of his left thigh extending to his upper thigh and hip joint. An ultrasound scan of his left hip, a chest X-ray, electrocardiography and Doppler ultrasound of his popliteal pulses detected no abnormality. Blood cultures, samples of pus from a skin rash and samples for clinical chemistry were taken. Initial laboratory results are given in Table .\nOn further review, the child was assessed as having septic arthritis with a high suspicion of necrotizing fasciitis and septicemia or infective endocarditis. Thus, treatment with clindamycin, ceftriaxone, vancomycin and cloxacillin was started. Later the same day, the cellulitic area around his right knee was noticed to increase rapidly and a computed tomography scan revealed a collection or abscess around his left hip but not involving the capsule of the joint. An immediate exploratory laparotomy and drainage of the pelvic wall abscess under general anesthesia was arranged. During the operation, 200 ml of straw colored fluid was collected and a deep pelvic wall abscess was found, measuring 8 × 6 × 4 cm, adjoining his hip joint capsule and near to the obturator canal. There was thick shiny brown pus in the cavity extending superiorly towards the inlet of his iliac bone, inferiorly to the superior and inferior ramus of his left pelvic bone. The thick joint capsule was intact and there was no evidence of gluteal abscess, but there was a compression from the external and greater tuberosity of the hip bone by the thick pus collection. The pus was drained. Our patient was transferred to the intensive care unit (ICU) although the post-operative condition was very satisfactory. While in the ICU, our patient started to have persistent cough productive of white sputum and was observed to have bilateral crepitations in all his lung fields. A chest X-ray was suggestive of acute respiratory distress syndrome with ground glass appearance. He required inotropes, and had difficulty ventilating resulting in the need for intubation and artificial ventilation. However, our patient's condition deteriorated rapidly and he died 48 hours after admission. An autopsy was remarkable for necrotizing multi-organ failure involving his lungs, kidneys, thymus and other organs. It also revealed congestion, edema and hemorrhage of his lung alveoli, necrosis of his kidney epithelia and Hassall's corpuscles and microabscesses of his thymus gland.\nLaboratory results received after the death of our patient revealed grossly abnormal data. These are also shown on Table . |
The patient was a woman aged 30 years and 2 months at the initial consultation. She visited the hospital with a chief complaint of severe pain in her maxillary and mandibular front teeth and a spaced dental arch. Her face was bilaterally symmetric, and she had a convex facial profile (). The anterior occlusal relationship included an overjet of 2 mm and an overbite of 4 mm; the molar occlusal relationship was bilateral Angle Class I, and the arch length discrepancy was +2 mm for both the maxilla and mandible. The lateral dentition had relatively good occlusion, but the bilateral maxillary central incisors showed mesial rotation, and her previous dentist had joined the mandibular front teeth with resin, presumably to prevent tooth mobility (Figures and ). Cephalometric analysis showed the following: ANB, 6; FMA, 30; U1-SN, 106; and IMPA, 99 ( and ). Therefore, the patient's facial type demonstrated a mesofacial pattern, and she was diagnosed orthodontically with an Angle Class I spaced dental arch.\nThe radiographic findings indicated vertical bone resorption in the mesial portions of the right maxillary and mandibular first molars, and the maxillary and mandibular front teeth showed high-grade bone resorption (Figures and ). On the periodontal disease chart, there were swelling of the gingiva in the same location and a periodontal pocket exceeding 4 mm. Bleeding on probing was observed (). The front teeth of the lower jaw had been joined with resin at another hospital to prevent tooth mobility. There was also moderate loss of the mesial interdental papilla in the gingival recession area of the bilateral maxillary lateral incisors (Figures and ). Dental findings showed a reduction in the mesial bone level; therefore, the patient was diagnosed as Class III according to Miller's classification of gingival recession []. In this case, given that periodontal lesions were found in the maxillary and mandibular teeth and molar areas, the patient was diagnosed with malocclusion associated with extensive moderate chronic periodontitis. Further, when we examined night-time parafunction using a BC [, ], strong functional contact was noted on the marginal ridges on the mesial side of the bilateral maxillary central incisors and the incisal edges of the bilateral lateral incisors, as well as the right canine, first premolar, and first molar (). These locations generally correlated with the locations of the patient's symptoms of periodontal disease according to the periodontal disease chart (). The dental findings indicated widening of the periodontal space in the lateral dentition, suggesting that the condition may have been associated with occlusal trauma. Written informed consent was obtained from the subject for publication of this case report and the accompanying photographs, figures, and data.\nBased on the above findings, the patient was diagnosed with occlusal trauma and an Angle Class I spaced dental arch associated with extensive moderate chronic periodontitis. The treatment objectives were resolution of the discrepancy, establishing appropriate anterior guidance by capturing the correct tooth axis inclinations for the maxillary and mandibular front teeth, and attenuation of the occlusal trauma. If there were stabilization of functional occlusion after use of a retainer and no progression of periodontal disease, we planned to perform palatal gingival grafting to the tooth cervix of the bilateral maxillary lateral incisors.\nA periodontal disease specialist treated the periodontal tissue before orthodontic treatment was commenced. We made the patient aware of the importance of her oral environment and explained the importance of being motivated for the ongoing oral management needed. Approximately 3 months later, there was improvement in the pocket depth, and the bleeding on probing and gingival swelling had resolved, indicating improvement of the periodontal disease (). Given that the patient's awareness of the importance of maintaining her oral environment had also improved, we initiated active treatment.\nFor the active treatment, we used a Roth setup with a 0.022-inch slot bracket and started leveling using maxillary and mandibular 0.012-inch round nickel titanium wires. We then increased the wire size sequentially and were using a 016 × 022-inch stainless steel wire after 6 months. We then attached a hook between the maxillary and mandibular lateral incisors and canines and closed the gap using intermaxillary elastics to exert an extremely weak orthodontic force.\nThe BC showed strong functional contact with the right maxillary lateral dentition before starting active treatment, so construction of appropriate anterior guidance and molar spacing was considered for detailing. At the completion of active treatment, the patient started using a retainer after night-time parafunction was reassessed using the BC (). The active treatment lasted 1 year and 8 months (Figures –). A Begg-type retainer plate was used for both the mandible and maxilla. Two years after starting use of the retainers (Figures –), the BC assessment was performed again, and the periodontal disease was reexamined (Figures and ). After the state of occlusion and the periodontal tissue were checked, the patient underwent coronally advanced flap repositioning surgery with a connective tissue graft for root coverage of the labial side of the tooth cervix of the bilateral maxillary lateral incisors using palatal mucosal connective tissue ().\nIn a photograph of the oral cavity taken after orthodontic treatment, the maxillary and mandibular spacing had closed, and a continuous and appropriate overbite and overjet were acquired. The findings indicated acquisition of good lateral incisor interdigitation (Figures and ). Panoramic findings indicated good parallelism of the roots of the teeth (). Dental findings showed tooth root resorption of the left maxillary lateral incisors, but the lamina dura had become clearer. In addition, the widening of the right maxillary first molar periodontal space had disappeared, and bone regeneration was noted in the mesial area ().\nThe BC findings after completion of treatment indicated weakening of the strong functional contact that was present in the right maxillary lateral dentition and front teeth (Figures and ). In the cephalometric superimposition (), the mandible was slightly rotated clockwise, and the patient's profile was virtually unchanged. Dental findings showed slight elongation of the maxillary and mandibular molars, and the angles of the tooth axis inclinations of the maxillary front teeth had lessened (Figures and , ). After 2 years of using the retainer, when the BC assessment was performed again and periodontal disease was reexamined (Figures and –), there was no major change from that at the end of active treatment (Figures , , and and ). Therefore, the patient underwent coronally advanced flap repositioning surgery with a connective tissue graft for root coverage of the bilateral maxillary lateral incisors. Seventeen months after surgery, the patient had improved oral hygiene, had acquired esthetically good periodontal tissue, had stable functional occlusion, and was satisfied with the outcome (). |
A 55-year-old woman was admitted to our center with recurrent episodes of disabling episodes of palpitation and dizziness for 6 months. The clinical tachycardia presented with abrupt onset and offset and could be terminated by 5 mg of verapamil. She had undergone a left modified radical mastectomy for breast cancer 21 years prior. The patient had been diagnosed with hypertension and diabetes mellitus at that time. A chest radiograph revealed no evidence of cardiomegaly. Echocardiography revealed no evidence of structural heart disease with a normal left ventricular function. The 12-lead electrocardiogram (ECG) at the time of admission demonstrated regular sinus rhythm with a narrow QRS complex and a normal axis (, left panel). An ECG recorded during an episode of palpitations revealed a narrow QRS complex tachycardia with a cycle length of 480 ms. The P wave polarity preceding the QRS complex was negative in leads V4-6, biphasic (initially negative and a late positive component) in leads V1 and V3, and undetermined in the limb leads (, right panel).\nAfter giving informed consent, an electrophysiological study was performed without sedation. Three catheters were introduced to the right atrium, the right ventricular apex, and at the His-bundle region via the femoral veins. Also, a 7-Fr multipolar catheter was advanced within the coronary sinus via the left subclavian vein. During initial ventricular pacing, the ventriculoatrial conduction was absent. A tachycardia was induced and terminated reproducibly with incremental atrial pacing and extrastimulation. During the tachycardia, the local electrogram recorded at the His bundle preceded the onset of the surface P wave by 40 ms and the proximal coronary sinus by 15 ms ().\nTen radiofrequency applications were delivered near the His-bundle region where the atrial activation during the tachycardia recorded from the distal electrodes of the ablation catheter, preceded the onset of the surface P wave by 45 ms. The tachycardia was terminated and junctional beats occurred frequently and AV block was observed transiently during applications of radiofrequency energy. However, the tachycardia was induced and sustained after radiofrequency energy deliveries at these sites. Mapping in the left atrium was performed to find the earliest atrial activation site with retrograde transaortic approach. The earliest left atrial activation was located in the anteroseptal region. The earliest left atrial activation was later than that in the right atrium by 5 ms. No His potential was found at this site ().\nTo find the other earliest atrial activation site, attempts were made to map from the aortic sinus of Valsalva. Mapping was performed using a 7 Fr quadripolar catheter with a 4-mm distal electrode (Blazer II, Boston Scientific, Natick, MA, USA). With detailed mapping at the aortic sinus of Valsalva using a retrograde transaortic approach, the earliest atrial activation was found within the non-coronary sinus of Valsalva where the local electrogram during the tachycardia recorded from the distal electrodes of the ablation catheter preceded the onset of the surface P wave by 55 ms (). After confirming the location of the ostia of both coronary arteries and identifying the contour of the aortic sinus of Valsalva by an injection of a contrast agent, (), an radiofrequency energy application delivered at that site using a maximum power of 30 W and maximum electrode to tissue interface temperature of 50℃ terminated the tachycardia 5.8 seconds after initiating the application (). No Junctional beats occurred. No tachycardias were inducible after the catheter ablation. With incremental atrial pacing, the paced cycle length producing AVN Wenckebach block was 280 ms, which was the same as before the ablation procedure. A cardiac MRI was performed to determine the anatomic relationship with the other structures (). The patient was discharged with no need for medications, and she has done well with no recurrence of the tachycardia during a 10-month follow-up. |
A 34-year-old male patient was admitted to the hospital, with the complaint of dizziness for more than 1 month. The patient had no obvious neurological deficits except for dizziness. The physical examination indicated that the patient was conscious, who could give right answers to the questions. Moreover, there was a bulge on the left frontal-temporal parietal bone, with a slightly hard texture and no obvious tenderness (). The muscle strength and muscle tension of the patient’s limbs were normal. There were no obvious abnormalities in the cranial nerve examination. For the past history, before about 1 month, the patient was treated for gastric ulcer in a local hospital and had been given the clotting factor VIII. The patient has a family history of hemophilia. The head CT showed abnormal density lesions on the left frontal-temporal parietal bone, with multiple irregular calcifications within the border, as well as clear boundaries (). The skull MRI showed a large clump-like mixed signal at the top of the left frontal ridge, with a slightly higher signal on T1WI and a mixed signal on T2WI, and enhance was observed on contrast-enhanced images (). After admission, the patient was subjected to complete preoperative preparation and surgical treatment. Neurological navigation was used to determine the extent of skull defect before surgery to make a surgical incision (). The lesion was observed with complete capsule, containing brown blood clot-like tissue (). The lesion was completely removed (). After resection, the pathologic examination displayed obvious blood clots and fibrosis hematoma, accompanied by inflammatory cell infiltration and calcification (). On day 3 after surgery, the right upper limb muscle strength was decreased and CT exanimation showed that the patient had an epidural hematoma, which was conservatively treated (). Clotting factor VIII substitution therapy was used for the intraoperative and postoperative treatments. Specifically, at 1 day before and during the operation, coagulation factor 2000U and plasma were supplemented to maintain the level of coagulation factor VIII above 80%. Thereafter, 600–800U coagulation factor was supplemented daily for 2 weeks. The patient was discharged on day 14 after surgery. At discharge, the patient was conscious, with the I/A healing of the surgical incision. The right upper limb muscle strength returned to level 3, and the residual limb muscle strength was level 5. After 6 months, the muscle strength of patient’s limbs was normal. Then, the patient received cranioplasty (). |
A 63-year-old Japanese man presented with sudden onset chest pain radiating to his back and weakness in both lower limbs. Past medical history included mild coronary artery disease that did not require intervention, atrial fibrillation, secondary polycythemia associated with smoking, psoriasis and degenerative spondyloarthirits, and no history of other connective tissue disorders. There was no previous history of cerebrovascular or peripheral vascular disease. He was transferred to our institution over 12 hours from initial presentation, and was assessed by our multidisciplinary team (cardiothoracic surgeon, vascular surgeon and an interventional radiologist). On examination his blood pressure was 225/136 mmHg and there was clear ischemia of both lower limbs with bilateral absent femoral pulses. The sensory and motor function in the lower extremities was significantly reduced and abdominal examination was unremarkable.\nComputed Tomographic Angiography (CTA) revealed a complex type-A aortic dissection with the primary entry in the aortic arch leading to a dissection flap arising within the inferior aspect of the aortic arch and distal aorta extending to involve the entire thoracic aorta. The true lumen was small and severely narrowed beyond the level of the right renal artery, disappearing entirely just above the aortic bifurcation (Figure and Figure ). No contrast could be visualized in the native iliac arteries and there was reduced blood flow in the celiac axis and the primary branches of the superior mesenteric artery which were perfused only by a very small channel of contrast seen extending from the true lumen. The transverse colon appeared thick-walled but both liver and spleen were normal. His left kidney was well perfused from the false lumen but there was no enhancement of the right kidney, which received its arterial supply from the true lumen. There was no involvement of the head and neck vessels or coronary arteries and there was no pleural or pericardial effusion.\nArterial bloods gas analysis revealed a mild acidosis (pH 7.34 with a base excess of -5.7) and an elevated lactate level of 11.9 mmol/lt. Blood pressure control was administered by beta-blockade and gylceryl-trinitrate infusion. Following stabilization, surgical management took place in 4 stages:\n1) Endovascular insertion of 2 stents: Through a right axillary and bilateral common femoral approaches, a 150 mm covered stent graft (Medtronic, Santa Rosa, USA) was deployed into the thoracic aorta, distal to the left subclavian artery. A further covered stent (14 × 14 × 60 mm) (Medtronic, Santa Rosa, USA) was deployed in the infra-renal aorta, improving right but not left femoral circulation. The right axillary wound was temporarily closed with a conduit for cannulation use in the subsequent repair of the aorta. This was directly followed by femoro-femoral bypass grafting.\n2) Femoro-femoral bypass grafting: An 8 mm Dacron graft was used for right to left femoro-femoral bypass restoring left lower limb perfusion. This resulted in a full complement of palpable pulses in both lower limbs.\n3) Stabilization in the Intensive Care Unit (ICU): The patient was observed closely particularly with regards to any indicators of persisting mesenteric ischemia. The biomarker lactate played a key role in our management and was measured by taking regular peripheral arterial samples. Having previously been >10 mmol/lt, overnight the lactate fell to 7.2 mmol/lt, then 3.1 mmol/lt and by the next morning (during 8 hours period) returned to normal levels. The normalization of the lactate levels indicated the stabilisation of the patient's condition with resolution of the visceral and peripheral ischemia. Based on biomarker levels and clinical status, a decision was subsequently made to proceed to surgical repair of the dissection.\n4) Surgical repair of the aortic dissection: Following median sternotomy and cannulation via the previous right-axillary artery conduit, cardiopulmonary bypass was instituted and the patient was cooled to 22°C. Antegrade cardioplegia and cerebral perfusion were applied. Total circulatory arrest time was 20 min and total bypass time was 120 min. The entry point tear was located, the hemi-arch was excised, the false lumen was obliterated with 6- interrupted Teflon felt pledgetted sutures. We specifically passed these pledgetted sutures through the proximal stent in the medial part of the descending thoracic aorta providing extra strength in these stitches and potentially reducing the risk of stent migration or creation of endoleak in this weak part of the aortic wall. A 28 mm Dacron conduit was then anastomosed (hemi-arch replacement) and the patient was rewarmed to 37°C. The chest was packed and left open for delayed closure, which was performed 48 h later.\nThe outcome of this staged approach was very successful (Figure and Figure ) and our patient recovered well. His progress was complicated by a hospital-acquired pneumonia requiring prolonged intubation and formation of a tracheostomy. The total ITU stay was 33 days. He was gradually rehabilitated, and was discharged 40 days after admission. |
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. |
Due to persistent headaches and the qualitative alteration of consciousness in a woman aged 58 years, on 11 July 2011, a head NMRI was performed, and it showed an expansive lesion in the left frontal portion of the brain, measuring 60 × 50 × 40 mm (Fig. ). The tumor was accompanied by a large edema (Fig. ). As the first step, dexamethasone was included with a dose of 8 mg/day. The surgical procedure was performed on 25 August 2011, and a maximum tumor resection was performed on that occasion.\nIn the period between 08 November and 23 December 2011, the patient underwent radiation with 46 Gy, followed by radiation of the tumor base with 14 Gy in 14 fractions. During radiation, the patient had been receiving TMZ in a dose of 120 mg daily for 42 days. Afterwards, 6 cycles of TMZ (240 mg during each cycle) were administered.\nThe patient started to use standard phytotherapy together with combined RT/CT, and then together with monotherapy with TMZ, and continued to use it after the completion of the oncological treatment. She had been taking PT at full capacity and without interruption for 24 months. Five months after the completion of PT, the patient began to complain of an intense headache; so in April 2014, a control NMRI was performed, and a recurrence of the underlying disease in the frontal portion of the head on both sides, in the shape of a butterfly, was found on that occasion. On the right side, prominent was a larger area of 56 × 47 × 43 mm in diameter that occupied the front third of the corpus callosum (Fig. ).\nAfter these findings, the patient was reintroduced to oncological treatment, which consisted of the combined RT/CT followed by planned 6 cycles of monotherapy with TZM in a daily dose of 260 mg for 5 days during a cycle of 28 days. After the third cycle of the treatment with TZM, a control MRI was performed on 04 November 2014, which showed that the dimension of the larger area, located in the right frontal lobe, which occupied the area of the corpus callosum, was 73 × 49 mm (Fig. ). Due to the progression of the tumor, the treatment with TMZ was not continued. With this, the oncological treatment was completed, and medical treatment continued with the regular intake of antiepileptic drugs and, when necessary, antiedema therapy with synthetic corticosteroids.\nThe patient continued to use standard phytotherapy immediately after the recurrence had been diagnosed. After control imaging performed on 04 November 2014 that showed there had been a progression of the tumor, a PTS combination of herbal medicines was introduced instead of StPT.\nControl MRI imaging from 26 March 2015 showed that further progression of the tumor had stopped. We should mention that the blocking of tumor growth occurred at the time when PT was the only way of treatment (Fig. ). In the course of the next 4 months, the patient was relatively stable, and the occasional crises were repressed by introducing, or increasing, the dose of corticosteroids (at first 8, and 16 mg/day of dexamethasone afterwards). However, in early August 2015, there was a sudden deterioration, the patient fell into a coma and died in mid-August 2015. |
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. ). |
Sixty-three-year-old female patient was admitted to the Department of Endocrinology of Muğla Sıtkı Koçman University Research Hospital with the complaints of hoarseness and discharge from the anterior neck wall which were present for the last 6 months. The patient underwent a near total thyroidectomy 17 years ago but no surgery or pathology records were available. The neck ultrasound showed recurrent nodular goiter and a diagnostic FNAB guided by palpation was performed six months before. Two weeks later the patient had wound discharge and hoarseness which was not improved by a course of antibiotic therapy and was referred to our hospital. Physical examination of the patient revealed a sinus opening with seropurulent discharge located superior to the thyroidectomy incision and the tissue surrounding the sinus opening was moderately swollen and was hyperemic (). A 1 cm nodule was palpated in the left side of her neck. No cervical lymph adenopathy or any other systemic finding was found. White blood cell count, neutrophil, eosinophil, C reactive protein, sedimentation rate, liver and thyroid function tests, and antithyroid antibodies were all in normal range. Culture of the discharge did not grow any bacteria. A cervical USG showed a 9 × 7 mm nodule with mixed echogenicities in the left remnant thyroid tissue and a 9.5 × 3.5 mm fistulized fluid collection ().\nCervical MRI revealed a 10 × 6 mm subcutaneous tract that was opening to the skin and a minimal fluid intensity that was consistent with postoperative granulation tissue. The patient underwent surgery and the exploration revealed that the sinus tract was ending near the berry ligament close to the left thyroid cartilage and left recurrent laryngeal nerve with silk suture remains. The left recurrent laryngeal nerve was intact; however, it was thickened comparing to the right. The sinus tract and the remnant thyroid tissue were removed with laryngeal nerve monitoring. The pathology report showed that the sinus was associated with chronic inflammation, granulation tissues and adenomatous hyperplasia was present in the remnant thyroid. |
A 61-year-old man underwent resection of a part of his tongue due to tongue cancer and was admitted to our hospital for hepatocellular carcinoma with about 5 cm diameter of tumor at the liver segment IV. Computed tomography (CT) showed that the tumor was enhanced during the arterial phase and washed out during the portal phase, and the tumor pressed the right anterior branch to the main branch of Glisson and the middle hepatic vein; hence, the diagnosis of hepatocellular carcinoma was made (Fig. ). The indocyanine green retention rate at 15 min was 21.8%. Child-Pugh score was A. The patient tested negative for hepatitis B surface antigen and hepatitis C virus antibody. He had a history of excessive consumption of alcohol, and alcoholic liver damage was considered as a possibility. Partial hepatectomy with segments IV + V and cholecystectomy with cystic duct-tube drainage were performed. Intraoperative findings indicated that the anterior branch of bile duct was exposed at the resected area, and some small bile ducts were ligated. On POD 1 following hepatectomy, bile leakage developed from the drain placed in the foramen of Winslow. CT showed fluid collection in the cavity between the liver and fistula to drain. Cholangiography via the endoscopic bile duct enhancement showed no communication between the common bile duct and abdominal cavity. Drip infusion cholangiography (DIC)-CT revealed the bile duct of the peripheral side. We maintained simple drainage to reduce the cavity. On POD 19, this patient had fever and CT revealed that the fluid collection has increased (Fig. ). Percutaneous drainage to the cavity near the liver cut surface was performed. Cholangiography via the c-tube did not show the anterior branch of the bile duct. Fistulogram from the drainage tube at the abdominal cavity showed the bile duct at segments V and VIII (Fig. ). We diagnosed the bile leakage from the isolated bile duct of segments V and VIII. Further management was needed to control the persistent biliary leak of 200–250 mL/day. Liver function was evaluated again. The indocyanine green retention rate at 15 min was 27.7%. LHL15 was 0.575. Liver volume of segments V and VIII was 260 mL, and remnant liver volume was 1272 mL, which were calculated using the 3D image analysis system (SYNAPSE VINCENT; Fuji Photo Film Co., Ltd.). Functional remnant liver volume (FRLV) was calculated based on the liver volume using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced MRI for 20 min []. FRLV after liver resection of segments V and VIII was 2176 mL. Even if the function becomes extinct by PTPE to segment V and VIII, remnant liver volume was sufficient. We considered that bile leakage could not be cured with either PTPE or bile duct ablation alone, because of the large volume of bile leakage more than 200 mL per day. The therapeutic strategy involved combination therapy of PTPE and bile duct ablation. First, percutaneous transhepatic cholangiography drainage (PTCD) tube was inserted to the bile duct of segment V. PTPE with coil embolization was performed to the part of the portal vein of segments V and VIII by puncturing the part of the portal vein of segment V. The liver volume of segments V and VIII was decreased from 260 to 123 mL after PTPE. After the PTPE, bile leakage decreased to about 50 mL/day. We confirmed that cholangiography via the PTCD tube showed the bile duct at segments V and VIII. For bile duct ablation, 1.2 mL pure ethanol was injected from the PTCD tube. Over 1.2 mL of ethanol leaked into the abdominal cavity. After ethanol injection, the PTCD tubes were clamped for 5 min. Then, another bile duct ablation with 2.0 mL of pure ethanol was performed 1 week after of the first procedure. After bile duct ablation, bile leakage has decreased from 50 to 10 mL/day gradually. The patient left the hospital, and he was rehospitalized and reinjected with 2.0 mL of pure ethanol for three times. The drainage tube and bile duct tube were removed on POD 139 (Fig. ). The clinical course is summarized in figure. Complications with combination treatment of PTPE and bile duct ablation were not noted. |
A 74-year-old lady with a history of hypertension and known case of breast cancer presented to our clinic with a swelling of the left proximal arm for the past three years. Patient was of Punjabi by ethnicity and was a Pakistani national.\nShe had under gone a modified radical mastectomy (MRM) 16 years ago in 1990 for infiltrating ductal carcinoma of the left breast, received 25 fractions of radiotherapy, followed by Tamoxifen for five years. The patient had a history of gradual increase in the size of the swelling upper arm and complained of non-radiating, mild to moderate pain with appearance of nodular lesions along antero medial aspect of upper arm (); that had ulcerated in the proceeding 8 weeks. There was no history of fever, numbness and paresthesias in the left upper limb. On examination the patient was afebrile; with lymphedema of entire left arm. A 12 × 6 cm area of multiple ulcerated lesions with surrounding erythema and induration and absence of deep infiltration was noted. Motor power and range of motion was normal both at the elbow and shoulder joint. Biopsy from the mass confirmed the diagnosis of lymphangiosarcoma ( and ). A lymphovascular invasive pattern was seen and immunohistochemistry was positive for endothelial cell markers () (CD 31-CD36). There was no evidence of distant metastasis on metastatic workup. CXR showed bilateral pleural thickening more marked on the left side. CT scan of chest revealed thickening of the skin overlying the mass and non specific ground glass appearance in the upper lung fields bilaterally. No active pulmonary lesion was seen. Ultrasound liver and gallbladder was also normal. MRI showed a soft tissue mass occupying the medial side of the left upper arm with evidence of extension through the sub-coetaneous tissue and up to the muscle layer with enhancement (), with absence of osseous disease on bone scan. Disarticulation of the left shoulder joint was performed successfully. The patient developed metastases in the brain and lungs 5 months after the procedure and expired a month later. |
A 70 year-old female patient visited the hospital through the emergency room for acute subdural hematoma. The patient had undergone left TKR under spinal anesthesia for degenerative arthritis in another orthopedic hospital, but symptoms such as headache, vomiting, and decreased consciousness appeared on the fourth day postoperatively. Computed tomography (CT) revealed acute subdural hematoma, and therefore, the patient was transported to our hospital for an emergency operation. According to her past history, she had been on medication for hypertension that included 100 mg of aspirin from one year before the initial visit and did not show any head trauma or particular clinical or family history. The administration of aspirin stopped seven days before the operation. The complete blood cell count (CBC) and coagulation tests done preoperatively for the left TKR were normal. According to the anesthesiologist from the previous hospital, the spinal anesthesia was done between L4 and L5 in the left lateral decubitus position using a 24-G Quincke needle using the median approach, and the first trial was successful. After verifying the cerebrospinal fluid (CSF) leakage, 12 mg of 0.5% hyperbaric bupivacaine was injected. There was no pain or abnormal findings during the injection of the drug. Following the spinal anesthesia, the sensory block to the T8 dermatome was verified and then the operation was done. The left TKR took two hours, and the intraoperative vital signs were relatively stable. The estimated blood loss was about 300 ml, and two units of packed red blood cell were transfused in the operation room and ward. There were no abnormal findings and the vital signs were stable during the patient's bed rest for the first three days postoperatively. On the fourth day postoperatively, the patient suddenly complained of non-positional headache and vomiting, followed by decreased consciousness. Thus, she had a brain CT, which revealed acute subdural hemorrhage. Then, she was transported to our hospital for an emergency operation. When the patient arrived at our hospital, she was drowsy (or drowsy mentality). A second brain CT revealed a cerebral edema and left deviation from an acute subdural hemorrhage at the right fronto-temporo-parietal lobe. Therefore, an emergency craniectomy and hematoma removal was done (). The operative findings showed a new hemorrhage under the hematoma surrounded by a capsule, that is, an acute-on-chronic subdural hematoma due to the rebleeding. After removing the hematoma, cortical arterial bleeding was found in two regions and hemostasis was done. The patient recovered without any postoperative, neurological sequelae, and she was transferred to another hospital for rehabilitative therapy of the left knee. |
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 61-year-old man underwent resection of a part of his tongue due to tongue cancer and was admitted to our hospital for hepatocellular carcinoma with about 5 cm diameter of tumor at the liver segment IV. Computed tomography (CT) showed that the tumor was enhanced during the arterial phase and washed out during the portal phase, and the tumor pressed the right anterior branch to the main branch of Glisson and the middle hepatic vein; hence, the diagnosis of hepatocellular carcinoma was made (Fig. ). The indocyanine green retention rate at 15 min was 21.8%. Child-Pugh score was A. The patient tested negative for hepatitis B surface antigen and hepatitis C virus antibody. He had a history of excessive consumption of alcohol, and alcoholic liver damage was considered as a possibility. Partial hepatectomy with segments IV + V and cholecystectomy with cystic duct-tube drainage were performed. Intraoperative findings indicated that the anterior branch of bile duct was exposed at the resected area, and some small bile ducts were ligated. On POD 1 following hepatectomy, bile leakage developed from the drain placed in the foramen of Winslow. CT showed fluid collection in the cavity between the liver and fistula to drain. Cholangiography via the endoscopic bile duct enhancement showed no communication between the common bile duct and abdominal cavity. Drip infusion cholangiography (DIC)-CT revealed the bile duct of the peripheral side. We maintained simple drainage to reduce the cavity. On POD 19, this patient had fever and CT revealed that the fluid collection has increased (Fig. ). Percutaneous drainage to the cavity near the liver cut surface was performed. Cholangiography via the c-tube did not show the anterior branch of the bile duct. Fistulogram from the drainage tube at the abdominal cavity showed the bile duct at segments V and VIII (Fig. ). We diagnosed the bile leakage from the isolated bile duct of segments V and VIII. Further management was needed to control the persistent biliary leak of 200–250 mL/day. Liver function was evaluated again. The indocyanine green retention rate at 15 min was 27.7%. LHL15 was 0.575. Liver volume of segments V and VIII was 260 mL, and remnant liver volume was 1272 mL, which were calculated using the 3D image analysis system (SYNAPSE VINCENT; Fuji Photo Film Co., Ltd.). Functional remnant liver volume (FRLV) was calculated based on the liver volume using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced MRI for 20 min []. FRLV after liver resection of segments V and VIII was 2176 mL. Even if the function becomes extinct by PTPE to segment V and VIII, remnant liver volume was sufficient. We considered that bile leakage could not be cured with either PTPE or bile duct ablation alone, because of the large volume of bile leakage more than 200 mL per day. The therapeutic strategy involved combination therapy of PTPE and bile duct ablation. First, percutaneous transhepatic cholangiography drainage (PTCD) tube was inserted to the bile duct of segment V. PTPE with coil embolization was performed to the part of the portal vein of segments V and VIII by puncturing the part of the portal vein of segment V. The liver volume of segments V and VIII was decreased from 260 to 123 mL after PTPE. After the PTPE, bile leakage decreased to about 50 mL/day. We confirmed that cholangiography via the PTCD tube showed the bile duct at segments V and VIII. For bile duct ablation, 1.2 mL pure ethanol was injected from the PTCD tube. Over 1.2 mL of ethanol leaked into the abdominal cavity. After ethanol injection, the PTCD tubes were clamped for 5 min. Then, another bile duct ablation with 2.0 mL of pure ethanol was performed 1 week after of the first procedure. After bile duct ablation, bile leakage has decreased from 50 to 10 mL/day gradually. The patient left the hospital, and he was rehospitalized and reinjected with 2.0 mL of pure ethanol for three times. The drainage tube and bile duct tube were removed on POD 139 (Fig. ). The clinical course is summarized in figure. Complications with combination treatment of PTPE and bile duct ablation were not noted. |
An 18 year-old male patient presented with the chief complaint of pain and discolored upper front tooth. He had incurred trauma to the teeth due to a fall from a two-wheeler motor vehicle more than 10-years ago and underwent endodontic treatment followed by crown immediately after the trauma for the maxillary right central incisor. Patient was symptomless for sometime but in due course developed periodic swelling and now since 6 months had noticed intermittent pus discharge. On consulting another dentist, endodontic treatment for the right lateral incisor was started but as the pain was progressively increasing, so the patient was referred by the dentist to the college. The patient's medical history was noncontributory and vital signs were within normal limit.\nIntraoral examination revealed the presence of porcelain fused to metal crown in right maxillary central incisor associated with a sinus tract in the periapical region. Tracing of the sinus tract with gutta percha confirmed the involvement of the central incisor. The tooth was tender on percussion and palpation. The periodontal status was normal (probing depth <3 mm) with no mobility ruling out any periodontal pathology. The lateral incisor showed incompletely done root canal treatment. Radiographic examination of the central incisor revealed poorly obturated root canal with incomplete root formation. The root end had thin dentinal walls with apical flaring and periapical rarefaction of 2-3 mm []. The lateral incisor had intact periodontal ligament space and showed complete root formation. Electric and cold tooth vitality testing were performed for all the maxillary anterior teeth except the maxillary right central incisor. The right lateral incisors gave a negative response and all the other teeth gave a positive response. According to the clinical and radiographic findings, there were two treatment options available for the central incisor, either a surgical removal of the periapical lesion followed by retrograde filling or a nonsurgical endodontic retreatment with apexification. Taking into consideration the current guidelines, a more conservative nonsurgical approach was chosen as the line of treatment.\nThe tooth was anesthetized by 2% lidocaine with 1:100000 adrenaline followed by the removal of the crown. The reasons for the removal of crown were poor aesthetics and marginal gap between the crown margin and the finishing line. After isolation with rubber dam, access was gained in the central incisor with Endo Access Bur (Dentsply Maillefer, Ballaigue, Switzerland) with water spray. There was frank purulent discharge from the tooth once the pulp chamber was reached. Gutta percha removal was carried out with H-files []. Working length was estimated by an apex locator (Root ZX mini- J Morita MFG. Corp. Kyoto, Japan), but due to inconsistent reading, an additional intraoral periapical radiograph (IOPAR) was also taken for confirmation. Access cavity modification and working length determination were also carried out for the lateral incisor. Minimal instrumentation of the central incisor with manual K-files # 140 (Beutelrock, Munchen, Germany) was carried out with a light parietal action to avoid further weakening of the already thin dentinal walls along with passive irrigation with 10 ml of 3% sodium hypochlorite and 2% chlorhexidine solution (Sigma Chemicals, St. Louis, MO, USA) alternatively with sterile saline. Irrigation was carried out with side-vented irrigation needles (R C Twents irrigation needle, Prime Dental Products Pvt. Ltd, Mulund Mumbai) keeping them 1 mm short of the radiographic apex and no attempt was made on shaping the canal. Furthermore, irrigants were activated with Endoactivator (Dentsply, Maillefer, Ballaigues, Switzerland) tip size 5× (large 35/04) at a speed of 10.000 cpm with 2-3 mm vertical pumping action keeping the tip 2 mm short of apex without damaging the apical tissue, for the removal of pulpal remnants, debris, and remnant bacteria. The aim was introduction of the irrigant deeper into the dentinal tubules, lateral canals, and inaccessible areas. The canal was dried with a large size paper point and an intracanal dressing of triple antibiotic paste containing minocycline, ciprofloxacine, and metronidazole (100 μg each ml−1) with propylene glycol as vehicle was packed 1 mm short of the radiographic apex. The access cavity was temporarily sealed with resin-modified glass ionomer cement (Fuji II LC, GC, Bonneuil sur Marne, France) and the patient was recalled after 2 weeks. The shaping and cleaning of the lateral incisor was completed with rotary NiTi files (Protaper, Dentsply, Maillefer, Ballaigues, Switzerland) up to size F-2 and RC prep (Premier Dental Products, Norrstown, PA, USA) as a lubricant. A total of 2% chlorhexidine gel was placed as an intracanal medicament in the lateral incisor.\nAfter 2 weeks, when the patient was asymptomatic. The tooth was again anesthetized and isolated followed by removal of intracanal dressing with copious irrigation and ultrasonic files. The canal was flushed with 10 ml of 3% hypochlorite followed by 10 ml of sterile saline and dried with absorbent paper points. Biodentine™ (Septodont, St. Maurdes Fossés, France) was manipulated according to manufacturer's recommendation and placed in the apical one-third of the root canal with the help of Micro Apical Placement system (Dentsply, Maillefer, Ballaigues, Switzerland). It was condensed into the canal with plugger to create an apical plug of 5 mm and was left undisturbed for 15 min. The lateral incisor was obturated using lateral condensation technique with AH Plus sealer (Dentsply DeTrey, Konstanz, Germany) and restored. The hardness of the apical plug was checked with an endodontic plugger and the remaining portion of the canal was sealed using thermoplastic gutta percha (DiaGun, DiaDent Group international, Chungcheongbuk-do, Korea) [] and restored. Follow up clinical examination after 3 weeks showed complete healing of the sinus tract and absence of any clinical symptoms. The patient was recalled for checkup after 1 year, and IOPAR [] and CBCT [Figure -] was advised. Both showed progressive involution of periapical radiolucency and healing with a calcific barrier at the apex. |
In the orbital examination, a 67-year-old male patient coming to the ophthalmologist with complaints of blurry vision showed subretinal fluid and choroidal folding, and these findings were considered as metastatic lesions. The chest X-ray ordered due to the patient's complaints of persistent cough for a couple of months showed a right hilar mass. On thorax computed tomography (CT), multiple nodular lesions in bilateral lungs and left pleural effusion was detected (fig ), and a transbronchial bronchoscopic biopsy of the lower posterior lobe of the left lung was determined as primary lung adenocarcinoma. Positron emission tomography (PET)-CT showed a primary involvement in the medial segment of the left lung and widespread hypermetabolic nodules in bilateral lungs, metastatic mediastinal lymphadenopathies and widespread skeletal metastases, the majority in the vertebral column, pelvic bones and in the proximal part of the bilateral femurs. No mass lesions were seen in brain magnetic resonance imaging (MRI). On repeat fundus examination, yellow-white choroidal swelling with irregular borders in the right eye (fig ), yellow choroidal lesions and serous retinal detachment in left eye (fig ) was observed. In optical coherence tomography (OCT) images, retinal swelling and choroidal irregularities were noticed (fig ). Orbital MRI showed plaques of a maximum thickness of 2 mm with pathologic contrast enhancement in posterolateral regions of the bilateral globes. No pathologic findings were seen in bilateral optic nerve tracts and neural parenchyma. Laser ablation was administered to large lesions. Due to widespread bone pain, palliative RT was given before systemic therapy and zoledronic acid treatment was started. A first palliation of 30 Gy was given to lumbar 4 vertebrae, pelvic bones and the proximal half of the right femur in 12 fractions. The second palliation site was thoracic 5–12th vertebrae treated with 30 Gy in 10 fractions. External RT to orbitae was started next, with the radiation field excluding the neural parenchyma (fig ). After the third fraction of orbital RT, the patient demonstrated involuntary muscle movements, nonsensical speech and impaired balance. Even though not proven radiologically, these findings were evaluated as likely cranial metastases clinically, and the RT plan was revised to cover the cranium and bilateral orbitae to the palliative dose of 30 Gy with 3D conformal RT. During the follow-up period, the performance status of the patient advanced to ECOG performance status 3, and approximately 4 months after the diagnosis, the patient died because of disease progression. |
A 65-year-old Hispanic woman presented to the emergency department with a 1-week history of intermittent fever. She was seen by an emergency room doctor at that time and was sent home after being diagnosed with pneumonia after a chest radiograph was performed showing a questionable left lung base infiltrate and discharged with levofloxacin and ibuprofen. The patient returned to the emergency department 3 days later because of worsening symptoms described as weakness and inability to walk coupled with fever of 101 degrees Fahrenheit. As per the family, the patient was unusually confused, had difficulty with comprehension, and articulating her needs. In addition to these symptoms, the patient denied any other constitutional symptoms, sick contact, recent travel, or interaction with pets or animals. A thorough physical examination revealed crackles in the right middle and lower lungs; therefore, another chest radiograph was performed showing increased patchy density at the left lung base as compared with prior exam. She was started on 1 gram of ceftriaxone daily and 500 mg of azithromycin daily for treatment of the pneumonia at this time. A series of neurological examinations initially revealed a mildly confused elderly woman who was, nonetheless, oriented to person, time, and place. The patient stated she felt weak but was able to move her legs. She could move her arms but could not raise them more than approximately 10 inches. Consequently, the neurologist ordered the first CT scan which had unremarkable findings. On day 2 of admission, the patient was awake, alert, but oriented only to person. She denied headache but had a rigid neck with her speech becoming increasingly incomprehensible although she was able to follow few simple commands. Neurological exam was significant for asymmetric facial droop and left arm dropping fast than right and drop arm test. Stroke notification was called, and another noncontrast CT of the head was performed which was unremarkable.\nLater on the second day of admission, she became unresponsive and required intubation and was transferred to the Medical Intensive Care Unit (MICU). She only responded to painful stimuli by moving all extremities. For the next two days, the neurological examination showed a rapidly progressing ascending paralysis with decreased deep tendon reflexes of the upper and lower extremities. During her stay in the MICU, subsequent chest radiographs and respiratory, blood, and urine cultures were acquired, and a lumbar puncture was performed. She was started on treatment for suspected bacterial and viral meningitis with azithromycin, ampicillin, ceftriaxone, and vancomycin while awaiting test results. Acyclovir was also administered due to suspicion of a herpes simplex encephalitis. Dexamethasone and IViG were administered for suspicion of acute disseminated encephalomyelitis. Respiratory cultures were recovered from an endotracheal aspirate revealing light yeast formation. CSF obtained from lumbar puncture was positive for elevated proteins and normal white blood cell count. Considering the unique CSF findings, Guillain–Barré Syndrome (GBS) was considered, and its etiology was invested. Nerve conduction studies and an electromyography (EMG) were performed revealing acute sensorimotor axonal and demyelinating peripheral neuropathy consistent with GBS. Serology tests were subsequently ordered and West Nile virus IgM was reported positive. CSF serology was tested for Lyme and herpes simplex virus which were negative. Urine was also tested for Legionella sp. which resulted negative. Findings were reported to the Department of Health (DOH), and the case was discussed with hospital medical team and family members.\nGiven the patient's presentations and the serological tests, it was determined that GBS secondary to WNV infection was most likely the diagnosis. Treatment for meningitis was discontinued, and intravenous immunoglobulin was continued for 10 days and plasmapheresis would be considered thereafter. After 4 days of 30 mg IViG, she showed substantial improvement moving her toes and closing her fist. At 10 days, she was able to relay requests with improved concentration and without facial droop, and also muscle strength improved on a daily basis. After completion of 10 days of IViG, no further plasmapheresis was initiated considering her continued improvement and supportive care was recommended. The hospital course was complicated by hyponatremia and serum hypo-osmolality considered secondary to Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). She was treated with fluid restriction and followed closely by the nephrology specialist adjusting her fluid intake daily. She remained in the hospital until hyponatremia was corrected and maintained. The total hospital course was 20 days, and she was thereafter transferred to a rehab facility where she continued to improve. As of the time this paper is being written, the patient has regained full functionality of her upper extremities and is no longer requiring ventilator support. Nonetheless, lower extremity weakness has remained unchanged, unfortunately. |
A 61-year-old female patient without any medical history presented at our clinic with a palpable mass associated with pain in the right breast. She discovered a small mass in her right breast just after completing the breast feeding period, which increased in size gradually for 25 years. There was no nipple discharge, fever, history of breast trauma, hormone replacement therapy or family history of breast or ovarian cancer. She did have close contact with sheep and dogs.\nUpon physical examination, a large palpable mass with regular borders was identified within the right breast. The nipple, areola and skin were normal. There was no palpable lymph node in the right axilla. The left breast and axilla were normal, and systemic examination did not show any abnormality.\nHer mammograms showed two (large and small) oval and dense masses within the upper outer quadrant of the right breast (Figs and ). The largest mass was about 4 × 3 cm and multilobulated, and the small mass was about 1 × 1 cm well circumscribed in its contours.\nThere were associated calcifications at the periphery of the large lesion and diffuse linear microcalcifications at other areas of the breast. The left breast was within normal limits. The ultrasound revealed a large heterogeneous and lobulated mass that contained mixed hypo- and hyper-echoic degenerative contents with a small internal anechoic cyst at the periphery of the lesion in the upper outer quadrant of the right breast. There were no associated enlarged axillary lymph nodes.\nInvestigation revealed that the complete blood count, chemistry and liver function test were within normal limits with the exception of the echinococcal hemagglutination test, which was positive. The chest x-ray and abdominopelvic ultrasound were normal.\nWe suspected a hydatid cyst because the patient came to our clinic from an epidemic area. We decided on mass excision. The risks and benefits of the procedure were clearly explained to the patient, and consent was obtained. The total mass excision was performed without any spillage, and the procedure was uneventful. When the cyst was opened, endocysts were found, thus confirming it as a hydatid cyst, so the frozen examination not performed. The pathology report revealed eosinophilic membranes with a laminated appearance and massive calcifications, which are characteristic of a hydatid cyst of the breast. |
Case 2 involved a 64-year-old woman with a fibroadenolipoma in the lower inner quadrant of her left breast. The mammography report notes the breast tissue is extremely dense (BI-RADS category D). Fibroadenolipomas (also known as hamartomas) are typically benign masses containing an admixture of ducts, lobules, fibrous stroma and adipose tissues in varying proportions. The contrast between the fibroadenolipoma and the surrounding tissue is uncertain, particularly in a breast noted as heterogeneously dense.\nThe global maximum of the cost function in is located at with a local maximum at . Both images are shown in in blue and red, respectively. The image reconstructed at the local maximum at shows many responses in the lower inner quadrant, which is consistent with the clinical history of the patient reporting a fibroadenolipoma in that quadrant. However, the image is very difficult to interpret with multiple responses of similar magnitude. The image reconstructed at the global maximum at also shows a lot of energy in the lower inner quadrant, but also some smaller responses elsewhere in the breast, including in the upper outer quadrant, although that response is 6 dB lower in amplitude than the main response in the image at . The image reconstructed at is similar to the image at but with lower overall amplitude (3 dB lower). Although the image reconstructed at also contains a response in the lower inner quadrant which may correspond to the fibroadenolipoma, there is also many other responses with similar magnitude in the image.\nExtremely dense breasts such as that of Patient 2 would be expected to have higher dielectric properties. However, the cost function rewards images reconstructed at lower dielectric properties very highly. Although it is difficult to draw any definite conclusions as the dielectric properties of the breast are not certain, it is likely the images rewarded by the cost function are reconstructed below the average dielectric properties of this particular breast and the images contain mostly spurious noise and clutter.\nHowever, across the entire reconstruction permittivity range, no one image is characterised by one single response. As may be expected from a breast noted as extremely dense, all images contain many responses of similar magnitude. The poor image quality of this clinical case study may also be explained by a number of other factors, such as:Uncertain contrast between the fibroadenoma and the glandular and fibrous tissues in the rest of the breast; Difficulty in isolating reflections from the benign lesion from the reflections from the other glandular and fibrous structures in the breast; Acquisition challenges due to high attenuation in the dense breast tissues.\nDue to these factors, it is difficult to predict what a “correct” radar-based image should look like for this clinical case study.\nThe left breast of the 35-year-old Patient 3 was scanned. The mammogram indicated extensive microcalcifications around 3 o’clock in the lateral aspect and the magnetic resonance report showed enhancements from the 2 o’clock to 6 o’clock radian. Additionally, the magnetic resonance report showed a focal mass near the nipple. A region of invasive ductal carcinoma in the upper outer quadrant of the breast was reported after post-mastectomy pathology. The invasive ductal carcinoma was measured as , although due to the location of the diseased tissue near the chest wall, it is uncertain how much of the disease was present within the imaging domain.\nA prominent global maximum is present in the cost function at . This corresponds to an image with a single response located in the centre of the breast about 3 from the nipple. This response has an SMR of dB and is nearly 11 dB larger in magnitude than the next highest response. This prominent response may correspond to the focal mass that was identified in the magnetic resonance image or, similar to Patient 2, this may be an artefact. In particular, due to the comparatively large reconstruction permittivity and the resulting large delay values, environmental noise, signals from longer propagation paths and errors in the artefact removal algorithms may be randomly cohering at this point in the centre of the imaging array. The minor peak at also shows a response in the same location as the global maximum, but with an SMR of 40 dB.\nThe image in the original study, reconstructed at , is shown with the image at the local maximum at in . In the original image, the maximum response is located just above the nipple which could potentially correspond to the focal mass detected in the magnetic resonance image. In the image at the local maximum at , the maximum responses in the image are located towards the chest wall.\nAlthough the breast contained extensive disease in this case study, no image clearly shows a response which could definitively be said to correspond to the invasive ductal carcinoma. The breast was noted as scattered heterogeneous according to the mammogram, meaning the average dielectric properties of the breast would be expected to be low. However, the image reconstructed at is highly rewarded. Although this may correspond to a focal mass noted in the clinical history of the patient, it may also be an artefact due to reconstruction with overestimated dielectric properties. |
An 80-year-old man with early Parkinson's disease suffered a basal ganglia stroke in November 2017. He was admitted under the geriatric team who commenced him on poststroke treatment and rehabilitation. Over a period of three weeks, he began to develop increasing abdominal distension with associated decreased oral intake, wasting, and electrolyte derangements including refractory hypokalaemia. He was consulted on by the Acute Surgical Unit who organised an abdominal X-ray which showed marked bowel distension and proceeded to manage him with rectal tube decompression and aggressive electrolyte replacement. The rectal tube remained in situ for approximately 1 week before being removed, during which time the patient was able to resume a normal oral intake and participate in regular physiotherapy. However, within 1 week of rectal tube removal, he again became distended with associated decreased oral intake and electrolyte derangement. He once again had a rectal tube inserted with subsequent improvement and was consulted on by the renal team to further investigate whether his hypokalaemia was the primary issue or a consequence of his chronic megacolon. They failed to find anything significant, and upon removal of the rectal tube, the patient once again relapsed.\nAt this point, the patient was referred to the colorectal team for ongoing consultation.\nFlexible sigmoidoscopy was performed to exclude any evidence of mechanical obstruction, and a lengthy discussion was had with all involved regarding the appropriateness for surgical resection or caecostomy. Given the patient's malnutrition and poor functional status, this was not deemed to be in the patient's best interests, and a decision was made to trial the patient on subcutaneous neostigmine which has been shown to be of benefit in a number of small case series on acute megacolon. He was commenced on 0.25 mg subcutaneous neostigmine four times a day with twice daily microlax enemas. This produced some effect over the period of a week with improvements in abdominal distension, appetite, and activity. As such, a decision was made to begin reducing the dose as most previous studies have used neostigmine only for a few days before weaning or ceasing. Upon reducing the frequency to three times a day, the patient began to experience some increased bloating but to a much lesser extent than previously, and he was continued on this dose for a further week.\nA decision was made with the patient, his wife, and the treating team to commence discharge planning, but it was decided that it would be unlikely for the patient to be able to continue on subcutaneous neostigmine on discharge. A small summary series looking into the use of pyridostigmine was reviewed, and it was thought this may provide a reasonable alternative for the outpatient setting, and the patient was transferred from neostigmine to pyridostigmine. Unfortunately, over the next 6 days, the patient once again became increasingly distended and unable to eat. He developed increasing abdominal pain and difficulty breathing and a decision was made to terminate the trial with immediate rectal tube decompression and resumption of subcutaneous neostigmine. However, the neostigmine was noted to have less effect than on initial commencement. Surgical options such as caecostomy or colostomy were considered; however, given the patient's frailty, there were significant concerns regarding the patient's ability to tolerate an anaesthetic resulting in other options being sought.\nUp until this point, the only intervention that seemed to have a consistent effect seemed to have been rectal the insertion; however, this was only undertaken when the patient was very distended with difficulty breathing and unable to manage any oral intake, and the idea of prolonged rectal tube decompression was dismissed due to the risk of rectal ulceration and the difficulties with long-term management. This however promoted the idea of a different approach. We have had long-term robust data in urology into the concept of intermittent self-catheterisation for urinary retention, and it was thought that the same concept could potentially be extrapolated to intermittent rectal tube decompression for management of megacolon. The patient himself was unable to self-insert a rectal tube, but up until this point, the patient's wife had been administering twice daily microlax enemas. As such, we broached the idea with the patient and his wife whether she would be willing to learn rectal tube insertion for decompression. Having been in hospital for more than 5 months at this point, they were willing to consider any options that may give them an opportunity for discharge into the community with some degree of symptom control and they readily agreed.\nOver the next 3 days, we did daily rectal tube education with the patient and his wife with good decompression of both gas and faeces. A decision was made to use a 28 or 30Fr Foleys catheter as the equipment was easily available, and the soft-tipped tube minimised the risk of accidental rectal injury. The duration between rectal tube insertion was then gradually increased with insertion based on patient symptoms of discomfort and decreased appetite to the point where insertion was occurring approximately every three days. The patient reported subjective improvement of symptoms and also optimism at the prospect of potential discharge, while the patient's wife felt confident managing rectal tube insertion, drainage, and removal. There was also an associated decrease in supplemental potassium replacement, increased weight, and increased functional status from fully dependent to partially dependent. After a six month stay in hospital, the patient was finally able to be discharged to a nursing home with the facility providing equipment for ongoing decompression and ongoing follow up in the colorectal outpatient department. |
We present the case of a 24-year-old woman who presented to the family medicine clinic complaining of left shoulder pain for three months duration. The pain was stabbing in nature and was non-radiating. She reported that her shoulder pain was aggravated by raising her arms above her head. The pain was not associated with numbness or weakness. There was no history of preceding trauma. The patient scored the pain as 5 out of 10 on the severity scale. Further, the patient reported that the pain was constant with no progression in its severity. The past medical history was remarkable for intermittent asthma. She underwent laparoscopic appendectomy five years ago with no signs of complications. She did not require any previous hospitalization. She had never smoked nor consumed alcohol before. The family history was non-contributory.\nUpon examination, the patient appeared comfortable. Her vital signs were within the normal limits. Examination of the left shoulder reveals a restricted range of motion of the left shoulder due to the pain. The supraspinatus impingement test was positive. However, examination of the right shoulder and the cervical spine revealed no abnormalities. Further, examination of other systems, including the cardiorespiratory and abdominal systems, was normal. Initial laboratory investigations, including hepatic and renal profiles, were within the normal limits (Table ).\nIn view of the aforementioned clinical findings, the initial diagnosis was supraspinatus tendinosis. The patient was prescribed oral analgesic medications and was advised to undergo a number of physiotherapy sessions. Six weeks later, the patient presented to the clinic again and reported she did not have any improvement in her symptoms. Hence, the patient underwent a local injection of corticosteroid in the supraspinatus region. However, the patient returned back after one month with the progression of her pain, and the pain became associated with numbness radiating to his arm. Of note, the patient had not had any plain radiographs performed in the primary care clinic.\nIn light of the lack of clinical improvement despite the multiple physiotherapy sessions and the corticosteroid therapy, the patient was referred to undergo an ultrasound examination of the shoulder. The ultrasound demonstrated intact rotator cuff tendons with no evidence of tendinopathy or discrete tears. The patient was referred to the orthopedic clinic for further evaluation and management.\nThe patient underwent a frontal radiograph of the chest which demonstrated a well-defined opacity located in the apex of the left lung. The opacity was at an acute angle with the lung (Figure ). The differential diagnoses of this mass were very broad. The differential diagnoses included loculated effusion, hematoma, lipoma, fibroma, metastases, and mesothelioma. A computed tomography scan of the chest with intravenous contrast was performed for further characterization. The scan demonstrated the presence of erosion to the vertebral body (Figure ). Such findings raised the suspicion of a neurogenic tumor. Subsequently, the patient underwent magnetic resonance imaging which re-demonstrated the contrast-enhanced lesion with its extension to the adjacent neural foramen (Figure ). The radiological diagnosis was a neurogenic tumor. Subsequently, the patient underwent an ultrasound-guided biopsy and the histopathological examination of the obtained specimen was consistent with schwannoma.\nThe case was discussed in the multidisciplinary oncology team meeting to make the appropriate management plan for the patient. Resection of the tumor was planned and the patient agreed to proceed with the surgery. The patient underwent video-assisted thoracotomy with brachial plexus exploration. Complete resection of the tumor was achieved with no complications. The patient tolerated the procedure well and had an uneventful recovery. The patient was discharged on the sixth postoperative day. After two months of follow-up, the patient remained asymptomatic with no active complaints. |
M.G. 30-year-old male patient was admitted to the Department of Ear Nose Throat in DEU Hospital with the main complaint of not hearing the safety belt alarm in his car. Subsequent to his history taking, he was referred to occupational disease outpatient clinic in the hospital. He has been working as a home agent for a call center for the last 50 months. He has been working 8 h a day and 6 days a week. His work equipment consists of a monitor and a headset.\nHis equipments have no amplificator. The system is accessed by a password and the incoming calls are directed by team leaders to the related operators. He was mainly serving clients from mechanical maintaining and repair sector clients, thus he described frequent high pitch noise and parasite particularly at the beginning of the conversations. He said, “I have to control the noise level manually since I do not have the amplificatory device….” In his occupational history, he describes the time between high noise level and parasite and manual modification as 3-5 s. He also described ear pain after some of these exposures. A call is received every 3-5 min; 17% of the work time is passed in passive mode, waiting for a call. The breaks are managed by the operator himself or by the team leader. He also mentioned other employees with hearing problems during occupational history, but we did not have a chance to examine any other employees yet.\nHe reported no periodical health examinations and very limited occupational health and safety training was given to him only at the beginning of the job. Although we requested personal noise exposure and environmental noise measurements from the company, no answer was received. The audiometry test at the start of work was normal [].\nThere was no history of smoking or alcohol use, regular drug use, autotoxic drug use, chronic diseases, and exposure to high-pitched noise such as the explosion in his personal and family history, and no particular noise exposure during his military service. There was no history of diving, shooting, or listening to music at high volumes. His daily activities do not include any high-level exposure yet we tried to categorize his daily exposure according to the national regulations.[] He does describe a very sedentary everyday routine including limited time in traffic (daily city traffic 70 dB and automobile horns 80 dB). He describes end shift fatigue and headache so he says “I prefer to stay in a quite environment thus I do not listen high volume music or television (radio music sound 70-80 dB).”\nThe case was evaluated in consultation with the Department of Ear Nose and Throat. The physical examination revealed normal autoscopic results in both ears, the Weber was lateralized to the right, and the Rinne test was pathologically positive in both ears. A pure sound audiogram showed a mean pure sound of 27 dB loss in the right and a mean pure sound of 35 dB loss in the left ear, while there was a sensorineural hearing loss manifesting a sudden decline after 1000 Hz []. The other physical examination findings were usual.\nIn accordance to the history, physical examination, and audiometric results along with the initial audiometric test, other reasons were excluded, and the patient has been diagnosed as noise-induced occupational hearing loss. He was recommended to reduce the noise exposure and put under yearly follow-up by the committee of occupational diseases. |
A 40-year-old woman was referred to The Orthopaedic Oncology Center with a chief complaint of “pain in my left calf for the past ten years.” She reported that her symptoms of pain in her calf began approximately 10 years ago. She described the pain initially as throbbing in nature that was exacerbated with activity and with ankle dorsiflexion and was relieved with rest and warm compresses. At that time, she noted a mass in her left calf that was about 2 inches in size, which did not fluctuate in size and was nontender. She continued to have mild to moderate pain on a regular basis but did not seek medical attention. Instead, she avoided prolonged walking. Approximately three years ago, the pain became more constant and severe. She began walking with a limp due to the inability to dorsiflex her foot to neutral position and she walked on the tip toes of her left foot. For the past 3 years, she has only been able to walk on her tip toes due to an equinus contracture. Three months prior to presentation, in our office, the patient experienced an acute exacerbation of pain in her left calf and sought medical attention from her primary physician. She was prescribed narcotic analgesia without significant relief of her symptoms. The patient was subsequently referred for an MRI. As initial work-up for this lesion, she had an MRI of the left lower extremity.\nThis showed an ovoid mass centered in the soleus muscle measuring 6.8 cm in the craniocaudal dimension, 5.2 cm in the transverse oblique dimension, and 4.6 cm in the oblique dimension. Edema in the soleus muscle and surrounding musculature were noted ().\nFollowing the MRI, she was referred to the orthopaedic oncology service. She believed that the mass had increased slightly from the time she first noticed it 10 years earlier. She had no other associated symptoms. Her past medical history included only a previous hysterectomy with tubal ligation and unilateral oophorectomy and gastroesophageal reflux. She had no history of prior radiation therapy. The only medication she was taking was low dose narcotics for her pain. Her only allergy was a rash to nitrofurantoin. She was married and denied any alcohol, tobacco, or illegal drug use. She had no family history of sarcomas, only a grandmother with non-small cell lung cancer and a paternal aunt and uncle with adenocarcinoma of the colon and an aunt with uterine cancer. Her physical exam revealed an equinus contracture of 20 degrees with plantar flexion from 20–30 degrees of the left ankle. There was a well-defined, firm, and tender deep-seated 5 × 5 cm soft tissue mass in the midcalf. There were no cutaneous changes or skin discoloration or lymphadenopathy. The mass did not change in size when the extremity was elevated or placed in a dependent position. Though this lesion was suspected to be a benign cavernous hemangioma, due to the patient's significant symptoms, she elected for the resection of her left lower extremity soft tissue tumor.\nAt the time of surgery, a longitudinal incision along the posteromedial aspect of the left leg was made. The plane between the gastrocnemius and soleus was developed and the mass was easily identified. Grossly, there was an irregular red-brown to tan-appearing friable mass intertwined with skeletal muscle with associated large vascular channels consistent with a cavernous hemangioma. Manipulation of the ankle under anesthesia was performed bringing the ankle to 10 degrees of dorsiflexion in order to correct the equinus contracture. She was placed in an ankle dorsiflexion splint postoperatively. |
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. |
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 29-year-old gravida 1, para 0 woman was referred to our tertiary center at 24.4 weeks of gestation with a suspected cardiac anomaly. Her previous medical history was unremarkable, and she had no family history of congenital malformation. Quad tests and other prenatal laboratory findings were within normal ranges. A fetal echocardiography was performed and the four-chamber view of the heart revealed cardiomegaly with a right ventricular dilatation without definite contractility, but no obvious right atrial dilatation (). There were no discernible tricuspid leaflets (), indicating the absence of a tricuspid valve structure. Color Doppler imaging showed forward and backward flows from the right atrium to the right ventricle without evidence of tricuspid regurgitation (). Because the tricuspid valve structure was completely absent and also because there were communicating flows between right atrium and right ventricle, the fetus was thought to have a condition other than tricuspid atresia which is characterized with an absence of communication between right atrium and right ventricle. Functional pulmonary atresia was also associated. No other abnormalities were detected.\nFollowing the counseling on the postnatal outcomes, the parents decided to continue the pregnancy, and did not want to undergo fetal karyotyping. Subsequent serial echocardiographic examinations showed no demonstrable changes. A follow-up evaluation at 35.5 weeks of gestation revealed newly developed skin edemas, pleural effusion, and ascites suggestive of fetal hydrops. An emergency cesarean section was therefore performed.\nA male neonate of 2,160 g was delivered and was cyanotic with an Apgar score of 3 and 5 at 1 and 5 minutes, respectively, and an SaO2 level of 50%. An initial echocardiography indicated an Ebstein anomaly type-D, stenotic form with almost full atrialization of the right ventricle leaving only a very small functional portion of this ventricle (). A modified Starnes operation (right atrial reduction plasty with a right ventricular obliteration, central shunt and ligation of the patent ductus arteriosus) was performed on postnatal day 5, and surgical findings confirmed the initial diagnosis. Unfortunately the baby died on postoperative day 3 because of continuous mediastinal bleeding. |
An 11 year-old right-handed girl was referred to our clinic for her painful and swollen left wrist. The patient was a successful student and there was no relevant family history. She had painful wrist without swelling for past two years and had no history of antecedent trauma. The pain was constant, dull and more intense at nights and was not activity-related, so she referred to a health medical center where the general practitioner took an X-ray from her left wrist and referred her to an orthopaedic surgeon because a lytic lesion was in her carpal scaphoid bone (). At that time, the patient was advised for a complete work up but her parents refused further investigation. In spite of constant pain, the patient did not take any pain killer or anti inflammatory agent to subside the pain. Gradually the wrist started to swell and pain became worse and finally two years later she was referred and admitted to an orthopaedic surgery unit in a university hospital where a complete work up was done. At this time, left wrist was swollen, there was a tumor with hard consistency on dorsal and wrist palmar especially on radial side with mild tenderness. The wrist was stiff with minimal motion range and grip power was de-creased. Physical examination otherwise was normal. New X-ray revealed marked osteopenia of the wrist and adjacent bones and an osteolytic expansile lesion with opacities in its matrix in the scaphoid area ().\nBone scan showed increased uptake in the scaphoid area. CT scan revealed lytic expansile lesion with internal calcification in scaphoid ().\nMRI of wrist reported a relatively welldefined heterosignal mass lesion in the scaphoid bone, which was surrounded by edema in adjacent soft tissues with central signal void foci, which could be calcification, hemosiderin or flow void vascular structures and no evidence of fluid-fluid level. Chest X-ray and blood tests were normal. The patient underwent a biopsy through volar approach and specimen sent to histology revealing osteoblastoma. Once again her parents refused further operation at that hospital. Four weeks later the patient was admitted to our center. This time the pain was more intense and the wrist was swollen and stiff and there was a longitudinal scar on volar radial side of the wrist. The tumor was palpable on volar and dorsal of the wrist radial side. After consultation with parents, we opened the joint through volar approach with incorporating the scar of previous incision. The anterior capsule was invaded by red tan tumor of scaphoid but other carpal bones were unaffected. A 2×2.5×2 cm tumor along the affected soft tissue was removed ().\nAgain the histologic report indicated osteoblastoma (). We did not disturb radial collateral ligament of the wrist. The palmris longus tendon was placed in the void space and strip of flexor carpi radialis attached to its insertion was used to reinforce the anterior aspect of joint by passing it through a hole in the distal radius. Then the wrist was immobilized in long arm cast after insertion of a transarticular pin. Six weeks later, we opened the cast and removed the pin to start physical therapy (Figure ,). After 12 weeks of physical therapy, the patient was pain free and the wrist was stable in clinical examination. The wrist motion range was 20 degrees in extension, 15 degrees in flexion, 5 degrees radial deviation and 10 degrees ulnar deviation. The patient will have long term follow up in regard to the aggressive nature of the tumor. |
We report a 65-year-old man who was brought into the emergency department at an early hour as a potential subacute stroke patient. He presented with left facial droop, slurring of speech and gait instability, resulting in collapse at home. At baseline, he was independently mobile, able to self-care and was able to walk up to a mile a day. He described that the symptoms were actually gradually worsening over a span of three to four days. He described that he has been feeling weak equally in all four limbs with occasional pins and needles sensation. On looking to left and right, he reported nausea secondary to double vision. He denied having headache, ear pain or discharge, fever or visual loss. He later admitted experiencing dysphagia for solids and liquids but they do not feel obstructed.\nOn further investigation, we noted that four weeks prior to this presentation, he was seen at the emergency department with one week history of sore throat. Diagnosis of tonsillitis was made and he was discharged with five days course of oral amoxicillin. The symptoms lasted for a week before it resolved but he felt as if he was losing his voice over the next three days. A tonsil swab sample was obtained during this attendance, which was later reported as normal.\nHis past medical history constituted only of hypertension, for which he takes amlodipine. His family history is unremarkable. In terms of his social history, he used to smoke tobacco cigarettes until 12 years ago. He smoked for about 30 pack-years. He drinks alcohol socially, amounting to about eight units of alcohol per week. He used to work as a bartender for 10 years.\nHis observation parameters on admission were stable with heart rate of 90 beats per minute, blood pressure of 130/70 mmHg, respiratory rate of 18 breaths per minute and temperature of 36.8 degree Celsius. Physical neurological examination demonstrated somewhat reduced power in upper limbs and lower limbs with Medical Research Council (MRC) grading of 4 to 5 out of 5. There was deep tendon areflexia in all four limbs. On walking, he demonstrated ataxic gait. There was also nystagmus in all horizontal gazes and dysmetria on finger-nose testing. On examining his face, we noted left-sided ptosis with left-sided lower motor neurone facial nerve palsy. On examining his eye movement, he demonstrated incomplete horizontal and vertical gaze palsy.\nFollowing the local stroke protocol, CT imaging of the head was carried out and the result was unremarkable. In view of the complex set of presenting symptoms a few weeks apart from each other and normal CT, he was deemed unlikely to be suffering from a subacute stroke, and hence stroke treatment was not given. He was thought to have Bell’s palsy as a part of the diagnoses. Therefore, he was given 1 mg/kg of oral prednisolone as per the Trust guideline. He was admitted for observation and over the next few days, he was deemed unsafe to swallow. Decision was made to feed him through the nasogastric tube.\nFollow-up MRI during the admission showed T2 hyperintense foci in cerebral white matter representing ischaemic gliosis, which raises the suspicion of an underlying demyelinating disease (Figure ). Upon discussion with the neurologist from the nearby tertiary centre, potential diagnosis of an acute inflammatory demyelinating disease secondary to recent upper respiratory tract infection such as MFS was made. Further laboratory investigations were carried out (Tables -).\nThe positive titre of anti-GQ1b antibody confirmed the diagnosis of MFS. On top of that patient also showed cross reaction with anti-GT1a antibody, which we believe contributed to his characteristic cranial nerve involvement, which in this case, referring to the facial nerve and bulbar palsy.\nOur patient was closely monitored in a medical ward with frequent spirometry check. His full vital capacity (FVC) was consistently over 2,500 cm3. He received only supportive care throughout, though we did plan to administer intravenous immunoglobulin in case of deterioration. He made significant physical improvement with residual ophthalmoplegia after one week of admission. After four days, his dysphagia resolved and the nasogastric tube was removed. As for the ophthalmoplegia, we provided him with prism lens. He underwent intensive rehabilitation thereafter and was followed up by the local neurologist on a three monthly basis. |
A 9-month-old female patient was referred to the Department of Pediatric Dentistry with a painless swelling of 3-month duration on the ventral surface of the tongue in the medial plane. There was no pain associated with the swelling as per history given by the parents. The parent could not recollect any history of trauma. On examination, the swelling was of the same color as that of the normal mucosa, firm in consistency, nonulcerated measuring about 13 × 7 mm (). Parent gave history of appearance of swelling only after eruption of lower central incisors and increased with time. The patient was noticed with a continuous habit of movement of the tongue over lower incisors during clinical examination. The child was very uncooperative, weak in health due to immature birth, was not opening mouth even for initial diagnosis procedure, and was not feeding properly due to lesion on the tongue. It was concluded on the basis of history given by the parents (as swelling appeared only after eruption of lower central incisors) and clinical examination that fabrication of some protective appliance can hinder repeated trauma of the tongue due to lower incisors and can save procedural time.\nA custom-made impression tray was fabricated on the cast of any other random patient of almost same age group to achieve a tray of the size of the patient (). Impression was made with an impression compound material (), and impression was poured to achieve cast of the female child patient (). The appliance was fabricated with the self-cure material () and delivered to the patient (). Follow-up was done twice after 1-week duration twice.\nOn 1st week of the follow-up period, swelling size was reduced. Swelling completely subsided at the second follow-up period of 14 days (). The patient was recalled for follow-up visit at 6 months to check any recurrence of the lesion and no recurrence was noticed ().\nOn the follow-up visit posttreatment, parents displayed satisfaction with the treatment as the child was feeding properly. |
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. |
The case refers to a 72-year-old Caucasian woman, diagnosed in 1995 (at the age of 58) with a squamous cell carcinoma (SCC) of the left lateral border of the tongue (). The patient underwent hemiglossectomy associated with an en bloc resection of the corresponding lateral floor of the mouth and conservative neck dissection. Postoperative microscopic examination of the specimen revealed a multifocal low grade carcinoma and one lymph node metastasis (pT1pN1pMx G1). The resulting tissue defect was primarily closed with local flaps, and a 6-week postoperative radiotherapy (60 Gy) was delivered. Five months after the primary surgery the patient noted a swelling in the right lateral neck. A submandibular fine-needle aspiration was performed confirming the diagnosis of “metastatic carcinoma.” The patient was then treated with a right conservative neck dissection associated with resection of the submandibular gland. After this second intervention, no signs of recurrent disease were observed, and the patient was rehabilitated with a resin removable partial prosthesis anchored to the remaining teeth. During the following years, the patient lived healthy but lost her teeth due to periodontal disease with the resultant impossibility to wear the prosthesis.\nThe patient was then referred to our department needing a new prosthesis. At the time of observation, medical history was significant for controlled hypertension and no other systemic diseases. Physical exam revealed defects and limitation in tongue mobility and a bridge of scar tissue connecting one side of the tongue to the alveolar ridge (Figures and ). The patient was referred for having suffered from limitation in tongue mobility since the surgical excision of the tumour, having difficulties in speech intelligibility and mastication.\nAfter evaluating bone volume with a computed tomography scan and considering patient's complaints about the ability to chew and move the tongue, it was proposed to perform a soft tissue correction before proceeding with the extraction of the only residual tooth and the placement of two endosseous implants to support an overdenture. The aim of the proposed surgical procedure was to reestablish a suitable anatomy eliminating the fibrous scar resulting from the cancer resection, improving tongue mobility, and contextually deepening the sublingual sulcus and vestibular fornix for the receipt of the prosthesis.\nIt was used a diode laser (Wiser, Doctor Smile, Brendola, Italy) with a wavelength of 980 nm and 2 W power, operating in continuous-wave mode (CW), an optical fiber of 320 μm, and a fluence of 2488 J/cm2. The radiation of this device is selectively adsorbed by hemoglobin, causing a thermal effect that allows a precise surgical cut. After local infiltration of anesthesia (without vasoconstrictor just to enhance hemoglobin light absorption), an incision was made transversally to the ridge involving both the vestibule and the floor of the mouth, dissecting tissues almost till the periosteum and muscles (). After simple dissection, no more surgical manipulations were necessary. At the end of the procedure, it was acceptable to allow the laser wound to heal by secondarily epithelialization, and no sutures were applied. The patient was then instructed and informed about the importance of doing tongue exercises (like lifting and protruding) to avoid the formation of new scars. Although no vasoconstrictor had been used, laser-induced coagulation guaranteed an adequate bleeding control during the surgery with good visibility. The procedure was fast and well tolerated. Immediately after the procedure, the patient showed an improvement in both tongue mobility and speech articulation. Gradual reepithelialization and no signs of infection occurred during the following weeks. The patient reported no particular discomfort in the postoperative period, and no scar tissue has formed. At 28 days, the defect was completely closed ().\nSix months after laser correction and extraction of the residual canine, two implants of 4.1 mm diameter and 13.0 mm length (ExFeel, Megagen Implant Co., Republic of Korea) were placed in the parasymphyseal region of the mandible under the guidance of a surgical template and submerged (). At the time of implant placement, primary stability was obtained, and no signs of bone alterations were clinically observed during the healing period.\nSix months later, an overdenture retained with two free-standing attachments was delivered to the patient. After an early period of adaptation, the patient reported an improved masticatory function in relation to her new diet regimen and defined herself as satisfied (Figures and ). |
A 63-year-old Japanese man with chronic renal failure due to diabetic nephropathy was treated with hemodialysis in the Department of Internal Medicine at the Japan Community Health Care Organization Fukui Katsuyama General Hospital. A gradually enlarging tissue mass was identified as a lymph node by the lesser curvature of the stomach on plain CT in June 2017. The patient had already undergone an endoscopic examination of the upper digestive tract in February of that year and was diagnosed with chronic atrophic gastritis, but no neoplastic lesions had been identified. The patient, who had no complaints, was referred to a gastroenterologist in July 2017. He underwent an enhanced CT study of the abdomen with a venous bolus injection of contrast medium. A tissue mass that measured 18 × 15 mm was observed adjacent to the lesser curvature of the stomach, and there was no communication with the gastric wall. Enhanced CT showed homogeneous, high enhancement of the tissue mass in the early phase that was attenuated but prolonged after 120 seconds (Fig. ). The findings of predominant enhancement during the arterial phase suggested the possibility of a paraganglioma, a solitary aneurysm, an extragastrointestinal stromal tumor (EGIST), Castleman disease, a solitary fibrous tumor, or a splenotic nodule. Based on the high and homogenous enhancement pattern, the location of the tissue mass, and the lack of a past history of trauma, we suspected a paraganglioma, an aneurysm, or an EGIST. Annual plain abdominal CT had been performed since 2013, and we reviewed all of these previous scans. The soft tissue nodule of interest measured 10 × 8 mm in diameter in June 2013, 10 × 9 mm in July 2014, 16 × 10 mm in July 2015, 16 × 11 mm in June 2016, 18 × 14 mm in June 2017, and 18 × 15 mm in February 2018 (Fig. ). These images revealed a gradual and obvious increase in the tumor size. Magnetic resonance imaging (MRI) of the abdomen showed a well-circumscribed mass by the lesser curvature of the stomach with low signal intensity (SI) equivalent to that in the muscles or spleen on T1-weighted imaging (T1WI), relatively high SI on T2-weighted imaging (T2WI) and no drop in SI on out-of-phase T2WI (Fig. ). These findings exclude the possibility of an aneurysm because of the absence of a flow void; rather, the anomaly was considered a tumor without a fat component. The patient underwent 123I metaiodobenzylguanidine (123I-MIBG ) scintigraphy at the University of Fukui Hospital, but abnormal accumulation of the isotope was not detected. He was referred to our department for surgical resection of the enlarging tumor and a definitive diagnosis. The patient had a medical history of diabetic nephropathy and chronic renal failure. On physical examination, the patient had a height of 170 cm, a body weight of 61.5 kg, a pulse of 65 beats/min, a blood pressure of 117/77 mm Hg, and a body temperature of 36.8°C. Anemia, jaundice, edema, and malnutrition were not found. No abnormalities were detected in the skin or subcutaneous tissue. Superficial lymph nodes were not detected on palpation. His abdomen was flat and soft, and no mass was detected on palpation. Routine laboratory tests on the day after dialysis showed leukopenia (white blood cell count, 2,900/μL), anemia (red blood cell count, 3.85 × 106/mL; hemoglobin, 12.6 g/dL; hematocrit, 39.5%) and renal dysfunction (blood urea nitrogen, 33.2 mg/dL; creatinine, 8.65 mg/dL). The plasma levels of vanillylmandelic acid (VMA; 48.2 ng/mL, normal range, 3.3–8.6 ng/mL) and homovanillic acid (HVA; 22.2 ng/ml, normal range, 4.4–15.1 ng/mL) were elevated. Considering the imaging results and the chronic enlargement of the tissue mass, we made a preoperative diagnosis of paraganglioma in the lesser omentum as the most likely diagnosis even though we were not able to reach a definitive diagnosis. The patient underwent laparoscopic surgery in February 2018 (Fig. ). A dark red, elastic, soft tumor was located in the lesser omentum without extension to the stomach wall. The tumor was surrounded by the peritoneum of the lesser omentum and was fed by some branches of the left gastric artery. After placing clips on the feeding vessels, the tumor was easily resected. During the operation, no remarkable changes in blood pressure or heart rate were observed.\nMacroscopically, the resected specimen showed a dark red, smooth surface with a thin capsule. The tumor was soft and elastic, measuring 15 × 13 mm, and it was well demarcated. Histological examination revealed that the tumor had well-differentiated blood vessels containing endothelial cells (Fig. A-C), which were positive for cluster of differentiation (CD) 31 and CD 34 (Fig. A and B) but negative for D2–40, glucose transporter 1 (GLUT-1) (Fig. C and D), vascular endothelial growth factor A, insulin-like growth factor 2 (IGF-2) and pericytic elements. The endothelial cells showed hemophagocytosis (Fig. D). The tumor cells had no nuclear atypia, and there were no malignant findings. Regarding the proliferative capacity of the tumor, the molecular immunology Borstel 1 (MIB-1) index was 8.5% (Fig. E). The tumor was diagnosed as a capillary hemangioma based on these findings.\nThe patient showed an uneventful recovery, and he was discharged from the hospital 4 days after the operation. At the 1-year follow-up, the patient had no recurrence of the tumor. |
A 5-year-old female Nigerian child who was referred to our surgical facility on account of recurring abdominal pain. The pain was localized to the central abdomen, being colicky, aggravated by feeding and relieved occasionally by taking antacids. The episodes were frequent but erratic with the colics occurring mostly within 15 to 30 minutes of feeding; it was usually severe enough to stop her activities during the episode of the pain but she was a normal cheerful child in between the colics. She had occasional postprandial vomiting which sometimes relieved the symptoms. The vomitus contained only recently ingested meal and it did not contain blood. There was neither abdominal distention nor constipation. No history of diarrhoea, passage of worms, or haematochezia was found. There were neither fever, weight loss, nor anorexia. There was no groin swelling but she had a small umbilical protrusion which had been present since birth and had not changed in size even during the episodes of abdominal pain.\nThe frequent episodes either kept her away from school totally or prevented her from participating in the school activities. Before the onset of the episodic abdominal pains, she had never been operated upon, she had not been admitted to the hospital, and she had not been diagnosed of any chronic illness. Her genotype is AA. Both parents were anxious and they had taken her for review by several physicians on separate occasions including general surgeons and a paediatric surgeon.\nOn examination by all the physicians she visited, the only consistent positive abdominal finding was umbilical facial defect measuring 0.5 × 0.5 cm which was considered nonsignificant; otherwise she was a normal, well-nourished child. She was diagnosed as having mesenteric adenitis, gastroenteritis, helminthiasis, and peptic ulcer diseases at one time or another and had treatment for these varying diagnoses to no avail.\nAfter several reviews and treatment with no finding of any organic disease, the assessment became non-specific abdominal pain with possibility of a child who is seeking attention. Psychotherapy was employed with no improvement in the clinical condition. Because of persistence of the symptoms, she had repair of the umbilical facial defect without abdominal exploration because this was the only possible diagnosis that had not been treated and could not be treated nonoperatively.\nAbout two weeks after the repair of the umbilical defect, the symptoms resumed but now with the addition of hyperactive bowel sounds this led to a consideration of postoperative adhesions which further heightened the anxiety of the parents. Further evaluation with plain abdominal X-ray, abdominal ultrasound, gastrografin meal and follow-through showed no abnormalities. Upper gastrointestinal endoscopy and diagnostic laparoscopy were considered but were not done because there was no paediatric scope and there was no expertise for diagnostic laparoscopy at the time. Abdominal computer tomography was not done because the parents could not afford its cost. Eventually, a diagnostic exploratory laparotomy was done because of the continuing psychosocial and physical trauma suffered by the parents and the child.\nAt surgery, the bowel was examined from the duodeno jejunal junction to ileocecal junction. A pale yellow subserosal lesion was seen in the antimesenteric border of the jejunum about 45 cm from the duodeno-jejunal junction. There were enlarged mesenteric lymph nodes but there were neither adhesion nor other abnormalities. A wedge resection of the lesion was carried out and the bowel was repaired in a single layer using long-term absorbable sutures. The enlarged mesenteric nodes were also biopsied. She did well and was discharged home on the 6th post-operative day. The patient has been followed up serially in the clinic at one month, three months, six months, and a year after the procedure. She has been free of symptoms and has since that time been regular and participating fully in school activities. |
A 9-year-old male presented with a swelling on right side neck of 2 years duration. There was no associated pain or history of trauma prior to appearance of the swelling. On examination, it was a firm, freely mobile swelling in the posterior triangle of the neck measuring 1 cm × 1 cm. The overlying skin was normal. Clinical figure is not available. Clinically inclusion cyst was the diagnosis in case 1 and case 2 and in case 3 clinical suspicion of an enlarged lymph node was considered. FNAC was performed using 23G needle and 10 mL syringe. Wet fixed and air dried smears were stained with H and E and Giemsa respectively. FNAC was done followed by surgical resection in all the three cases for histological confirmation of diagnosis.\nMicroscopy of case 1 and case 2 show moderately cellular smears comprising of sheets of degenerated anucleated and keratinized squamous cells (ghost cells). Few cluster of basaloid cells having large, round, regular basophilic nuclei with evenly dispersed chromatin and large nucleoli with ill-defined cytoplasmic margins and sheets of anucleated squames along with focal areas of calcified debris. Case 1 showed few scattered giant cells in addition to the above mentioned findings and case 2 in addition showed a solitary cluster comprising of small squamous cells with small, dark nuclei and scant dense cytoplasm surrounded by basaloid cells [Figures and ].\nCase 3 on FNA showed highly cellular smears comprising mainly of singly lying and clusters of small and medium sized basaloid cells showing mild pleomorphism with round to ovoid vesicular nuclei, dispersed nuclear chromatin, occasional nucleoli and mild to moderate cytoplasm with well-defined cell borders. Cells within the clusters at places showed overlapping and nuclear molding. Background showed few naked nuclei, cellular debris and mixed inflammatory infiltrate along with the occasional mitosis []. A cytologic diagnosis of PMX was rendered in case 1 and case 2 and biopsy advised. However, case 3 was earlier categorized as squamous cell carcinoma/appendageal tumor on the basis of predominance of basaloid cells showing pleomorphism and occasional nucleoli. But considering the patients young age, duration of the swelling and lack of significant pleomorphism made us do a careful reexamination of smears which eventually showed an occasional ghost cells and a diagnosis of PMX cannot be rule out was given on review.\nHistopathological examination in all three cases showed typical picture of PMX showing mainly nests of basaloid cells, few islands of ghost cells along with foreign body giant cells and focal areas of calcification. Giant cells were absent in case 1 and calcification was absent in case 3 [Figure and ]. |
A 70-year-old lady presented with a three-month history of low back pain radiating to the bilateral anterior thigh. Progressive worsening of her pain caused difficulty in standing and ambulation. However, there was no associated numbness in the lower limbs, neither were there any disturbances to her bowel and bladder function to indicate cauda equina syndrome. There was a history of unspecified amount of weight loss over the last six months. Further history revealed the patient had suffered squamous cell carcinoma of the cervix 20 years ago and hysterectomy was performed. Currently, she did not report any postmenopausal vaginal bleeding, pelvic or abdominal pain or anything else to suggest recurrence of the disease. On physical examination, there was tenderness over the thoracolumbar junction vertebrae region. There was good muscle power in all four limbs with preservation of sensation and tendon jerk. Gynecological examination and systemic examination were otherwise unremarkable.\nRoutine blood investigations and tumor markers were within normal range. MRI of the spine showed a multilevel lytic lesion with compression fracture of the T12 vertebrae. CT scan showed metastatic lungs nodules, but no evidence of pelvic mass to suggest local recurrence of cervical tumor. The provisional diagnosis at this point was metastasis of the spine and lungs with an unknown primary.\nCT-guided needle biopsies performed at the lytic lesions of the vertebrae at the level of T12 and L3 demonstrated spindle-shaped neoplastic cells of soft tissue origin but lack any malignant feature to suggest a sarcoma. A repeat biopsy was performed at a different level which was again inconclusive. PAP smear did not report recurrence of cervical malignancy. Due to difficulty in obtaining a diagnosis, positron emission tomography (PET) scan was performed to aid us in finding a primary source (Figure ). The scan revealed numerous hypermetabolic foci involving the entire skeleton as well as a few enlarged hypermetabolic right femoral nodes.\nThe patient was complaining of worsening bilateral thigh pain. Right thigh examination revealed a soft tissue swelling measuring 8x6 cm at the anteromedial aspect of the thigh. MRI of the bilateral femur showed multiple lesions of both femurs (Figure ) and a heterogeneously enhancing mass at the anteromedial aspect of the thigh encasing the right superficial femoral vein (Figure ). Our initial opinion was that the soft tissue mass was an extension of femoral metastatic disease though we could not exclude the possibility of a soft tissue sarcoma.\nAt this point, despite the failure to obtain tissue diagnosis, a decision was made to perform surgery for pain relief. No tissue biopsy was performed at the thigh prior to surgery as it was apparent that whatever the diagnosis, the treatment would be palliative. Surgery would also allow us to obtain more samples for histopathological examination to aid our oncologist in determining adjuvant therapy. Due to extent of the disease in the right proximal femur, excision of the right thigh tumour (Figure ) and skeletal reconstruction with proximal femoral megaprosthesis were performed (Figure ). Metastatic lesion of the left femur was curetted and osteosynthesis of the proximal femoral nail with cement to cover the lesion (Figure ). Intra-operatively, tumour was noted at the anteromedial aspect of the proximal right thigh surrounding the superficial femoral vein.\nMicroscopic examination revealed hypercellular tumour composed of spindle-shaped neoplastic cells arranged in intersecting fascicles (Figure ). The spindled neoplastic cells exhibit moderate to marked pleomorphism, round to plump, blunt-ended, vesicular to hyperchromatic nuclei, some with prominent nucleoli and abundant eosinophilic cytoplasm. Occasional bizarre cells with enlarged multinucleation were also noted. Mitotic figures and tumor necrosis were present. Immunohistochemically, the neoplastic cells were positive for SMA and focally for desmin. The neoplastic cells infiltrated the surrounding skeletal muscles and adipose tissue. The final diagnosis based on histopathological examination of the right thigh mass was pleomorphic leiomyosarcoma, likely of vascular origin with distant metastasis.\nThe spinal metastasis was treated conservatively with a brace. Subsequently, the patient underwent postoperative adjuvant radiotherapy over the right femur and spine. Four months post-operatively, she developed bilateral pulmonary embolism with right lower limb deep vein thrombosis. CT pulmonary angiography also noted worsening lung and bone metastasis with a new right hilar lymph node, in keeping with disease progression. She is currently wheelchair-bound and receiving palliative medical treatment. |
A 29-year-old Greek female right-handed hairdresser presented in our outpatient unit with a draining cyst in the palm of her left hand. Nineteen years ago, after accidental drop of strong glue between her middle and ring fingers, a papule had developed in the third web space. She reported that customers' short cut hair often penetrated the third web space skin. She was otherwise healthy and had never suffered from another skin disease. In September of 2003, however, while in pregnancy, she had first reported symptoms consistent with acute inflammation on the palm of her left hand. The papule had developed into sinus, gained connection within the skin and evolved into fistula with hairs protruding in the palm of the left hand. Although the patient had already noticed these alterations, she did not pay much attention to the lesions, as they did not excruciate her.\nTwo years later she visited our outpatient unit with a chronic sinus on the palm of her left hand. The drainage had persisted for two weeks and had not resolved with oral antibiotic therapy. The sinus was 4 cm long, it had two external openings, in the palm of the hand and in the third web space, and the track contained multiple hairs of different colours (Figure ). Palpation of the interdigital fold provoked discharge of purulent fluid. Examination of the remaining interdigital spaces of both hands and feet did not reveal any pathological lesions. Furthermore, no signs of lymphadenitis occurred.\nA probe was passed along the sinus (Figure ). Surgical excision of an area of chronic inflammatory tissue with a sinus tract and multiple visible hairs was carried out under local anesthetic. The drainage and discomfort resolved immediately after the excision. After careful curettage, since all the granular tissue had been removed, the skin was closed by primary intention (two layers). In this way, the functional result could be better and achieved quicker. The patient was discharged the same day and a course of oral antibiotic therapy (amoxycillin-clavulanic acid: 1 g × 2) was administered for 4 days.\nWithin 1 week the wound healed well (Figure ). Histology revealed epithelial-lined tract with multiple embedded hairs and surrounding foreign body reaction granuloma. There has been no recurrence over the next 12 months and she continues working as a hairdresser. |
A 54-year-old male patient visited to emergency department for minor head injury after he slipped down on stairs. He underwent brain CT scan on approximately 2 hours after trauma (). He presented no clinical abnormality on initial neurologic examinations except mild headache; his vitals were stable, Glasgow Coma Scale (GCS) score was 15 (E4V5M6), pupils were normal bilaterally, and there was no history of loss of consciousness. Also, he had no recent history of any medical treatments or other hematologic disorders, hypertension, diabetes mellitus and alcoholism. No bony fracture, intracranial lesion, or mass effects were detected on CT scan. He was monitored and treated for symptomatic control in the emergency department. Then, the sudden onset of generalized tonic-clonic seizure was developed on 8 hours after trauma. Newly found acute subdural hematoma (ASDH) was detected in left cerebral convexity on subsequent brain CT and midline was shifted less than 2 mm (). There was no history of additional trauma while he was treated in the emergency department and no evidence of underlying medical dysfunction in laboratory findings. On further examination, hematologic test including coagulation profile and peripheral blood morphology was confirmed within normal range. The patient referred to neurosurgery department and admitted to intensive unit care. We followed-up repeated CT 24 hours after admission; there was no change of amount of hematoma. Though he sustained moderate headache, vitals were stable and GCS score was 15 without neurological deficit. The volume of ASDH did not change during serial CT on 3 and 5 days of admission. However, on 8 days of admission, upper and lower extremity motor grade of patient were deteriorated to grade 4 on right side. CT scan disclosed increasing amount of mixed-dense subdural hematoma (SDH) with mass effect (). There was no evidence of acute cerebral infarction or other intracranial lesions except SDH on diffusion weighted magnetic resonance image (). The patient became presenting intense headache and disorientation. Emergent surgical intervention of craniotomy with hematoma removal was performed and semisolid blood clot was evacuated. On the 1st post-operative day, CT showed no mass effect with midline recovery (). The patient's motor grade was nearly recovered to grade 5; however, recurrent ASDH was detected on follow-up CT scan on 3rd postoperative day (). Surgical intervention of craniotomy and hematoma evacuation was re-conducted in a same manner. The patient was discharged on the 10th postoperative day with GCS score of 15 and Glasgow Outcome Scale of 5 (). |
A 51-year-old female patient visited the department of Oral Medicine and Radiology, Yenepoya Dental College, Mangalore with a complaint of pain while chewing since 1 year. She also gave a history of small soft tissue mass in relation to the upper arch which has developed to the present size over a 12-month period. The patient has been wearing upper removable complete denture for 6 years. Pain was moderate and intermittent. The patient used to wear the denture during night time also. Her denture had become loose over a period of time and teeth were attrited. Her medical and family history was noncontributory. She had no deleterious habit like tobacco chewing. Extra oral examination showed no abnormality. She was moderately built and nourished. Intraoral examination revealed multiple hyperplastic tissue folds in the right maxillary buccal vestibule extending from the right lateral incisor region to the third molar area with maxillary denture flange fitting in between the tissue folds []. There was an irregular ulcer measuring 2 × 1 cm in diameter on the surface of the lesion in relation to first molar covered with slough. The lesion was firm, nontender except in the area where ulcer was present. Palatal mucosa was normal and there was generalized recession of gingiva in the lower arch and bilaterally molars were missing. The denture hygiene was poor. On the basis of history and clinical examination a provisional diagnosis of denture-induced hyperplasia was made. The patient was instructed not to wear the denture. Hexigel ointment was prescribed to be applied on the ulcer. Oral prophylaxis was done in the lower arch. The patient was educated and motivated to maintain the oral hygiene. Seeing the extent of the lesion, a surgical resection was planned along the full length of the maxilla after reviewing the patient for any medical condition. The tissue was infiltrated with local anesthesia containing adrenaline 2% and posterior superior alveolar, infraorbital and greater palatine nerve blocks were given. Using a no. 15 surgical blade an outline for resection in a wedge shape was made along the length of the lesion. The resection was then carried out from the midline till the posterior tuberosity region. Hemostasis was achieved. The field was cleaned with betadine and saline solution. A primary closure was achieved using 3-0 vicryl suture material []. Postoperatively, antibiotics and analgesics were prescribed. The patient was instructed not to wear the denture and rinse the mouth with chlorhexidine mouthwash. The excised specimen [] was sent for histolopathological examination. It revealed hyperplastic epithelium in most of the areas, and the underlying connective tissue was fibrous, with moderate inflammatory infiltrate consisting of predominantly lymphocytes. The patient was recalled for follow-up after a week and the healing was satisfactory. The new denture was fabricated after 1 month []. The patient is on regular follow-up for 6 months and there was no recurrence of the lesion till date []. |
A 53-year-old man was found dead from the driver of a passenger van, upon arrival at the city of destination. With other passengers leaving the van, he waited for the man to descend, thinking that he was asleep. The victim was immediately brought at the city hospital, where the death was declared. The autopsy was performed immediately the same day; samples were sent at the Institute of Forensic Medicine where microscopy was made on the organs of interest.\nThe medical staff examined the previous medical files and documentation of the victim; no chronic diseases were suggested. He was referred to be a heavy smoker (30 years with twenty cigarettes per day); he was obese; but no hypertension or other major risk factors were found. Toxicology revealed no signs or suggestions for medications, intoxications, or recent use of ethanol.\nThe day of the trip the victim woke up early and left his home at dawn; he used to go working every day at the city of destination.\nThe forensic pathologist performing the autopsy found nothing unusual at the thoracic cavity, no enlargement of cardiac rooms was seen. The autopsy showed no thrombi inside the cardiac cavities; nor was any sign of thrombotic event found in the major extra cranial vessels. The coronary arteries showed atherotic signs compatible with the age and the body mass (his weight was 97 kilograms for a height of 165 centimeters).\nThe brain was swollen and clearly hyperemic; a massive basilar thrombus with complete occlusion of the median segment of the basilar artery was macroscopically seen ().\nThe dissected basilar artery, from the origin of the vertebral arteries to its top, is shown (); samples of brain stem tissues were microscopically examined. The occlusion of the basilar artery was in the median portion; thrombotic fragments were found as well in the oral portion of the basilar artery.\nThe brainstem showed an infarcted zone in the pons, with secondary hemorrhagic changes, mainly in the form of multiple petechial hemorrhages. Pontine arteries showed extensive alterations, mainly in the form of severed endothelium, which suggested a thrombotic-traumatic mechanism as the main etiological factor ().\nMicroscopically, evidence of thrombotic fragments in the pontine arteries was found as well (), with thrombus formation expanding longitudinally ().\nThe occlusion of the basilar artery was considered from the forensic experts and the consultant staff as the causative factor of death. In face of lacking other etiological factors that could have explained the impressive thrombotic occlusion of basilar artery, leading to immediate death, the experts concluded that minor cervical trauma could be responsible. In fact, the victim was found seated in the van in a very precarious position in the last row. Interviewed from the coroner, the passengers referred a very unstable trip in a bumpy and poorly driven car, with the driver obliged to slow down several times, causing even some displacement of the passengers inside the vehicle. The shocks that the victim absorbed on the posterior region of his neck during the braking episodes possibly caused the thrombotic occlusion of the basilar artery, with expansion of the occluding fragments to the pontine arteries; the immediate death probably followed one of those shocking moments, due to pontine infarction. The role of other causative or predisposing factors remained unclear. |
A 75-year-old right-handed woman presented to our hospital with a 2-year history of slowly growing painless masses in the left middle and little fingers. The patient had a generally good healthy condition and had no history of trauma or injury. She had worked as an oyster handler (takes out oyster meat from the shell) for a long time. Clinically, the masses were on the palmar aspect of the left third and fifth distal phalanges. The yellow aspect of the mass was translucent through the skin ().\nPhysical examination showed painless enlarging subcutaneous masses at the left third and fifth distal interphalangeal (DIP) joints with decreased range of motion. A radiograph showed that joint space narrowing and the shadows of the masses were consistent with the physical examination findings. Magnetic resonance imaging indicated that the masses were mainly located around the joints of the third and fifth distal phalanges on the left hand. The masses had low intermediate signal intensity on T1- and T2-weighted images, and their borders were irregular. According to these findings, we suspected this condition to be a soft tissue tumour, such as a giant cell tumour or a fibroma on the tendon sheath or a malignancy. We decided to perform surgery to obtain a more definitive diagnosis by histopathologic examination and to improve the appearance of the affected fingers.\nMarginal resection was performed with the patient under general anaesthesia. A chalky substance was drained from the incised part, and the substance was found to have spread throughout the extensor of the ulnar and radial sides to the DIP joint. Thus, it was necessary to remove the substance, including a part of the extensor and bone. The articular surfaces of the base of the distal phalanx and the head of the middle phalanx were resected and a 1.0 mm K-wire was inserted into the joints for arthrodesis. Similar intraoperative findings were noted in the middle and little fingers. We could easily close the skin in the little finger, whereas a 2.2 cm × 2.0 cm skin defect remained in the middle finger (). Therefore, we performed a reverse ulnar digital artery flap reconstruction ().\nThe histologic examination revealed a crystalloid material surrounded by giant cells, indicating a foreign body reaction. The surgical procedures were uncomplicated with infections, and the healing process was good, although mild congestion occurred. We pulled out the K-wires 3 weeks later, and a detachable thermoplastic splint was applied for 6 weeks to protect the DIP joint. The patient underwent consultation with an internist for further gout treatment. No recurrence of the gout was observed during the follow-up period, and the effects of the treatment did not interfere with her daily life, although the joints were fixed at 10° flexion (). |
A 35-year-old male patient, a carpenter by profession reported to our department with swelling and pain on the left mandible since 3 weeks []. He met an accident 1 month before while polishing the furnished wood in the workplace and lost his consciousness due to hit of the wooden piece on the face during the incident. He had taken to the Primary Health Centre by the coworkers and received the emergency care. Only the deep wound on the face was sutured without any imaging investigation. After 1 week swelling formed on the left mandible with difficulty in opening mouth and associated pain. Extra orally, a vertically placed wound scar with suture marks of approximately 6 cm in length is seen extending from a line joining the ala-tragus line toward the lower border of mandible []. Swelling over the left mandible was tender and hard in consistency. Mouth opening was <10 mm making it difficult to examine intraorally. A digital panoramic radiography was taken, which showed multiple faint mixed radiopaque radiolucent appearances in the periapical region of mandibular left first permanent molar and second molar with a radiolucent line in between giving the radiographic feature of osteomyelitis and fracture of the jaw []. On careful examination, tiny multiple radiopaque spots are seen on the radiograph within the area of interest having a glittering appearance. To assess whether any breach in the lower cortex and also to ascertain what exactly the glittering thing was, a mandibular occlusal radiograph was taken. In the occlusal radiograph, well-defined multiple linear radio opaque structure of approximately 4 cm long and 5 mm wide not contacting the bone was detected []. With the patient under general anesthesia, the involved area was explored intraorally and multiple pieces of the fractured polishing disc were retrieved []. The wound was irrigated and closed by layer. The patient had an uneventful recovery in the postoperative period with improvement in mouth opening and reduction of swelling and pain in the left mandible [Figures –]. |
A 54-year-old woman with a right visual field defect was referred to the neurosurgery department of our hospital. Her MRI findings raised the suspicion of the presence of a giant cavernous aneurysm of the right ICA. Consequently, a cerebral angiography and balloon occlusion test were planned. The right ICA angiography disclosed a giant cavernous aneurysm (23×24×27 mm) with a communicating artery, which arose from the sac of the giant aneurysm and flowed to the posterior circulation (). Despite this, the vertebrobasilar angiography was not remarkable (). Next, a balloon occlusion test was performed in the right ICA. After expanding the balloon, the control angiography disclosed the anterior communicating artery in well patent, in addition to the posterior communicating arteries, which were also were patent but small in size. The basilar artery system was connected with the right internal carotid system by another two persistent anastomoses, which supplied a continuous blood supply to the giant aneurysm and then to the distal end of the right ICA (). Consequently, the right cerebral hemisphere was likely in well perfusion based on these communication channels. Moreover, the patient passed the balloon occlusion test. As for the anastomoses, one arose from the aneurysm sac, near the normal origin of the meningohypophyseal trunk (), and joined the basilar artery near the junction of the middle and upper thirds (). As described in multiple studies, this represents the PTA (-). Another anastomoses was smaller in caliber than the PTA, and arose from the basal part of the giant aneurysm, but joined the basilar artery at the caudal point (). Moreover, it was clearly visualized after occlusion of the PTA with detachable coils under general anesthesia on another day (). The radiographic anatomy was consistent with the criteria of POA as described by Lie (). In his article, Lie quotes that the POA arises from the carotid artery within the carotid canal, emerges from the internal acoustic meatus, and joins the basilar artery at a caudal point.\nObviously, these persistent anastomoses greatly complicated the endovascular therapy management. A second balloon occlusion test was performed after embolization of the PTA and the POA with detachable coils under general anesthesia. The tests still revealed a negative result. Then, the giant aneurysm was isolated by detachable balloons. The patient was discharged uneventfully on the seventh day following the procedure. Her right visual field defect improved without any evidence of clinically significant thromboembolic events at the six and 12 month follow-up. |
A 27-year-old woman, para 2, referred to the gynecology oncology clinic at King Fahad Medical City, Saudi Arabia on January 2017, with a history of right vulvar swelling for 9 months. She noted the mass first by herself during her last pregnancy at 18 weeks. It was gradually increasing in size especially during the postpartum period with no other symptoms. She had 2 pregnancies, ended by cesarean deliveries for obstetric indications. Her last pregnancy was singleton, uncomplicated during antenatal and she delivered at term. During postpartum period, she breast feed her baby and her menstrual period returned back after 35 days without any significant symptoms. She had no history of any medical illnesses or allergies. She denied the use of any medications. She has no family history of any malignancies.\nHer body mass is 18.8 kg/m2. Abdominal examination was normal. External genital examination revealed a single ovoid, pedunculated mass coming from the inferior side of the right labia majora which measured about 6×4 cm. It was soft in consistency, freely mobile without abnormalities of the surrounding skin. There was no palpable inguinal lymphadenopathy. Vaginal and speculum exam revealed no abnormalities and no adnexal mass was detected. Basic blood work up and ultrasound of the pelvis were performed which revealed no abnormalities. At this point we decided to proceed with wide local excision.\nEight weeks postpartum: The patient underwent wide local excision of the mass without any complications and the lesion was sent for histopathology (see Fig. ). The histopathological assessment revealed features of ectopic mammary tissue. The patient was discharged home the day following surgery with follow-up after 4 weeks. She discharged on oral analgesia and advice for wound caring and no restriction for breast feeding. Postoperatively, she developed a wound gapping that was managed conservatively successfully with the help of wound care team. She recovered completely and has gone back to her normal daily activity. Consent for publication of the report and the image was obtained from the patient. |
A 16-year-old boy presented with the complaints of hitting the bed or wall with his head during sleep, with a frequency of one or two nights per week. He was oblivious of what was happening in the night, but was informed by his parents regarding his abnormal activity during sleep. Because of the same reason, his parents did not allow him to spend night away from his home. Thus, it was interfering with his social life and he wanted medical help. On the other hand, parents sought consultation because they were worried about not only the abnormal activity during sleep but also the possibility of a head injury during these episodes.\nThe parents reported that this problem started at the age of 1 year where he would usually bang his head on the bed or pillow during sleep. Each episode would last about 2-5 min and was self-limiting. During these episodes, the child would assume prone position with knees close to his chest and then he would hit the bed or pillow or wall with his forehead. The movements were rhythmic and stereotyped. The episodes used to recur at varying intervals each night during which it was difficult to wake up the child. Often, the banging used to be so strong that the child had injured himself. A decrease in the frequency of the episodes was noticed after the age of 10 years. During childhood, the episodes were recurring at a frequency of three to five nights per week; but after the age of 10 years, they had reduced to one or two nights per week. Moreover, these episodes became limited to the second half of the night. Whenever he was woken up from these episodes, he reported amnesia regarding the movement.\nThe child was following a regular sleep schedule with bed time at around 11 p.m. He used to fall asleep easily and wake up by himself at around 6 a.m., feeling fresh. He regularly took 1-h nap during the day.\nThe child was born full term through normal delivery and achieved developmental milestones on time. He was attending 10th grade and was performing well in all academic activities at the time of presenting to us. He was well adjusted at school and enjoyed a good social circle. Medical and developmental histories were unremarkable. There was no history to suggest epilepsy, developmental delay, pervasive developmental disorder, substance abuse, or any other psychiatric illness. There was no history of any other type of stereotyped movement disorder during wakefulness or sleep. Chronic sleep deprivation, restless legs syndrome, sleep-talking, sleep-walking, sleep-related breathing disorder, narcolepsy, were also ruled out. The family history was negative for sleep disorder, epilepsy, neurological disorder, or psychiatric illness.\nHis neurological examination and mental status examination did not reveal any abnormality. Medical and Ear Nose and Throat (ENT) examinations were normal. His neck circumference at the level of cricothyroid was 32 cm, and his body mass index (BMI) was 20.08 kg/m2 , (height 158 cm, weight 50 kg). Awake electroencephalography (EEG) and computed tomography (CT) scan of Brain were normal.\nA diagnosis of sleep-related RMD, head banging, was made and a video-synchronized full night polysomnography was ordered. The polysomnography was repeated on a second night since the child did not present any of the symptoms on the first trial. After the diagnosis was made, he was prescribed clonazepam 0.25 mg at bedtime and followed up for 3 months. Parents did not report any episode during this period.\nPolysomnography was performed with Easy III data acquisition system (Cadwell, Kennewick, WA, USA) using a standard montage.[] Data were analyzed according to the American Academy of Sleep Medicine AASM guidelines.[]\nTotal sleep time was 416 min. Sleep-onset latency was 1 min. Wake time after sleep onset was 3 min. Morning report suggested usual quality sleep with sleep efficiency of 99%. Rapid eye movement sleep (REM) latency was reduced (47 min). Hypnogram suggested usual stage shifting during the night. Length and amount of different sleep stages were adequate. Arousal Index during the test night was 0. The patient rested in supine position without frequent changes. The study ruled out sleep-related breathing disorder, with a respiratory disturbance index (RDI) of 2 (all were post-arousal central sleep apneas). Occasional limb movements were observed during sleep, with the periodic limb movements during sleep (PLMS) index of 7. Electrocardiogram did not show any abnormality. Rhythmic movements of 1 Hz were seen during stage 2 sleep []. The child scratched his cheek and assumed the frog-like posture with knees below abdomen and arms folded. He then started banging his head on the pillow for nearly 2 min. Then he woke up and laid down on the bed again. The movements were rhythmic []. Alpha activity in posterior leads and predominantly theta activity with movement artifacts (1 Hz) was seen in frontal leads []. No epileptiform activity was observed []. |
A 57-year-old woman, presented to the ENT clinic with gradual loss of hearing and bilateral ear discharge. She also noticed that pieces of bone were extruding from her left ear. She had been suffering from chronic bilateral ear discharge since her early teenage years. The physical examination done by the otorhinolaryngologist had shown some ear discharge, but there was no evidence of abscess formation, nor was there any facial nerve palsy noted. A presumptive diagnosis of bilateral chronic suppurative otitis media was made. Her blood investigations were essentially normal apart from the normocytic normochromic anemia. Ear swabs from the external auditory canal were sent for microbiological analysis (culture and sensitivity) for pathogens, including Mycobacterium tuberculosis.\nA CT scan of the temporal bones revealed sclerosis of both mastoid air cells with presence of soft tissue, bony erosion and bony fragments within the external auditory canal ( and ). She was started on treatment with oral co-trimoxazole because the initial clinical diagnosis prior to the imaging studies was chronic suppurative otitis media. Her ear discharge resolved and her hearing improved. The cultures were negative for pathogens, including tuberculosis. After completing two months of oral antibiotics, she began to notice discharge from her right ear. Due to the recurrent nature of the infection, a tissue biopsy of the ear was performed and sent for culture and sensitivity screening.\nThe tissue biopsy of the affected ear isolated a rapidly growing atypical mycobacterium – Mycobacterium abscessus which was resistant to co-trimoxazole (Bactrim) but sensitive to imipenem (intravenous beta-lactam antibiotics), clarithromycin and azithromycin. She was commenced on imipenem and clarithromycin. Intravenous amikacin was administered initially for synergistic reasons but the patient was unable to tolerate amikacin and it was withheld. This dual antibiotic regime was continued for a total of 40 days without any complications.\nA repeat CT scan of the temporal bone showed consolidation of the previously inflamed bony lesions but was unable to give any information on the activity of infection. A Gallium-67 (67Ga) scan was performed and showed raised 67Ga uptake in the right petromastoid region ( and ). The left petromastoid region showed near normal, but slightly increased radiotracer uptake. This indicated the presence of active infection and the need to continue treatment.\nUpon completing the initial regime of antibiotics, she was started on oral doxycycline 100mg bd, clarithromycin 500mg bd and moxifloxacin 400mg bd for life. She has been on regular follow up since then and has been well. |
A 39-year-old woman in her 3rd pregnancy booked with us at 12 weeks of gestational age. Her previous pregnancies had culminated in normal vaginal deliveries. She is a housewife with a moderately active lifestyle. Aside from a history of on and off constipation, her past medical history was unremarkable and her current pregnancy was managed as a low-risk pregnancy. All her booking visit investigations including thyroid status were normal. She was on calcium supplements throughout the pregnancy and iron supplementation in second and third trimesters. Her booking BMI was 28 and total weight gain was 9 kg.\nAt 39 weeks of gestation, she went into labour spontaneously. Following approximately 4 h of the latent period, she had a spontaneous rupture of membranes. On admission to the labour ward, her cervical dilatation was 4 cm and well effaced with one mild contraction per 10 min. No rectal enema was given on admission to labour ward. Second review after 4 h revealed the similar vaginal examination findings while she was experiencing only 2 moderate contractions per 10 min. After careful evaluation, oxytocin infusion (5 mIU/ml) was commenced and maintained to achieve 3–4 contractions per 10 min. She opted to have nitrous oxide and intramuscular pethidine as pain relief and had liberal oral fluids during active first stage of labour. Active phase of the first stage lasted 5 h in total, after which active pushing in the second stage was attempted for nearly 45 min. At this stage, a moderate caput had developed with grade 2 moulding and the diagnosis of deep transverse arrest was made. The attempt at manually rotating the fetal head in the labour room failed. Since the patient declined a trial of instrumental delivery, an emergency cesarean section was performed. During the cesarean section, the uterine incision was noted to have a right sided extension towards the vagina which was sutured carefully. No bladder damage was noted. Total blood loss was approximated at 400 ml, and her baby weighed 2.9 kg. She was commenced on oral fluids 2 h postoperatively and mobilized after 6 h from surgery. Standard post-operative bladder care, catheter care and fluid management were given. Urinary catheter was removed on post-operative day 1 and the patient was discharged on the second post-operative day after spontaneous bowel opening with paracetamol and NSAIDs for analgesia, oral antibiotics for 5 days with prophylactic dose of low molecular weight heparin for 7 days and iron supplements for 6 months.\nOne week later she had presented to the general practitioner with a history of no bowel movements for 6 consecutive days and anuria for the last 3 days. She was prescribed stool softeners and a rectal enema and was directed to the emergency department by the general practitioner. However, patient did not present to the emergency department initially as she had a bowel movement. Over the next day she complained of severe abdominal discomfort and progressive abdominal distention with difficulty in breathing and persistent anuria prompting her to ultimately present to emergency treatment unit.\nOn admission she was hemodynamically stable, and her abdomen was distended with evidence of free fluid. As she had undergone a second stage cesarean section, the team decided to catheterize and rule out the possibility of a bladder injury causing urine leakage into the peritoneal cavity. Catheter drained 1 l of clear urine and subsequent ultrasound of the abdomen and pelvis showed normal bladder contour, normal ureters and moderate amount of peritoneal free fluid. Her renal function tests showed evidence of acute kidney injury, which were as follows:\neGFR − 16.67 ml/min/1.73m2.\nBlood Urea − 150.5 mg/dl.\nSerum creatinine − 3.32 mg/dl.\nDigital rectal examination revealed significant fecal loading and manual dis-impaction was done; followed by rectal enema. Subsequently she was commenced on oral laxatives. Upon further evaluation of the patient’s history, it was revealed that she had constipation throughout the latter part of her pregnancy which she had failed to mention in previous appointments with her caregivers.\nOver the next 12 h the patient produced 12 l of urine. Her laboratory investigations revealed hyponatremia with serum sodium level of 123 mmol/l (reference range – 136- 145 mmol/l). Patient’s urine protein level was 8.1 mg/dl (reference range – 0 – 15.0 mg/dl) and urine protein: creatinine ratio was 0.38 (reference range- less than 0.2). The patient had a serum osmolality of 301 mOsm/kg (reference range – 275- 295 mOsm/kg) with a urine osmolality of 270 mOsm/kg (reference range – 700-1500 mOsm/kg) showing an inability to concentrate urine despite the physiological response of serum hyperosmolality. Her urine full report and urine culture were unremarkable with urine specific gravity at 1.015. Spot urine sodium was 66 mmol/l.\nHer other laboratory investigations were as follows: serum potassium – 5.1 mmol/l (reference range – 3.5 – 5.1 mmol/l), serum chloride – 89 mmol/l (reference range – 98 – 107 mmol/l), serum calcium – 8.2 mg/dl (reference range 8.6–10.0 mg/dl), serum magnesium – 1.4 mg/dl (reference range 1.6–2.6 mg/dl). Her liver function tests were normal and 2D echocardiogram had no abnormal findings.\nUpon advice from the consultant nephrologist, fluid replacement was done with liberal oral fluids and intravenous fluid replacement at less than 10% of the previous hour urine output. Oral calcium supplements, oral sodium chloride replacement and single dose of intravenous magnesium sulphate infusion of 1 g was added to her treatment regime.\nMarked clinical improvement of the patient was seen over the course of the initial 12 h with resolution of her abdominal discomfort and difficulty in breathing. Subsequent 24 h saw persistent polyuria with the patient’s condition being stable. Close monitoring of the urine output hourly ensured proper fluid balance with serial laboratory values for serum electrolytes, urine and serum osmolality and renal function assessment every 12 h fortifying the ongoing management. Over 36 h after onset of diuresis patient’s renal function and other laboratory values returned to normal with the settling of polyuria more than 48 h after onset.\nThe patient was discharged on the day after resolution of polyuria with a foley catheter in-situ which was subsequently removed a week later. Patient resumed normal voiding of urine after catheter removal. Post-void residual volume 1 week after catheter removal was ultrasonically confirmed to be less than 50 ml. |
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 56-year-old male was referred to the plastic surgery clinic with a four-year history of a skin lesion on the dorsum of his right thumb (). The lesion was initially diagnosed by a dermatologist as a porocarcinoma and a partial amputation of the thumb was then performed by a community plastic surgeon in December of 2016. Unfortunately, the lesion re-appeared on the distal aspect of the right thumb stump in August of 2017. The patient had no significant past medical history and was not on any medications.\nOn physical examination the patient had a 1.8cm by 1.3cm well circumcised indurated lesion over the dorsum of his right thumb stump (). The mass was firm, non-tender, and mobile over the deep structures. The patient had no palpable lymphadenopathy. The patient was then sent for a metastatic workup, which involved a computer tomography (CT) scan of the chest, abdomen, pelvis, and a bone scan. The CT scan indicated a positive enlarged lymph node in his ipsilateral axilla that was presumed to represent a metastasis.\nThe patient subsequently underwent a surgical excision in August of 2017 of the eccrine porocarcinoma of the thumb with an amputation at the level of the distal interphalangeal joint, and fine needle aspiration of the ipsilateral enlarged axillary node. A wide margin of 2.0 cm was used to ensure margins were clear of the tumor on the thumb. Histologic examination of the thumb specimen showed persistent ulcerated invasive eccrine porocarcinoma that involved the epidermis, dermis and extended into the subcutis with no involvement of bone. There was extensive lymphatic involvement that extended beyond the breadth of the main tumor and closely approached the peripheral margin of resection. Histologic examination of the right axillary node was positive for malignant cells that were consistent with poorly differentiated porocarcinoma and highly suspicious for metastasis. Axillary lymphadenectomy was subsequently performed and histological examination revealed metastatic involvement in 2 out of the 42 excised lymph nodes. CT examination of the rest of the body at the time of axillary resection was unremarkable.\nFollow up initially was unremarkable and the wound healed well. However, four months after the operation the patient had a CT scan demonstrating a seroma in the axilla that required drainage. Seven months after surgery, a suspicious lesion was identified in the scar of the right amputated thumb (). Subsequently, the new lesion was excised with clear margins after two operations and histologic examination was positive for recurrent porocarcinoma. During the second excision the plastic surgery team completed a transfer of the flexor pollicis longus tendon to the distal bone stump to help maintain some of the adduction strength of the thumb (). In May of 2018 the patient presented with new subcutaneous lesions. Biopsies of the right chest wall, right anterior axillary line, and right radial wrist revealed metastatic porocarcinoma. The patient received radiation therapy to the right axillary bed. Subsequent discussions with medical and radiation oncology revealed the progressing difficulty of the situation- as metastatic porocarcinoma is so rare, there are few studies investigating treatment protocols. The conversation initially shifted from curative intent to improving quality of life, however after treatments with paclitaxel (175 mg/m2), carboplatin (area under the curve = 5), and intralesional interleukin 2 (IL-2) injections the metastases responded with near complete disappearance of the cutaneous lesions. After one year of follow-up the patient was still responding well to this maintenance treatment. |
A 42-year-old female was presented by vague central abdominal discomfort not responding to symptomatic treatment for months. She was admitted to our hospital with an attack of melena not associated with hematemesis. Upper gastrointestinal (GI) endoscopy showed a smooth bulge in the second part of the duodenum, measuring 30 mm × 30 mm, just above the papilla [] with a small depression at its summit, too small to allow the passage of the upper GI endoscope []. Abdominal CT revealed a large epigastric complex cystic lesion, most likely a cystic pancreatic neoplasm [] with fluid and gas inside but no ascites, lymphadenopathy or evidence of metastasis. EUS showed a large complex cyst, measuring 55 mm × 62 mm, with thick irregular wall and a large central area of fluid and gas shadow inside [Figures and ]. The lesion appeared separable from the pancreatic head, but it was inseparable from the duodenal wall. Due to the presence of fluid and gas inside the duodenal related cystic lesion, the diagnosis of a large duodenal diverticulum with a narrow mouth was suggested. As the wall of the cystic lesion was thick and irregular, EUS-fine needle aspiration (EUS-FNA) was done to verify the possibility of a mass developing inside a duodenal diverticulum []. However, EUS-FNA revealed nonspecific inflammatory process. After consulting the hepatobiliary surgical team, surgical exploration was decided. Laparotomy revealed a large mass originating from the duodenal wall and encroaching upon the pancreatic head []. Intraoperative biopsy and frozen section revealed a muscular tumor. Pancreaticoduodenectomy was done. Postoperative incision in the lateral wall of the resected second part of the duodenum showed a pin hole opening of the mass inside the medial wall of the duodenum []. This explains the presence of a large amount of fluid and gas inside the mass simulating a duodenal diverticulum. Histopathological examination and immunohistochemical staining revealed a spindle cell neoplasm, positive for c-kit 34 and 117 and the final diagnosis of a duodenal malignant GIST was made. |
A 7-year-old male child presented with a 1-week history of fever, cough and earache at a local district hospital. The child had previously been investigated for hypernasal speech by the speech and language therapy team, with normal palatal studies. There was no other previous medical or family history of note.\nThe initial chest radiograph revealed a possible diaphragmatic hernia and the patient was transferred to our institution for further investigation. The chest radiograph on arrival demonstrated a large air filled cavity at the left lung base. Further smaller cystic cavities were seen medially at the left base and right mid zone. The possible differential diagnoses included lung abscesses or diaphragmatic hernia (Fig. ).\nThe child underwent a CT scan which demonstrated a large left sided empyema with an air fluid level (Fig. ). The left lower lobe was collapsed with a multiloculated fluid collection. The appearances were suggestive of a necrotic lung abscess. The suggestion was that a Staphylococcus species was the most likely organism to account for the pattern of infection.\nA further finding on the CT was of a large thrombus within the left pulmonary vein extending into the left atrium and a segmental left lower lobar pulmonary embolus (Fig. ). The left hemidiaphragm was intact. The abdomen and pelvis showed no further source or complication of sepsis.\nThe patient underwent a left thoracotomy the day after admission. This revealed a bronchopleural fistula at the left lung base. A pleural debridement and insertion of a serratus anterior muscular flap to seal the fistula was undertaken. The thoracic cavity was washed out with warm saline.\nPost operatively, two left sided chest drains were left on free drainage. There were persisting smaller cavities within the left lung. Serial chest radiographs over the next 7 days demonstrated a persisting, increasing left pneumothorax and worsening consolidation of the left lung (Fig. ). On the 8th post-operative day, the child suffered an acute respiratory deterioration with a reduction in oxygen saturations. The chest radiograph revealed a new right-sided tension pneumothorax which required emergency drainage (Fig. ).\nAn otolaryngology review commented on discharge from the left ear. The microscopy results from the ear swab taken showed heavy growth of a gram negative bacterium, with pus cells.\nCT of the head with contrast revealed opacification of the left mastoid air cells with multiple ring enhancing abscesses throughout the brain, the largest of which in the left cerebellar hemisphere, measuring 4.4 × 2.9 cm in maximal axial dimensions (Fig. ). There was non occlusive thrombus of the left internal jugular vein and superior sagittal sinus (Fig. ). A repeat CT thorax revealed persisting left lung abscesses, a left sided collection and a new post drainage large, right-sided haemothorax.\nThe cerebellar brain abscess was drained surgically, with pus sent for microscopy and culture. This returned gram negative coliform organisms and pus cells. The antibiotic therapy was modified to account for the new microbial sensitivities. The appearances of both the brain and chest improved over the next 10 days with complete resolution of the intracerebral abscesses and thrombosis (Fig. ). There was a slower resolution of the chest. The patient was discharged from our institution after 16 weeks. |
A 40-year-old premenopausal Caucasian woman without comorbidities underwent surgical treatment seven years before the presentation of this case report for a clinical diagnosis of uterine myoma. The postoperative histological examination revealed the presence of a LMS and a hysterectomy with lymphadenectomy was thus performed. The tumor was estrogen and progesterone receptor positive. A staging computed tomography scan detected bilateral, multiple lung metastases of about four to six mm. Six years before the presentation of this case report the patient underwent first-line chemotherapy with Adriamycin® (doxorubicin) and ifosfamide but after six cycles of therapy the lung metastases had increased in size and a new lesion had appeared in the abdomen near the right psoas muscle. It was decided to perform a partial resection of the lung metastases (with histological confirmation) and an ovariectomy.\nSecond-line treatment with sorafenib was begun but was rapidly discontinued because of toxicity and treatment with dacarbazine was started as third-line. After three cycles, progression in the lung metastases was detected and continuous infusion of ifosfamide was administered as fourth-line therapy for the following two months. Then the patient was discharged from a National Oncologic Centre to be treated with palliative care.\nWhen the patient arrived in our Department, further progression in the abdomen and chest caused an inability to walk due to nerve impingement and pain and a fifth-line of treatment was begun with docetaxel and gemcitabine. In these 11 months the patient showed a partial response and regained the ability to walk. Disease stabilization in the following six months was achieved with anastrozole (sixth line) and at the next progression the patient was treated with paclitaxel and liposomal doxorubicin (seventh line) for 19 cycles and then with trabectedin (eighth line) for eight cycles, until May of two years before the presentation of this case report. It is noteworthy that more than four years had passed since the initial diagnosis and the patient continued to feel well (with only right leg pain, and three points on visual analogue scale, VAS). After eight cycles of trabectedin the lung metastases and pelvic lesion increased to three cm and 18cm, respectively, causing bilateral ureteral compression and an increase in leg pain (VAS eight to nine).\nIn July of two years before the presentation of this case report the patient’s performance status (PS) was two on the Eastern Cooperative Oncology Group (ECOG) scale and a bilateral nephrostomy was performed. A ninth-line of treatment was started with temozolomide at a dose of 150mg/m2/day for five days every four weeks. Despite the negative status of O6-methylguanine-deoxyribonucleic acid (DNA)-methyltransferase promoter methylation (this kind of test is performed for patients with glioblastoma multiforme to predict response to temozolomide []), a rapid response to therapy was observed with a reduction in the pelvic lesion, resolution of pain and removal of the nephrostomies (Figures and ). The patient returned to her normal life and was able to use her bicycle and to perform activities without leg pain or fatigue (ECOG PS 0) that would previously have been unthinkable. Treatment with temozolomide was completed after 24 months, with very good tolerance, but further progression was detected. The patient recently began a new line of therapy (the tenth) with pazopanib and is currently doing well, six years after the start of treatment. |
A 28-year-old male was referred to the department of oral and maxillofacial surgery for evaluation and management of a left facial mass. He had no other medical problems and no known food or drug allergies. At the age of 15 years, he noticed a mass on his left cheek eminence, which was excised and was told that it was a sebaceous cyst. Three years later, he had a local recurrence of the facial mass that was surgically excised again showing the same pathology. A third recurrence in the same area occurred 4 years later and was excised with the overlying skin. However, at this time the pathology specimen proved to be pilomatrixoma. The mass recurred again few years later and has been growing slowly over the past 3 years prior to presentation.\nClinical examination of the face showed a firm, nontender mass infiltrating the overlying skin of the left buccal subunit measuring about 5 × 3 cm. The overlaying skin had bluish discoloration (). There was no limitation of the mandibular range of motion. Cranial nerve exam was grossly intact. The neck was supple with no palpable masses or cervical lymphadenopathy. Intraoral exam was unremarkable.\nAnother incisional biopsy was done under local anesthesia, which confirmed the diagnosis and ruled out malignant transformation. A contrast enhanced magnetic resonance imaging (MRI) study showed a heterogeneously enhancing mass in the subcutaneous tissues overlying the left platysma muscle at the level of the mandible (). The adjacent musculature and bone marrow maintained their normal signal intensity. The mass was surgically excised including the overlying skin with a safety margin of 1 cm. About 6 × 5 cm skin was marked over the pilomatrixoma and was included in the specimen. The incision was carried through the skin, subcutaneous tissues, and the superficial musculoaponeurotic system (SMAS). The buccal and marginal mandibular branches of the left facial nerve were identified and preserved. The resulting cheek defect measured about 6 × 5 cm () and was reconstructed using a cervicofacial flap (). Postoperatively, the patient recovered well without any appreciable facial nerve deficits or wound complications. He had no evidence of disease recurrence in his one-year follow up. |
A 54-year-old male with a diagnosis of perforation peritonitis with chronic renal failure and coronary artery disease was brought to the emergency department. Due to his poor peripheral venous access and for CVP guided fluid therapy, the plan was made to get the central venous access. After ensuring appropriate coagulation status, the right subclavian vein was chosen for catheterization. A seven French percutaneous 15 cm length triple lumen catheter was used by Seldinger technique. Under all aseptic precautions, the vein was cannulated with introducer needle in first attempt by a resident doctor in the absence of expert supervision and assistance. Following this guidewire was introduced through the needle without any resistance (length of guide wire introduced inside vein was not noticed). During threading of catheter over the guide wire, patiently made a sudden jerky movement which distracted the trainee doctor. To prevent patient movement, he tried to hold the patient's right shoulder with one hand and started putting the catheter with wire inside the subclavian vein without holding guide wire tip as such. This lead to loss of guide wire inside the catheter inadvertently but on gently pulling out the catheter, no part of the guide wire was found outside puncture site. Immediately call made to senior doctors for this mishap. Urgently chest X-ray was obtained which showed the proximal tip of the guide wire in a subclavian vein near the junction with IJV []. Although patient remained stable throughout this period, the plan was made to remove the guide wire by surgery. Patient was explored under general anesthesia through a transverse incision in the right supraclavicular fossa. Meticulous dissection was carried out to expose right subclavian vein and tip of the guide wire was felt in subclavian vein with a finger. A small venotomy about1 cm made proximal to the junction with IJV, through which guide wire retrieved and the incision closed with 6-0 proline. Following this primary procedure, that is, an exploratory laparotomy was performed without any complication. The postoperative period was uneventful, and patient discharged on 7th day. |
The patient was a 15-day-old female infant with an upper lip cleft on the left side. Her parent's chief complaints were cleft lip and nose aesthetics. The infant was the second child and there was no family history of congenital birth defects. Her delivery had been normal and her medical history showed no systemic disorders. Clinical examination revealed a vertical separation of two-thirds of the left side of the upper lip with an intact nasal sill. The left naris was somewhat depressed, and the nasal tip deviated to the cleft side. The cleft lip was associated with an alveolar notch [Figure and ]. The objective was to close the lip parts toward each other, improve the symmetry of the nose, and correct the notching of the alveolar region. For this purpose, a modified molding appliance was made to improve nasal esthetics and to stimulate vertical growth at the alveolar notch. The appliance was designed with two nasal parts for both right and left sides. The left part was made as usual, but the right part as only a ball [Figure and ]. This modification was thought to be useful to better control the nasal septum. The left side was raised weekly, using acrylic, while the other side was activated mesially to support the nasal tip and septum. In addition, an alveolar correction was made by removal of a portion of the acrylic from the intraoral area weekly. Strip bands were also used to facilitate closing the lip.\nAfter establishing a more vertical left naris, the cleft lip was reconstructed at 5.5 months using the Millard technique with Mohler's modification []. A nasal stent was applied for retention, and she was checked monthly for 6 months []. The nasal stent was custom-made with acrylic (because of its rigidity) and it was more vertical on the cleft side. After removal of the nasal stent, the patient was checked annually. At the ages of 2 and 4 years, she showed no asymmetry in the frontal view and had acceptable nose and lip appearances [Figures and ]. The notch appearance at the cleft site was improved. Clinical examination of the left central and lateral deciduous teeth showed a cross-bite at 4-year of age. She has not received any other surgical interventions. Follow-up is continuing annually. |
A 32-year-old male patient was admitted to the emergency department with a penetrating injury on the right side of the neck, just behind and below the right ear, accompanied by evident weakness of the right side of his face.\nThe patient was a usually healthy man with no accompanying medical conditions; he was not taking any medication and reported no known allergies. This was a first accident he had in his workplace.\nThe patient acquired the injury when a construction protractor with a sharp tip fell from a height while he was working on a construction site. The protractor fell from a height of approximately two stories directly on his neck causing a small, penetrating injury behind and below his right ear as shown in . After the impact, the patient described some bleeding from the injury site which stopped on compression.\nUpon admission, there were no signs of acute bleeding, his vital signs were in physiological ranges, and his neurological status was unchanged except the evident asymmetry of the face caused by incomplete, clinically peripheral right FN palsy evaluated as House Brackmann (HB) grade IV, as shown in .\nOtoscopic findings were normal bilaterally. A small retroauricular penetrating injury measuring 1 cm in diameter and 1 cm in depth was evident with mild edema of the right parotid region.\nLaboratory blood analysis showed values of physiological ranges.\nAn emergency soft tissue CT scan with contrast was performed, and a retroauricular subcutaneous gas collection measuring 0.6 cm was described, approximately 1.2 cm below the stylomastoid foramen, which corresponded the presumed sharp object entry trajectory. The right parotid showed normal morphology, without hematoma, and it showed no signs of bone of vascular trauma of the head or neck. CT scan that most closely presents the entry trajectory is presented in .\nThe wound was copiously cleaned, a passive rubber drain was inserted, and the wound was sutured. The surgical management was limited to the skin and soft tissue. No formal attempt of FN exploration was conducted. The drain was removed 2 days later. There was no bleeding or edema after surgical management.\nThe patient received tetanus toxoid (TT) and tetanus immune globulin (TIG) vaccine. Additionally, dual antibiotic therapy (amoxicillin + clavulanic acid and metronidazole) was prescribed, and intravenous infusion of methylprednisolone was delivered in a tapering dosage schedule (250 mg daily for the initial 2 days, and over the next 10 days, was tapered by 40 mg every 2 days). Also, proton-pump inhibitors were administered for gastroprotection. Blood glucose levels were monitored simultaneously during the corticosteroid therapy, for which the levels varied between 4,8 and 6,9 mmmol/L.\nAudiologic examination was conducted. Pure-tone audiometry verified normal hearing on both ears. Tympanometry showed type A tympanogram bilaterally. Acoustic stapedial reflex was intact bilaterally.\nThe mainstay of therapy was corticosteroid (SC) therapy which was given in a tapered manner for the following 14 days beginning with 2 mg/kg of methylprednisolone parenterally. The patient also received gastroprotective medication (proton-pump inhibitors) with the CS therapy.\nThe patient was released on the 7th day after injury with continuation of CS therapy in the form of tablets. The patient was engaged in physical therapy in the form of facial rehabilitation for acute facial palsy.\nThe patient attended regular ENT follow-up, first weekly for the first month and afterwards monthly. No additional medication was prescribed.\nOn ENT follow-up examination 6 months after the incident, his FN status was completely normal with complete restoration of the FN function evaluated as HB grade I. His recovery was otherwise uneventful. |
A fifty five year-old man presented to the emergency room (ER) with a localized pain at the right iliac fossa. There were no histories of nausea, vomiting or any other complaints associated with the pain. History taking revealed that the pain was colicky in nature around the epigastric region when it started 3 days ago. The pain increased gradually by the next day, which eventually localized at the right iliac fossa before the case presented to our ER.\nThe pain at the right iliac fossa was a continuous type which was aggravated by any kind of movement and was relieved by rest. The patient did not give any past history of medical or surgical problems. There were no known drug allergies or use of any medications. He was afebrile. Abdominal examination revealed localised tenderness and with guarding in the right iliac fossa. The baseline work up was normal. The appendix was not visualized on ultrasonogram but revealed minimal fluid collection in the right iliac fossa. A diagnosis of acute appendicitis was done and a plan for emergency appendectomy was made. During operation, Gridiron incision was made to visualize the appendix, which was mildly inflamed. On cut section, the mucosa was found to be inflamed and the presence of a faecolith was noted. Following appendectomy, the presence of inflamed bowel with food flakes and purulent collection raised suspicion of intestinal perforation. We decided to explore the entire bowel. The incision was converted to Rutherford Morrison incision. Bowel examination revealed two small jejunal perforations around 2 mm size in the antimesenteric border, approximately 250 cm proximal to ileocaecal junction. On palpation of the adjacent bowel, a hard, bony and sharp object was felt. This object was removed through the perforation site. The perforations were repaired in two layers with 3/0 polygalactin and 3/0 silk sutures. A pelvic drain was placed, after which the abdomen was closed in layers. Postoperative recovery was uneventful. Histopathology report of the appendix revealed eosinophils, which indicated receding appendicitis. The extracted sharp and bony foreign body was discussed among the surgical team as a sharp piece of animal bone. After patient recovery, both the patient and caretaker were interviewed in detail about the food history before the pain started. The history revealed the ingestion of home cooked buffalo meat with alcohol in the evening by the patient. The patient usually consumed buffalo meat with alcohol in the evenings. The object was confirmed as a ‘buffalo bone’ by both the patient and the caretaker (Figs. , ). |
A 77-year-old man with a medical history of coronary artery disease, mild aortic stenosis, diabetes mellitus type 2, hypertension, and hyperlipidemia presented with symptoms of unstable angina. Cardiac catheterization revealed three-vessel coronary artery disease, and he was scheduled for a CABG. A preoperative transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 47% with global hypokinesis and mild aortic stenosis with a mean gradient of 20 mmHg. The left atrium was mildly dilated but without echogenicity or irregularity. No obvious mass was identified in the left atrium.\nThe patient was brought to the operating room for CABG. Before the start of the procedure, TEE confirmed mildly reduced left ventricular systolic function and mild aortic stenosis. Imaging also revealed a 12 mm × 6 mm mass in the left atrium, attached to the ridge of epicardium dividing the left upper pulmonary vein and the left atrial appendage []. The mass was small, highly mobile with a homogenous central core and filamentous projections. Differential diagnosis included thrombus, benign cardiac tumor, or other malignancy such as a sarcoma. Suspicion was particularly high for an atrial myxoma due to the location, mobile nature of the mass, and somewhat globular appearance. However, the mass was much smaller in size than a typical myxoma and demonstrated peripheral filamentous elements more consistent with either thrombus or papillary fibroelastoma. Due to the potential for malignancy or embolization, the decision was made to resect the tumor. Given the precise echocardiographic localization of the mass to the left atrial appendage, the mass was approached directly through the left atrial appendage. The mass identified on TEE was easily visualized at the junction of the left atrial appendage and left atrium proper, and easily excised in its entirety, revealing an irregular tan colored, soft, and gelatinous mass with focal hemorrhage []. Attention was then turned to the coronary artery bypass component of the operation, which proceeded as planned. His postbypass TEE demonstrated complete excision of the mass, and postoperative course was unremarkable. Final pathology of the left atrial mass revealed fibroelastoma []. |
A 45-year-old male patient reported to the Department of Prosthodontics with a history of surgical resection of his upper jaw. The detailed history revealed total maxillectomy was done to resect sarcoma 1 month ago []. The patient was on Ryle's feed. Surgical reconstruction was attempted with the right side of the face as donor site, but was unsuccessful []. On examination, the oral nasal communication was evident []. Healing mucosa with no clinical evidence of recurrence of the lesion, loss of soft tissue support, were noted. The goal of the treatment was not only to provide an obturator to close the defect but also to discontinue nasal feed and facilitate oral feeding. The choice of the interim obturator to treat the defect was clear, but the method of retention of the prosthesis remained a challenge. This was over come by the innovative use of an orthodontic facebow. The patient desired to have a prosthesis that would facilitate his swallowing function without regurgitation, and not to have the prosthesis retained in the mouth. Hence, a prosthesis that can be worn during feeding and removed for the rest of the time to facilitate soft tissue healing was planned. The orthodontic facebow and the brackets to retain the head gear would accomplish the requirement of clinical situation. The subsequent appointments and the procedure were done as follows. In the first appointment, an alginate impression was made []. The cast was poured with dental stone, and a denture base was fabricated using a light-cured acrylic sheet. Occlusal rims were fabricated on this denture base [Figure and ]. The denture base served the dual purpose of the special tray that was used to record the maximum supporting area using a soft liner [] and to record the jaw relation [Figure and ]. Recording the centric relation was not considered a mandatory step for fabrication of the prosthesis. The main objective of the prosthesis was to prevent oro-nasal regurgitation and to provide an appropriate seal between the oro–nasal cavities. Hence arbitrary bite registration was done []. The cast was poured with dental stone. The upper and lower casts were articulated in a three point articulator with the recorded bite [] and teeth arrangement [] was done to give support to the remaining structures. A wax try-in was done for the patient []. During the try-in stage, orthodontic face bow was inserted into orthodontic buccal tubes which in turn is inserted into the trial denture [Figure and ]. The outer arc is inserted into head gear that gains retention from the scalp []. The retention of the denture was verified during this procedure. The aim of the prosthesis was to help in enhanced feeding and to prevent regurgitation of fluids into the oro-nasal cavity. The patient was given fluids to verify regurgitation. After satisfactory intake of fluids, the patient's comfort was evaluated. The denture was processed and inserted for the patient. Any sharp flanges were smoothened, and a soft liner was added to the tissue surface. To improve retention of the prosthesis during feeding orthodontic facebow was attached to the denture with face bow brackets. |
We present a 78-year-old male with a previous medical history of prostate cancer, which was treated with radiation therapy, who secondarily developed urethral strictures for which he had recently undergone a urethral stricture dilatation. He presented the following day with altered mental status, nausea, and lethargy. He had no previous symptoms of headaches or other neurologic deficits. He was physically active and had otherwise been in excellent health. His family history was positive for pancreatic cancer in his father. He did not smoke or consume alcohol. On admission to the hospital, he was hyponatremic with a sodium level of 120. After fluid resuscitation, his sodium normalized to 136. A computed tomography (CT) scan revealed a mass lesion in his right posterior temporal lobe for which neurosurgery was consulted. His encephalopathy improved and his neurologic exam at the time of consultation only demonstrated a superior quadrantanopsia in his left visual field that was consistent with confrontation testing. He was placed on intravenous steroids, anticonvulsants, and an MRI scan of the brain was performed, which revealed a 4.6 x 3.1 cm mass lesion in the right posterior temporal lobe with minimal mass effect and heterogeneous contrast enhancement (Figure ).\nAfter a discussion with the patient and his family, the decision was made to proceed with an open biopsy after his hematuria had resolved. The patient had a CT scan of the chest abdomen and pelvis prior to discharge, which was negative for malignancy. The patient had an outpatient follow-up appointment with repeat MRI brain three weeks later, which revealed a progression of the mass, with an interval increase in size to 5.4 x 3.4 cm, with minimal worsening of the local mass effect and vasogenic edema while on oral steroids (Figure and Figure ).\nOne week later, the patient underwent a craniotomy for resection of the tumor. The initial specimens were obtained and sent to pathology prior to resection. The intra-operative frozen diagnosis was read as a hypercellular lesion with rare mitotic figures, favoring inflammatory versus infectious process. The decision was then made to wait for the final diagnosis before removing the mass, and the patient was discharged home after an uneventful three days in the hospital.\nThe histology of the lesion was unusual in that there was hypercellularity, conspicuous Creutzfeldt cells with multiple micronuclei, and abundant histiocytes on immunohistochemical evaluation (Figure ). Vascular proliferation and fibrin thrombi were identified. The proliferation index was relatively low in certain areas. Additional immunohistochemical and molecular data were sought to achieve a diagnosis. The atypical cells were negative for the IDH1 p.R132H mutant protein and a subset of lesional cells showed expression of p53. The expression of the ATRX protein was retained. Sections were sent for further analysis with fluorescence in situ hybridization (FISH) studies, which found no evidence for PTEN loss or epidermal growth factor receptor (EGFR) amplification. The absence of alterations in either of these genes failed to provide evidence for a diagnosis of glioblastoma, World Health Organization (WHO) grade IV. Therefore, the tissue was sent for analysis with a next-generation sequencing panel covering frequently mutated regions in 50 cancer-associated genes (Ion AmpliSeq™ Cancer Hotspot Panel v2; ThermoFisher). No somatic mutations were detected in the tissue examined. Although the histologic findings are unusual, and the molecular tests performed did not reveal a specific genetic alteration, a consensus review of the histologic features by three neuropathologists led to the final diagnosis of glioblastoma, WHO grade IV, with atypical histologic features.\nThe patient was taken back to the operating room approximately four weeks later for a more definitive resection of the residual tumor, which was without complication, and postoperative imaging revealed the expected subtotal resection of the tumor (Figure ).\nThe surgical specimen from the second surgical resection was also evaluated by three neuropathologists; the histologic features were similar to the initial biopsy with additional findings including cortical infiltration and subpial spread of the tumor cells, which provide additional evidence to support a diagnosis of glioblastoma, WHO grade IV. |
A 10 years old male patient presented to our department with dental trauma that had occurred 1 week back resulting in coronal fracture of the left upper central incisor (). Electrical pulp testing revealed positive results hence, indirect pulp capping was done and patient was recalled at regular intervals. No symptoms were reported by the patient but on clinical assessment, electrical pulp testing yielded negative results and radiographic assess-ment at the 6 months recall visit showed the apical root development of the tooth to be arrested (). It was, therefore, decided that apexification was indicated before endodontic treatment could be carried out for the affected tooth. The treatment plan was to form an artificial apical barrier after cleaning and decontamination of the canal with sodium chloride solution. Access cavity preparation was done for the tooth under rubber dam and working length was determined by the radiographic method (). Shaping was limited to the coronal third of the canal (with gates glidden drills) to facilitate direct instrument access to the foramen. Biodentine is an inorganic non-metallic compound presented in the form of a capsulated powder and a liquid twist cap bottle (). The capsule con-taining the powder was tapped and opened, followed by the addition of five drops of liquid from the single dose container to the capsule. The capsule was then closed and placed in an amalgamator for 30 seconds. The mix obtained is creamy in consistency, can be manipulated for 6 minutes and takes a further 6 minutes for setting.\nThe canal was filled with two increments of Bioden-tine with an amalgam carrier. The first increment of Biodentine was inserted into the canal using a reamer of the largest diameter fitting into the canal–ISO size 110. The material was then delicately pushed toward the apex with a root-canal plugger of ISO size 100. Several increments were similarly inserted and then condensed to form a plug of adequate thickness (> 4 mm). After verifying that the material was hard-set, the thickness of the apical barrier and adaptation of the material to the dentinal walls was confirmed radiographically (). Obturation of the canal was done with gutta-percha using the lateral condensation technique (). Post obtura-tion complete coverage prosthesis was planned for the tooth. Crown preparation was done () and a full coverage acrylic crown was luted into place using resin-modified glass ionomer cement (). It will serve as a medium term solution for protection of the endodonti-cally treated tooth and esthetic restoration of the crown morphology as well.\nThe patient was recalled after 1 month. History and clinical examination showed satisfactory healing, and an intraoral periapical view was taken which showed adequate periapical response as well. |
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 45-year-old male patient was referred to our clinic with the diagnosis of left superficial femoral artery pseudoaneurysm detected by Doppler ultrasonography that was performed to investigate the pulsating mass in the left upper thigh and edema of the particular extremity. He had been diagnosed with Behcet's disease three years ago with the symptoms of recurrent oral aphthous ulcers, bilateral lower extremity repeating venous thrombosis, and positive Pathergy test. In his history, there were left inguinal hernia operation in 1994, left meniscus operations in 2003 and 2007, and gastric bleeding in 2001 and 2003. Familial Mediterranean fever was diagnosed in his uncle and cousin, coronary artery disease in his sister, and valvular heart disease in another sister as family history. He received pulse steroid therapy (1 gr methylprednisolone) for 3 days followed by 60 mg methylprednisolone and 1 gr cyclophosphamide per day as soon as the pseudoaneurysm was detected. His symptoms did not relieve and the pulsating mass enlarged despite immunosuppressive therapy. The arterial pathology was confirmed with computerized tomography angiography, which revealed an 117 × 63 × 75 mm pseudoaneurysm confined to the mid segment of the superficial femoral artery, which compressed and occluded the superficial femoral vein (). We decided surgical treatment after consulting the patient with the rheumatology clinic and following the consent of him.\nOperation was performed with general anesthesia. The pseudoaneurysm was approached through a direct incision above the artery at the mid segment of the thigh. The relatively disease-free segments of the proximal and distal superficial femoral artery were looped and controlled. The diseased segment of the artery was severely destructed () and a repair was not suitable. Following heparinization the diseased segment of the artery was replaced with biosynthetic vascular graft interposition (Omniflow II, 6 mm × 60 cm, Bionova). The anastomosis regions were augmented with graft materials rolled around the anastomosis to prevent pseudoaneurysm formation (). Postoperative course was complicated with surgical site infection and reexploration. The graft was excised and saphenous vein, which was harvested from the contralateral leg, was interposed between the relatively healthy segments of the superficial femoral artery for the treatment. Again the anastomoses were reinforced with segments of saphenous vein. The culture of the extracted specimen indicated E. coli and the patient was treated with ciprofloxacin. On the third postoperative day, the patient was again taken to the operating theatre due to severe bleeding. The saphenous vein was found to be destructed and replaced with a biosynthetic graft. Immunosuppressive regime of the patient was not stopped during his hospitalization period or interventions and reinforced with 1 gr methylprednisolone before and after the operations. He was discharged home on the seventh postoperative day despite the fact that postoperative course was complicated with elongated serous discharge from the incision which stopped after 42 days. He had been free of symptoms, received immunosuppressive therapy, and followed up regularly.\nThe histopathologic examination of the excised arterial segment revealed focal foamy macrophage accumulation, marked fibrosis at the intima, and chronic nonspecific inflammation at the adventitia level of the vessel. |
Our first case was a 54-year-old Caucasian man, admitted to the emergency department 4 hours after a fall from horseback with severe dysphonia and bloody sputum, without dyspnoea or any respiratory distress. He suffered severe blunt trauma to the head and neck by the horse stepping on his throat. He had no previous medical or surgical history. He was haemodynamically stable. Clinical examination showed a mild oedema with cutaneous haematoma and subcutaneous crepitation in the cervical region. Examination of the oral cavity and oropharynx was normal. The fibre endoscopic examination of the larynx showed a bulge at the level of the posterior wall of the hypopharynx, fresh blood in both piriform sinuses with no laryngeal oedema or paralysis of the vocal folds. A CT scan showed an extensive emphysema from the skull base to the level of the mediastinum and a displaced fracture of the thyroid cartilage on the left side (). Endoscopic examination of the upper aerodigestive tract under general anaesthesia showed no lesion of the oesophagus or the trachea, but a mucosal laceration of the left aryepiglottic fold with exposure of the thyroid cartilage as well as obstructive laryngeal oedema was observed. The patient underwent immediate surgical exposure of the neck via an anterior horizontal incision. Exploration of the larynx showed a displaced fracture in the left para—median part of the thyroid cartilage. Open reduction of the displaced cartilage fragments and their fixation was done using two miniplates fixed to the cartilage with four screws of 1.5 mm (). A tracheotomy was performed because of the laryngeal oedema.\nAntibiotic treatment was introduced (co-amoxicillin 1.2 g intravenous three times per day) associated with corticotherapy for 5 days. Nutrition by a nasogastric tube was followed by progressive introduction of oral feeding. Postoperative CT scan 3 days later showed a regression of the emphysema and symmetric alignment of the thyroid cartilage (). The tracheotomy was removed after 6 days with a total regression of the laryngeal oedema. The patient was hospitalised for 7 days. Antibiotic treatment was continued orally for a total of 14 days. Follow-up at 1, 3, 6 and 12 months after surgery showed no complication or persisting sequelae. A subjective assessment of the voice by using the Voice Handicap Index-10 (VHI-10) showed a score of 3 out of 40. The fibre endoscopic control showed normal vocal fold mobility and good healing of the laryngeal mucosa without exposure of the screws into the larynx (). No respiratory problems or any swallowing difficulties were observed. |
The patient is 50-year-old Caucasian female with a history of hypertrophic cardiomyopathy. She presented with complaints of worsening shortness of breath, dyspnea on exertion, and near syncope. Her other medical history includes hypertension, gastroesophageal reflux disease, and asthma. Preoperative TEE revealed subaortic stenosis with a peak gradient of 42 mmHg and septal hypertrophy. Cardiac catheterization revealed normal coronary arteries with an ejection fraction of 60%.\nShe was offered alcohol septal ablation but elected to receive extensive transaortic septal myectomy with two bypass runs, and TEE showed no septal defect, peak gradient across the left ventricular outflow tract at 3 mmHg in the operating room. The patient later became progressively hypotensive requiring vasopressor support and remained hypoxic in the intensive care unit (ICU). Bedside TEE showed a new VSD about 14 mm in size with left to right shunt and lay behind the septal leaflet of the tricuspid valve []. The patient was taken back to the operating room emergently. The delayed presentation of VSD was unclear and might be related to damage to the perforator artery of the septum and continued myocardial infarction led to the creation of VSD. Bovine pericardium patch repair was attempted to fix this defect surgically unsuccessfully after multiple cardiopulmonary bypass runs. Extracorporeal membrane oxygenation (ECMO) was initiated, and the patient was transferred to ICU in a critical condition.\nInterventional cardiology was consulted for the possible transcatheter closure of the defect, and the patient was taken to the cardiac catheterization laboratory. Amplatzer muscular 14 mm VSD closure system was attempted through the right femoral vein without success utilizing a purely transcatheter technique. The following deployment of the RV disc, tugging on the device resulted in dislodgement of the device, indicating most likely a tear of the pericardial patch. Due to the paucity of surgical options available, it was determined that a hybrid approach with direct visualization of the VSD and transcatheter closure would be tried.\nIn the operating room, a right atriotomy was created to expose the VSD by the surgeon without removing tricuspid leaflets. Because of the large defect size, the much larger Amplatzer atrial septal defect closure device was attempted. Initially, a 14 F sheath with a 24 mm AMPLATZER® atrial septal occluder was inserted through the right atriotomy across the VSD under TEE guidance. On deployment of the left and RV discs, the delivery cable was left attached to the system while the surgeon closed the right atriotomy. TEE revealed severe mitral regurgitation due to impingement on the anterior leaflet of the mitral valve from the left ventricular disc [Figures and ]. This device was retrieved and a smaller 18 mm AMPLATZER® atrial septal occluder was deployed. The right atrium was again closed over the cable so that we could visualize the device within the filled heart. TEE revealed good placement of the closure device with neither perturbation of the anterior mitral leaflet and nor the aortic valve in two-dimensional and three-dimensional (3D) [Figures , and ]. The delivery cable was released from the device and TEE revealed only trace basal inferior communication left []. The ECMO was turned off temporarily during TEE evaluations to detect any shunts or regurgitations by color Doppler. Unfortunately, she still required full ECMO support for a prolonged period of time in the ICU. The family decided to withdraw care, and she died on postoperative day 14. |
A 61-year-old man underwent resection of a part of his tongue due to tongue cancer and was admitted to our hospital for hepatocellular carcinoma with about 5 cm diameter of tumor at the liver segment IV. Computed tomography (CT) showed that the tumor was enhanced during the arterial phase and washed out during the portal phase, and the tumor pressed the right anterior branch to the main branch of Glisson and the middle hepatic vein; hence, the diagnosis of hepatocellular carcinoma was made (Fig. ). The indocyanine green retention rate at 15 min was 21.8%. Child-Pugh score was A. The patient tested negative for hepatitis B surface antigen and hepatitis C virus antibody. He had a history of excessive consumption of alcohol, and alcoholic liver damage was considered as a possibility. Partial hepatectomy with segments IV + V and cholecystectomy with cystic duct-tube drainage were performed. Intraoperative findings indicated that the anterior branch of bile duct was exposed at the resected area, and some small bile ducts were ligated. On POD 1 following hepatectomy, bile leakage developed from the drain placed in the foramen of Winslow. CT showed fluid collection in the cavity between the liver and fistula to drain. Cholangiography via the endoscopic bile duct enhancement showed no communication between the common bile duct and abdominal cavity. Drip infusion cholangiography (DIC)-CT revealed the bile duct of the peripheral side. We maintained simple drainage to reduce the cavity. On POD 19, this patient had fever and CT revealed that the fluid collection has increased (Fig. ). Percutaneous drainage to the cavity near the liver cut surface was performed. Cholangiography via the c-tube did not show the anterior branch of the bile duct. Fistulogram from the drainage tube at the abdominal cavity showed the bile duct at segments V and VIII (Fig. ). We diagnosed the bile leakage from the isolated bile duct of segments V and VIII. Further management was needed to control the persistent biliary leak of 200–250 mL/day. Liver function was evaluated again. The indocyanine green retention rate at 15 min was 27.7%. LHL15 was 0.575. Liver volume of segments V and VIII was 260 mL, and remnant liver volume was 1272 mL, which were calculated using the 3D image analysis system (SYNAPSE VINCENT; Fuji Photo Film Co., Ltd.). Functional remnant liver volume (FRLV) was calculated based on the liver volume using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced MRI for 20 min []. FRLV after liver resection of segments V and VIII was 2176 mL. Even if the function becomes extinct by PTPE to segment V and VIII, remnant liver volume was sufficient. We considered that bile leakage could not be cured with either PTPE or bile duct ablation alone, because of the large volume of bile leakage more than 200 mL per day. The therapeutic strategy involved combination therapy of PTPE and bile duct ablation. First, percutaneous transhepatic cholangiography drainage (PTCD) tube was inserted to the bile duct of segment V. PTPE with coil embolization was performed to the part of the portal vein of segments V and VIII by puncturing the part of the portal vein of segment V. The liver volume of segments V and VIII was decreased from 260 to 123 mL after PTPE. After the PTPE, bile leakage decreased to about 50 mL/day. We confirmed that cholangiography via the PTCD tube showed the bile duct at segments V and VIII. For bile duct ablation, 1.2 mL pure ethanol was injected from the PTCD tube. Over 1.2 mL of ethanol leaked into the abdominal cavity. After ethanol injection, the PTCD tubes were clamped for 5 min. Then, another bile duct ablation with 2.0 mL of pure ethanol was performed 1 week after of the first procedure. After bile duct ablation, bile leakage has decreased from 50 to 10 mL/day gradually. The patient left the hospital, and he was rehospitalized and reinjected with 2.0 mL of pure ethanol for three times. The drainage tube and bile duct tube were removed on POD 139 (Fig. ). The clinical course is summarized in figure. Complications with combination treatment of PTPE and bile duct ablation were not noted. |
The patient was a 71-year-old male diagnosed with renal AL amyloid nephrotic syndrome in March of 2007 and underwent a stem cell transplant in December of 2007, obtained an organ response with urinary protein falling from 10.5 g/24 h to 1.5 g/24 h. The patient developed congestive heart failure in July of 2013 and underwent an endomyocardial biopsy that demonstrated amyloid. Proteomic typing demonstrated that this patient had TTR cardiac amyloid, and genetic studies demonstrated the TTR gene to be wild-type, so-called senile cardiac amyloidosis. He died at the age of 79 of progressive heart failure 39 months following the diagnosis of TTR cardiac amyloidosis. Comment: This patient had two types of amyloidosis. He had AL amyloidosis successfully treated and had not relapsed after 9.5 years but subsequently developed age-related cardiac amyloidosis that could have easily been misdiagnosed as relapsing AL if cardiac biopsy and proteomic analysis had not been done.\nOver 15 years ago, it was common to identify amyloid in a patient with a monoclonal gammopathy and assume that this was AL type. However, in 81 patients with TTR amyloidosis, an M protein was found in 20 of the 81 and an abnormal free light chain ratio in 8 of the 81. A second study of wild-type TTR amyloidosis also demonstrated a monoclonal protein in 25% of patients. Finally, even when AL is diagnosed with proteomic analysis, this does not indicate whether the amyloidosis is localized or systemic. Attention must be given, particularly to those patients who present with amyloid in a skin biopsy, bladder biopsy, laryngeal biopsy, or at the edge of a colonic ulcer or polyp, that the amyloid may be a localized AL amyloidosis that requires no intervention.\nMany specialists, when encountering a patient with biopsy of an organ containing amyloid, refer to a cancer care provider uncertain of the type of amyloidosis. The first step for all biopsied tissues, shown in an algorithm (Fig. ), would be mass spectroscopic analysis. In patients with AL amyloidosis, measurement of bone marrow plasma cells and FISH genetics, as would be done in multiple myeloma patients, are indicated. For staging purposes, one needs to know the NT-proBNP, troponin, and the difference between the involved and uninvolved immunoglobulin free light chain. If not already done, echocardiography or magnetic resonance imaging of the heart is required since the extent of cardiac involvement is important for prognosis. For patients with light chain amyloidosis in the absence of symptoms, the role of routine skeletal imaging, as is done in multiple myeloma, is not well defined due to a lack of high quality evidence.\nIf ATTR is identified by mass spectroscopic analysis, this patient should have presented with peripheral neuropathy or cardiomyopathy. The next step in evaluation would be pyrophosphate scanning of the heart (Fig. ). A strong positive scan would suggest that the amyloid is of TTR origin. Any patient with TTR amyloid should have gene sequencing of the TTR gene to distinguish wild-type TTR, as is seen in senile cardiac amyloidosis, from the very rare mutations of TTR that lead to inherited amyloidosis. Since familial amyloidosis is not treated with chemotherapy, these patients should be referred for genetic counseling, consideration of liver transplant, diflunisal or doxycycline therapy, or one of the expanded access programs for agents that suppress translation of liver TTR messenger RNA into the fully-formed TTR protein. Patients with wild-type TTR amyloidosis are usually over the age of 70, 90% are men, and half have carpal tunnel syndrome. Currently, there is no standard of therapy. Although the evidence is weak, trials of diflunisal and doxycycline should be considered (rationale discussed below).\nStaging of AL amyloidosis is based on a four-point system where one point is assigned for a DFLC > 18 mg/dL, a cardiac troponin T > 0.025 mcg/L, or an NT-proBNP ≥ 1800 ng/L. This provides a staging system of I, II, III, IV based on the number of points assigned (0, 1, 2 or 3). The staging system has been validated in multiple datasets, including patients treated with stem cell transplantation, patients on clinical trials, and non-transplant patients treated with standard chemotherapy. Other effective staging systems include a European staging system where Mayo 2004 stage 3 was sub-classified into 3 sub-stages using systolic blood pressure and NT-proBNP at 100 mm Hg and 8500 ng/mL, respectively and a model based on the number of involved organs, creating a 4-stage model (1 organ, 2 organs, 3 organs, 4 or more organs; organ model).\nThe first successful treatment for AL amyloidosis was melphalan and prednisone introduced in 1972. Autologous stem cell transplantation was reported in 1996. High-dose dexamethasone was introduced in 1997. Melphalan and dexamethasone was reported in 2004. There have been multiple reports on the use of thalidomide, lenalidomide, and pomalidomide, as well as combinations of IMIDs with alkylating agents, but IMIDs are poorly tolerated in patients, particularly those with cardiac AL amyloidosis. The first step in assessing therapy for an AL amyloid patient, as shown in an algorithm (Fig. ), is determination of their eligibility for stem cell transplantation. Using transplantation in AL amyloid is theoretically better than it is for multiple myeloma. Unlike multiple myeloma, the tumor mass being treated is less with a median of approximately 10% plasma cells at diagnosis and a median dFLC of only 24 mg/dL. Unfavorable genetics, seen in nearly a quarter of patients with multiple myeloma [such as 1q+, t(4;14), and −17p] are present in <5% of patients with light chain amyloidosis. The proliferative rate of plasma cells is lower in AL amyloidosis patients, suggesting that once a response is obtained, it is likely to be more durable than is seen in multiple myeloma. In fact, in the pre-novel agent era, ten-year survival of patients with AL amyloidosis undergoing stem cell transplantation was 43%. A prospective randomized trial of melphalan and dexamethasone with stem cell transplant also favored stem cell transplantation, although the comparator arm did not contain novel agents. With careful patient selection, the therapy-related mortality has been reduced to approximately 2%. Patients that do not achieve greater than a VGPR can have bortezomib-based consolidation post-transplant, which significantly upgrades treatment response post-transplant. A prospective randomized trial demonstrated an improved survival outcome with bortezomib-dexamethasone prior to stem cell transplant. The current policy at Mayo Clinic is to give induction chemotherapy for patients who have >10% plasma cells prior to proceeding to stem cell transplant (Fig. ).\nEven with the strong preference for autologous stem cell transplant, no more than 25% of newly diagnosed patients are eligible by virtue of age, renal function, and extent of cardiac failure. The remaining 75–80% are candidates for chemotherapy. Melphalan and dexamethasone demonstrates impressive survival in patients that are capable of receiving full-dose therapy with a median survival of just less than 8 years. There have been reports of cyclophosphamide-thalidomide-dexamethasone, lenalidomide-dexamethasone, melphalan-dexamethasone-lenalidomide, cyclophosphamide-lenalidomide-dexamethasone, but none of these are currently used in the Mayo Clinic algorithm due to toxicity and the preference for bortezomib. It should be noted that lenalidomide raises the NT-proBNP in AL patients. CyBorD or VCD (cyclophosphamide-bortezomib-dexamethasone) was first reported to be effective in 2012. In the original iteration, cyclophosphamide was given orally weekly, dexamethasone orally weekly, and bortezomib subcutaneously weekly. In this original trial, 17 patients were treated, 10 with symptomatic cardiac involvement with a 94% response rate and 71% complete response rate with an additional 3 patients who were previously deemed ineligible for stem cell transplant to become eligible. These results were validated in over 230 patients with AL amyloidosis, demonstrating a median survival in excess of six years, with all patients surviving in stage 1 disease and a median survival of less than one year in stage 4 disease. Survival was dependent on response depth, with patients achieving a VGPR or better having the best outcome. Achievement of a VGPR is used in the algorithm to determine whether second-line therapy should be considered. In using bortezomib-based therapy, one needs to be aware that response rate is poor in patients with t(11;14), a genetic abnormality seen in nearly 50% of patients with AL amyloidosis. The presence of t(11;14) should lead one to strongly consider stem cell transplantation over bortezomib, since this genetic abnormality does not have an unfavorable impact in transplanted patients. Predictors of early death after therapy initiation include the Mayo stage and greater than two organs involved. The value of cyclophosphamide when combined with bortezomib remains unproven.\nDaratumumab, approved for the treatment of relapsed multiple myeloma as a single agent as well as in combination with lenalidomide or bortezomib, clearly shows activity in the treatment of patients with AL amyloidosis and appears to have a low-toxicity profile. In 2017, 24 patients with light chain amyloidosis were reported, and only 5 failed to achieve a PR or better; 9 of the 24 achieved a complete response. ClinicalTrials.gov lists two phase 2 trials assessing daratumumab in the treatment of AL amyloidosis (NCT02841033 and NCT02816476). The combination of VCd and daratumumab is also recruiting as a phase 3 trial (NCT03201965).\nBecause of the high prevalence of t(11;14) in AL amyloidosis patients, Venetoclax, which has activity in multiple myeloma, particularly in those with the t(11;14), would be a natural candidate for the treatment of AL amyloidosis. It is given orally three days a week and does not appear to have cardiac toxicity. There is a phase 1 trial underway in patients ClinicalTrials.gov (NCT03000660).\nCarfilzomib, the second-generation proteasome inhibitor, has been tested. A high incidence of cardiac involvement with AL amyloid makes it a challenging agent to use. Traditional pre- and post-hydration can aggravate patients predisposed to congestive heart failure. Carfilzomib is associated with cardiotoxicity in nearly 10% of patients. A review of Medicare admissions presented at the American Society of Hematology showed that carfilzomib-treated patients had a higher risk of hospitalization. Hematologic responses have been reported, but its potential cardiotoxicity may be a barrier for wider implementation of this agent. Ixazomib has been the subject of a phase 2 trial with manageable toxicity and no cardiorespiratory toxicity (NCT01659658). A phase 3 trial of ixazomib-dexamethasone vs. physician-selected standard of care is underway (NCT01864018).\nDiflunisal plays no role in the treatment of AL amyloidosis but may play a role in the treatment of wild-type and mutant TTR amyloidosis by preventing destabilization of the TTR tetramer. A phase 3 trial demonstrated benefit in patients with mutant TTR neuropathy. Given its efficacy, it is a consideration off label for patients with wild-type TTR amyloid and TTR cardiac amyloid.\nDoxycycline has been used in patients with both AL and TTR amyloidosis with cardiac involvement. In vitro, doxycycline appears to disaggregate formed fibrils. A trial from Mayo Clinic demonstrated that patients who achieved a hematologic response to stem cell transplant had a significantly longer overall survival post stem cell transplantation when given doxycycline compared to those receiving penicillin. In a second study, which was case control, 26 patients receiving doxycycline were matched to 50 controls. The response rate was significantly higher in the doxycycline compared to controls, and the 12-month survival was 84 vs. 58%. Although there is no high-quality evidence and it has not been validated in a prospective randomized trial, doxycycline is a consideration if no other therapies are feasible.\nAlthough chemotherapy can effectively reduce the light chain burden and disrupt further deposition of AL amyloid, it does nothing for resident amyloid in tissues. Three monoclonal antibodies are undergoing studies now in patients with light chain amyloidosis that have derived maximal benefit from chemotherapy but have persistent organ dysfunction. The NEOD antibody was administered to a total of 69 patients. Among 14 cardiac evaluable, there were 8 responders. Among 15 renal evaluable, there were 9 responders. The manufacturer discontinued the development of NEOD001 for AL Amyloidosis because the Phase 2b PRONTO study did not meet its primary or secondary endpoints. In addition the Phase 3 VITAL study was discontinued based on futility analysis. The murine monoclonal antibody, 11-1F4, recognizes an amyloid-associated conformational epitope. In 26 patients, 8 were evaluable for organ response and 5 achieved this. No toxicity >grade 3 was recognized. This trial is ongoing. The third antibody approach is targeting serum amyloid P component, which has the potential to disaggregate the amyloid fibril. Pretreatment with Miridesap depletes serum amyloid P so that the antibody dezamizumab can access amyloid in tissues. This antibody may be applicable to all forms of amyloid, not just AL or TTR. It has been demonstrated to reduce the stiffness of the liver, and SAP scanning has shown regression of deposits. Amyloid fibril targeted therapy with monoclonal antibodies is promising for the management of all forms of amyloidosis. Dissolution of amyloid fibrils can improve organ function.\nIn AL amyloidosis, selected patients may successfully undergo renal or cardiac transplantation to assist with organ recovery. For patients that have single-organ involvement and control of the plasma cell proliferative process, organ transplantation may be considered. Stem cell transplantation can be safely performed in patients with dialysis-dependent renal failure. Failure to achieve a complete response is no longer considered a contraindication to organ transplantation because of the increased availability of therapeutic options and direct organ donor programs. Once the patient has an established complete response, consideration of renal transplantation may be undertaken. Cardiac transplantation has also been performed in patients with AL amyloidosis. However, most patients with advanced cardiac AL amyloidosis are not candidates for high-dose therapy and may tolerate standard-dose chemotherapy poorly. In these patients, it may be appropriate to do cardiac allografting and then follow with autologous stem cell transplantation. Long-term survivorship has been reported in highly selected patients who fulfill the criteria of deep hematologic response and single-organ involvement. Lenalidomide therapy is best avoided in organ transplant recipients that are considered for post organ transplant chemotherapy. |
Herein we presented the case of a 48-year-old male who presented to our emergency service due to ocular pain and blurred vision in his right eye. While cleaning an oven with a metallic brush, the patient felt a foreign body sensation in the right eye. Best-corrected visual acuity of his right eye was 0.9.\nSlit lamp examination of the anterior pole of the right eye revealed conjunctival congestion, watery discharge. Around 12 o’clock, a metallic foreign body was detected near the corneoscleral limbus, which perforated the cornea, the iris, the anterior capsule of the lens and the lens (). We could not perform the full examination of the posterior pole, so we could not establish the trajectory of the intraocular foreign body. Ocular B-scan was not performed because of the penetrating corneal wound. X-ray of the orbit did not offer enough details and computed tomography could not be performed at that time in our service.\nAfter performing an anti-tetanic prophylaxis, we decided to extract the intraocular foreign body by using a forceps. Since it had a helicoidal shape, we had to perform several circular movements (). We were surprised to find out that the wire that perforated the eye was almost 20 mm long (). We injected an antibiotic in the anterior chamber and placed a contact lens to protect the cornea and facilitate the healing of the point-like corneal wound\nOn the first day postoperatively, the slit lamp examination revealed a stable anterior chamber and a totally opacified lens with anterior capsule rupture. B-scan ultrasound showed no sign of vitreous haemorrhage and an attached retina. Visual acuity of the right eye was hand motion determined because of the traumatic cataract. We decided to extract the opacified lens. Due to the age of the patient, the lens was very soft so we performed its extraction with a blunt cannula under viscoelastic protection, with good results (). We noticed a posterior capsule break because the foreign body passed through the lens into the vitreous cavity. Surgical aphakia was corrected with an intraocular lens fixated to the posterior face of the iris. At one week follow-up, the best corrected visual acuity was 0.8 and the retina was attached. |
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 44 year old male presented on account of bradycardia (44 beats per minute) which he observed while routinely checking his blood pressure at home with a digital sphygmomanometer. He had been otherwise asymptomatic for cardiac diseases from childhood. On physical examination, he had a regular pulse of 64 beats per minute with a few missed beats. Cardiac auscultation was normal. The resting 12 Lead electrocardiogram showed normal sinus rhythm with atrial ectopics (Heart rate of 70 beats per minute). Biochemical and haematological profile were unremarkable.TTE showed an abnormal membrane bisecting the left atrium (LA) into two chambers []. In the parasternal long axis view, this membrane ran parallel to, and a short distance behind the aortic root and then curved anteroinferiorly to insert some distance away from the mitral valve ring. This membrane was seen bisecting the LA at the atrial appendage in the apical four chamber view. It was difficult to image the whole of the membrane on a freeze frame analysis. The M mode Echocardiographic appearance of the membrane revealed a linear echo lying anteriorly within the LA, behind the aortic root. This echo shows a movement resembling a stenotic mitral valve. Doppler evaluation did not show any intra-atrial gradients. Both atria were not dilated and the pulmonary veins did not have abnormal flow velocities.\nA ridge of tissue was seen inserting into the lower portion of the interatrial septum adjacent to the atrioventricular valves, and partially divided the right atrium (RA) into two chambers -the superior and inferior compartments []. The origin of this tissue was in the region of the ostium of the inferior vena cava. This is most likely a very prominent Eustachian valve (EV) resulting in an appearance of a Cor triatriatum dextrum. The valve was immobile during the different phases of the cardiac cycle and no obstruction to flow was demonstrable at the level of the EV. The estimated pulmonary artery systolic pressure was 25 mmHg and the main pulmonary artery was not dilated.\nThe remaining valves were normal and there were no other associated cardiac defects.\nThe patient was placed on antiplatelet prophylaxis (Aspirin 75 mg daily). |
A 38-year-old Middle Eastern woman presented with a slowly enlarging abdominal mass of 12 years duration. According to the patient, a surgeon had attempted to resect the mass 12 years earlier, but could not do so due to excessive bleeding from the tumor. She was offered no further treatment.\nAt presentation, her main complaint was epigastric discomfort. She also gave a history of some mild back pain and occasional abdominal pain. Her appetite was good and she had not lost weight. There was no history of vomiting, change in bowel habits or melena. She had been diagnosed with a peptic ulcer many years ago.\nOn examination she looked healthy with no clinical jaundice or pallor. Abdominal examination revealed a large upper abdominal mass with thinned overlying skin. It had minimal mobility and was not tender. The rest of the examination was normal. Her hemoglobin level was 10.8 g/dL, with hypochromic microcytic red blood cell indices. Otherwise, all blood tests were normal. A computed tomography (CT) scan of the abdomen revealed a 20 cm retroperitoneal mass in the region of the head of the pancreas (Figure ). It appeared to push and stretch the surrounding structures. There was no evidence of metastases to the liver or lung. Upper gastrointestinal endoscopy was performed, showing a 2.5 cm ulcer in the second part of the duodenum with a clot at its center. There was no intraluminal mass. A deep biopsy was taken, but was not diagnostic.\nTumor embolization was planned to decrease tumor vascularity before resection. Angiography revealed that the hepatic artery was the main feeding vessel; however, embolization was not possible because the celiac axis was kinked and the catheter could not be advanced into the feeding artery. After preparation she was taken to the operating theater. A midline incision over the previous scar was performed. The tumor was very vascular with large venous tributaries draining into the portal circulation. It lay posterior to the pancreatic head and duodenum, pushing them anteriorly. A pancreaticoduodenectomy (Whipple procedure) was performed with the dissection kept outside the pseudocapsule of the tumor, taking care not to rupture the tumor. The patient tolerated the procedure well and had an uneventful recovery. Histopathological examination revealed a 22 cm tumor arising from the second part of the duodenum. The tumor showed moderate cellularity and mildly atypical spindle cells arranged in fascicles with a low mitotic count (1/50 high power field) and no necrosis (Figure ). Prominent skeinoid fibers were seen. The tumor was negative for c-kit, SMA and S100 protein, but positive for CD34. Although it was c-kit negative, the features were consistent with the diagnosis of GIST. The tumor was considered of high malignant potential because of its size. Imatinib mesylate (IM) was considered as an adjuvant treatment but the patient could not afford it. She continued to do well, however, and was free of any recurrence the last time she attended the clinic, 34 months after the operation. |
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 69 year-old male patient was admitted with difficulty urinating and nocturia for 3 months. The digital rectal examination did not indicate any hardness or nodules of the prostate, and an abdominal ultrasound revealed an enlarged prostate and the prostate specific antigen (PSA) value was normal. Fourteen months prior to this admission, he had undergone video-assisted thoracic surgery for the wedge resection of left upper lung lobe due to the left upper lung mass found in chest CT scan (), and pathology revealed infiltrating lung adenocarcinoma with T2N0M0 staging (). Re-examination of chest CT on this admission indicated no evidence of disease recurrence after lung lesion resection (). Then the patient was diagnosed with benign prostatic hyperplasia (BPH) and received holmium laser enucleation of the prostate, an effective transurethral procedure to treat bladder outflow obstruction due to BPH. The pathology revealed benign prostate hyperplasia as expected. Four months after surgery for BPH, the patient had no improvement in symptoms and continued to complain of dysuria and perineum pain. Urinalysis was negative for infection and PSA was not elevated, however an MRI of the pelvis indicated posterior urethral mass without any regional lymphadenopathy or other sites of lesion. Urethrocystoscopy under general anesthesia found the mass in the membranous urethra near the verumontanum (), and transurethral loop electrosurgical excision was conducted to remove the mass. Due to the infiltration of tumor into normal urethral tissue, the transurethral operation aimed to resect as much tumor tissue as possible, so as to facilitate pathological diagnosis, but it was difficult to guarantee negative margins. Routine hematoxylin and eosin stained sections indicated adenocarcinoma () and further immunohistochemical staining showed negative PSA, positive thyroid transcription factor 1 (TTF1) and Napsin A, confirming the urethral metastasis of lung adenocarcinoma. To identify the latent metastases to other sites and recurrence from primary lung adenocarcinoma, the patient underwent brain MRI, chest CT, abdominal ultrasound and emission computed tomography for whole-body bone scan and received negative results, suggesting isolated urethral metastases. The patient was restaged as T2N0M1 of lung adenocarcinoma, and chose 6 courses of systematic chemotherapy (pemetrexed combined with nedaplatin) plus bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor at 3 weeks intervals. The therapeutic regimen was well-tolerated, and obviously relieved the patient from dysuria and perineum pain. |
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 54-year-old Caucasian male presented with eight-month history of progressively worsening shortness of breath. Five years before, on a routine physical examination, he was found to have a harsh systolic murmur along the left upper sternal border for which he underwent a transthoracic echocardiogram (TTE). The TTE showed mild systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient. A definite septal abnormality could not be excluded based on the TTE. Subsequently, he underwent a cardiovascular magnetic resonance imaging (CMR) to characterize the lesion and was found to have a basal anterior septal mass measuring 15.2 × 5.9 mm. The signal intensity by T1 and T2 was consistent with fatty tissue. Moderate LVOT acceleration was also noticed in the vicinity of the septal mass. The LVOT gradient was further evaluated by an exercise stress echocardiography which demonstrated a resting LVOT gradient of 10 mmHg that significantly increased to 69 mmHg at 79% of maximal predicted heart rate and returned to baseline at a heart rate of 88 bpm. It also showed a significant bileaflet systolic anterior motion of mitral valve at peak heart rate as compared to the baseline without any significant mitral regurgitation. No intervention was performed due to lack symptoms and good functional capacity. He was followed up with a CMR every other year, which showed small increments in size but he remained clinically asymptomatic.\nEight months prior to this report, he started experiencing dyspnea with exertion which progressively worsened. During this presentation his cardiac examination demonstrated a loud crescendo-decrescendo 5/6 systolic ejection murmur along left sternal border that worsened with Valsalva. A TTE was performed which demonstrated the previously visualized nonmobile septal mass () and a trace mitral regurgitation. It also demonstrated a marked increase in the peak systolic pressure gradient across the LVOT reaching 246 mmHg with Valsalva compared to the previous echo (). His blood pressure on that day was 142/60 mmHg. Taking this into account his left ventricular peak systolic pressure was >350 mmHg. There must have been a component of contamination by the mitral regurgitation, but irrespective of that he undoubtedly had a significantly high pressure gradient across the LVOT. For better tissue characterization, a CMR was repeated which demonstrated an interval increase in the size of mass to 21 × 7 mm (). Postgadolinium images did not show any evidence of uptake and there was no involvement of the subendocardium or the valves. It also showed a moderate mitral regurgitation with posteriorly directed jet along with LVOT turbulence.\nThe patient was referred for surgical evaluation and he underwent a surgical resection of the mass via transaortic approach. Intraoperatively the mass was identified as a fibrofatty tissue, which was resected without any complications. His postoperative course was uneventful. His symptoms significantly improved after the surgery permitted him to resume work.\nHistopathological examination of the excised specimen showed benign hypertrophic myocardial muscle cells which revealed variation in the size and shapes of the nuclei. These myocytes were dispersed in between unencapsulated mature adipocytes with vacuolated cytoplasm. There were no mitotic figures or signet ring structures and the adipocyte nuclei were not hyperchromatic or indented, which ruled out liposarcoma (Figures : low power and : magnified).\nAt the two-month follow-up visit he felt exceptionally well and had resumed all his activities without any limitation. A repeat echocardiogram showed a resting pressure gradient of 7 mmHg () and peaking at 33 mmHg with Valsalva maneuver () that was significantly improved from the presurgical gradient of 246 mmHg. |
A 20-year-old male was referred to our clinic due to a gradual increase in pain along with swelling in his right knee. These symptoms had first appeared 1 year earlier and had worsened during the previous 3 months. Five years prior to presentation, he underwent a curettage and cavity filling cementation with polymethyl methacrylate (PMMA) cement for a chondroblastoma of the proximal tibia at another hospital. His postoperative course was uneventful and he continued to work at his job and performed light exercises comfortably. Approximately 5 years after surgery, the patient reported insidiously progressive knee pain with restricted range of motion, as well as intermittent clicking at various knee positions. He had no history of major knee trauma.\nPhysical examination revealed moderate swelling and pain around the knee joint without heating. The range of knee motion was restricted to an extension of -15° and a flexion of 110°. Wasting of the quadriceps muscles was observed. Plain radiographs showed no evidence of local tumor relapse, but suggested intra-articular extension of PMMA. Computed tomography (CT) of the knee showed protrusion of cement into the knee joint through a broken subchondral bone and articular cartilage in both the medial and lateral tibial spines of the tibia and scraping of the lateral aspect of the intercondylar notch (). Arthroscopy revealed a full-thickness loss of articular cartilage in the area of the lateral tibial spine, the absence of subchondral bone, and a sharp bump of the exposed PMMA cement from the previous surgery, with bony erosion of the lateral wall of the intercondylar notch ().\nThe patient was treated by debridement of the articular cartilage remaining on the area of the lateral tibial spine, followed by shaving off and contouring of the PMMA cement bump with an arthroscopic burr to prevent scratching of the lateral surface of the intercondylar notch (). The cement that protruded above the articular cartilage of the tibial plateau was removed carefully, so as not to destroy the cement bump that filled in the subchondral cavity below the surface of the articular cartilage of the tibial plateau. Remnant cement debris created by burring was avoided by using the outer sheath of the shaver from which the blade had been removed. The cement debris was swept away in the irrigation fluid flowing from the knee joint through the hole of the outer sheath of the shaver. Postoperative CT showed that the cement bump had been removed (). Postoperatively, the patient was allowed to bear weight as tolerated with crutches and without limiting knee motion. At first follow-up on postoperative day 7, the patient showed full knee motion without pain. At 26 months, the patient showed maintenance of full knee motion and was pain-free. |
The patient was a 19-year-old woman who was born with a scalp defect. The defect healed after conservative wound management early in her life. She had no specific medical history and no signs of neuropsychiatric problems. Neither her parents nor brothers had dermatologic or systemic problems.\nShe first visited our clinic for evaluation of her scalp lesion 10 years ago, when she was nine years old. The scalp lesion had been replaced by fibrotic tissue and appeared to be an atrophic alopecic patch (). Examination of skin biopsy specimens from the scalp showed an irregularly thickened epidermis, atrophic dermis with upward extension of the subcutaneous tissue, and mild fibrotic changes and loss of periadnexal structures (). A diagnosis of aplasia cutis congenita was made based on clinical and histologic features.\nDuring the 10 years after her last visit, atrophic and nodular skin changes on the right side of the trunk and limbs began to appear and become progressively more prominent, while the syndactyly of the right fourth and fifth toes, which had not been identified previously, was negatively influencing her quality of life. Thus, the patient returned to our clinic and a complete physical examination of the body was performed. We identified multiple, variously sized, and well-demarcated atrophic patches that were mostly confined to the right trunk and leg (). Some lesions appeared as brown or yellow protruding masses, and were accompanied by deposited and herniated fat tissue. The atrophic patches and protruding masses were arranged in a linear fashion following Blaschko's line. We observed only a few atrophic patches on the patient's left leg. We also noted the syndactyly of the right fourth and fifth toes ().\nA skin biopsy from the right calf revealed prominent dermal atrophy and extension of subcutaneous fat toward the upper dermis (). Focal dermal hypoplasia, also known as Goltz syndrome, was diagnosed on the basis of clinical and histologic findings. Because most of the skin lesions were confined to the right side of the body, the focal dermal hypoplasia in this case was identified as the almost unilateral form.\nBecause the patient complained of discomfort from syndactyly of her right fourth and fifth toes, we referred her to the Department of Plastic and Reconstructive Surgery to surgically manage this condition. |
A 56-year-old Caucasian woman presented with a 4 cm in diameter lump in her left breast. She had a screening mammogram done 3 years earlier which was reported as suspicious but the patient did not seek medical attention for this period. She was otherwise fit and well without any significant past medical history. She was not on any medications and did not have previous admissions to a hospital. She did not have any family history of any form of cancer.\nThe patient underwent a triple assessment for the breast lump which was found to be suspicious in both the clinical and imaging investigations.\nThe mass was confirmed to be a grade II invasive ductal carcinoma on core biopsy which was strongly positive for estrogen (ER) receptors while it was negative for progesterone (PgR) receptors. The tumor was HER-2 negative.\nDuring pre-treatment, staging investigations, which included computerized tomography (CT) scan of the chest and abdomen, she was found to have a 13.5 cm mass in her left ovary, a small amount of ascites and a large right pleural effusion. The pelvic ultrasound showed a 13.5 cm × 10 cm × 8 cm hypo-echoic ovarian mass with an irregular necrotic, also hypo-echoic central area and moderate amount of ascitis.\nConsidering the common presentation of ovarian carcinomas with similar picture and the association of breast cancer with ovarian carcinomas, initially the ovarian mass was thought to be metastatic as was the pleural effusion. Serum tumor markers showed a raised CA125, (59 u/ml with normal values < 24) supporting the malignant nature of the ovarian mass. The pleural effusion was aspirated but cytology was indeterminate. Aspiration of the pleural effusion caused a pneumothorax. Due to persistent fluid drainage through the chest tube, the patient eventually underwent thoracoscopic pleurodesis with simultaneous biopsy of the pleura, 6 months after diagnosis. The pleural effusion did not recur after this procedure and the pleural biopsy taken at the time showed no malignancy. The patient from the beginning was strongly against mastectomy and she was commenced on neo-adjuvant Letrozole 2.5 mg daily with a view to perform breast conserving surgery later. The breast cancer became impalpable within 1 year and continued to respond to Letrozole. Meanwhile, regularly repeated pelvic ultrasounds initially showed a reduction of the ovarian mass size (Fig ), which had an irregular necrotic area in its centre (Fig ), and then an unchanged picture (Fig. and ) without any progression of the disease. Repeated CA 125 values showed a decline and subsequently a normalization of the value (15 u/ml) during the following 3 years. All these changed our initial impression about the malignant nature of the ovarian mass and the extent of the breast cancer. Since, the breast cancer size plateau at 1 cm and 3 years after the diagnosis the patient was advised and persuaded to have some surgery. She only agreed to have wire – guided excision of the breast primary lesion, sentinel node biopsy and axillary sampling. Despite the indication for hysterectomy and bilateral salpingo-oophorectomy, the patient declined extensive procedures and agreed only to have the ovarian mass excised laparoscopically. During the laparoscopy there was no residual ascitis, the ovarian tumor was mobilized laparoscopically and removed through a small Pfannestiel incision extending horizontally to the left of the midline only.\nHistological examination of the 11 cm firm, solid ovarian mass (Fig. ) confirmed the presence of a benign ovarian fibroma. Her breast cancer was completely excised with good margins but the sentinel lymph node contained metastasis while 2 of 4 sampled nodes contained isolated tumor cells on immunohistochemistry. Since the patient declined axillary clearance, she was referred for post-operative radiotherapy to the breast and axilla. The CA 125 remained within the normal range postoperatively (15 u/ml). |
The patient is a 33-year-old female patient with personal history of NF1 (without any family history in the two previous generations) characterized by multiple Café au lait macules and multiple neurofibroma nodules in distinct regions of the skin which involve the scalp, neck, back, abdomen, and all the extremities.\nThe patient has a normal evolution of her disease with no incidents; she is an independent professional and refers no other symptomatology. Eventually, she complains of pain due to the mechanical compression of one of the neurofibromas. After considering the genetic counseling, the patient decides to get pregnant. During the second trimester of her pregnancy, she started to note gradual and progressive growth of one of the neurofibromas located in the anterolateral left portion of the neck, in the angle formed by the thyroid gland and the common carotid artery. Such growth gradually increased to the point where by the end of the pregnancy it had a diameter of approximately 10 cm × 15 cm, it made swallowing difficult, dysphonia, and generated local pain (nonneuropathic pain) []. The consistency was smooth in the peripheral contours, but firm in the center, mobile, and no skin changes were noted. She has an uneventful full term pregnancy with a C-section delivery.\nAfter neuroimaging evaluation, a surgical approach is decided 3 months after the C-section using general anesthesia and microsurgical dissection. A tumor mass was identified, with a superficial wall, free from vascular or cervical major nerve structures, with a clear serous liquid content that after decompression, modifies the tumoral morphology immediately, allowing identification of the layers of the cystic lesion. The visceral portion of the capsule was found attached to the external plane of the thyroid gland and to the carotid artery adventitia, which was preserved. The postsurgical evolution was normal, without any complications. There were no alterations regarding phonation or deglutition, and there was a normal recovery of the external anatomy of the neck without any evidence of tumoral mass. The analysis of the fluid reported no cytological alterations and culture was negative for infection. The hematoxylin and eosin stain shows the presence of neoplastic cells, nuclear and diffuse cytoplasmic positivity to S-100 protein []. |
A 67-year-old woman presented to our hospital with undifferentiated carcinoma of the thyroid gland with local metastasis to neck lymph nodes that was diagnosed based on needle biopsy outside our hospital. The patient presented with no other remarkable symptoms while she had few past medical histories. The tumor size was large enough to raise suspicion of skin involvement during her evaluation at the referring hospital. She was then referred to our hospital due to skin involvement and the need to sacrifice the surrounding large vessels, such as the right common carotid artery and right subclavian artery and vein, during tumor resection and total thyroidectomy (Fig. ). At first, various flaps such as the DP flap, the pectoralis major myocutaneous flap, the latissimus dorsi flap, and free flaps were considered as candidates for reconstruction of the skin defect. We decided against using a pectoralis major myocutaneous flap because a portion of the right subclavian vein, brachiocephalic vein, and proximal portion of the right internal thoracic artery and vein would have to be sacrificed with dissection of the right neck and paratracheal lymph nodes, while salvaging the right common carotid artery (Fig. a, b). The right DP flap was likely to be excluded as an option before pulsation of the second intercostal perforator artery was confirmed using a Doppler stethoscope. Ultimately, the DP flap was designed and elevated in the usual manner because the 2nd and 3rd intercostal perforator arteries were detected by the Doppler stethoscope. Bleeding from the distal edge of the flap was enough to confirm blood supply of the flap, even after sacrificing the branch of the thoracoacromial artery, and the flap was elevated completely. A portion of the skin on the right side of the neck was undermined and used as a skin flap, followed by setting of the DP flap, which allowed for the airtight closure of the skin defect (Fig. c-e). A portion of the donor site of the DP flap was covered by a meshed skin graft taken from the lower left abdomen. The postoperative clinical course was uneventful to hospital discharge. Because the pathological diagnosis was undifferentiated carcinoma of the thyroid gland, chemoradiotherapy was administered, with no adverse effects. There were no signs of recurrence or metastasis 2 years postoperatively, while the range of motion of the right shoulder improved and no scar contracture developed around the skin graft (Fig. , Additional file : Figure S2 and Additional file : Figure S3). |
A 38-year-old woman, gravida 1, was referred to our hospital for further evaluation of a pharyngeal cyst of the fetus at 35 weeks gestation. Prenatal ultrasonography showed that the fetus had a 3 × 2×2 cm hypoechoic simple cystic mass in the pharyngeal region, without signs of internal blood flow by Doppler examination (Fig. and ). Amniotic fluid volume was normal. Fetal MRI at 35 weeks gestation indicated the presence of a 3 × 3×2 cm simple cystic mass on the left side of the posterior pharyngeal gap, a mass that showed marked extrinsic compression of the airway (Fig.). A prenatal diagnosis of pyriform sinus fistula was made on the basis of these findings. There was no family history of congenital malformation.\nThe prevention of asphyxia at birth was of such importance that the mode of delivery was discussed extensively, with combined input from obstetrics, neonatology, anesthesiology, and pediatric surgery. The ex utero intrapartum treatment (EXIT) procedure was adopted to manage airway access at birth. The cesarean section was performed at 37 weeks of gestation under deep maternal and fetal anesthesia. The fetus was delivered via the EXIT procedure, and the endotracheal tube was placed to establish the airway in the first attempt. Direct laryngoscopy showed a mass that demonstrated extrinsic compression of the airway at the level of the larynx. At that time, an opening of the pyriform sinus fistula was not observed. A male neonate weighting 2684 g, with Apgar scores of 5 and 6 at 1 and 5 min, respectively, was delivered with no apparent neck mass or visible cutaneous sinus.\nThe neonate was admitted immediately to the neonatal intensive care unit. On admission, ultrasonography showed a well-circumscribed hypoechoic mass lying adjacent to the left lobe of the thyroid. Six hours after birth, MRI indicated the presence of a 4 × 3×1 cm simple cystic mass in the left side of the posterior pharyngeal gap. This cyst compressed the airway mostly at the level of the oropharynx, but did not show complete airway obstruction (Fig.). Although the endotracheal tube was removed the next day, the neonate showed signs of respiratory distress, which was managed by continuous positive airway pressure (CPAP).\nOn the ninth day after birth, computed tomographic scan showed an expanded cyst filled with air, indicating communication with the pharyngeal cavity, which marked extrinsic compression of the upper airway. The infant was taken to the operating room. The diagnosis was confirmed by preoperative laryngoscopy and catheterization of the fistula. A left cervical transverse incision was performed, and the pyriform sinus cyst and entire fistulous tract were excised. Histopathological examination showed that the cyst was lined with ciliated epithelium with adherent thyroid tissue. The postoperative course was uneventful. The infant was discharged 10 days after the operation having completely recovered. |
The second case concerns a 50-year-old Caucasian man who was admitted to our clinic after a CT scan in an external hospital indicated suspicion of an acute occlusion of the SMA. Primary CT scan findings are shown in Figure . The patient presented with severe abdominal pain and vomiting. On reviewing the patient's medical history, it was discovered that he had a colitis ulcerosa, first diagnosed one year previously. In September 2013, the patient underwent a sigma-resection with the creation of a descendostoma resulting from a covered perforated sigma diverticulitis. At that time, thrombosis of the inferior mesenteric vein and a branch of the portal vein could be seen and as a result, anticoagulation with Rivaroxaban was initiated and has been maintained ever since.\nInitial blood tests showed elevated CRP and leukocytes, whereas serum lactate level was within normal range. Following admission to the emergency room, the interdisciplinary decision was made to transfer the patient immediately to the operation theater, as clinical symptoms made a bowel infarction likely. We resected the dissection membrane from proximal SMA to the first arcade artery. Reconstruction was done using a saphenous vein patch. Macroscopic observation showed no signs of intestinal infarction; thus, intestinal resection was not necessary. Postoperative, the patient was admitted to the ICU with an abdomen apertum. Anticoagulation was managed using intravenous heparin and an aPTT of 50-70 seconds. In due course, medication was changed to platelet inhibition with acetylsalicylic acid.A control CT scan was performed on the first day following the operation. Adequate intestinal perfusion could be seen with no signs of bowel infarction, as was verified by a second look laparotomy. Figure shows the representative findings of the control CT scan. A colonoscopy five days after the operation was able to exclude intramural ischemic lesions and abdominal pain was already absent at this time. In due course, negative wound pressure therapy was performed with wound dressing changes at intervals of four days. It was possible to cover the abdomen and to bridge the fascia defect using a Vicryl mesh; thereafter, a definite closure could be performed.\nFollowing the operation the patient needed a bowel rest, nasogastric suction and intravenous fluid therapy. We were able to initiate a light diet after the complete resolution of abdominal pain and eventually return the patient to a normal diet. The bridging of nutritional support was required. The patient could be mobilized and will perform postdischarge rehabilitation. |
Clinical details are shown in the family pedigree chart [].
A 68-year-old female scientist presented with asymptomatic multiple firm subcutaneous nodular lesions over both the upper extremities since two decades. She gave history of frequent falls since childhood, either due to sudden inversion of left foot or sudden flexion of left knee.
She had also suffered from sprain of her left foot on many occasions and a fracture of 5th metratarsal bone at 23 years of age. Her first child was born at eight months due to premature rupture of the amniotic membrane.
There was history of frequent subluxation and mild dislocation of her right shoulder joint associated with occasional pain since 20 years. She had an accident due to sudden inversion of her left foot with subsequent fracture of both tibia and fibula with crushed left medial malleolus, which was surgically corrected. Apart from a meniscal tear of her left knee joint a few months back, she also had a recent fall with fracture of middle phalanx of left 3rd toe.
She was highly myopic since childhood and recently underwent cataract surgery in both eyes, corrected with IOL. She was neither a diabetic nor a hypertensive.
She was of average height and slightly obese. General and systemic examinations revealed no abnormality. No hyper mobility of the joints was seen. Mild hyper extensible skin was present over her forearms and dorsa of the hands.
Gorlin sign was positive []. Multiple painless and non-tender firm mobile subcutaneous nodules of various sizes ranging from 1 cm to 2 cm were present over her upper extremities, mostly over the lateral aspect of her right arm and flexor aspect of her right forearm. These were only palpable nodules and not visible lesions, suggestive of spheroids. Telangiectasia and superficial veins were seen through the apparently thin translucent skin above both knees. She had an asymptomatic piezogenic pedal papule on her right heel.
Routine blood and urine examination were normal. GTT revealed impaired glucose tolerance. Lipid |
A 49-year-old male patient reported to the department of Oral and Maxillofacial Surgery, Government Dental College, with a painless sessile growth of size 2 × 3 cm on the lingual attached gingiva in relation to mandibular incisors of one month duration. Clinically, only four mandibular anterior teeth were present which includes left incisors, right central incisor, and canine. Rest of the teeth were extracted due to chronic generalized periodontitis. Clinical examination revealed the lesion to be soft to firm in consistency with no bleeding on probing. Grade 3 mobility of anterior teeth was found except for the left lateral incisor which was grade I mobile. The overlying mucosa appeared blanched and no evidence of ulceration was noticed. Oral hygiene was poor.\nRadiographic examination showed extensive bone resorption in relation to the mandibular anterior (left lateral incisor to right lateral incisor) region with a floating tooth appearance []. A tentative diagnosis of pyogenic granuloma was suggested by the oral surgeons as there were no other symptoms. All the teeth with grade 3 mobility were extracted and the lesion was excised.\nAfter 20 days of initial excision, the patient came back with the presentation of recurrent lesion at the same site, i.e. on the gingiva in mandibular anterior teeth region in the extracted area [] along with two other similar looking lesions on palate close to the alveolus on the left side in the molar region and in the maxillary tuberosity area on the same side []. On examination, the lesions were reddish in color, firm in consistency and bleeding on probing was also noticed. Submandibular and sublingual lymph nodes were enlarged and fixed, but no involvement of the supraclavicular, superficial and deep cervical lymph nodes. Patient was also complaining of weight loss and dull radiating pain in the left shoulder. Medical history revealed nothing.\nOn routine investigation, hemoglobin was seen to be reduced by two units over a period of 20 days.\nOrthopantomogram revealed bone loss in the edentulous alveolus in relation to lower left and right incisor area and left canine – premolar region []\nAll the three lesions were excised in the department of oral surgery and sent for histopathological examination. On gross examination, there were three bits of firm consistency; light brown in color. Size of the larger bit was 1.5 × 1 × 1 cm, and two smaller bits of size each 1.5 × 0.5 × 0.5 cm.\nHistopathological examination of all the received specimens was done. Two out of three bits showed stratified squamous epithelium overlying connective tissue, which appeared torn at places which was thought to be a processing error. Underlying connective tissue showed some atypical cells with granular cytoplasm which were arranged in alveolar pattern. Large atypical hyperchromatic cells and some clear cells with nucleus pushed to one side were also seen. None of the cells had any resemblance to the native cells of oral mucosa []. The other two bits showed features of granulation tissue. The histopathological report was suggestive of metastatic malignancy. but we could not pinpoint the origin of the cell.\nPatient underwent human immunodeficiency virus (HIV) test to rule out any HIV associated tumor, but it came negative. Other differential diagnoses were malignant minor salivary gland neoplasm, angioproliferative lesions, melanoma, and lymphoma. To rule out malignant salivary gland neoplasm, immunohistochemistry using P63 was done which again came negative. Immunohistochemical (IHC) markers, leucocyte common antigen (LCA) and CD 34, were used to rule out lymphoma and angioproliferative lesions, respectively. To rule out metastasis from lung and thyroid, thyroid transcription factor (TTF-1) was used which also came negative. Immunohistochemistry for cytokeratin showed focal positivity [] which suggested metastasis from kidney or gastrointestinal tract (GIT) or lung.\nUltrasound of chest and abdomen showed hyperechoic bilateral adrenal mass. X-ray chest suggested a homogenous opacity in the apex of left lung [] with destruction of underlying ribs. Right lung appeared clear. X-ray was suggestive of Pancoast tumor. Computerized tomography (CT) scan of chest and abdomen with IV contrast revealed an irregularly and poorly enhancing soft tissue density mass in the apico-posterior segment of left upper lobe of size 6.2 × 5 cm []. Involvement of the pleura and left second rib posteriorly was noticed. Left apical soft tissue mass lesion measuring approx 7 × 5 cm with destruction of the adjoining posterior aspect of left rib was also noted. Surrounding pneumonitis was present. The picture was suggestive of a primary in the lung. Well defined poorly enhancing areas were noted in the aorto pulmonary window and left hilum suggestive of enlarged lymphnodes of size 3 × 2 cm. A left suprarenal mass was noted of size 5 × 3.2 cm []. Right adrenal gland was also enlarged. There was no pleural effusion. Thyroid, trachea, bronchial tree, heart, and vascular structures appeared normal. Liver, biliary radicles, and spleen were appearing normal. There was destruction of sternum, mid dorsal vertebral body, and pedicle.\nCT scan of head and neck region revealed destruction of left alveolar process with enhancing soft tissue component. There was destruction of floor of the left maxillary sinus with soft tissue component into it []. Infiltration into anterior aspect of left pterygoid and masseter muscles was noted. Multiple enlarged bilateral level IA, IB, and II nodes were noticed. A cyst measuring 1.3 × 1 cm was noted within median glossoepiglotic fold.\nThe lesion was diagnosed as bronchoalveolar carcinoma of the left lung metastasized to bilateral adrenal glands and multiple sites in the oral cavity. Patient was referred to the Regional Cancer Centre, Trivandrum, for further treatment. Though chemotherapy was instituted, the patient died after nine months of initial diagnosis. |
A 50-year-old Native American female presented to the ER with a bladder infection, and a urine culture grew E. coli. She was treated with trimethoprim/sulfamethoxazole and developed a diffuse rash including the palms and soles. There was no lymphadenopathy present upon physical exam. One month later, she presented to the clinic with a month of severe pounding headaches, blurry vision in the right eye, and pain over the temporal area on the right side. Her ESR was elevated with a normal CRP. The suspected diagnosis was giant cell arteritis, and she was started on 60 mg of oral prednisone daily that helped the headaches. A temporal artery biopsy was done and showed no evidence of vasculitis. The patient was tapered from the steroid and started having progressive blurry vision and floaters. Three months later, the patient presented to the emergency department and was admitted to the hospital due to the blurry vision and floaters at which time she had a positive fluorescent treponemal antibody absorption test. She was HIV negative. The patient had a Venereal Disease Research Laboratory test of the cerebral spinal fluid done which came back negative. Her cerebral spinal fluid cell count was 178 nucleated cells with 164 lymphocytes, and protein was 53 mg/dl. She had a serum rapid plasma reagin titer of 1 : 1024. She was diagnosed with secondary and early neurosyphilis for which she was started on 24 million units per day of IV penicillin G, and severe uveitits for which she was started on 60 mg of oral prednisone and 1% prednisolone acetate eye drops. The uveitis was likely secondary to the syphilis infection. A CT scan of the head showed four osseous lesions (Figures –). An immunohistochemical stain of a skull biopsy was done which came back positive for Treponema pallidum, thus confirming syphilis as the cause of the bone lesions. An echocardiogram was performed which did not show any significant cardiac defect. The patient completed 14 days of 24 million units per day of IV penicillin G, and there was no evidence of a Jarish–Hexheimer reaction. Upon follow-up, the patient still complained of blurry motion, but denied a headache or skin rash. The eye exam showed improvement and showed no signs of ocular syphilis. Four months after discharge from the hospital, her blood rapid plasma reagin titer was 1 : 256 that is more than a fourfold decrease from her baseline, and a CT scan of the head showed the osseous lesions were unchanged from the previous CT scan. Three months after her previous follow-up, her serum rapid plasma reagin titer was 1 : 128. A repeat lumbar puncture showed 18 nucleated cells with 16 lymphocytes, and protein was 42 mg/dl. A repeat Venereal disease research laboratory test of the cerebral spinal fluid was done and came back positive with a 1 : 8 titer that was negative on the previous exam, which is hypothesized to be a false negative result. The patient was lost to further follow-up. |
A 29-year-old white female patient who suffered from palpitation was referred to Quaem Hospital for further evaluation. The patient's vital signs at the time of admission indicated an O2 saturation level of 98% prior to receiving oxygen therapy, while all other vital signs appeared normal.\nThe patient's electrocardiography revealed normal sinus rhythm, short PR interval, and delta wave.\nTransthoracic echocardiography results showed normal left ventricle size and systolic function with mild CS dilation. A pulsatile echo-free space was observed at the interventricular septum base and posterior side of the left ventricle indicating a maximum diameter of 1.96 cm × 1.33 cm [ and Movie 1] which was connected through isthmus to the CS. Two-dimensional and color flow Doppler study results indicated that CS connection to the right atrium appeared to be atretic. The diagnosis was further confirmed using agitated saline injection. We did not observe any air bubbles entering from the right atrium into the CS during the agitated saline injection procedure [].\nThe accessory pathway electrophysiology procedure at the time of CS cannulation was challenging. Therefore, we elected to perform a coronary angiogram procedure which focused on the venous phase. Our evaluation showed the presence of CS atresia, diverticula (which was pulsatile echo-free space in echocardiography), and LSVC [].\nBased on our clinical investigations as described herein, we have determined that LSVC is the only pathway for CS blood drainage when considering the anatomy of the disease. We have successfully shown that the diseased anatomy is responsible for the incorrect and reversed blood drainage in the patient. Such disorders can be diagnosed through echocardiography procedures using color flow Doppler and pulse Doppler studies. The combination of echocardiography alone with agitated saline injection would not have resulted in detecting the air bubbles entering into the CS due to retrograde blood drainage and CS atresia [].\nOur study results suggest a conservative clinical approach, and imaging modality is required for diagnoses and management of patients suffering from similar abnormal anatomy as described herein.[] However, patients suffering from accessory pathway, and arrhythmias should be considered as potential candidates for additional ablation therapy. |
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 fifty six year old gentleman was referred to our hospital with the complaints of gradually increasing difficulty in breathing and dry cough for one month and an audible wheeze for the last seven days. He denied any history of fever, weight loss or anorexia. His background history revealed that he was a smoker and had quit smoking three months earlier, and was taking antihypertensive medicines for the last three years. Three months prior to the present complaints, the patient had received thrombolytic therapy (Urokinase) for an inferior wall-plus right ventricular myocardial infarction. Few hours after thrombolysis, he had developed severe cardiogenic shock with left ventricular dysfunction and was put on mechanical ventilatory support, and also needed an intra aortic balloon pump to support his heart. Subsequently, he underwent angiography and PTCA to the left circumflex coronary artery. The patient made a good recovery after definitve treatment for heart failure was initiated and was extubated four days later and was discharged from the unit in a stable condition after twelve days.\nThe patient's general physical examination was unremarkable except for an audible wheeze. A Chest radiograph was normal. Pulmonary function tests showed reduction in the expiratory flow rate. Direct laryngoscopy showed normal movement of both the vocal cords. He underwent diagnostic bronchoscopy and on bronchoscopy, multiple membranous web like stenosis on the upper tracheal cartilages with small pedunculated soft tissue growth distal to the stenosis was seen []. Punch biopsy was taken from the growth and histopathological examination showed chronic granulation tissue comprising of numerous thick wall blood vessels with dense stroma and reactive fibroblasts.\nUnder short general anesthesia, the granulation tissue was removed by electrosurgery and the stenosed segment was dilated by PPD™ esophageal progressive balloon Dilator (TeleMed System Inc. USA, Balloon length 8 cm and largest external diameter of 17mm with 118 PSI). The maximum diameter was held for 30s and the procedure was repeated thrice. The patent was hyperoxygenated before each maneuver. After the third dilation, the achieved diameter was as per expectation [].\nAfter the procedure, the patient received prednisolone 30mg once daily and Amoxy-clavulanic acid combination 625mg twice daily for three days. After three months, the follow up bronchoscopy showed no further narrowing and the patient remains asymptomatic for the last one year. |
Subsets and Splits
No saved queries yet
Save your SQL queries to embed, download, and access them later. Queries will appear here once saved.