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A 74-year-old man was referred to our cardiovascular center for the evaluation and treatment of mitral regurgitation (MR). He had been complaining of aggravation of dyspnea (New York Heart Association functional class IV) for the preceding 3 weeks, and atrial fibrillation and severe MR were detected from other clinic. The patient had medical history of hypertension and chronic obstructive pulmonary disease for 15 years, and received endovascular aneurysm repair for abdominal aortic aneurysm 8 years ago. He had coronary artery disease and chronic kidney disease, also.\nThe patient was admitted to the intensive care unit because of uncompensated heart failure and careful control of pulmonary edema with chronic kidney disease. We performed transthoracic echocardiography with subsequent TEE to comprehensive evaluation of mitral valve disease. The patient presented tachypnea and orthopnea before the TEE procedure, less than minimal dose of sedative agent was administrated to lessen patient's discomfort, 1 mg of lorazepam, 25 mg of fentanyl, intravenously. As we checked for the mental status, the patient was not sedate, before and during the insertion of TEE probe. The insertion of TEE probe was performed with the patient in left lateral decubitus position according to the following standardized technique: the probe was inserted through the midline and gently advanced to pass the first pharyngeal curvature corresponding to the base of the tongue. The probe was then extended, and the patient was asked to swallow, at which point the probe was further advanced to enter the esophageal inlet. When the probe has reached to the root of tongue, the patient suddenly changed his position form left decubitus to supine position and gave force to the neck, and resisted to probe insertion. The probe got lodged at right-side of hypopharyngeal area so that failed to advance. At second attempt, TEE probe was advanced into esophagus easily during swallowing with patient's cooperation. TEE demonstrated severe eccentric MR with medial commissural prolapse due to chordae rupture (A3-P3 commissure) with left ventricular dilatation, mild tricuspid regurgitation ().\nThe patient complained of painful throat and odynophagia after TEE. The physical examination revealed tenderness and crepitus on right anterolateral area of neck (Level III) 3 hours later after TEE. Subcutaneous emphysema was detected on subsequent neck X-ray (). Iatrogenic hypopharyngeal or esophageal injury was suspected, antibiotic treatment with piperacillin/tazobactam was initiated and the patient was not allowed to eat or drink. Computed tomography (CT) scan revealed subcutaneous emphysema without involvement of mediastinum, but the level of injury was not detected (). Esophagogram with gastrograffin swallowing showed no visible contrast leakage (). Fiberoptic nasolaryngoscopic examination identified edema of the right posterolateral wall of the hypopharynx and hypopharyngeal bruise but there was no evidence of rupture or perforation. Intravenous antibiotic therapy was continued and nasogastric tube feeding was done. Laboratory analysis revealed an elevation of the white blood cell count (20.36 × 103/µL) and C-reactive protein (CRP; 28.54 mg/dL).\nWe tried to find any evidence of esophageal injury because treatment strategy would be different if the esophagus was involved. An ENT specialist and a GI specialist agreed with hypopharyngeal injury without esophageal damage after multiple tests. We concluded the lesion was limited to the hypopharynx because the presence of hematoma at the right side of hypopharynx, consistent with the direction and the depth of the probe passage. Further, there was no evidence of esophageal injury on serial follow-up multimodality imaging studies.\nAfter 5 days from the injury, the subcutaneous emphysema disappeared and the patient remained afebrile with improvement of the leukocyte count and CRP (). However painful neck mass around anterolateral area of neck was noticed (Level III). The follow-up CT without contrast showed a right parapharyngeal and retropharyngeal abscess secondary to hypopharyngeal injury (). Ultrasound guided needle aspiration was done for abscess drainage. Yellowish fluid in the abscess was analyzed for cytology and revealed as acute inflammatory cells predominantly neutrophils. As the patient's systemic status was stable with decrease of the leukocyte count and CRP, the antibiotics (piperacillin/tazobactam) was considered to be susceptible. The antibiotic treatment with piperacillin/tazobactam was maintained for 14 days with the drainage of abscess because no organisms were identified from the abscess fluid culture and repeated blood cultures.\nOn 7th day after TEE, second swallowing study was performed and no leakage was demonstrated (), infectious parameters were continuously decreased, and follow-up fiberoptic nasolaryngoscopic examination demonstrated no evidence of perforation or rupture in hypopharyngeal cavity. So the patient was allowed to start eating small portions of soft food.\nAfter 14 days of antibiotic therapy, when the infection was controlled completely, the patient had successful mitral valve repair with tricuspid annuloplasty with St. Jude Medical Tailor ring 31 mm. |
A 28-year-old female patient reported to the department with a chief complaint of difficulty in eating food because of swelling in the left upper gums and cheek for the last 2 years. The patient first noticed it around 8 years back when it was of a size that was barely noticeable and didn't hamper her mastication and then slowly it increased to the present size. It was otherwise asymptomatic but for the last 2 years because of the increase in its size, it was getting impinged between the teeth. On asking about obvious facial asymmetry and discoloration with respect to the left side of the face patient gave a history of being operated which was present since childhood and was initially 1–2 cm and continued to increase in size with age. Therefore, surgery was done to remove the mark and a skin graft from the thigh was placed over the left cheek area. After few years of surgery, the patient noticed swelling over the left side of the face, the upper part of the nose and around the left eye which slowly increased over a period of time to the present size. On extraoral examination a well-defined periorbital growth of size 4 cm × 2.5 cm was noticed on the left side which was extended laterally in a reversed c shape curve, demarcated by a surgical line [Figures and ]. The overlying skin was bluish-black in color. On palpation, it was nontender and doughy in consistency with a firm nodular growth appreciated in relation to the infraorbital region having bag of worm consistency, no bruit or pulsation were present. Graft with hair growth along surgical lines was present on the left middle third of the face with respect to the cheek, zygomatic and postauricular region. The bluish-black pigmentation with irregular margin was present with respect to left side bridge of nose and left corner of the mouth. Drooping of the left corner of the mouth present because of pressure from the swelling. The facial nerve examination was normal. Intraoral examination revealed mucosal growth with respect to attached gingiva of left upper canine (23) to left second molar (27) which was approximately 4.5 cm × 1.5 cm in size almost covering occlusal aspect of teeth, having pink in color and smooth surface with normal-appearing surrounding mucosa []. The growth was non-tender with mixed soft to firm consistency giving bag of worm feel. Similarly, two mucosal growth seen from left buccal mucosa, one 1cm posterior to left retrocommisure area and 2nd on anterosuperior aspect corresponding to 23 measuring 0.7 cm × 0.4 cm and 0.3 cm × 0.2 cm respectively. The left upper first molar (26) was missing.\nOn the basis of the above clinical findings differential diagnosis for pigmentation includes mongolion spot, melasma, blue nevus, drug-induced hyperpigmentation and for growth PNF, congenital melanocytic nevus (as hyperpigmentation and hypertrichosis common in both), vascular malformation was given.\nAn intraoral periapical radiograph (IOPA) with respect to 25–28 region and Orthopantograph (OPG) was advised for the patient. IOPA showed distal inclination of 24, 25 and mesial inclination of 27 and missing 26 along with the erosion of crest of alveolar bone with respect to 25, 27 [].\nOPG was advised for the patient which showed thinning of the left zygomatic arch, along with deepening of the sigmoid notch with elongated coronoid process and obliteration of left maxillary sinus with multiple septation was observed [].\nUltrasonography revealed soft tissue thickening with respect to left temporal, infratemporal, orbital and buccal mucosa with vascularity seen on color Doppler with areas of subtle erosion of bone at places. Further for full bony extent contrast-enhanced computed tomography (CT) Scan was advised. CT finding suggested a heterogeneously enhancing soft tissue thickening involving the left side of the face infiltrating temporal, infratemporal fossa and masticatory space []. There was subtle erosion of underlying bone and thickening with expansion (remodeling) at the lateral wall of orbit, zygomatic arch and anterior surface of maxilla of the left side. There was the widening of the inferior orbital fissure. The soft-tissue thickening seems to be infiltrating into the left buccal mucosa and lateral aspect of the left orbital, however the globe appears normal. There was remodeling of the left maxillary sinus causing it to decrease in size in the transverse direction. Minimal mucosal thickening seen with respect to bilateral maxillary sinus. The radiographic impression was for PNF with differential diagnosis of low flow vascular malformation was given. Incisional biopsy was done. The surgical sample was subjected to histopathological evaluation. H & E section showed interlacing bundles of spindle cells exhibiting wavy nuclei []. These cells were in association with delicate collagen bundles and variable amount of myxoid matrix and foci of mast cells which confirmed the diagnosis of plexiform neurofibroma.\nFurther dermatological and ophthalmic consultation was done for the patient to rule out Neurofibromatosis 1. No café au lait spots or any other neuromas were detected and ophthalmic examination was normal.\nThus we concluded it to be the rare case of isolated PNF with nevus of ota. The patient underwent debulking procedure under general anesthesia as because of the massive extent total excision was not possible. The patient was informed about symptoms and chances of its malignant transformation and was advised regular follow-up. Six-month postsurgery, patient did report the recurrence.\nAdditional informed consent was obtained from the patient for which identifying information is included in this article. |
We present here a case of a 21-year-old right-handed Romanian male, who was working in the United States on an employer-sponsored visa and presented to the emergency department of Atlantic Regional Medical Center in Atlantic City, New Jersey, with acute episodes of vomiting, diplopia, and ataxic gait and two episodes of tonic-clonic seizures. The patient was brought in by his acquaintances who reported headaches for two weeks along with vision changes and a slow decline in his mentation. His friends stated that the patient was becoming more tired and lethargic with a waxing and waning in mentation. Pertinent physical exam revealed Parinaud's syndrome with upward gaze palsy, diplopia, and unsteady gait. A CT scan was done in the emergency department that showed a pineal mass of 3 × 3 × 3.5 mm in size along with obstructive hydrocephalus and dilatation of lateral and third ventricles without any evidence of bleeding. The patient also had an episode of seizure in the emergency department and was administered a loading dose of Keppra 1000 mg and a maintenance dose of 500 mg twice a day intravenously. The patient was then admitted to the neurological critical care unit for further monitoring.\nNeurosurgery evaluated the patient and recommended to bolus 10 mg of IV dexamethasone and with the maintenance of 4 mg IV every 6 hours to prevent expansion and reduction of the cytotoxic edema from the mass effect. Given his symptoms of obstructive hydrocephalus with increased ICP of 22 mmHg, an endoscopic ventricular drain was placed for the drainage to relieve the pressure by the neurosurgeon. MRI of the brain revealed a pineal mass causing obstructive hydrocephalus via the compression of the cerebral aqueduct likely from a possible underlying intracranial germ cell tumor (, image R to L). MRI of the cervical, thoracic, and lumbar spine was done with and without contrast. No enhancing lesions were visualized on these images, and there was no evidence of drop metastasis or discrete mass lesion or pathologic enhancement in the spinal system (). A detailed MRI of the lesion revealed mass arising from the pineal gland with a diameter of 3.6 cm and predominantly solid component with discrete calcification inside the mass (Figures –). The tumor was causing compression of the tectal plate of the midbrain and subjacent aqueduct, which was resulting in obstructive hydrocephalus. To further evaluate, we obtained serum beta-hCG and alpha-fetoprotein to distinguish if the mass was a pure extragonadal germ cell tumor or NGGCT. Patient's serum alpha-fetoprotein levels were elevated to 215.8 ng/mL (normal range of 0-8 ng/mL), and beta-hCG level was noted to be 35 mIU/mL (normal range of 0-3 mIU/mL). Given the elevations of the tumor markers, this patient likely had an NGGCT; however, a definite diagnosis biopsy was needed. On day three of his admission, the patient received an endoscopic third ventriculostomy to improve the obstructive hydrocephalus and help in the drainage of the cerebrospinal fluid through the cerebral aqueduct system during which we also obtained a biopsy of the sample ().\nHowever, after this procedure, the patient developed a transient episode of central diabetes insipidus. On his laboratory analysis, he was noted to have sodium level of 145 mEq/L (range 135 mEq/L-145 mEq/L) with a urine osmolality of 161 and serum osmolality of 298. Central diabetes insipidus is defined as serum sodium concentration higher than 142 mEq/L in a setting of polyuria of 3000 cc/day with a plasma osmolality of 295 and a low urine osmolality, which were all noted in this patient. This was a complication likely from the EVT procedure. The patient was observed to be in transient triphasic response with the polyuric phase for five days, followed by an antidiuretic phase of 6 more days. We monitored his urine output very closely replacing cc per cc of volume by giving him by mouth and isotonic IV fluids. The patient was started on desmopressin, which was administered in the intravenous form initially and then converted to intranasal.\nThe patient subsequently developed hyponatremia likely also contributed from the desmopressin, and he was noted to develop cerebral salt wasting for which he was placed on hydrocortisone and later changed to fludrocortisone. Patient's urine output decreased at a goal less than 3 L in 24 hours with a normal serum osmolality. Pathology report came back, which revealed atypical cells were forming glandular architecture and solid area, which are all positive for Sal-4 and negative for CD30 and GFAP (glial fibrillary acidic protein) (). The atypical glands are positive for pancytokeratin and glypican-3, and the solid area is positive for OCT3/4 and CK117 (). These findings supported a diagnosis of mixed germ cell tumor with yolk sac carcinoma. However, due to the limited material, other components cannot be ruled out. Patient's electrolytes were normalized, and he was medically cleared to travel back to Romania where he would be following up with neurosurgery for further management of his NGGCT. |
48-year-old male patient was referred to our clinic (Department of Prosthodontics) regarding a complication in his lower two implant supported dentures (Figures and ). The relining procedure had been done directly in the patient's mouth using hard relining material by a dentist in private office. The denture could not be removed from the mouth and the reason was probably the excessive resin between the matrix and ball-attachments. Specifically, there was no movement on the left of the denture and thus we started the process from left matrix. Removing the matrix safely is the primary purpose of this technique. To this and the relevant portion of the denture was marked with indelible pencil (). A cylindrical resin was removed with a diamond bur at the level of matrix and by this way the matrix was removed safely (Figures and ). And then the excessive resin around the ball-attachment was removed with a conical diamond bur. After the process the denture was removed by pulling out gently (). The denture and left matrix are seen in Figures and . Previously made hard relining material was removed from the denture's internal and external surfaces. To perform the indirect relining technique and repairing the denture, light silicon impression material was applied to the inner surface of the denture and when placed in mouth patient was advised to close the mouth without pressure to avoid displacement of the soft tissues (). After laboratory procedures performed, the denture, occlusion, borders, and soft tissue adaptation were evaluated. The final image of the repaired denture was seen in Figures and .\nThe aim of this case report was to present a technique for removing the denture which locked to ball-attachment because of excessive hard relining resin material flows around the ball-attachment. The advantage of the presented method is that it may be extended to other clinical situations when facing a similar complication for implant supported dentures and also that the technique is simple and does not require special equipment. |
A 20-year-old woman presented to our hospital with a 9-month history of pain in her right hip and a 3-month history of limping. Nine months previously, the patient had developed pain in her right hip after a fall from riding a bicycle. After 6 months of conservative treatment while bedridden, she gradually progressed to weight-bearing walking; however, her pain was not relieved and she exhibited obvious lameness. Before the injury, the patient had free movement and normal function of the right hip, and she had no history of abnormal bone morphology. A plain radiograph of the lower limb showed that the edges of the fracture ends were sclerotic, and obvious fracture lines were present. The proximal fracture end was hyperosteogenic relative to the distal fracture end, but the two fracture ends were not connected to each other (). At the time of admission, the patient had no spinal deformity and no obvious tenderness or percussion pain of any spinous process. The right leg was 2 cm shorter than the left leg. The right hip exhibited tenderness and joint movement disorder. Right hip flexion (passive activity) was 100°, back extension was 10°, and internal and external rotation movement disorder was found (the patient was unable to cooperate with the examination of internal and external rotation because of pain). The pain was aggravated during passive activity, and the skin sensation and blood circulation of the lower limb were normal. No abnormality was found in the preoperative examination. X-ray examination showed no obvious collapse or deformation of the femoral head, change in the hip joint space, limitation of joint range of motion, or obvious signs of osteoarthritis.\nConsidering that the patient was young and her condition did not conform to the indications for hip replacement surgery, hip preservation therapy was the first choice. A plain radiograph showed that the fracture of the right femoral neck was an old nonunion, and the Pauwels angle at the fracture line was >50°, indicating an adduction fracture. The main cause of fracture nonunion was high shear stress and poor stability of the fracture ends, and the secondary factor was destruction of the blood supply to the femoral head. Therefore, the focus of treatment was to reduce the Pauwels angle at the fracture line through surgical osteotomy and create an abduction fracture, reduce the shear force after internal fixation of the fracture ends, and create an ideal mechanical environment for fracture healing. We considered whether to perform a vascularized fibular graft at the same time; however, the predicted postoperative effect was unclear because of the large degree of surgical trauma, and the patient would not have been able to tolerate the graft procedure. Therefore, we decided to treat the right femoral neck fracture with nonunion of the greater tuberosity by interval valgus osteotomy and internal fixation. We recommend valgus intertrochanteric osteotomy for nonunion after the femoral neck fracture.\nThe scheme of the osteotomy was designed before the operation. First, the angle between the fracture line and a horizontal line (Pauwels angle) was measured. Next, we determined the angle after osteotomy (in principle, <30°). The angle of osteotomy was equal to the Pauwels angle of the fracture minus the designed Pauwels angle after the operation. We selected a side steel plate with an angle of 135° to 155°. A larger angle of the side steel plate resulted in a larger angle of insertion of the fixing needle. The angle of insertion of the fixation pin refers to the angle between the fixation pin and the lateral cortex of the femur. This angle is equal to the angle of the side plate minus the angle of the osteotomy.\nThe patient underwent epidural anesthesia. She was then positioned on her back on the fracture table, with her feet fixed on the pedals and her right hip padded at 30°. The operation was carried out under the fluoroscopic control of a C-arm X-ray machine. A 20-cm lateral straight incision was performed over the right hip. After the skin and subcutaneous fascia were incised, the posterior margin of the lateral femoral muscle was cut, a femoral neck compression nail was introduced, and the bone canal of the abduction osteotomy was designed 3 cm below the greater trochanter. After the osteotomy, a goose head nail plate (Ideal Medical Industries, Ningbo, China) was fixed. Before the goose head nail was inserted, a guide needle was inserted into the femoral head from under the greater tuberosity of the proximal femur through the neck of the femur. In the anterior and posterior positions, the goose neck screw insertion point was located between the greater tuberosity and the osteotomy line and screwed into the femoral head along the axis of the femoral neck; the goose head screw in the lateral position was located in the middle of the longitudinal axis of the femoral neck. The success of abduction osteotomy and the location of the goose head nail were confirmed by C-arm X-ray examination. The incision was washed and sutured. No skin traction was needed after the operation to encourage activities while bedridden. If self-control of the affected limb was possible (i.e., straight leg elevation) about 1 week after the operation, the patient was allowed to get out of bed with double crutches and walk without bearing weight until the fracture healed.\nFor 3 months after the operation, the patient rested in bed and stood without weight-bearing. After this 3-month period, she stood on the unaffected foot with the assistance of crutches, and the affected leg was partially weight-bearing within the tolerance of the lower limbs (). After 6 months, she finally abandoned the crutches and was able to walk, and X-ray examination showed that the fracture had healed (). Periodic X-ray reexaminations were performed at 1, 2, 3, 6, 9, and 12 months postoperatively to dynamically observe the fracture healing. X-ray reexamination 1 year after the operation indicated that the fracture line had disappeared and that the fracture had healed. The right hip active flexion was 120°, and back extension and internal and external rotation movement were 20°. The right Harris hip score was 78, and the visual analog scale score was 1. The internal fixation device was removed within 1 year after the operation (). At the time of this writing (18 years following surgery), good bone union was observed (), and the Harris hip score had increased to 92. Extension of the affected hip was 10°, active flexion was 120°, adduction movement was 20°, abduction movement was 40°, internal rotation movement was 20°, and external rotation movement was 30°. The patient has engaged in hard labor with no difficulties, and no signs of osteoarthritis or osteonecrosis have been found (). |
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 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The winged scapula did not emerge when the patient pushed on a wall at chest level. Radiographs showed a small bony fragment in the ventral side of the ISA, with a narrow space between the fragment and the scapular body (). Computed tomography revealed a bony protrusion extending from the medial scapular border to the bony fragment, with a narrow gap between the protrusion and the fragment (Figures –).\nThe patient was instructed to avoid elevating the left arm for 2 months and then performed reinforcement exercises of the SA such as the scapular push-up and the bear hug using an elastic band for 2 months. At examination 4 months later, the periscapular pain and the winging of the scapula with the arm at the side and in active flexion had resolved. The push-on-the-wall test at waist level was negative, and the range of motion of the left arm was the same as the unaffected side, except for a 15° limitation in external rotation. Although the radiographic findings were the same as at the first visit, computed tomography demonstrated bony union (Figures and ). The patient was permitted to use the left arm without restrictions.\nAt the time of the final follow-up 10 years of postinjury, the patient reported that there was an occasional painless click and a sporadic floating feeling of the scapula with initial active flexion of the arm. However, there was no pain or any disturbance to the patient's activities of daily life and work as a physical therapist. The patient's colleague confirmed the disappearance of the winged scapula associated with shoulder movement. The DASH score was 0, and the Constant score ratio compared with the right shoulder was 100% [, ]. |
A 49-year-old woman with the complaint of 15-year history of a small mass on the right 4th finger was referred to the dermatology clinic. Her past medical history revealed that a mitral valvuloplasty was performed 20 years before; she was otherwise healthy according to her statements. Family history was negative and there was no history of trauma to the site of the mass. The mass did not cause any pain or disability and there was a slight increase in its size which made the patient visit the physician.\nOn physical examination, there was a firm and round subcutaneous mass on the dorsal side of the proximal interphalangeal joint of the right 4th finger []. The mass measured approximately 1 cm in diameter and was immobile and nontender. The overlying skin had normal appearance, and the range of motion of the affected finger was intact. There were no other notable findings in her physical examination. The patient underwent an excisional biopsy and the mass was sent to our laboratory for pathologic evaluation.\nOn gross examination, the specimen in formalin container was an irregular skin tissue measuring 1 × 0.6 × 0.4 cm and a tan, firm, encapsulated oval-shaped nodule with a maximum diameter of 0.7 cm attached to the deep side of the skin tissue was evident. After tissue processing and preparing glass slides, microscopic evaluation revealed a dermal neoplasm consisting of nodular proliferation of neoplastic cells with round to oval and sometimes wavy nuclei, some of which were arrayed with palisading features and formed verocay bodies. On immunohistochemical study, S100 protein was strongly expressed in tumoral cells []. The neoplastic nodules were surrounded by a fibrous capsule in some foci. The lesion lacked necrosis, there was no marked cell crowding, or generalized nuclear atypia accompanied by significant mitotic activity seen in the malignant counterpart called malignant peripheral nerve sheet tumor (MPNST).[] Based on histologic findings, the main differential diagnoses were plexiform schwannoma and plexiform neurofibroma. However, considering the significant correlation of the plexiform neurofibroma with neurofibromatosis type I[] and the negative history of the patient as well as microscopic findings such as the presence of verocay bodies, lack of myxoid stroma and diffuse, and strong immunohistochemical staining for S100 protein, we excluded the diagnosis of plexiform neurofibroma, and the final diagnosis of plexiform schwannoma was made. |
A 47-year-old man presenting with a painful mass on the left anterior scalp visited our hospital. The patient had a 40-year history of a yellow patch-like lesion on the same site with an irregular surface accompanied by itching and hair loss. The size of the lesion had not changed over time but had suddenly begun to grow 4 months before.\nOn physical examination, the patient had a hard, palpable, immobile mass measuring 7×7 cm accompanied by bleeding, discharge, an irregular surface and a red ulcer on the left anterior scalp (). The patient also had bilateral palpable masses on the parotid gland and cervical lymph nodes. The patient had no specific underlying disease or family history of cancer. Due to the rapid growth of the mass, a malignant tumor was suspected.\nFor further evaluation, a punch biopsy and computed tomography (CT) were performed. On CT scans, the patient had an exophytic, heterogeneously enhancing mass measuring 6.9 cm, accompanied by multiple masses on both parotid glands and the posterior neck (). On punch biopsy, there were signs that were suggestive of SC. The patient received a whole-body CT scan and a positron emission tomography scan for evaluation of distant metastases. However, no metastases were observed other than those to the parotid and cervical lymph nodes. The patient was therefore suspected of having SC of the scalp with lymph node metastases. The patient was planned for surgery but was lost to follow-up due to financial constraints.\nAt 3 months, the patient returned to us with bleeding from the scalp mass whose size had increased to 11×11 cm (). The mass was accompanied by the presence of tissue necrosis, severe pain, and bleeding. Finally, the patient was surgically treated with wide local excision and radical lymph node dissection.\nUnder general anesthesia, wide local excision was performed, including excision of entire layers of the scalp with a 1-cm safety margin. In frozen sections, no tumor cells were observed at the resection margins, including the deep margin.\nAfter resection, the size of the defect was measured as 13×13 cm. We planned for a V-Y island flap for which the parietal branch of the left superficial temporal artery served as a pedicle. A triangular flap was designed on the posterior area of the defect. We performed a subcutaneous fat layer dissection from the side of the pedicle up to 3 cm above the ear. To elevate the flap, we performed a subgaleal dissection from the opposite side of the pedicle to 3 cm above the ear. The defect was reconstructed by advancement of the flap. The donor site defect was located on the posterolateral side of the vertex. To reduce the skin graft area and move it to the posterolateral side, an inferiorly based rotation flap using the occipital scalp was performed. The area remaining after the rotation flap was covered by split thickness skin graft. This was followed by bilateral radical neck lymph node dissection and lymph node biopsy.\nThe surgical biopsy revealed a large solid tumor characterized by ulcerative cutaneous lesions that occupied vast portions of the dermis with infiltrative growth. Moreover, there were well-defined, solid lobules of neoplastic cells composed of large, pale or clear cells with coarsely vacuolated cytoplasm and focal squamoid differentiation. Such neoplastic cells were well to moderately differentiated and had a lobular infiltrative pattern (). There was lymphatic invasion with neoplastic lymphatic emboli, but there was no perineural invasion. The neoplastic cells also showed positive immunohistochemistry for epithelial membrane antigen. Moreover, a lymph node biopsy showed metastases to 13 of 84 lymph nodes. The patient was finally diagnosed with EOSC with lymph node metastases.\nAt a 1-month follow-up, the patient had three recurrent tumors, measuring 1×1 cm, on the surgical margin of the scalp (). Three months of radiation therapy was planned for the recurrent tumors. External beam radiotherapy was performed with doses of 200 Gy for the first 2 months and 250 Gy for the last month. Despite a decrease in the size of the masses, the patient did not achieve complete remission. Therefore, the patient underwent wide excision of the tumors with frozen section under local anesthesia. The defects were reconstructed by primary repair and rotation flap.\nAt 5 months, the patient complained of dyspnea even while walking on flat ground. Chest radiography revealed the presence of multiple nodules in both lungs, which were not previously present (). This was suggestive of lung metastases of SC. The patient was therefore planned to undergo chemotherapy but was again lost to follow-up. |
A 13-year-old boy presented with pain, swelling, deformity and inability to bear weight. He gave a history of a fall on glass pieces while playing 9 days ago. He was asymptomatic for the first 4 days after the fall. Later he developed pain and knee swelling. He was taken to a nearby hospital where X-rays of the knee were done; no abnormality was noticed and was prescribed analgesics. Symptoms worsened after 2 days when he developed deformity of knee and inability to bear weight on the affected side. He was then taken to a different hospital where he was diagnosed to have a foreign body in his knee and referred to our institution for further management. He gave no history of locking or giving away sensation.\nOn examination, the left knee was in 30 degrees flexion, supra-patellar fullness and mild effusion was noted. An oblique skin laceration of 1x1 cm was noted lateral to the patella (). There was no active discharge from the wound or local raise of temperature. Tenderness was noted around the knee. The skin overlying the knee joint appeared normal. Boy was unable to move his knee due to pain and did not allow us to examine him thoroughly.\nAntero-posterior and lateral radiographs of the knee done 5 days prior to admission showed a radio-opaque shadow measuring about 1x1 cm in the supero-lateral quadrant of the knee, residing in the superficial planes, perhaps in the subcutaneous tissues (). This explains the child not having symptoms for the first 4 days. At the time of presentation to our out-patient department freshly taken radiographs revealed radio-opaque shadow in the inter-condylar region of the knee in front of the tibial attachment of the anterior cruciate ligament (ACL) resembling an avulsion of the ACL from the tibial plateau (). With the working diagnosis of foreign body in the knee, the boy was taken up for emergency arthroscopy. MRI scan of the knee was not considered as the history and follow-up events suggested a foreign body in the knee and this would not have changed our management plan.\nUnder general anaesthesia, the knee deformity was spontaneously corrected suggesting that it may have been due to muscle spasm. Arthroscopy was carried out with the standard lateral and medial portals. About 50 ml of normal looking synovial fluid was drained out. We found a glass piece measuring 1 cm x 1 cm () lying in the inter-condylar notch in the space between the ACL and the lateral surface of the medial femoral condyle. The glass piece was removed () arthroscopically with the help of a small artery forceps by increasing the size of medial portal. The synovium in the supra-patellar pouch, medial and lateral gutter was hyperaemic. There was no obvious damage to menisci or the articular surfaces of the femoral or tibial condyles except for some abrasions (video 1).\nA partial tear in the ACL at the femoral attachment with 10-20 % of fibres being involved was noted probably due to the sharp edges of the glass piece (). The cut fibres were trimmed and examined under anaesthesia (, video 2). Anterior drawer, Lachman, Pivot shift and posterior drawer tests were all normal. Varus and valgus stress tests for collateral ligaments were normal. Hence, it was decided not to reconstruct the ACL. The chondral abrasions were smoothened out using a shaver. Joint was thoroughly washed and portals sutured. There was a small tear of 1x1 cm in the lateral retinaculum below the skin laceration, which was repaired. The skin laceration was debrided and sutured.\nWound healed subsequently without any infection. Post-operative radiographs revealed no foreign body in the knee. Post-operatively, the boy was allowed full weight-bearing and knee mobilisation exercises were started. No deformity was noted post-operatively. At the end of 1 year of follow-up, patient had full range of motion with no complaints of instability. He was involved actively in all sports activities. The parents were advised to review in case of any symptoms later. Discussion\nPenetrating injuries of the knee are relatively rare. Many of the times, penetrating wounds (i.e., after an accidental fall, road traffic accidents) remain the major cause of foreign body in the knee. Remaining injuries are sustained by missiles shot by machinery for civilian use (e.g., power-gun nails, needles, staples) or by weapons []. Rarely, the cause can be iatrogenic (e.g. arthroscopic instruments for e.g. tip of shaver blades, staples, suture materials, anchors, broken screws used for graft fixation) [, ].\nForeign bodies can be classified as radio-opaque and radiolucent. Metal, glass pieces, and lead objects are radio-opaque and can be identified on X-rays. Objects like thorns, stones, suture material, and bio-absorbable screws are radiolucent and can only be detected by an ultrasound or an MRI []. The presence of a local scar can give a clue to the underlying pathology, as in our case a glass piece had entered from the antero-lateral aspect of the knee joint. Whereas in some cases the cause of uncertain knee complaints especially in children can be due to foreign bodies which penetrated unnoticed into the joint cavity [].\nA foreign body in the knee joint is an absolute indication for operation []. Earlier the better, as the amount of intra-articular damage increases with time. A foreign body intruding the knee joint in childhood can go unnoticed initially and can cause symptoms for the first time in adult age []. Fragments can become adherent to the capsule or reside within synovial recesses or bursa without producing any symptoms for a very long time. Symptoms are usually caused by the foreign bodies which are mobile within the knee joint, resulting in meniscal damage or recurrent locking episodes [].\nIn our case, the glass piece resided in the subcutaneous soft tissue for few days and later migrated into the knee joint to cause symptoms. Late migration of other foreign bodies like bullets, broken arthroscopy probe tips into the knee joint have been reported in literature [, ]. There is also a report of late migration of a glass piece of nearly 1.5 cm in size into the knee joint after remaining in the subcutaneous tissue for 7 years []. |
A 43-year-old man was brought to the emergency room due to bilateral shoulder and back pain after he fell off a three-story building. When he arrived at the emergency room, there were no other specific findings in tests for cognitive and neurological conditions and in a blood test. However, four hours after his arrival, he had an abrupt cardiac arrest with no obvious cause and cardiopulmonary resuscitation (CPR) was performed for about 3 minutes. All his vital signs were back to normal after the CPR but he was in a coma for about 30 minutes during which generalized tonic clonic seizures continued with the whole body stiff and trembling. He stayed in the neurology department for around 1 month to treat his status epilepticus and agents like midazolam, propofol, and sodium valproate were administered. As the one-month treatment period ended, he gradually recovered consciousness and the symptoms of continuous seizures during the acute phase were alleviated. Instead, seizures, which are contractions of muscles as if lightly jumping during sputum suction through the tracheostomy tube or pain stimulus, newly emerged. The amount of medications intravenously injected to treat the status epilepticus was gradually reduced and sodium valproate, levetiracetam, and clonazepam were orally administered in order to reduce the new patterns of seizures. For rehabilitation, the patient was moved to the department of rehabilitation medicine because he had problems with gait, language use, and activities of daily living (ADL) resulting from myoclonus.\nWhen he moved to the rehabilitation department, he had normal muscle strength in the upper and lower extremities and the neck, but he had myoclonus with irregular contractions of muscles as if jumping lightly in the upper and lower extremities, trunk, face, and tongue. Such muscle cramps were aggravated during emotional changes or voluntary actions and decreased while he was resting or sleeping. He scored 3 in the mini-mental state examination (MMSE), which indicated severe cognitive disabilities. He was entirely dependent on the assistance of others for functional activities such as sitting on the bed, walking, performing simple manual movements ,and eating. He needed a wheelchair in order to move.\nOne day after the CPR, when he had continuous symptoms of muscle cramps, his electroencephalogram (EEG) showed cyclic epileptiform waves (). However, after his move to the rehabilitation department, the epileptiform waves did not appear in the EEG when his muscle cramps had been stabilized (). EEG was performed when his condition did not change except for aggravated myoclonus after the dose of clonazepam was reduced. At this time, the epileptiform waves did not appear and only waveforms suggesting hypoxic brain injury were observed ().\nBrain magnetic resonance imaging performed three months after the CPR showed a slightlyincreased intensity of signals spreading over the white matter of both hemispheres, suggesting hypoxic encephalopathy ().\nFor about 4 months after he moved to the rehabilitation department, levetiracetam 200 mg, sodium valproate 1,800 mg, and clonazepam 4.5 mg were administered and occasional myoclonus gradually improved. During physiotherapy, there were symptoms of weakness, considered to be because of anticonvulsants, and a decision to reduce the amount of medications was made. We referred to a recent study by Frucht et al. stating that levetiracetam was effective in LAS and reduced the amount of clonazepam and observed aggravation of myoclonus. Therefore, we increased the dose of clonazepam to the prior level and the myoclonus improved to its original state. Due to the patient's sustained weakness, we reduced the amount of levetiracetam, but the weakness did not improve. However, a finding of aggravated myoclonus was not observed as it was when the amount of clonazepam was decreased.\nDuring hospitalization, he received progressive rehabilitation treatment as well as drug treatment. He had a lot of difficulty in gait and ADL because of myoclonus during voluntary actions, which was accompanied by dysphagia resulting from involuntary spasms of facial and tongue muscles. To resolve this problem, intensive gait, ADL, and swallowing therapy was performed. In particular, slow movements were induced during gait and ADL therapy because they led to a relatively less myoclonus.\nHe was discharged about 8 months after the CPR; he was able to sit on the bed, grab a string and stand for around 15 minutes with minimal assistance. His condition improved so he could move by himself in a wheelchair although independent walking was impossible. His cognitive function improved as well he scored 21 in the MMSE. |
A 30 years old male patient was brought to Oral and Maxillofacial surgery casualty of Medical College Kottayam with a penetrating facial injury by a wooden log passing through the left lateral side of his face below the angle of mandible and protruding through oral cavity causing comminuted fracture of mandible after a road traffic accident. There was moderate bleeding and respiratory distress. No history of vomiting or loss of consciousness. From the history it was noted that the wooden branch was initially of length of 8 feet. In the local hospital the wooden log shortened out up to 2 feet and was then referred to Medical College Kottayam.\nAt the time of admission the patient complained of dyspnea and dysphasia. On examination there was significant oronasopharyngeal bleeding with no neurological deficit. Moderate trickling of blood from the entry site was noted. The blood pressure was 140/90 mmHg and the pulse rate was 110/min. The wooden log was seen protruding through his mouth []. The management of the patient was done by following the advanced trauma life support (ATLS) guidelines established by the American College of Surgeons, which begins with a rapid assessment of the airway, breathing, and circulation.[] Airway management in such a patient with penetrating injury to the neck was challenging. The patient was unable to lie in supine position due to long wooden log stuck behind the neck. There was high chance of aspiration of blood and saliva. The patient was planned for tracheostomy to secure airway, since the patient was unable to lie down in the supine position due to obstruction of wooden log posteriorly. Therefore the wooden log was shortened out near close proximity to the left retromandibular region []. The patient was then positioned on right lateral and tracheotomy was performed under sedation and local anesthesia. General anesthesia was then administered through the tracheostome []. With the airway secured, breathing and circulation were evaluated and managed in the standard manner, following the ATLS protocol. The secondary survey was conducted after the patient was initially stabilized. There were no other associated injuries.\nA midline lip-split incision was given till the anterior extension of the penetrating wound. Exploration was performed through existing mandibular symphysis fracture. Comminuted fracture of left body of mandible and symphysis were identified. Access was gained by swinging the mandible through the fracture symphysis [].\nAfter adequate exposure the wooden log was removed in toto []. Lingual and facial artery were identified and ligated with 2-0 silk. No other foreign body was seen. Hemostasis was achieved and the area cleaned with betadine saline wash. There were no injury to great vessels and nerves of neck. Reduction and fixation of fracture mandible was done by stainless steel mini pates and screws []. Wound was then closed in layers after securing the suction drain. Post-operative CT scan of head and neck was advised to rule out head injury, cervical spine injury, other maxillofacial injury if any and foreign body. CT scan revealed that there were no associated head injury, cervical spine injury, maxillofacial injury and any other foreign body [].\nPost operative evaluation showed no injury to facial and lingual nerve. The patient had an uneventful postoperative period and was discharged on the 10th day with tracheostomy tube removed. He was followed up regularly. Review after 1 month [] showed no functional or major aesthetic problems. |
A 39-year-old British Caucasian female in good general health with known history of rheumatoid arthritis presented to us complaining of recurrent bleeding from anterolateral arthroscopic portal of left ankle. She is known to have rheumatoid arthritis with no coagulation disorders. The patient had undergone arthroscopic synovectomy of left ankle done on 3 weeks previously, using 4.0-mm and 30 degree arthroscope under tourniquet control through anteromedial and anterolateral ports. There had been bleeding from the anterolateral port site post operatively but this had stopped quickly. The patient had been reviewed three times following the procedure by various doctors for similar problem who diagnosed as wound infection and discharged with assurance and oral antibiotics.\nClinical examination revealed tender, indurated, an expansile pulsatile mass of over the anterolateral port site on the left ankle and pain with range of motion of ankle. There was a 1 cm wound with a central necrotic area over a swollen area measuring 3 × 6 cm (Figure ). The wound had a persistent slow ooze of bright red blood and on palpation the swelling was pulsatile. Both the dorsalis pedis and the posterior tibial arteries were palpable. Sensation and perfusion of foot was normal. A duplex scan was performed which demonstrated triphasic flow in the dorsalis pedis and a pseudoaneurysm of the anterior tibial artery. Normal flow was reported in the anterior tibial artery from the upper calf to the site of the aneurysm, in which no flow seen. The patient had two units of blood transfusion, as she was breathless, pale and haemoglobin level was found to be 8.2 g/dl. Plain radiographs of the ankle did not demonstrate any abnormality, unlike osseous erosion due to pulsatile pseudoaneurysm at central to lateral side of distal tibia (Jang et al 2008).\nThe patient was referred to the vascular team and underwent an urgent exploration. Intra-operatively, the findings were pulsatile mass with necrotic tissue, a moderately large cavity of pseudo aneurysm filled with fresh blood clots. The distal anterior tibial and dorsalis pedis arteries were isolated. The distal anterior tibial and proximal dorsalis pedis were found to be serrated and breached for 3 centimetres and in contact with sac. The damaged artery was identified proximally and distally and clamped (Figure ). The clots from the sac were evacuated without compromising the blood supply to the foot. The patient made an uneventful recovery and was discharged to home after second look and closure of wound in 3 days. We reviewed her in outpatient clinic two weeks later, where she had made a good recovery with no residual symptoms. |
A 30-year-old Caucasian female presented to the emergency department (ED) after being hit in the head by a baseball sustaining a laceration to her right lateral forehead. She did not lose consciousness and was driving herself home from a baseball game when she began to develop urticaria, tongue swelling and difficulty breathing. She stopped at a local fire station where her rapidly worsening symptoms were treated with 0.3mg of intramuscular (IM) epinephrine before transport to our ED approximately 30 miles from the fire station.\nAt the time of her arrival, her urticaria had subsided, but her tongue swelling persisted such that she had difficulty speaking and some discomfort with swallowing but was tolerating her own secretions without difficulty. She denied vomiting or present shortness of breath, but she did initially feel short of breath prior to epinephrine administration. She complained of a headache but no neck pain since the trauma, and she was not confused.\nHer physical exam revealed a patient who was appropriately alert and oriented with a Glasgow Coma Score (GCS) of 15 and completely intact neurologic exam. She had a 4cm laceration over the right side of her forehead with minimal bleeding after being bandaged at the local fire station but no other deformity. She was tachycardic with a pulse of 110 beats per minute with a blood pressure of 118/76mmHg. Her respiratory rate was 22 breaths per minute with oxygen saturation of 98% on room air and no active stridor or wheezing noted. Her skin exam revealed several minor urticarial lesions on her anterior neck and trunk but no other lesions.\nShe reported no history significant past medical or surgical history and denied any allergies or history of allergic reactions. There was no family history of hereditary angioedema, and the patient was not taking any prescribed or over the counter medications. She stated that she had not been stung or bitten, and had ingested no new foods prior to or after being hit by the baseball.\nIn the ED she received methylprednisolone 125mg intravenous (IV), diphenhydramine 25mg IV, famotidine 20mg IV and one liter of normal saline. A non-contrast computed tomography (CT) of the head was negative for fracture or intracranial hemorrhage. Her forehead laceration was subsequently repaired without difficulty.\nAfter a period of observation in the ED, her tongue swelling had not improved. Because she had persistent tongue swelling and lived more than one hour from the hospital, she was admitted to the hospital for airway observation. She was discharged 18 hours later with improvement in her swelling and no recurrent allergic symptoms. |
A two-year-old male child was admitted to our hospital with the chief complaint of severe bleeding in mouth cavity due to trauma since two weeks before admission. Parents gave written informed consent to report this case and accompanying images. The patient was born to unrelated parents with an uneventful pregnancy and normal vaginal delivery. There was no history of bleeding disorder in the family.\nHis past medical history was remarkable for severe anemia, and packed red blood cell transfusion secondary to epistaxis, when he was five months old. He had not undergone any further evaluation for the cause of his bleeding at the time. Furthermore, he had experienced an episode of severe lower GI bleeding due to food allergy when he was one year old.\nAt admission he was found to have petechiae on buccal mucosa and fecal discoloration due to GI bleeding. He received packed red blood cells and fresh frozen plasma to manage his bleeding. On physical examination, we noted multiple abnormalities in his musculoskeletal system and skin. He had lymph edema in left leg, hemihypertrophy, and macrodactyly in both feet. Hemihypertrophy was prominent in left upper and lower limbs, with maximum swelling in left forearm and left foot, and visible fusion between the 2nd and 3rd foot digits (, ).\nThe skin abnormalities included thickening of skin and epidermal nevi over the trunk and lower extremities, with the largest one being 5×5 cm in diameter. Another prominent feature in this case was macrocephaly (head circumference=52 cm).\nWith the history of severe bleeding and recurrent blood product transfusion, we suspected a hemorrhagic disorder. Blood coagulation findings including prolonged activated PTT (66 seconds with APTT Control 31 sec) and reduced level of Factor VIII activity (5% conducted after transfusion of fresh frozen plasma) were consistent with the diagnosis of hemophilia A.\nPatient's other significant test results were as follow: normal activated PTT mixing test, normal factor XIII screen test, normal PT activity, normal fibrinogen level, and normal PT INR. We also found factor IX activity to be 88%.\nRadiographic images confirmed dispro-portionate overgrowth in the left leg (). Color Doppler sonography of arteries and veins revealed normal flows and there were no signs of deep vein thrombosis. In popliteal area of both legs there were some enlarged lymph nodes with the largest one being 11×8 mm in diameter. The patient also underwent abdominal and brain MRI, which were reported as normal. According to the diagnostic criteria and after ruling out similar disorders, the diagnosis of Proteus syndrome was established.\nAccording to the rating scale in Tachdjian's Pediatric Orthopaedics, our patient had macrodactyly, hemihypertrophy of left leg, thickening of skin, epidermal nevi, and macrocephaly with total score of 14.5. A score of 13 or more is required to establish a diagnosis []. In our case, genetic study was not done and according to his mother, asymmetric disproportionate limb overgrowth has a progressive course. Also there was not a positive family history in this case. |
A 15-year-old boy presented at with a history of progressive deformity of the back and dull continuous back ache for the past six months, exertional dyspnoea for one month, progressive weakness of both lower limbs for the past 15 days, and loss of bladder and bowel control for the past two days. He gave a history of trauma (fall from a height of 3 feet) 7 years previously, following which he noticed progressive deformity of the chest.\nOn examination he showed a kyphoscoliotic deformity in the upper thoracic region, where the third to seventh ribs were absent on the left side, with visible cardiac pulsations. Complete loss of motor power was apparent in both lower limbs with complete absence of sensations from below the umbilicus with exaggerated deep tendon reflexes, extensor plantar, and clonus bilaterally.\nRadiological featuresof the thoracic spine and chest are described in , . A chest X-ray taken four years previously at 11 years of age showed almost normal appearing ribs with normal thoracic vertebrae, indicating that the disease was not congenital and was progressive. All the biochemical investigations performed were within normal limits, ruling out any metabolic or endocrine pathology. All the imaging modalities were consistent with angiomatosis lesions affecting the bone.\nThe patient underwent Pedicle screw fixation, laminectomyand deformity correction. The resected bone samples were sent for histopathological examination (). Intraoperatively, the bones were found to have a thin cortex and appeared to be honeycomb-like. Increased vascularity of the bones was observed and the morphology of the posterior elements was altered. The hold of the screws in the diseased vertebra was reasonably good. Good cord pulsations were seen after decompression. A chest tube was inserted on the left side due to an incidental pleural tear. On the second postoperative day, the drain was removed and the patient was made to sit up-right. The patient was administered bisphosphonates and was referred to Physical Medicine and Rehabilitation ().\nThe patient recovered well postoperatively. At 4 weeks he was able to sit on his own, was able to walk with minimal support, and the neurology improved to American Spinal Injury Association (ASIA) grade D. The patient was reviewed at 1 year follow up. He was asymptomatic without any progression of the disease clinically or radiologically. |
A 40-year-old female patient presented with severe low back pain after falling down the stairs. The patient was immediately admitted into another hospital. Physical examination showed tenderness on the thoraco-lumbar area. No significant neurological deficit was found. Routine biochemical and hematological tests were within normal limits. The patient underwent urgent plain radiographs, computed tomography, and magnetic resonance imaging, which showed acute compression fracture of the T11 and T12 vertebrae with mild height loss of the vertebrae (). Her back pain did not improved despite treatment with bed rest for 2 weeks. The patient underwent T11 and T12 transpedicular VP with continuous visualization with fluoroscopic guidance (). The neurological status of the patient remained intact, and she was discharged with significant improvement of her back pain on the third postoperative day.\nAfter the VP, the patient's condition continued to improve for 2 weeks. She was readmitted to the same clinic now with acute back pain, radiating down to both legs that started suddenly when she was walking on a flat road. Her symptoms did not improve despite conservative treatment for 1 week. She was then referred to our institute. There was no recent history of trauma since the fall and no other significant medical history except for taking oral analgesics. Neurologic examination showed intact muscle power and sensations. She had no bowel or bladder incontinence. The right straight-leg-raise test elicited pain in the leg at 40° which was exacerbated by ankle dorsiflexion. T1 and T2 weighted magnetic resonance imaging was taken, which showed high signal intensity mass lesion in the intradural extramedullary space located at the low thoracic, lumbar, and sacral area (). Her coagulation battery including platelet count, prothrombin time, and partial thromboplastin time were within normal range. Open surgery was recommended, but, she refused. Intravenous dexamethasone was given for 10 days. Her back pain and leg pain rapidly improved over 2 weeks. Magnetic resonance imaging on the 20th hospital day revealed that the spinal SDH had almost completely resolved(). She was discharged without any neurologic deficit. |
A 71-year-old Chinese man who was previously healthy presented to our clinic with a 3-month history of episodic cough with the production of thick yellow sputum. This was accompanied by generalized fatigue, subjective fevers, weight loss and night sweats. Symptoms improved somewhat with over-the-counter antipyretics and cough suppressants. One month prior to the visit, he noticed streaks of bright red hemoptysis, which prompted him to seek medical care. Shortly after an initial chest radiograph (CXR) showed a left upper lobe cavity, a finding later confirmed by computed tomography (CT) scan (Figure ), he was referred to the chest clinic for further evaluation.\nThe patient was born and raised in China, where he had lived and worked as a veterinarian for most of his life until he moved to the US in 1981. He had a negative purified protein derivative upon arrival to the US. He had no prior medical problems and was not taking any medication at the time of his visit. He denied any history of alcohol, tobacco or recreational drug use and had no knowledge of sick contacts. On physical examination, he appeared younger than his stated age and in no apparent distress. His examination was relevant only for bronchial breath sounds over the left upper hemithorax.\nHis CXR and CT scan showed a well-defined left upper lobe cavitary lesion with associated contralateral mediastinal lymphadenopathy. Due to the suspicious appearance of the lesion, a positron emission tomography (PET) scan was ordered along with induced sputum for cultures. Diagnostic bronchoscopy or percutaneous needle biopsy were discussed with the patient and his family, but he did not want any invasive tests. The PET scan showed increased metabolic activity in the left upper lobe lesion as well as in areas of lymph nodes in the contralateral mediastinum; in addition, an area in the left lobe of the thyroid also showed a strong signal which prompted a referral to the thyroid clinic.\nDuring this time, the first sputum sample grew an acid-fast bacillus that was also present in the two subsequent samples. While the initial suspicion was for Mycobacterium tuberculosis (TB) or a non-tuberculous Mycobacterium, biochemical studies identified the bacteria as Tsukamurella pulmonis. Given that infections with this organism can manifest as cavitary pneumonia, and since the patient remained symptomatic, we decided to start him on oral Rifabutin 300 mg daily and oral Levofloxacin 500 mg daily, a regimen chosen based on the antibiotic susceptibility profile (the organism was resistant only to sulfas and tetracycline) and available clinical studies in immunosuppressed patients [].\nAfter starting therapy, he noticed significant clinical improvement, reduction in sputum volume and resolution of hemoptysis. Upon the recommendation of the endocrine specialist, an aspiration biopsy of the thyroid was performed, which revealed papillary thyroid carcinoma. Given our continued concern regarding the pulmonary lesion and the lack of radiographic improvement after 6 weeks of antibiotic therapy, the patient was again asked and eventually agreed to undergo a percutaneous CT-guided biopsy of the left upper lobe lesion. This revealed adenocarcinoma consistent with a primary lung origin and associated tissue necrosis without evidence of infection. While tissue culture grew Tsukamurella, the organism was not identified in tissue sections or in acid-fast stains of tissue sections in which inflammatory changes were absent. Although subsequent staging suggested that it was amenable to surgical resection, the patient opted for medical management while continuing treatment for Tsukamurella infection for a total of 6 months. One year after his last cycle of chemotherapy, the patient remains in remission and sputum samples obtained every 3 months after termination of antibiotic therapy have not shown recurrence of Tsukamurella.\nOriginally described as a human pathogen in 1982 [], members of the genus Tsukamurella belong to the aerobic actinomycetes and are phylogenetically related to species of the Rhodococus, Mycobacterium and Nocardia genera. Morphologically, Tsukamurella is a rod-shaped, Gram-positive organism that in most cases demonstrates mild acid-fast staining; more rarely, it may exhibit more substantial acid-fast staining similar to that seen with the Mycobacterium species. In culture, growth of Tsukamurella requires incubation for 48 hours in aerobic conditions and temperatures between 24 and 37°C. When seeded in a Lowenstein-Jensen agar, Tsukamurella colonies exhibit a rough, creamy appearance and, microscopically, these organisms tend to become arranged either in chains or dense clusters.\nThe presentation of pulmonary infections with Tsukamurella bears a striking similarity to the clinical syndrome seen with mycobacterial infections [,]. Clinically, patients may complain of persistent fever, weight loss, anorexia, productive cough and hemoptysis. Radiographic evidence of upper lobe infiltrates is not uncommon and, in the absence of therapy, these may progress to tissue necrosis and cavitation. Immunosuppressed patients may present initially with cavitary lesions, suggesting a more accelerated course in these individuals [].\nSince the original description of Tsukamurella infection occurring in the setting of cavitary pneumonia in a patient who failed traditional tuberculosis therapy, reports of other clinical syndromes have been described, including sepsis [], catheter-related infections [], conjunctivitis [] and infections related to a foreign body [], among others. Sputum samples may show the presence of Gram-positive rods, but the intensity of acid-fast staining is variable, often leading to confusion with Mycobacteria or Nocardia. To facilitate identification of Tsukamurella, several microbiological tests can be performed (Table ) [,]. The importance of making an accurate microbiological diagnosis is underscored by the fact that Tsukamurella is resistant to many of the drugs used in the treatment of TB or non-tuberculous Mycobacteria, such as streptomycin, cycloserine, rifampin, isoniazid, ethambuthol, p-amino salicylic acid and capreomycin among others []. Thus, a delay in diagnosis, or inadequate treatment, may promote progression to cavitary disease and the risk of life-threatening complications, such as massive hemoptysis and respiratory compromise.\nWhile we failed to observe the physical presence of the organism on the tissue biopsy, the organism grew from the tissue cultures suggesting that absence of organisms may have been due to low bacterial load and/or sampling error. To the best of the authors' knowledge, this is the first report of the coexistence of primary lung adenocarcinoma and Tsukamurella in humans. Despite the lack of reports of such an association, several investigators have reported a similar event in patients with TB. Given the limited clinical experience with Tsukamurella infections, treatment guidelines have not been well established. The choice of antibiotics is hampered because many of the antibiotics used to treat TB or non-tuberculous Mycobacteria are ineffective for Tsukamurella. A common approach to treating cavitary pneumonia due to Tsukamurella in immunosuppressed patients includes the use of Rifabutin and a fluoroquinolone for 6 to 9 months, with follow-up sputum cultures to document bacterial clearance []. It may be useful to perform susceptibility studies in vitro, however, there are no interpretative breakpoints for the genus Tsukamurella. Whether other classes of antibiotics may be equally effective either as single therapy or in combination is unclear at this time. Despite the limited evidence in support of our management strategy, it seems to have been effective in controlling the patient's infection as no evidence of recurrent growth was obtained after the treatment period was over. However, future studies should aim at establishing better guidelines to aid in the effective management of this infection. |
A 16-year-old boy was admitted to our department with a history of increasing shortness of breath, chest pain and hemoptysis which had started approximately 7 days prior to admission. On admission, the patient was dyspneic and mildly cyanotic. On examination, the respiration rate was 40 breaths/ min; crepitate and bronchial rales were heard in the two lung fields. The blood pressure was 100/70 mm Hg. The pulse rate was 110 beats/ min. The neck veins were distended. The Liver and the spleen were palpable but no tender. There was no edema. The electrocardiogram revealed sinus tachycardia, incomplete right bundle block, right axis deviation, and right ventricular hypertrophy. The Chest radiography disclosed regular masses scattered throughout both lung fields (). Laboratory results were within normal limits except for a mild eosinophilia. The titer of antiechinococcal antibodies was positive. Angioscan of the chest showed distended distal branches of the right and left pulmonary artery due to partial occlusion by cystic lesions and multiple segmental defects with multiple pulmonary hydatid localizations ( and ). An intra right atrial mass was also detected. Spiral CT scan of the abdomen showed normal liver, spleen, pancreas and kidneys.\nA two-dimensional echocardiography in the apical four chamber view showed a large cystic mass measuring 19 x 22 mm, with a large implantation basis adhesive to the right side of the inter atrial septum with an extension to the right ventricle (). No cysts in pericardial cavity were revealed. The pulmonary artery trunk, left and right branches were mildly distended without any proximal cysts.\nThe clinical history, the imaging findings and the prevalence of hydatid cysts in our country led to the diagnosis of a pulmonary embolism complicating cardiac hydatid cysts. No MR angiography was performed.\nThe patient was operated on an emergency basis. The operation was performed through a median sternotomy incision under extracorporeal circulation. The pericardium was carefully opened and a cardiopulmonary bypass was initiated under cold potassium cardioplegic arrest. The operative field was protected by sheets with hypertonic saline solution.\nOblique right atriotomy was performed; the cyst (2 cm in diameter) was exposed through the incision. The resection of the totality of the atrial cystic formation was performed; the content of the mass was multi vesicular ( and ). The interatrial septum, judged thin and delicate was strengthened by sutures. The interventricular septum explored was normal. The atriotomytomy was closed. The second step was the exploration of the pleural cavity through the fifth intercostal space and peripheral pulmonary cysts were removed. The residual cavities were closed. The postoperative course was uneventful.\nThe patient was discharged after 8 days and treated with Albendazole. 18 months later, he was doing well. We noticed a spectacular regression of the distal pulmonary artery cysts. The patient has a check-up every 6 months by physical examination, chest roentgenogram, echocardiography and anti-echinococcal antibodies test. There has been, until recently, no evidence of thoracic hydatidosis recurrence and no signs of chronic pulmonary hypertension. |
A 79 year old male with history of sick sinus syndrome associated with frequent syncopal events underwent dual lead pacemaker implantation with atrial and ventricular active fixation leads. Six months post implant he experienced acute inferolateral ST-segment elevation myocardial infarction complicated by cardiogenic shock and underwent successful primary percutaneous revascularization. During diagnostic coronary angiography the angiographic catheters were identified to engage the previously implanted pacemaker leads. Inadvertent positioning of the atrial and ventricular leads via the left subclavian artery to the right coronary cusp and left ventricular apex, respectively, was confirmed with detailed fluoroscopy and selective subclavian angiography. Pacemaker interrogation confirmed lack of atrial capture and normal ventricular sensing and capture thresholds. Following revascularization, the patient had an uneventful hospital course and was discharged on appropriate medical therapy including antithrombotic therapy with aspirin and thienopyridine. Warfarin was not instituted due to persistent anemia and requirement of dual antiplatelet therapy.\nGiven the high risk position of the atrial lead tip in close proximity to the right coronary artery ostium, the patient was electively admitted one month later for transarterial lead removal. Under general anesthesia and in a hybrid operating theater and catheterization laboratory, vascular access was obtained in the right and left femoral arteries and right femoral vein. Prior to systemic anticoagulation, the left subpectoral pocket was opened under sterile conditions, and the subcutaneous tissue was carefully dissected until the leads were visible and freed. Venipuncture was performed using the Seldinger technique, and the left axillary vein was accessed. Two active fixation pacemaker leads were implanted in the right ventricular outflow tract and the right atrial appendage, respectively. Fluoroscopy and aortography were performed demonstrating the dual pacemaker system (). Aortic arch angiography demonstrated a type 1 arch and no significant disease in the origin of the great vessels. Using 5-French diameter, 90 cm length guiding sheaths, the right and left common carotid arterieswere selectively engaged over a guidewire. Carotid angiography revealed nonobstructive disease in the intracranial and extracranial portions bilaterally. Unfractionated heparin was administered to achieve an activated clotting time of approximately 350 seconds. A distal embolic filter wire (Spider, EV3 Inc., Plymouth, MN)was then deployed in the distal segment of the both internal carotid arteries. Selective left subclavian angiography was then performed, confirming the pacemaker leads entry point in the subclavian artery, but no critical subclavian arterial stenosis. Unfractionated heparin was administered to achieve an activated clotting time of approximately 350 seconds.\nStylets were then advanced through the chronic transarterial leads, and after retracting the active fixation mechanism, gentle traction on the ventricular lead enabled withdrawal without requirement of laser extraction. Similarly, the atrial lead was manually withdrawn from the aortic root, and both leads were carefully pulled back until the tips were in close proximity to the insertion site of the subclavian artery. Over an antegradeguidewire, intravascular ultrasound was performed to ensure appropriate sizing for an 8mm x 60 mm self-expanding nitinol covered stent (Viabahn, W.L. Gore, Flagstaff, Arizona) placement. The stent was delivered and positioned between the proximal and distal insertion site margins and deployed immediately as the leads were withdrawn (). Angiography confirmed adequate stent expansion and no contrast extravasation. The distal embolic protection devices were subsequently withdrawn. Following the procedure, the patient remained hemodynamically stable, and recovery was uneventful without neurological or vascular complications. |
A 3-month-old female child was seen by one of us (SV) in a multi-specialty hospital upon the request of the pediatrician. She was born after a normal full-term vaginal delivery and had no history of consanguinity in her parents. The child was thought to have hemorrhoids with a large hemangioma in the perineal area present since birth. Upon examination the child had a skin-colored perianal protrusion that was clearly located posterior to the anus []. There was in addition a large midline hemangioma that started from the gluteal cleft all the way to the medial root of the thigh skirting around the vulva []. The presence of inflammation around the pyramidal protrusion could not be assessed because of the presence of the large hemangioma. The parents said the child was born with a ‘red patch’ in the area of the hemangioma which evolved over the past 3 months into a hemangiomatous red plaque. The child also had a large hemangioma on the contralateral side of the face with involvement of the lower lip []. There were no neurological complaints. There were also small hemangiomas found on the ventral aspect of the left forearm and dorsum of the left foot. The hemangiomas were explained in detail to the parents and they decided not to give any oral corticosteroid for the perineal hemangiomas and rather wait for a year. A head and neck as well as spine X-ray was performed that did not show any abnormality. CT scan/MRI was refused by patient's parents due to cost factor. A referral was made to the pediatric surgeon for biopsy of the pyramidal lesion which they refused. A provisional diagnosis of large perineal hemangioma with a perianal skin tag was made. The large facial segmental hemangioma was thought to be Sturge-Weber syndrome with no clinical evidence of internal involvement. The patient was prescribed topical clobetasol cream under monthly supervision after which the lesion had flattened a little and showed a whitish area with pronounced flattening. |
A 66-year-old woman diagnosed with advanced gastric cancer and multiple liver metastases was referred to our hospital in March 2003. She was not a carrier of the hepatitis virus, or an alcoholic with previous hepatic disease. Furthermore, she did not have a family history of malignant neoplasia. Gastrointestinal fiberscopy upon admission showed an irregular ulcerative lesion on the anterior wall of the gastric corpus (Figure ), and the pathological diagnosis from the biopsy specimens was poorly differentiated adenocarcinoma (Figure A, B). Abdominal computed tomography (CT) images revealed four space-occupying lesions with diameters of 2–3 cm with internal heterogeneity due to a relative lack of effect of the contrast medium in the liver (Figure ). This suggested the presence of metastasis from the gastric cancer and no enlarged lymph nodes around the stomach. A barium enema revealed no evidence of dissemination or colon tumors. Based on these findings, the patient was diagnosed with Stage IV gastric cancer with hematogenous metastases according to the Japanese Classification of Gastric Carcinoma [].\nWe administered chemotherapy with docetaxel and oral S-1 to treat the gastric cancer and liver metastases []. Seventeen cycles of this regimen over a period of one year considerably reduced the gastric cancer and liver tumors, and new cancerous lesions did not appear. However, adverse effects prevented the patient from continuing with this regimen. We considered that all of the lesions were completely resectable at this point, and the patient provided written informed consent to proceed with surgery at 14 months after starting chemotherapy.\nAscites and peritoneal disseminated lesions were not evident during the procedure, which included total gastrectomy and partial liver resections for all liver tumors. Pathological examination revealed that no viable tumor cells remained in the stomach and chemotherapy resulted in complete remission of the gastric cancer. The liver tumors were immunohistochemically positive for smooth muscle actin (SMA), desmin and h-caldesmon, and negative for c-KIT, CD34 and S-100 (Figure ). Furthermore, an average of 20 mitoses per 10 high power fields was observed in the liver tumors, which were diagnosed as being LMS with high mitotic activity. Until that point, we considered that the liver tumors were metastases that had developed from the gastric cancer. However, the histological type of the liver tumors was LMS and not adenocarcinoma. Thus, we had to assume that the liver LMSs were primary tumors that developed from liver or metastatic tumors from an unknown primary LMS.\nWe administered only oral S-1 as adjuvant chemotherapy after the surgery. However, 11 months after this treatment, four liver tumors developed and we changed the chemotherapy to irinotecan and cisplatin. This regimen was ineffective and the liver tumors gradually enlarged. Furthermore, a tumor-like mass in the sigmoid colon was incidentally discovered on CT scan and positron emission tomography/computed tomography (PET-CT) during this therapeutic process; this gradually increased in size to 3 cm in diameter. Colonoscopy revealed a lesion protruding from the submucosa with a normal mucosal surface (Figure ). Although we suspected that this tumor might be a solitary peritoneal metastasis from gastric cancer, our assessment was that complete resection of the colon tumor and all of the liver tumors would be feasible.\nA second surgical resection of the four liver tumors and a partial colon resection proceeded at 2 years and 5 months after the commencement of first-line chemotherapy. The sigmoid colon and liver tumors were all immunohistochemically diagnosed as LMS (Figure ). This finding indicated that the LMS had originated in the sigmoid colon, and that the multiple liver metastases had arisen from a colonic LMS that was accompanied by advanced gastric cancer at the time of the first admission.\nThe patient underwent a third liver resection to treat two new liver metastases that developed at 7 months after the second procedure. This was because we considered that there might be only a limited chance of a good response to chemotherapy in the case of the LMS, and all of the liver metastases were also completely resectable. Thereafter, despite ifosfamide and epirubicin chemotherapy followed by dacarbazine, multiple liver and lung metastases eventually developed and the patient died at 4 years and 10 months after the first presentation at our hospital. |
A 62-year-old woman who underwent surgery and radiation therapy for a left temporal lesion at another hospital 40 years before presentation was admitted to our hospital due to progressive aphasia and right hemiparesis. She was found to have a 4 × 3 cm subcutaneous mass in the left temporal area of the head []. Computed tomography (CT) imaging showed destruction of the left temporal bone and a partially calcified mass lesion []. T1-weighted contrast-enhanced magnetic resonance imaging (MRI) showed an enhancing mass with intracranial and extracranial cystic components (5 cm and 3 cm in diameter, respectively) [ and \n]. Although detailed information related to the previous surgery and radiotherapy was not available, a semi-urgent surgery was planned because two of the cystic lesions were growing rapidly, and the patient’s symptoms continuously worsened after admission.\nThe surgical procedure was performed in the right semilateral position under general anesthesia. The scar of the previous operation [] was reincised, preserving a frontal branch of the superficial temporal artery. An additional skin incision was made around the subcutaneous mass lesion, and an island-shaped portion of skin and temporal muscle covering the subcutaneous mass was left intact on the tumor side. The surrounding skin flap was then flipped, and artificial bone constructed during the previous surgery was observed on the vertex side of the tumor []. A small bone window was made just above the artificial bone using a high-speed drill. Subsequently, a continuous narrow craniectomy approximately 1 cm in width was performed surrounding the tumor and the artificial bone []. This procedure was carefully performed using a ruler to maintain the safety margin of the tumor and to avoid tumor cell dissemination. A dural incision surrounding the tumor and the previous artificial bone were made using the space created by the narrow craniectomy []. The middle meningeal artery, one of the main feeders of the tumor, was coagulated and cut during this procedure. The temporal bone, dura mater, and intracranial tumor were lifted gradually, and the branches of the middle cerebral artery and the cortical veins were carefully detached from the mass lesion. Subsequently, en bloc resection of the tumor with adjacent skin, temporal muscle, skull, dura mater, and a thin slice of the temporal lobe cerebral cortex was achieved []. After completion of hemostasis, the dura mater defect was reconstructed with fascia lata, and the temporal bone defect was reconstructed with artificial bone (Cemex® Bone Cement, Tecres S.p.A., Italy). After repeated intraoperative tissue expansion of the adjacent scalp using a 30 ml balloon in a 20-French Foley catheter [ and ], a local rotation skin flap was created on the dorsal side of the skin defect [ and \n]. The skin defect was covered with this rotation skin flap and the expanded surrounding scalp, and a primary closure of the skin of the head was achieved [].\nThe temporal bone defect was shown to be adequately reconstructed with artificial bone on postoperative CT imaging []. No residual tumor was identified on postoperative T1-weighted contrast-enhanced MRI [ and ]. Histological analysis revealed that the tumor was comprised atypical spindle cell components with focal cartilaginous differentiation [ and ]. The tumor was diagnosed as an OS, though the nature of the sarcoma remains unknown. Her symptoms, including aphasia and right hemiparesis, gradually improved within 2 months, and she was discharged from our hospital with no neurological deficits. Because a CT scan of the body revealed no evidence of tumor metastasis, and her blood test showed a mild leukocytopenia of unknown origin (leukocyte, 2860/µ; neutrophil, 1400/µ; and lymphocyte, 1200/µ9), she was carefully observed in the outpatient clinic without postoperative adjuvant chemotherapy. The condition of the skin of the temporal region remained excellent without any signs of infection [], and no recurrence was found on follow-up MRI at 1 year after surgery [ and ]. |
A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with right lower limb weakness. The first and second removals of the tumor via open surgery remained as Simpson grade IV because of hardening of the tumor and adhesion to surrounding structures including the SSS. The remaining tumor massively recurred within 1 year after the last discharge despite γ-knife radiosurgery following the second tumor removal (\n). We attempted removal of the tumor combined with SSS resection because obstruction of the SSS caused by the developed tumor was confirmed. The tumor was consequently removed as Simpson grade II. The residual tumor, including the dural tail sign, was not observed on postoperative magnetic resonance imaging (\n). The third histopathological result showed an atypical meningioma, World Health Organization (WHO) grade II. Postoperatively the patient was transferred to a rehabilitation hospital.\nThe patient who manifested a progressive headache was readmitted with a diagnosis of left dominant bilateral CSDH 1 month after removal of the tumor (\n). He had no clinical history, such as head injury, antithrombotic therapy, coagulation disorders, and alcohol abuse. In addition, postoperative images revealed no signs of CSDH. The left subdural hematoma alone was treated by burr hole surgery, which was successful (\n). However, recurrence of CSDH occurred 5 days after surgery. Although a second burr hole evacuation of subdural hematoma was performed, a third evacuation was required owing to its rapid recurrence within 2 days after the second evacuation. Because CSDH eventually changed to acute subdural hematoma (\n), craniotomy was accomplished 10 days after the third hematoma evacuation (\n). The hematoma and outer membrane of the subdural hematoma were eliminated as much as possible. Furthermore, the dura mater within the craniotomy area was removed and replaced with artificial dura mater. Histopathological features of the outer membrane of the subdural hematoma showed anaplastic meningioma, WHO grade III. Unfortunately, the patient died of worsening of general condition despite aggressive treatment one and a half months since the onset of CSDH although the subdural hematoma had obviously not recurred. His brain was investigated by autopsy after death. Histopathology of brain autopsy demonstrated invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma (\n). |
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 45-year-old lady presented with left supraorbital firm swelling for 3 months which started as a nodule of the size of a grain of rice. Swelling increases in size rapidly involving eyelid, entire orbit, and subsequently to the forehead. It also becomes intermittently painful. She started to loss her left eye vision gradually until it completely loss one month later. The patient presented to the ophthalmology clinic where further investigations were done. On examination, there was a huge soft to firm lesion involving entire left orbit extending to nasal bridge and forehead as shown in . Right eye vision is 6/12 with no visual field loss but left eye completely blind. There is no nodal involvement or organomegaly. Further detailed investigations ruled out systemic involvement. Computed tomography (CT) orbit and CT brain done as shown in . Due to the intracranial extension of the tumor, magnetic resonance imaging brain was done as shown in and the patient was referred to neurosurgical. The patient was planned for surgery electively 2 weeks later. On the day of admission 1 day before surgery, the tumor size has doubled compared to its size in clinic review 2 weeks prior. The patient subjected to craniotomy with total tumor excision and reconstructive cranioplasty approached through a bifrontal incision.\nIntraoperatively, the tumor is fleshy, friable, well defined, and highly vascular. The tumor noted to originate from orbital adnexa but sparing the globe. There is an invasion of bone and dura over the frontal lobe with 2 cm by 2 cm intracranial extra-axial tumor in the left frontal convexity. The frozen section was sent intraoperatively and reported as malignant tumor unable to rule out lymphoma. Thus, complete excision of the tumor was done including the bone, dura, and the intracranial tumor. Nasal bridge, frontal bone, and left eye orbital wall completely eroded by tumor, thus, needing reconstructive cranioplasty with titanium mesh, nasal bridge repair with sugar mesh, and orbital wall repair with orbital mesh. Normal anatomical shape of orbit and skull restored.\nPostoperation, the patient was extubated well with no new or worsening neurological deficit. CT brain done postsurgery as shown in []. Right eye vision still preserved. Histopathology finding reported as DLBCL of the orbit. The patient was referred to hemato-oncologist d started on Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone regime chemotherapy. |
A 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The winged scapula did not emerge when the patient pushed on a wall at chest level. Radiographs showed a small bony fragment in the ventral side of the ISA, with a narrow space between the fragment and the scapular body (). Computed tomography revealed a bony protrusion extending from the medial scapular border to the bony fragment, with a narrow gap between the protrusion and the fragment (Figures –).\nThe patient was instructed to avoid elevating the left arm for 2 months and then performed reinforcement exercises of the SA such as the scapular push-up and the bear hug using an elastic band for 2 months. At examination 4 months later, the periscapular pain and the winging of the scapula with the arm at the side and in active flexion had resolved. The push-on-the-wall test at waist level was negative, and the range of motion of the left arm was the same as the unaffected side, except for a 15° limitation in external rotation. Although the radiographic findings were the same as at the first visit, computed tomography demonstrated bony union (Figures and ). The patient was permitted to use the left arm without restrictions.\nAt the time of the final follow-up 10 years of postinjury, the patient reported that there was an occasional painless click and a sporadic floating feeling of the scapula with initial active flexion of the arm. However, there was no pain or any disturbance to the patient's activities of daily life and work as a physical therapist. The patient's colleague confirmed the disappearance of the winged scapula associated with shoulder movement. The DASH score was 0, and the Constant score ratio compared with the right shoulder was 100% [, ]. |
A 19-year-old healthy female presented to the musculoskeletal oncology clinic with a chief complaint of the right-sided groin pain for 3 weeks. The pain was progressive in nature and atraumatic in origin. The patient noted significant pain with functional activity in addition to nighttime pain. Oral anti-inflammatory medications did not relieve the pain completely.\nRadiographs were obtained by her primary care provider, which demonstrated a large, aggressive lesion with some mixed lytic and blastic features about the proximal femur (). On careful examination, there appeared to be a thin cortical rim over the margin of the lesion medially. Magnetic resonance imaging was obtained and demonstrated an aggressive appearing lesion centered near the inferomedial femoral neck as well as the lesser trochanter (). The lesion demonstrated a lytic appearance with some extension through the cortex. A soft tissue mass of approximately 6cm in size was present which abutted the iliopsoas and vastus musculature causing adjacent mass effect.\nThe patient underwent an open biopsy of the lesion through a posterolateral approach to the proximal femur. Sections from the curettage specimen showed a proliferation of relatively uniform large polygonal cells with eccentric round nuclei and abundant eosinophilic cytoplasm (). These cells were associated with the formation of new woven bone and seen growing in large sheets. By immunohistochemistry, the cells showed diffuse positive staining for SATB2, consistent with osteoblastic differentiation. Tumor necrosis was not present and mitotic activity was low (1–3 mitotic figures per 10 high-power fields). Overall, the morphologic features were consistent with an epithelioid osteoblastoma. After a diagnosis of epithelioid osteoblastoma was established, the patient returned to the operating room for extensive curettage of the lesion through a posterolateral approach followed by insertion of a short cephalomedullary intramedullary nail. Before insertion of the nail, an argon beam was used to ablate the curettage bony and soft tissue margin. Following insertion of the nail, the defect was then filled with allograft cancellous bone as well as demineralized bone matrix and the wound was then closed. The patient was made partial weight-bearing for a period of 6 weeks followed by full weight-bearing. Her pain was reported to be significantly relieved at the 6-week post-operative visit and she was ambulating with a mildly antalgic gait. One year post-operative imaging did not reveal any hardware complications or lesion recurrence (). In addition, on examination at the 1-year post-operative follow-up,the patient was not limited in gait or function. We will continue to follow the patient with serial radiographs and physical examinations for years to evaluate for recurrence. |
A 19-year-old male, educated till class 8, currently working as a tailor in a factory presented to the psychiatry outpatient department. The patient gave a history that 3 months back he had joined the gym where a friend told him that if he takes dexamethasone he would have better muscles and hence better looks. Therefore, he took 0.5 mg of dexamethasone tablet twice a day to increase his weight, although we do not have any written proof that he had taken the medications that he claims. He started taking these tablets as he thought he would look good on gaining weight. Although there was no preoccupation with weight or body image, he was not even spending excessive time thinking about his looks. There was no interference with his social life or his work. He took dexamethasone tablets for 2 months and had a weight gain of around 3 kg and also suffered mild gastritis, although not documented. Subsequently, he could not take the tablets for 2 days and on the second day he experienced GTCS characterized by tonic, clonic movements with up-rolling of eyes and tongue bite with loss of consciousness. There was also postictal drowsiness for 30 min. After the first seizure, he had gone to the emergency department of a nearby hospital, then dilantinzed exact details of which are not available, and he did not follow-up there and he did not even inform them about his steroid intake. Thereafter, assuming that the episode was due to missing medications, he again started taking the dexamethasone tablets, but at a dose of 0.5 mg once a day. After taking these tablets for 1 month, he again missed doses for 2 days and on the second day had a GTCS. Subsequently, he reported to the hospital outpatient department. There was no family history of seizures. There was no history of smoking, alcohol consumption or any other illicit substances abuse; there was no history of head injury or high-grade fever. The 19-year-old male patient was investigated regarding the seizure and to evaluate any adverse effect on any organ due to chronic steroid intake. Hemogram, electrolytes, blood sugar, liver function test and lipid profile were within normal limits. Contrast-enhanced computed tomography of the head and electroencephalography were normal. The patient was advised to stop the drug and was given lorazepam for 2 weeks and gradually tapered over 2 weeks; he did not develop any further seizure. |
A 22-year-old primigravida presented to the obstetrics department at 22 weeks gestation with a painful abdomen of 10 days duration. Her early pregnancy was uneventful and ultrasound examination had not been performed in the first trimester. On examination, her vital signs were stable and tenderness was present in the right iliac fossa and right lumbar region. The height of the uterus corresponded to 28 weeks gestation. Ultrasound showed a fetus of 22 weeks with placenta previa and cervical fibroid. Amniotic fluid was normal. Surgical causes of a painful abdomen were ruled out. The patient was managed conservatively with analgesics and antibiotics and discharged after her pain had subsided. Repeat ultrasound before discharge revealed the same finding. She was lost to follow-up and presented to the outpatient department at 40 weeks of gestation with no complaints for the rest of the antenatal period except for painful fetal movements. It was planned to perform an elective cesarean section for central placenta previa with transverse lie and cervical fibroid. Intra-operatively, as the abdomen was opened, the fetus along with the placenta were found lying in the abdominal cavity and with the left horn of the uterus seen separately lower down in the pelvis. A live term female baby of 3 kg was delivered with good Apgar score. The placenta was attached in part to the ruptured right rudimentary horn deriving its blood supply from it and part of it was attached to the layers of the peritoneum. As the placenta could not be separated from the right rudimentary horn, the placenta along with rudimentary horn and right fallopian tube were removed. The left tube and both ovaries were normal. One pint of blood was transfused. The postoperative period was uneventful and the mother and child were discharged in good condition. The histopathology report showed chorionic villi attached to bundles of smooth muscle of uterine cornu, as shown in Figure . Mother and baby were doing well at 6-week follow-up at the outpatient department. |
An 89-year-old female was diagnosed with lumbar spinal stenosis with bulging of the L2-L5 intervertebral discs. She had a history of chronic LBP for over 10 years which she took medicine for but had never had operative procedures or interventions. Her medical history included hypertension and hyperlipidemia, for which she was taking aspirin. She was diagnosed with a T12-L3 level compression fracture for which she received L2 level vertebroplasty. She had recently complained of LBP with left sided lumbar radicular pain. She was pharmacologically treated with nonsteroidal antiinflammatory drugs. Her blood tests, such as activated partial thromboplastin time, prothrombin time, and platelet count were all in normal ranges.\nAfter her aspirin was withheld for 5 days, the TFESI was performed under fluoroscopic guidance, with a 22-G Tuohy epidural needle at the left intervertebral foramen between the L4 and L5 levels in the prone position. After penetrating the skin, we checked for the absence of blood in the syringe before advancing the needle. We injected 4 ml of contrast media before drug injection. The contrast was injected and the patient had no particular abnormality and the lateral view image showed that the contrast spread well in the anterior epidural space (). After correctly positioning the needle, lidocaine with 1 mg of dexamethasone in 8 ml total volume was injected. The patient returned home on foot without any particular problem.\nThe next morning, 24 h after the procedure, the patient underwent an emergency MRI due to severe lower back pain and complaints of subjective weakness in the left leg. A lumbar spine MRI showed a 14 centimeter epidural hematoma extending from the T11 to the L5 level with cord compression at T11-12-L1-4 (). Physical examination showed that the lower extremity motor function grade was 5/5 and anal sphincter tone was normal. Although large amounts of hematoma were observed, neurological symptoms were believed to not be progressing because epidural bleeding was already clotted and no longer active. However, it is decided that epidural blood aspiration would be performed to relieve the patient’s pain by reducing pressure on the nerves. Under fluoroscopy-guided, the epidural space was localized at the L1-2 level with an 18-G Tuohy needle, with the bevel of needle facing cephalad, and using loss of resistance to normal saline in the prone position. After a multi-orifice epidural catheter was inserted 1 cm into the epidural space, approximately 2.5 ml of blackish-red sticky hematoma was aspirated from the epidural space. High sound pressure aspiration carries risks of causing other conditions, the focus was on reducing pressure in the epidural space by a small amount rather than a large amount. After the aspiration, the patient’s back pain decreased significantly. Through consultation with a neurosurgeon, emergency surgery was planned in the event that neurological symptoms occurred. With the patient’s consent, she was observed for several days.\nThe follow-up MRI taken 14 days later showed a decrease in the amount of hematoma and the degree of nerve compression (). The patient was discharged without surgical evacuation and any other symptoms. |
A 29-year-old woman presented to our hospital on February 12, 2013 at a gestational age of 40+2 weeks, combined with less amniotic fluid for 1 day. Two years ago, left ovarian cyst about 5.0 cm in size was found and no treatment was given. Membrane ruptured naturally at 19:45 on February 12, 2013. Oxytocin intravenous drip was given to strengthen uterine contractions at 8:45 on February 13. Fetal heart monitoring showed that the fetal heart decelerated with a ratio of 69 to 88 bpm. Oxytocin intravenous drip was terminated immediately. Persistent oxygen inhalation of oxygen was performed accordingly. The fetal heart continued to slow down, and fetal distress was considered. Cesarean section was performed in the transverse incision of lower segment of uterus under local anesthesia. About 1500 ml intraoperative hemoperitoneum was found in the operation. A full-term male infant was delivered. Left appendage and the left posterior wall of the uterus were adhered to the posterior wall of the pelvic and abdominal cavity. Meanwhile, multiple blood clot and active bleeding were seen. Combined with the medical history, intraperitoneal hemorrhage was suspected. The causes were unknown. Then the patient was transferred to abdominopelvic cavity exploration. Diffuse adhesion zone and blood clot were found in the posterior wall of uterus during the operation. The left ovary was adhered to the left posterior wall of the uterus and the posterior lobe of the broad ligament. The diameter of endometriosis cyst in left ovary was about 3 × 4 × 5 cm, and the rupture showed a length of 2 cm. There was no active bleeding. No chocolate like liquid was seen around the left ovary. Chocolate-like liquid was seen in the content of the capsule. Multiple inflammatory adhesions were found in the left posterior wall of the uterus, the blood vessel on the surface was opened. Multiple active bleeding was seen, and a local hematoma of 4 × 4 × 11 cm was formed on the serosal surface of the uterus. Then the left ovarian cyst was removed. The volume of hemorrhage and blood transfusion were about 2000 ml and 800 ml, respectively. The weight of the newborn was 3390 g, the 1-minute Apgar score was 6 (muscle tension- 2, breath-1, heart rate-1), the 5-minute and 10-minute Apgar score were 9 (muscle tension-1). The mother and child were recovered and discharged. |
A 10-year-old girl with no known medical issues presented to her primary care physician in October 2016 with complaints of left thigh and knee pain. The pain had been present for 1 month and was slowly getting worse. A radiograph was taken and a lesion was noted in the distal femoral metaphysis. The radiographs of the femur were concerning for an osteosarcoma, demonstrating a lytic lesion with an osseous matrix and an incomplete periosteal reaction. Immediate referral was made to an orthopedic oncologist, who saw her the next day. Magnetic resonance imagings (MRI) of the left femur was performed; the MRI correlated with the radiographs, corroborating aggressive features, including heterogeneous signal, contrast enhancement, soft tissue extension of the mass, and peritumoral edema. The patient was taken to the operating room for an open biopsy. Intraoperative pathologic assessment on frozen sections was consistent with osteosarcoma: pleomorphic spindle cells with nuclear atypia and associated osteoid. Staging was completed with computed tomography (CT) of the chest and a whole-body bone scan. The chest CT demonstrated two 1-mm nodules of indeterminate significance and the bone scan showed uptake only in the left femur. The final pathology confirmed the diagnosis of conventional osteosarcoma. The case was presented at the multidisciplinary sarcoma tumor board, and the patient began neoadjuvant chemotherapy 2 weeks after initial presentation. The multiagent cytotoxic treatment regimen proceeded according to the Children's Oncology Group AOST 0331 protocol, including doxorubicin, cisplatin, and methotrexate. The patient completed the full neoadjuvant course and was restaged with an MRI of the femur, with and without contrast, and a CT of the chest. Restaging revealed stable disease in the distal femur, albeit with a small pathologic fracture, and resolution of the two 1-mm nodules in the lungs, without development of any new nodules. Seventeen weeks after starting chemotherapy, the patient underwent local control with wide surgical resection and endoprosthetic reconstruction with a metallic distal femur replacement. Surgical pathology revealed widely negative surgical margins with >2 cm of surrounding uninvolved tissue and 90% necrosis. Chemotherapy was resumed per the AOST 0331 guidelines 3 weeks after surgery. The patient completed the course of chemotherapy 10 months after starting treatment, tolerating treatment with minimal interruptions. End-of-therapy scans were completed, revealing no observable disease on local imaging of the femur (radiographs), imaging of the lungs (CT), nor distant, nonpulmonary sites (positron emission tomography [PET]-CT).\nThe patient began surveillance every 3 months per the National Comprehensive Cancer Network guidelines for osteosarcoma []. Six months after completion of chemotherapy, 16 months after initial presentation with knee pain, the patient presented to the medical oncologist with abdominal pain. The pain had started 2 months previously and had initially been minor, so it had been treated symptomatically at home. On CT of the chest, a portion of the abdomen could be seen, revealing fluid around the spleen and liver, as well as two enlarged pericardial lymph nodes and a 2-mm nodule in the lung. Given the abdominal pain and the CT chest findings, a contrasted CT of the abdomen and pelvis was obtained by her medical oncologist. The abdominal CT demonstrated a large left lower quadrant mass (13 × 11 × 10 cm) with mineralization, a smaller adjacent mass, multiple masses throughout the abdominal cavity, and ascites (Fig. ). Four days later, a biopsy performed in the Interventional Radiology suite confirmed the diagnosis of metastatic osteosarcoma to the abdomen. The institution's Sarcoma Tumor Board decided that the burden of disease was too extensive for surgical intervention and considered palliative radiation and/or chemotherapy. However, the symptoms rapidly declined with suspected hemorrhage of the abdominal mass, resulting in hemodynamic instability. The patient was treated with supportive measures and entered hospice care. She died of disease 1 month after diagnosis of abdominal metastasis, 3 months after the onset of abdominal pain, 19 months after initial diagnosis of her disease. |
We present a case of a 70-year old Caucasian gentleman who underwent a living donor renal transplant 10 years ago following a diagnosis of glomerulonephritis aged 34. More recently, he had developed acute heart failure manifested by bilateral leg oedema, facial oedema and difficulty in breathing together with severe and difficult to control hypertension with wide pulse pressures. Biochemistry at the time of presentation revealed Cr 190 mmol/L and eGFR 27–32.\nThe patient had past history of several transplant biopsies performed to investigate repeated rise in serum creatinine level over the last 10 years. Clinically, there was audible bruit over the right side of the lower abdomen. Ultrasound, CT angiography scan and subsequently catheter angiography demonstrated very high flow arterial venous fistula within the transplanted organ (Fig. ), likely to be the cause of the patients symptoms of decompensated heart failure. The main transplant artery and veins, as well as all intra renal branches were aneurysmal with extreme tortuosity, especially in the intra renal vessels. The maximum diameter of the main transplant artery was 12 mm with relative narrowing at the origin. Other salient findings were ectatic and tortuous iliac vessels (Fig. ). Given the decompensated heart failure being caused as a result of the high flow AVF, patient planned for super-selective embolisation of the arterio-venous communication under interventional radiology.\nInformed consent was obtained and patient readmitted for elective super selective renal transplant embolization, to be performed under general anaesthesia in order to control the patient’s haemodynamic status. Given the knowledge of high flow through the AVM, plans were made to make both arterial and venous punctures. The contralateral left common femoral artery was punctured under ultrasound guidance and 6F sheath was inserted and positioned in the right common iliac artery. Through the sheath, the transplant artery was selected and 6mmx40mm angioplasty balloon was positioned and inflated at the origin of the transplant artery to reduce inflow and hence pressure into the AVM. The site of the AVM was approached via the venous side.\nSince the arterial side has a tight, almost 360°, backward bend to AV communication site and the venous channel has shorter and straighter path, a 6F sheath was inserted into the right common femoral vein, aiming to deliver the embolic device. Multiple attempts at cannulating the fistula from the venous side failed due to the predicted factors previously described. The tortuosity of the vessels led to difficult in reaching the exact site of the AVM, whilst the high flow from the arterial side continually forced the guide wires and catheters out of the transplant vein and back up into the common iliac vein as the inflated balloon at the origin of the artery failed to reduce the flow.\nTherefore, an additional 12F sheath and balloon (Medtronic ReliantM stent graft balloon catheter) were inserted into the venous ipsilateral side, coming from an insertion site just above the initial puncture. This balloon allowed transient occlusion of the common iliac vein (Fig. ), to ensure the guide wire remained in the transplant vein and not forced back into the host common iliac vein by the arterial pressure coming through the AVM. Once the wire was secured in situ, an occlusion plug (10mmx7mm) (AMPLATZER ™ Vascular Plug II, Abbott) was advanced through a 6F sheath and deployed across the fistula (Fig. ). This led to good embolic occlusive result with subsequent angiography showing no flow across the previous fistula (Fig. – (a) pre occlusion plug and (b&c) post occlusion plug).\nFollowing successful embolisation of the fistula, patient’s haemodynamic status remained stable. There was a transient rise in serum creatinine immediately after the procedure due to contrast nephrotoxicity from the procedure itself. In the proceeding weeks, the blood pressure decreased to around 130/85 systolic and serum creatinine improved to 138 on latest bloods. Of most importance, the patient is clinically significantly improved and has reported complete resolution of breathlessness and oedema – suggesting his symptoms were a direct result of the AVF causing high flow cardiac failure.\nUSS of the transplanted kidney performed 1 week after intervention showed good perfusion and no evidence of a residual or recurrent AV fistula. Follow up CT Angiogram performed 2 months after procedure confirmed good perfusion of transplanted kidney, stable position of the occlusion device at AVF site and resolution of the previous AVF (Fig. ). |
A 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 42-year-old female attended the office to investigate a localized ridge atrophy in the area of the upper right canine (). The patient was in good general health, with no history of systemic diseases, drug allergies, and smoking habits. Upon clinical examination, the patient was found to have a horizontal bone loss with a minimal vertical component and a coronal ridge width of 2 mm (). With respect to the soft tissues, the site was characterized by a thin gingival biotype with no keratinized mucosa. Further, the patient presented a skeletal class I deep bite with a history of an impacted canine extraction and a bone regeneration procedure carried out two years earlier, followed by infection of the graft itself. Radiographic examination, carried out with a Cone Beam Computed Tomography (CBCT) scan, confirmed the clinical evaluation and showed remnants of a non-well-defined graft consisting of few granules of a radiopaque material and a transcortical screw (). The patient feared to be treated with a conventional bridge and was seeking for an implant treatment and an aesthetic solution. Contextually, the patient complained about a dental apicoectomy performed in the lower incisors area, followed by a mucosal fistula occurred one year later.\nThe proposed treatment plan consisted of an orthodontic treatment in order to correct the deep bite and obtain a teeth alignment, followed by a bone and soft tissues reconstruction to place implants in a prosthetically driven position, two provisional crowns, and a gold ceramic crown. The patient refused to undergo the orthodontic treatment; hence only the rehabilitation of the canine area was chosen.\nThe first step consisted in the reconstruction of the bone defect by means of an intraoral corticocancellous block graft harvested from the chin area, taking advantage of the simultaneous treatment of the apicoectomy area in the lower incisors region. Before the surgery, the patient was provided with a full-mouth disinfection session. One day before the appointed surgical session, the patient was instructed to start with an antibiotic therapy consisting of amoxicillin clavulanate (Augmentin®, GlaxoSmithKline S.p.A., Verona, Italy) 1 g twice daily for six days. On the day of the surgery, mepivacaine 2% with epinephrine 1 : 100.000 (Carbocaina, AstraZeneca S.p.A., Milan, Italy) was used to induce local anesthesia, both at the mandible and at the upper left premaxilla. A double layer straight incision was first done below the mucogingival line in between the lower canines, to expose the apexes of the lower incisors as well as the symphysis area. The apexes of the lower incisors were then exposed; a surgical toilette was performed to remove the pathological tissue, followed by the creation of new apical seals obtained using a reinforced zinc-oxide cement (Bosworth® Super Eba™, Skokie, IL, USA) (). Subsequently, an osteotomy was conducted with rotating instruments in the underlying mandibular symphysis area to harvest a corticocancellous bone block (). The donor site was then filled with a native collagen sponge and a double layer suture was performed, with a 5-0 resorbable suture (Vicryl®, Ethicon Inc., Somerville, NJ, USA) on both the periosteum and the mucosal levels.\nThe recipient site was then prepared with a trapezoidal full thickness flap from the mesial side of the right lateral incisor up to the distal side of the right first bicuspid. The bone was then exposed () and the cortical plate was perforated with a round bur under copious irrigation with sterile physiological saline solution to promote rapid angiogenesis and migration of osteogenic potential cells from the endosteal compartment. The block, previously shaped, was adapted to the recipient site and fixed to the residual ridge with two transcortical screws (). The edges of the block were then smoothened with an oval bur and the graft was covered with a thin layer of anorganic bovine bone granules (Bio-Oss®, Geistlich Pharma AG, Wolhusen, Switzerland) () and a collagen membrane (Bio-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) (). Flaps were released with sharp dissection to allow tension-free closure. Horizontal mattress and single stitches were used to seal the surgical wound.\nThe reentry procedure was accomplished after a healing period of four months. The healing proceeded uneventfully and no complications were encountered. After elevation of a mucoperiosteal flap, no signs of graft resorption were observed as from the absence of exposed threads of the transcortical screws (). A 4.3 mm diameter per 13 mm length single implant (Camlog Screw-Line, Camlog Biotechnologies, Basel, Switzerland) was therefore placed in a prosthetically guided position (). A connective tissue graft (CTG), harvested from the inner part of the palatal mucosa at the surgical site, was placed to increase the thickness of the soft tissues ().\nAfter 4 months, being the quality of the soft tissues unsatisfactory (), a free deepithelized gingival graft was used to enhance the amount of tissue (). A first provisional crown was connected to the implant two months later, but the coronal level of the soft tissues was still aesthetically unacceptable, when compared to the contralateral canine ().\nHence, the need to move the gingiva more coronally induced the clinician to detect a technique able to correct the difference in height between the two canines. Being it impossible to perform a coronally repositioned flap, due to the presence of the acrylic crown associated with the absence of enough keratinized tissue, a combination of epithelialized and subepithelial CTG was chosen. A free gingival graft (FGG) was therefore harvested from the premolar-molar region of the palatal vault, prepared so as the apical part was disepithelialized leaving the connective tissue exposed, whereas the coronal part corresponding to the portion of the crown to be covered was left epithelized (). The recipient site was then prepared with a 64C beaver blade to create a partial thickness envelope around the canine gingival margin. Subsequently, the upper part of the graft consisting of connective tissue was inserted by leaving out the epithelial half-moon coronal portion (). A 6-0 nylon suture (Ethilon®, Ethicon Inc., Somerville, NJ, USA) was used to secure the graft in the proper position (). A new temporary crown was placed and adapted to the recipient site (). Six months later, impressions were taken and the final gold ceramic crown was placed ().\nAt the recall visit three years after the delivery of the final prosthesis, gingival levels of the upper canines appeared almost symmetric and clinically stable, with < 3 mm probing depths and no bleeding on probing circumferentially around (). The radiological examination conducted with a periapical X-ray using the long-cone paralleling technique demonstrated the maintenance of bone levels at the mesial and distal aspect of the implant (). |
An 18-year-old boy presented with a swelling in the right proximal leg following skeletal traction by a Steinmann pin, for the treatment of central fracture dislocation of the hip at a different hospital. The referral notes revealed a history of continuous and profuse bleeding from the pin tract site. On removal of the tibial pin the patient had repeated bouts of profuse bleeding from the wound. Each episode of bleeding had to be controlled with pressure bandaging leading finally to healing of the skin wound. At this time, the patient noticed a gradually increasing swelling in the vicinity of the healed pin-track. An MR angiogram was done at the index center, which revealed a pseudoaneurysm originating from the proximal portion of the anterior tibial artery []. The patient was then referred to us for further management. On examination, an ill-defined, fluctuant, compressible, nontender swelling was noted on the anterolateral aspect of right proximal leg. A healed scar mark of an upper tibial pin was noted []. The swelling was pulsatile and a bruit was audible. Dorsalis pedis and posterior tibial pulses were palpable. There was no distal neurological deficit. The clinical diagnosis was that of a pseudoaneurysm.\nDoppler ultrasound examination revealed a 3 cm × 3 cm soft mass with a hypoechoic oval lumen, the fluid filling consistent with the arterial flow.\nUnder epidural anesthesia and a tourniquet, the pseudoaneurysm was exposed through a longitudinal incision over the swelling. Proximal and distal control of the anterior tibial artery was obtained []. The aneurysmal sac was incised and the clot was removed to reveal a partial transection 3 mm × 3 mm in size, through which the sac was communicating with the arterial lumen []. The sac was excised and the rent in the artery was repaired by a lateral suture with 8-O nylon, using loupe magnification. The epidural catheter was retained for 48 hours for sympathetic blockade and the patient was administered Tab aspirin 100 mg OD and Tab pentoxiphylline therapy for four weeks. A follow-up MR angiogram at three weeks revealed good cross-sectional flow at the site of repair []. |
A 51-year-old male was diagnosed with glomerulonephritis by renal biopsy 25 years ago, and developed into chronic renal failure (uremia period), then received allogeneic kidney transplantation 2 years later. Cyclosporine A, azathioprine and a small dose of prednisolone were used to inhibit the immune response and reduce the rejection. The serum creatinine was lower than 2.3 mg/dL in the first 10 years after transplantation. Renal insufficiency began 15 years after transplantation. Other accompanying symptoms gradually appeared, including increased serum creatinine level, decreased urine volume, facial and lower extremities edema, hypertension, proteinuria, etc. There was little improvement of renal function after methylprednisolone shock therapy and renal nutrition treatment. The patient's condition worsened to uremia 15.5 years after transplantation and began regular hemodialysis. 21 years after transplantation, CT scan showed that there was a convex growth cyst-solid mixed mass in the cortex of the transplanted kidney. The volume was about 1.5 cm × 1.0 cm × 0.5 cm (Fig. A), which was increased to 2.5 cm × 1.5 cm × 1.5 cm in the 22nd year after transplantation. Considering that the transplanted kidney had lost its function and ruling out the possibility of tumor metastasis to surrounding tissues and distant organs, the patient received ICAN under general anesthesia.\nThe brief procedures of the operation were as follows. First, we exposed the transplanted kidney outside the peritoneum through an incision at the outer edge of the right lower rectus abdominis. We observed that the kidney adhered tightly to the surrounding tissues and could not be separated completely. Considering that sharp separation or forced dissection may cause serious damage to the surrounding organs or renal pedicle vessels, we decided to use ICAN. The inflammatory adhesive renal capsule was cut longitudinally along the long axis of the kidney, and separated with a vascular clamp in order to find out the space between the renal capsule and the cortex. The index finger was then extended into the space, and blunt separation was performed in the anterior, posterior, upper, and lower directions of the involved kidney. The adhesion of the renal pedicle at the hilum of the kidney was very light, therefore we cut the renal capsule at the renal hilum after bluntly separating in the loose plane under the renal capsule. Then the renal pedicle arteries and veins were together clamped, ligated, and cut, and the ureter was exposed and cut. Finally, the transplanted kidney was removed completely. During the operation, we had paid great attention to avoid massive hemorrhage caused by avulsion of the renal pedicle and antibiotics had been prophylactically used to prevent infection. The patient received regular hemodialysis treatment after the operation.\nGross observation showed that the transplanted kidney had atrophic changes. The tumor is located in the cortex of the transplanted kidney, with a convex growth, about 2.5 × 1.5 cm in diameter, and an intact capsule. After longitudinal incision, it was found that the tumor was multilocular cystic with a thick wall and granular inner surface (Fig. B, C). Histopathological examination revealed locally acquired cystic disease-associated renal cell carcinoma with focal hemorrhage, degeneration, fibrosis, and necrosis (Fig. ). The patient recovered well and was discharged 6 days after the operation. At the 12th month postoperation, no residual tumor or recurrence was found by imaging, and the creatinine level of the patient was about 3.5 mg/dL under hemodialysis treatment. The patient planned to have second kidney transplantation 6 months later, so we recommend that the immunosuppressive drug regimen be adjusted to mycophenolate mofetil because of the potential toxicity of cyclosporine A to the kidney. |
A 32-year-old Native American female was referred to cardiology for a newly diagnosed heart murmur and a history of previously diagnosed congenital heart disease. The patient reported atypical chest pain intermittently upon awakening but denies any palpitations or dyspnea. The patient had been diagnosed with a cardiac abnormality and murmur at birth, but she believed the murmur and abnormality had resolved. The patient was previously diagnosed with mild developmental delay, hyperthyroidism, and asthma. She lives with her parents and denies any alcohol or drug use. There was no family history of congenital heart disease. Clinical examination revealed a 3/6 systolic murmur at the left lower sternal border radiating to the apex. A continuous, high-pitched, and diastolic murmur was also were noted at the left sternal border.\nThe transthoracic echocardiogram showed an intracardiac shunt from the right coronary sinus of Valsalva to the right atrium creating inward movement towards the right atrium of the tricuspid valve during systole. The echocardiogram also revealed mild to moderate tricuspid regurgitation, right atrial enlargement, and right and left ventricles with normal size and function. Cardiac computed tomography angiography was obtained for better anatomical delineation of the abnormality, which showed presumably no evidence of coronary artery obstruction and a small ventricular septal defect in the mid-septum. The sinuses of Valsalva were found to be prominent with communication between the right coronary sinus at its base and the right ventricle (Figures and ). The computed tomography of the chest was unremarkable.\nThe patient underwent a right and left cardiac catheterization with aortography. The coronary angiography demonstrated a fistula between the proximal circumflex artery and the pulmonary artery (PA) (). Left ventriculography was normal. Aortic angiography showed passage of contrast between the aortic root and right heart chambers (). There was evidence of a large left to right shunt with a Qp : Qs ratio of 2.7 : 1.\nAfter testing was completed, the patient was ultimately found to have a sinus of Valsalva aneurysm of the right coronary sinus, an aorto-right ventricular fistula, a proximal circumflex artery to pulmonary artery fistula, and a small ventricular septal defect. She was sent for consultation with cardiothoracic surgery and surgical closure was recommended. She underwent repair of the sinus of Valsalva aneurysm with a Dacron graft, closure of the aorto-right ventricular fistula with a CorMatrix patch, reimplantation of the right coronary artery, ligation of the circumflex artery-PA fistula, and tricuspid valve repair with an Edwards annuloplasty ring. The patient had an unremarkable postop course and was discharged home. |
A 60-year-old male, ex-smoker, presented to the emergency department complaining of right colicky pain and high-grade fever 24 hours after being subjected to ESWL. Patient underwent an abdominal ultrasound revealing urolithiasis on the right side along with minimal urine stasis in the right renal pelvis. He was subjected to prophylactic antibiotic coverage and pigtail placement under fluoroscopic guidance with subsequent remission of fever and pain. Forty-eight hours later he complained of acute onset of sharp epigastric pain reflecting to the lumbar region. His physical examination revealed tenderness over the epigastrium with no abdominal palpable mass. The arterial pressure was mildly elevated (140–90 mmHg) and his pulses were 60 bpm. His lab workout revealed a blood count and a basic metabolic panel within normal limits, with the exception of WBC and CRP which were moderately increased. An abdominal duplex ultrasound was performed revealing a flap in the superior mesenteric artery. The CT angiogram of thoracic and abdominal aorta demonstrated an isolated superior mesenteric artery dissection, starting from its orifice, without SMA branch involvement (). Both true and false lumens were patent (). The diameters of the infrarenal aorta and superior mesenteric artery were normal. Additionally, the aorta and the iliac arteries were found abundant of atheromatous plaques.\nThe patient was transferred to our vascular department. We decided to start a medical treatment consisting of food and liquid restriction, close surveillance, intravenous administration of beta-blockers, and antithrombotic therapy with unfractionated heparin. After 10 hours the patient's symptoms had diminished and subsided 24 hours later. Liquid restriction was halted on the third day and food restriction on the fourth day of admission to our department. No signs of bowel ischemia were reported during the patient's stay in our department. On the seventh day of admission, the patient underwent a CT angiography revealing no change in the arterial dissection. The patient was discharged ten days after admission and was advised to receive warfarin orally and to undergo a follow-up CT angiography one month later. |
Patient A was four-years-old when he began receiving care at our Center. He had multiple siblings, including an older, much healthier sister who had CF. At the start of therapy, the patient's parents considered the long-term prognosis of their son when deliberating what treatments should be used. Would the disease be painful? What help, if any, would medications and other medical technology provide that herbal therapies had not? Is treatment futile in children with CF?\nFollowing lengthy conversations involving not only the patient's parents, but also the bishop and elders in his community, it was felt to be in Patient A's best interest to begin care with standard therapy for CF at our Center (Table ). A gas-powered generator was used to power the vest. Patient A, as well as all of our Amish and Mennonite patients, qualified for pharmaceutical companies' patient assistance programs for many of his medications. Those medications not covered under individual patient assistance programs were secured from pharmaceutical company representatives in the form of samples. Our hospital established a fee reduction program to help offset the cost of outpatient visits and inpatient hospital admissions for these families, all of whom qualified based on their income level. Notably, all of the aforementioned assistance was secured by our CF Center social worker, who was vital in communicating with the parents and helping them complete required paperwork.\nWhile standard therapies appeared to slow progression of the patient's lung disease, when his status worsened it was recommended by our Center physician that intravenous antibiotic therapy be instituted. The family consulted with their elders who recommended that such therapy be withheld because of its cost, and as use of such therapy would only prolong the dying process in a patient with a terminal disease. During discussions with the family, our Center physician stated that he believed the patient still would have a reasonable quality of life for several months or even a few years with use of intravenous antibiotics. Further, withholding of antibiotic therapy at the time of the discussions would result in a much longer dying process than if the patient lived a longer life with concomitant lung disease progression prior to withholding of aggressive therapy. After a number of discussions at our Center, the patient's parents allowed the introduction of intravenous therapy. They stated that if the medications did not seem to help their son's symptoms, it would be "God's will." At such a point they would not want to give him further intravenous therapy. Home intravenous therapy was instituted because the family could not afford to pay in-patient hospital charges.\nSeveral courses of intravenous antibiotic therapy were associated with a significant improvement of the patient's respiratory condition. However, after two years, he failed to respond to two intravenous antibiotic courses. At that time, the decision was made to withhold further intravenous therapy. The patient was provided supplemental oxygen at home that was generated by a concentrator, as well as on-going vest therapy. At the invitation of the patient and his family, a physician, respiratory therapist, and social worker from our Center made home visits to check on the patient as he deteriorated.\nAs he grew sicker, the patient was prescribed oral narcotics to be used as necessary for discomfort. Four months after withholding intravenous therapy, following eight years of treatment at our Center, Patient A died. According to his family, as has become custom within this community, all of his supplies, including the vest and medicines, were given to another child in the community with CF; in this case, his sister. The strong bond between the family and providers at our Center has led to Amish from other communities in New York to seek care at our Center at this family's advice. |
An 8-year-old girl, studying in second grade was brought by parents with complaints of fear of vomiting and feeling nauseated since about seven and half months. Around 20 days before the starting of symptoms, child had episode of acute and severe abdominal pain, high grade fever with 3 bouts of vomiting with nausea for a day. She was diagnosed as having acute appendicitis by a surgeon and was operated subsequently. Within around 10 days after operation, patient started having fear of similar episode of vomiting with repeated remembrance of the episode. She complained of feeling nauseated with excessive salivation and gastric regurgitation. The treating doctor did not find anything significant and was treated symptomatically. Parents were reassured about the symptoms. She started attending her classes but gradually her complaints increased. She had constant thoughts of feeling nauseated. She started eating less, avoiding outside food which she used to ask for previously. She would worry about the pungent smell of vomitus in toilet and ask mother to clean it frequently. The fear increased slowly to the extent that, she started avoiding playing with other children in a fear that they will avoid her and tease her if she vomited in front of them. She avoided school for the same reason and thought that teachers will have bad impression about her if she vomits in the classroom. Meanwhile, parents asked their close relatives to console her. But symptoms went on increasing and she started refusing to use a lift, travel in bus, going to park, market places, etc., Fear became generalized and patient started worrying that her parent may suffer vomiting, she would request parents not to go outside, not to travel in bus or use lifts. Her father was working in a different city and job required frequent traveling. She had persistent fear that he may suffer vomiting as he eats outside food and there is no one to take care of him. She would call him repeatedly on phone and ask to change his job. She also developed reduced and non-refreshing sleep with constant thoughts/worries about vomiting at night with complaints of nausea and regurgitation after having her dinner. History of occasional nocturnal enuresis was also present during this period.\nShe was referred for a psychiatric consultation. She refused separate interview of parents because of the fear that they will hide the illness from her. She elaborated all the complaints and said “I feel nauseated even when I hear a word ‘vomitus’ or ‘vomiting’ or if I see anybody vomiting”. She elaborated the incidence when she vomited after witnessing the same in the neighborhood. Besides this, there was no history of depressive or obsessive-compulsive features or eating disorder and no symptoms suggestive of other phobias. Past history was not significant. There was significant family history and both of her parents are suffering from anxiety disorder and taking regular treatment from a psychiatrist. Birth and developmental history did not reveal any significant abnormality. She was good in academics.\nOn mental status examination, patient described her mood as anxious with appropriate affect. In thought, there was preoccupation about the worries of having nausea and vomiting along with number of questions e.g., whether I will get better; Do I have some severe illness; Will your medicines have side effect of vomiting, etc., She was diagnosed as a case of Specific Phobia of Vomiting i.e., Emetophobia.\nAs it was very difficult to involve the child in counseling or psychotherapy because of severe anxiety, she was prescribed tablet Clobazam 5 mg in divided doses and Cap Fluoxetine 10 mg. She was admitted to a child unit to reassure her as she was not willing to take medicines due to fear of side effects. After a week, she and her parents perceived mild improvement in anxiety and she was somewhat comfortable. On further follow-up, child was taught relaxation and started on Graded Exposure therapy along with the medications. She was exposed to the materials or activities related to vomiting. First, she was asked to read hand written article which contained the word ‘vomitus/vomiting’ (multiple times) as many times as possible. After about a week, she was asked to witness the action of vomiting by parents which they were pretending, followed by behavior as if vomiting has caused no trouble and anyone can suffer it for a short duration. After around 15 days, she was advised to attend school with a facility to go to rest room whenever she has thoughts of vomiting followed by feeling of nausea. She used the rest room only for initial 2 days after which she was as regular to the classes as before the start of illness. She was asked to play with other children only for 15 minutes to begin with. This time was increased slowly from 15 minutes to 1 hour. When she didn’t have even a single vomiting during this period, she started accepting the fact that it was an irrational fear and that she can achieve a mastery over it. Slowly, she was exposed to the activities that can induce vomiting like smelling the toilet, spinning around, etc., She had nausea and she hesitated to do it initially, but with intermittent counseling and relaxation and frequently doing above activities, she could face the feeling of nausea with less fear than before. In view of severity of symptoms and family history of anxiety disorders in parents, patient was advised to continue medications. |
A 26-year-old woman (gravid 4, para 1) at 37 weeks of pregnancy with rapid enlargement in left anterior chest wall during pregnancy was admitted to our breast surgery unit. She first noticed a peanut size palpable accessory breast lesion at 10 weeks of pregnancy and during pregnancy the mass gradually increased along with pain. A similar symptom occurred in her last pregnancy 5 years ago, but the mass in left anterior chest wall was limited in the peanut size during the whole gestation period. A delayed surgical intervention was suggested. But the lump gradually regressed and disappeared after delivery.\nOn breast examination, two breasts looked symmetric with a couple accessory breasts below. The left accessory breast was obviously bigger than the right one that only had a light areola around a small nipple. An elastic, mobile well-circumscribed mass measuring approximately 15 cm × 15 cm was palpated on physical examination of the left accessory breast. Moreover, it was edematous and congestive with an increase in local temperature (Figure ). The breast ultrasound further demonstrated the mass was a relatively homogeneous solid with short stripe blood flow signal. A single live fetus of 37 weeks gestation was observed by abdominal ultrasound scan. So mammography and dynamic contrast-enhanced Magnetic Resonance Imaging(MRI) were not performed. The patient also refused the core needle biopsy.\nDue to progressive enlargement of the lump, diabrosis with bleeding occurred on the third day after admission. Since the fetus had been mature in the 37th week of gestation, we decided to perform the excision of the mass and accessory breasts after caesarean section. After a 2850 g male neonate was delivered, the right accessory breast and the mass with left accessory breast were removed. The pathological result came out with a giant tubular adenoma of 15 cm × 15 cm × 12 cm, the resected specimen appeared as a solid white elastic mass with a smooth surface. The cut surface was red-grayish. No hemorrhage or necrosis was present (Figure ). Microscopically, the lesion consisted of tightly packed homogenous glandular structures which were supported by a single layer of myoepithelial cells with sparse intervening stroma (Figure ). Milk overflowed from the left chest wall incision three days after operation and cured two days after the administration of bromocriptine. The postoperative course was uneventful and she discharged in good condition in two weeks. |
A 27-year-old Indonesian female presented with progressive knee swelling and pain for a month after a minor sprain. She had previously enjoyed good past health. She had no other joint symptoms or any systemic symptoms such as weight loss, fever and night sweats. Physical examination revealed moderate knee joint swelling with joint effusion. The knee could not be fully extended. No redness or increase in temperature of the knee joint was present. There was tenderness at the medial joint line. All the inflammatory blood markers were negative. Knee joint fluid aspiration yielded slightly turbid fluid with a small number of lymphocytes and a negative Gram stain and bacterial culture. Knee radiography revealed moderate soft tissue thickening in the medial aspect of the knee with mild to moderate osteolysis of the medial femoral condyles and moderate resorption of the medial condylar cortex (). Ultrasound of the knee showed a small to moderate-sized joint effusion with severe synovial thickening at the anteromedial aspect of the knee, mainly at the medial patellofemoral recess and the medial side of the knee joint (). Moderate cortical irregularity of the medial femoral condyle was present (). Only very mild vascularity was present within this area of synovial thickening. MRI showed a large soft tissue lesion present on the medial side of the knee joint (), involving the synovium and adjacent medial femoral condyle with moderate periosteal elevation. This lesion extended deep to the medial collateral ligament and extended into the intercondylar notch posteriorly encompassing the femoral attachment of the medial belly of gastrocnemius muscle. The soft tissue mass was slightly T1-hypointense and T2-hyperintense to skeletal muscle (, ). No evidence of hemosiderin was present. There were two moderately enlarged popliteal lymph nodes present (). In addition, abnormal bone marrow signal (low in T1 and heterogeneously high in T2 FSE) was present in the distal femur consistent with marrow involvement or infiltration (, ). Patient refused gadolinium contrast injection. Ultrasound guided biopsy of this synovial thickening/soft tissue revealed fibrous tissue infiltrated by diffuse sheets of atypical lymphoid cells (). Immunohistochemical staining of these atypical large lymphoid cells revealed positivity for lymphoid marker (LCA), B cell marker (CD20) and bcl-2. Proliferation index by Ki67 (MIB-1 immunostaining) was estimated as 95%. Features were compatible with diffuse large B-cell non Hodgkin lymphoma (NHL). The patient refused treatment B-cell NHL and further investigation (including abdominopelvic CT scan). However, physical examination did not reveal enlarged systemic lymph nodes or hepatosplenomegaly. In view of clinical absence of systemic involvement, this was considered to be primary lymphoma of the knee. There was no clinical or other evidence that the patient was immunocompromised. |
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 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The winged scapula did not emerge when the patient pushed on a wall at chest level. Radiographs showed a small bony fragment in the ventral side of the ISA, with a narrow space between the fragment and the scapular body (). Computed tomography revealed a bony protrusion extending from the medial scapular border to the bony fragment, with a narrow gap between the protrusion and the fragment (Figures –).\nThe patient was instructed to avoid elevating the left arm for 2 months and then performed reinforcement exercises of the SA such as the scapular push-up and the bear hug using an elastic band for 2 months. At examination 4 months later, the periscapular pain and the winging of the scapula with the arm at the side and in active flexion had resolved. The push-on-the-wall test at waist level was negative, and the range of motion of the left arm was the same as the unaffected side, except for a 15° limitation in external rotation. Although the radiographic findings were the same as at the first visit, computed tomography demonstrated bony union (Figures and ). The patient was permitted to use the left arm without restrictions.\nAt the time of the final follow-up 10 years of postinjury, the patient reported that there was an occasional painless click and a sporadic floating feeling of the scapula with initial active flexion of the arm. However, there was no pain or any disturbance to the patient's activities of daily life and work as a physical therapist. The patient's colleague confirmed the disappearance of the winged scapula associated with shoulder movement. The DASH score was 0, and the Constant score ratio compared with the right shoulder was 100% [, ]. |
A 62-year-old Caucasian gentleman with a history of previously treated right iris melanoma with secondary glaucoma and pale optic disc of the same side presented with gradual loss of left eye vision. The iris melanoma was treated with a ruthenium plaque (no iridocyclectomy was required) with no evidence of radiation retinopathy afterward. The cup–disc ratio was 0.9 in the right eye and 0.2 in the left eye. The BCVA of the right and left eyes was hand movements and 6/60, respectively. IOP was 23 mmHg in the right eye and 20 mmHg in the left. An OCT scan was carried out [], and the patient was also referred for electrodiagnostic assessment. Visual evoked potential to flash stimulation was grossly reduced from the right eye but was normal from the left eye. In addition, electroretinography (ERG) from the right eye were reduced and delayed to rod and cone stimulation, whereas ERG from the left eye appears to be normal. On the other hand, OCT examination revealed the presence of schisis involving the outer nuclear layer and to some extent in the inner nuclear layer and extending to involve the temporal half of the fovea. There also appeared to be an ODP with some areas of adjacent schisis to it but not extending to the fovea. OCT examination of the retinal nerve fiber layer confirmed marked optic atrophy in the right eye, but this was normal in the left eye. Overall, these findings were consistent with a left ODP maculopathy, which was quite significant since there was a loss of photoreceptors and the outer nuclear layer. However, there was no evidence of widespread retinal dystrophy in either eye.\nFollowing a discussion with the patient, he agreed to proceed with the least invasive of the treatment options, which is focal retinal laser treatment. On his follow-up appointment after the procedure, OCT showed resolution of the schisis cavity with associated outer nuclear layer thinning and foveal thinning with some subretinal fluid under the fovea, but BCVA in his left eye was 2/60. However, the patient was not keen on any further surgical intervention []. |
A 62 years old male presented to surgery emergency with chief complaints of multiple openings and faecal discharge from the openings in the right groin since 20 days. One month back he noticed a small swelling in right inguinal region after exertion. A day later, he developed fever with redness over inguinal region and few days later developed multiple openings with discharge of faecal material in the right inguinal region. No history of abdominal pain, constipation or any other bowel disturbances were present. There was no history of trauma and urinary or other abdominal complaints. There was no history suggestive of an inguinal hernia in the past, and nor was there a history of any type of surgical intervention.\nPatient was clinically examined and multiple openings were noticed in right inguinal region with faecal and pus discharge (Fig. ). Diagnosis of spontaneous faecal fistula was made and possibilities of appendicular abscess, tuberculosis of intestine, Crohn’s disease carcinoma colon, and actinomycosis were kept. Fistula was a low output fistula and patient was started on medical treatment and investigated thoroughly. On CT scan a small gut loop communicating with anterior abdominal wall and bilateral renal and hepatic cysts was reported with provisional diagnosis of enterocutaneous fistula and autosomal polycystic kidney disease.\nThere was no improvement in patient’s condition and patient had continuous faecal discharge. Exploratory laparotomy was planned. On opening the abdomen, a loop of distal ileum (about 20 cms proximal to ileocaecal junction) was found to be adherent to the internal inguinal ring which was retrieved back into the abdominal cavity (Fig. ). There was perforation over the loop stuck in the deep inguinal ring. Resection of the segment of ileum (Fig. ) involved was done with ileo-ileal hand sewn anastomosis. Mesh repair was not done for hernia defect due to faecal contamination and cellulitis. The internal inguinal ring was closed from inside of the peritoneal cavity with plicating sutures. The openings in the skin over the inguinal region were communicated with each ‘other and laid open due to cellulitis of the area involved and pus discharge. After achieving complete haemostasis and drain placement in pelvis abdomen was closed in layers. Final diagnosis of Richter’s hernia presenting as spontaneous faecal fistula was reached. Secondary suturing of the wound over inguinal region was done on 14th day. Post-operative recovery and hospital stay of patient was smooth and uneventful. |
A 28 year-old-man presented with progressive pain and swelling on the left thigh for 2 weeks prior to admission associated with intermittent fever. This pain started off as a deep boring pain associated with rest pain and night pain. It progressively got worst till he was unable to bear weight on the affected limb and was bound to a wheelchair. In addition to that, he also experienced constitutional symptoms such as loss of appetite and loss of weight. He denied history of cough, night sweats, haemoptysis or recent contact with tuberculosis patients. There were no recent skin or soft tissue lesions in him or any of his household contacts. No exposure to healthcare settings or any hospital interventions were elicited within the past one year. There was no previous medical history and he had not received antibiotic treatment in the past 3 months.\nOur patient is a civil servant who worked temporarily in Sabah, a state in East Malaysia. He is an avid deer hunter and 2 weeks prior to his clinical presentation he went deer hunting with a hunting partner and caught 3 deer from a forest in Tawau, a small town located at the south-east coast of Sabah. There was extensive direct contact with the deer carcass as he slaughtered the deer with a meat saw, skinned it, cut the deer meat into pieces and cleaned it up. They then cooked the deer meat and consumed it. Neither he nor his hunting partner had any food-poisoning symptoms after eating the meat. A few days after this hunting venture, the patient flew back to his family-home located about 1800 km from Tawau and was brought to the hospital by his family members as he was experiencing severe pain on his left thigh. According to our patient, his hunting partner also experienced fever and lower leg pain at about the same time as him. Unfortunately, we could not obtain any further history regarding his hunting partner as our patient lost contact with him once he left Tawau.\nApart from deer, he was not exposed to any other animals including companion animals. He is a regular smoker; however he does not use intravenous drugs and had no history of acupuncture, trauma, recent travel abroad or involvement in recreational activities like river rafting, diving or contact sports. He is single and denies homosexual behavior.\nHis vital signs on admission revealed a temperature of 38.7°C, heart rate of 90 beats/min and blood pressure of 120/78 mmHg. His left thigh was warm and tender with a deep ill-defined swelling measuring 20 cm by 8 cm. There were no discharging sinuses or other skin or soft tissue lesions noted. His left knee movement was restricted due to pain; however there was no swelling or tenderness of the knee joint. There was no inguinal lymphadenopathy and neurological and vascular testing was unremarkable. His lungs were clear both clinically and radiologically and examination of other systems was unremarkable.\nPlain anteroposterior radiography revealed an osteolytic lesion with erosion of cortex and periosteal reaction involving the mid-shaft of the left femur (Figure \n). A magnetic resonance imaging done (MRI) showed involvement of the mid-shaft of left femur with surrounding circumferential soft tissue involvement (Figure \n). The technetium-99 m bone scan showed isolated uptake of the left mid and distal femur (Figure \n). A provisional diagnosis of osteosarcoma was made based on the radiological findings.\nInitial blood investigations revealed leukocytosis (17.7 × 109/L) with 86% neutrophils, normal haemoglobin and platelets. The C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both markedly elevated at 45.6 mg/dL and 140 mm/hour respectively. All other blood investigations were normal. Blood cultures were taken on day of admission and we proceeded to a needle biopsy. Three days later, both blood and bone biopsy cultures grew MRSA.\nPatient was immediately commenced on intravenous vancomycin 1 gram bd, based on antibiotic sensitivity results. An incision and drainage was performed for the left thigh abscess and the cultures of pus also yielded MRSA. Management of the patient was complicated by a pathological fracture of the distal third of left femur sustained during an incision and drainage when a manipulation under anaesthesia was performed at the same time for the stiff knee (Figure \n). The fracture was managed with skin traction. Meanwhile, histopathological examination of the bone biopsy revealed acute on chronic suppurative inflammation with no evidence of granulomas or neoplastic cells. Ziehl- Neelsen stain did not reveal acid-fast bacilli and fungal stains were negative. A transthoracic echocardiogram done showed no evidence of valve vegetation, excluding the possibility of infective endocarditis. Ultrasound of abdomen did not reveal abscesses or other abnormalities. Placement of a peripherally inserted central catheter (PICC) line was done for long term antibiotics administration. Hepatitis B and HIV screening were performed and both were negative.\nOne month after initiation of treatment, the patient finally showed some improvement. His leukocytes, ESR and CRP demonstrated a downward trend and were 10.2 × 109/L, 125 mm/hour and 9.1 mg/dL respectively (Table \n). At about the same time, the patient developed swelling and tenderness of his left knee and a knee arthrotomy and washout was performed, the knee aspirate too grew MRSA with similar antibiogram as the previous isolates. Subsequently, fusidic acid was added to vancomycin. Following this, the temperature started to settle. Vancomycin level monitoring was regularly done to evaluate drug toxicity and vancomycin was continued till discharge.\nPatient was discharged on day 73 of admission with fusidic acid 500mg tds and rifampicin 300 mg tds and was advised non-weight bearing. At 2 weeks post-discharge follow-up, the leukocyte counts, ESR and CRP were 6.8 × 109/L, 93 mm/hour and 2.6 mg/dl respectively. It took 6 months for the ESR and CRP to normalize, indicating active inflammation; requiring 6-months of anti-MRSA therapy. During the subsequent months, the left thigh pain had improved substantially and patient was able to ambulate. Patient was back to work and was able to perform his daily activities without limitations within one year. At 2-year follow-up, he had full function of his left lower limb and there was no evidence of relapse.\nAntimicrobial susceptibility testing (Oxoid Ltd, Bastingstoke, UK) was performed and interpreted by the Clinical and Laboratory Standards Institute (CLSI) disc diffusion method.\nCharacterization of SCCmec types and detection of pvl gene was performed using conditions as previously described\n[]. Detection of 20 other virulent genes; sea, seb, sec, sed, see, seg, seh, sei, sej (enterotoxin genes); eta, etb, etd (exfoliative toxin genes), tst (toxic-shock syndrome toxin gene), efb (extracellular fibrinogen binding protein), fnbA, fnbB (fibronectin binding protein), cna (collagen-adhesin gene), hlg (γ-hemolysin genes), ica (intracellular-adhesin gene) and sdr (putative-adhesin gene) was performed by multiplex PCR using GoTaq DNA Polymerase (Promega Madison Wis, USA) following conditions previously described\n[-]. Typing of staphylococcus protein A (spa), mec-associated dru and multilocus sequence type (MLST) was performed using established protocols as described by web-based electronic database (\n;\n;\n), whereas typing of accessory gene regulator (agr) group was performed as previously described by Moore and Lindsay\n[]. |
We present the case of a 42-year-old male patient who presented to the emergency department complaining of low back pain for two days before presentation. He reported that the pain was started suddenly while he was playing golf. He described the pain as burning in character and has gradually increased in its severity. The back pain was localized and was not radiating to the lower limbs. He reported that the pain partially improved with simple oral analgesics like paracetamol. The pain was not related to posture or activity and the patient did not identify any exacerbating factors. He scored the pain as 7 out of 10 in severity and it often awakes him from sleep. There was no history of night sweat, fever, weight loss, urinary or bowel symptoms.\nThe patient reported that this was the first emergency visit for him with this complaint. He did not have any history of chronic back pain. His past medical history was remarkable for hypertension, dyslipidemia, and diabetes mellitus. However, his diseases were well-controlled. Most of his blood pressure measurements were below 140/90 mmHg. His last hemoglobin A1c level was 6.1%. Notably, the patient did not receive the vaccination for COVID-19 and he had a history of severe COVID-19 pneumonia requiring endotracheal intubation and mechanical ventilation. He stayed in the intensive care unit for eight days and was discharged home three days before the onset of his back pain.\nThe patient has not undergone any surgical operation in the past. His medication history includes metformin 500 mg twice a day, amlodipine 5 mg once a day, and simvastatin 20 mg once a day. He reported good compliance with his medication. He does not smoke or drink alcohol. His family history is remarkable for cystic fibrosis.\nOn examination, the patient was in distress due to the pain. His vital signs on presentation were as follows: pulse rate of 110 bpm, blood pressure of 124/82 mmHg, respiratory rate of 16 bpm, the temperature of 36.8℃, and oxygen saturation of 97% on room air. Examination of his back did not reveal any deformities and there was no focal tenderness. The range of motion was normal. The pain was not related to the motion. Importantly, the straight leg raise test was negative bilaterally. Examination of the cardiorespiratory system was unremarkable for any abnormality. However, the lower limb examination showed decreased temperature with absent pulses bilaterally.\nA basic laboratory investigation revealed a hemoglobin level of 13.9 g/dL, a white blood cell count of 7200/µL, and a platelet count of 350,000 µL. Other biochemical investigations, including renal and hepatic profiles, were normal. However, the D-dimer was slightly elevated with a level of 550 ng/ml (Table ).\nIn view of the clinical and laboratory markers, the patient underwent computed tomography angiography of the abdomen and pelvis which unexpectedly demonstrated occlusion of the lower abdominal aorta at its bifurcation with extension to both the common iliac arteries (Figures -). Such findings are consistent with aortic saddle embolism. Subsequently, the 12-lead electrocardiography showed a normal sinus rhythm and the transthoracic echocardiography showed no intracardial thrombus.\nAnticoagulant therapy with low-molecular-weight heparin was initiated immediately following the diagnosis. The patient was prepared for emergency endovascular treatment. A bilateral femoral artery catheterization was performed. The thrombus was completely aspirated by the guiding catheter. The patient tolerated the procedure without any complications. His symptoms showed significant improvement after the procedure. He was discharged on the third post-intervention day and was kept on aspirin as prophylaxis. |
A 26-year-old female patient visited the Department of Neurology at our institution with a chief complaint of headache and was referred to our department after lesions in the right cranial base and TMJ were discovered on magnetic resonance imaging (MRI). The patient did not have an unusual medical history, and no unusual symptoms were observed regarding the TMJ other than sharp pain in the left temporal region opposite the lesion. No unusual observation was made on the panoramic radiographs or computed tomography (CT) scans of the TMJ obtained in the first medical examination. On the MRI scans, the lesions were surrounded by a film that measured 11×11×7 mm and was positioned above the right temporal bone joint and TMJ. Within the lesion, a mix of high intensity and low intensity signals were observed on both T1 and T2 images.() Erosion and communication with the right TMJ were observed in the base of the right temporal bone.()\nAfter inducing anesthesia through nasotracheal intubation, open surgery was performed on the right TMJ using the preauricular approach. The superior joint space was exposed via open reduction while ensuring that the facial nerves were intact. No leakage of synovial fluid occurred upon exposure of the superior joint space, and no degenerative changes of the articular disc were observed. Loose bodies were found in the base of the glenoid cavity and were removed via curettage. A hole 2 mm in diameter was observed in the middle of the glenoid cavity. A lesion that extended to the skull through the pore contained loose bodies.() The dura mater was exposed following the removal of the lesion, but no cerebrospinal fluid (CSF) leak occurred. The exposure site was closed with Tachocomb (Nycomed International Management, Zurich, Switzerland), a type of collagen matrix barrier.\nBiopsy results showed clusters of synovial fibroblasts () and typical cartilage cells (). The patient was finally diagnosed with synovial chondromatosis.\nNo important symptoms other than decreased sensations in the ipsilateral side and tinnitus were observed, and the patient no longer complained of a headache. Two weeks after the open surgery of the TMJ, a maximum jaw range of motion (ROM) of 25 mm was noted, which returned to the normal value of 50 mm at 6 months after the surgery. Symptoms that caused discomfort, including tinnitus and decreased sensations, were also relieved.\nCT scans obtained before and after the surgery showed complete removal of the lesion in the right cranial base.() CT scans obtained 7 days after the surgery showed that approximately 2 mm of the area left by lesion removal was filled with air, which confirmed that neither perforation of the meninges nor brain herniation occurred. CT scans obtained at 3 months and at 2.5 years after the surgery showed reossification and satisfactory recovery of the defects caused by the lesion.() |
A 62-year-old male presented to our outpatient department with painless swelling of both his shoulders and restricted movements of the bilateral shoulder joints. His condition began when he was approximately 35 years old and he started experiencing reduced sensation in the bilateral upper limbs. No medical treatment was taken and the patient went to some osteopath who gave him some oil for local application. Patient condition did not improve and he started experiencing reduced sensations in the bilateral lower limbs. Despite that, he did not seek medical attention and his condition gradually worsened. There was no history of significant trauma in the past. Physical examination revealed generalized swelling about the shoulder, more on the left side []. On the right side, there was abnormal motion, distal to where the shoulder joint would be expected . On the other hand, the left shoulder joint was found to be dislocated, with humeral head anterior to glenoid cavity, leading to significant restricted joint movement. On palpation, the shoulder joints were nontender. Bilateral shoulder movements were restricted. Active forward flexion was 40 on the right and 30 on the left side, abduction 30 on the left and 25 on the right side and internal rotation bilaterally up to the sacrum. He had 4/5 shoulder abductor strength and 4/5 shoulder flexor and extensor strength bilaterally. Range of motion for passive movements was significantly higher than on active movements, more on the right side. Passive movement was painful on terminal range of motions. His biceps strength was 4/5, triceps strength was 5/5 while motor strength in bilateral distal extremities was 5/5. There was decreased sensation involving the entire upper extremities bilaterally and healed trophic ulcers found on the fingers and dorsal and ulnar border of the hand and forearm . The biceps, triceps and brachioradialis reflex were absent. There was muscle wasting in both upper limbs.\nPatient was worked up and X-ray, complete blood counts,erythrocyte sedimentation rate,fasting blood sugar,venereal disease research laboratory test level of vitamin B12, electromyography (EMG) and nerve conduction velocity of both upper limbs, measurement of the crystal for gout and pseudogout, magnetic resonance imaging (MRI) of cervical and thoracic spine and abdominal ultrasonography were performed. Although the overlying skin temperature was normal, still joint aspiration was performed to rule out the remote possibilities of an infected joint. No organism grew on culture. Other than radiography and MRI, all the hematological investigations were within normal limits, on the basis of which syphilis and diabetes were ruled out. A purified protein derivative test was nonreactive. X-ray of right shoulder showed complete destruction of humeral head with fragmentation, which falls into the resorptive variant of Charcot shoulder []. X-ray of the left shoulder showed anterior dislocation of shoulder with fragmentation of head and heterotopic new bone formation []. No biopsy was performed. MRI (magnetic resonance imaging)of cervical and dorsal spine showed large syrinx from the 3rd cervical to the 3rd dorsal spine []. At that time, various modalities of treatment were considered. Limb elevation, shoulder abduction brace and nonsteroidal anti-inflammatory drugs were advised. His swelling gradually subsided after 10 days of conservative treatment. As instability and not pain was the chief complaint, a custom-made shoulder abduction brace was advised on both the sides and underwent intensive shoulder rehabilitation programme. After that, the patient returned monthly and remained asymptomatic for the next 2 years. At the time of writing, the patient was doing well on this conservative mode of therapy and performing his daily activities and was able to perform his self-care. |
A 49-year-old woman presented to the emergency room with a chief complaint of “I am vomiting up my intestines since yesterday.” Her history of present illness dates back to approximately one year prior to presentation, when she started to experience nonspecific abdominal pain. She also complained of loss of appetite, dyspepsia, nausea, weight loss, and at times dizziness. Upon investigation of her presenting complaints in another hospital, she was found to have gallstones and underwent cholecystectomy five months back but she denied any relief to her abdominal pain or other symptoms.\nOver the past five months before her presentation, her symptoms were gradually worsening. She repeatedly presented to the outpatient department with similar complaints and her serologic examination was found to be positive for Helicobacter pylori infection, a common bacterial infection causing dyspepsia. Hence, she had been on several antacid medications, with the recent being a regimen of triple therapy (a proton pump inhibitor and two oral antibiotics) for Helicobacter pylori eradication completed three weeks before her emergency presentation.\nThe patient had been ill for the last two weeks period preceding her initial presentation to the emergency department with fever, arthralgia, and anorexia, which was diagnosed to be dengue fever and managed supportively. She presented again with epigastric pain, severe nausea, and vomiting of three days duration. She described that she had passed a total of one meter of her "intestine" in pieces in stool over the last three days associated with vomiting of various such segments on the last day. She brought the longest part (~ 1.5 meters) she vomited in a bag. The entire length of the expelled segments was estimated to be 4.5 meters in total. The patient stated that she had poor appetite during those two weeks and was almost fasting for the last two days.\nUpon direct questioning, the patient recalled an intake of raw beef about 18 months back in a social event - a relatively common local tradition. She denied any history of eating or even tasting pork.\nThe physical examination of the patient was unremarkable except for mild epigastric tenderness. Visual inspection of the vomitus brought by the patient from home in a bag was found to be a long segment of tapeworm proglottids. Vomiting of the proglottids was witnessed in the emergency room as shown in Figure . Scolex of the tapeworm could not be identified in those expulsions. Laboratory examinations for complete blood count showed white blood cell count of 3.0 × 103/μL, hemoglobin 13.6 g/dL, and platelet of 196 × 103/μL. An elevation in eosinophil count was not reported. Parasitological analysis of the stool detected eggs of Taenia species and Giardia trophozoites. The expelled proglottids were sent to the parasitology laboratory and evaluated microscopically, reporting gravid proglottids of T. saginata species. The patient was admitted with the diagnosis of taeniasis secondary to Taenia saginata infestation and given intravenous fluid with 10 mg metoclopromide for the nausea and vomiting. A single dose of 600 mg praziquantel was administered. Metronidazole 500 mg twice daily was also started for the incidental giardiasis. The patient reported instantaneous relief of symptoms and denied any passage of the adult tapeworm segments or proglottids neither through vomiting nor per rectum after the treatment. She described vomiting creamy contents in the first of her two-day stay in the ward. The patient was followed up in the outpatient department for seven months (assessed at one month, three months, and seven months), and she had no any complaint. She denied passage of proglottids or abdominal pain. Control stool examinations were done in each of the follow-up visits and were negative for ova and parasites. The patient provided written informed consent for publication of the details of her case. |
An eleven year old male patient reported with a complaint of the presence of a small sized tooth in the upper front region of the jaw since 4 years. Extra orally the patient presented with a symmetrical face and with a convex profile. Intra oral examination revealed that he was in the late mixed dentition period with retained maxillary primary left central incisor (61) and non eruption of the left permanent central incisor (21) [] and Angle's Class I molar relation. The radiographic examination consisting of intraoral periapical [], occlusal and panoramic views with an orthopantomogram revealed an irregular radiopaque mass suggesting of an odontome like structure between 21, 61 and 22 along with impacted 21 close to the nasal floor. A preliminary diagnosis of impacted permanent left central incisor due to the odontome like structure was made. The treatment plan included surgical removal of the calcified mass and guided eruption of 21 using Closed-Eruption technique.[] The following treatment objectives were established for this patient:\nSurgical removal of the calcified mass Guiding the eruption of 21 and to align it orthodontically To achieve good gingival attachment and symmetrical gingival margins for both the maxillary central incisors; and To create a stable functional occlusion.\nUnder local anesthesia, a full thickness mucoperiosteal flap was reflected from 11 till 22. The bone covering the odontome like structure was carefully removed and the calcified mass was retrieved along with the extraction of primary central incisor. Six supernumerary teeth were retrieved from the calcified mass, four teeth were conical in shape and two were in tuberculate form []. A final clinical diagnosis of an impacted maxillary central incisor due to multiple supernumerary teeth was made. The lingual surface of the exposed central incisor was etched, washed and a flat Begg bracket was attached to it. Elastomeric chain was engaged to the bracket on one side and the other end was left intraorally through the extraction socket []. The surgical area was thoroughly irrigated with betadine and normal saline, and the mucoperiosteal flap was sutured with 3-0 silk suture. The post-operative period was uneventful, healing was good and the sutures were removed after a period of one week.\nFixed orthodontic treatment with Begg appliance was planned in the maxillary arch. The maxillary first permanent molars were banded with round tubes. The maxillary right central incisor, right lateral incisor and left lateral incisor were bonded with flat Begg brackets. After the anterior teeth were aligned, a rigid base wire of 0.018” stainless steel (SS) Australian wire with a helix in the horizontal plane was placed in the maxillary arch. Light forces in the range of 10-15 gm were applied from the helix to the impacted tooth with the help of the other end of the elastomeric chain. Once the impacted tooth was sufficiently extruded and the labial surface was accessible, a bracket was bonded on the labial surface to continue further alignment. When all the anterior teeth were aligned, a torquing auxillary was used to torque the root of the left central incisor []. The appliance was debonded after a period of 9 months and a fixed retainer was bonded on the palatal surface of the maxillary incisors [] for stability. During the follow-up period, the patient showed an acceptable gingival contour and adequate width of the attached gingiva in relation to 21 []. |
A 50-year-old male visited our clinic with a major complaint of pain in the right knee that had started five days earlier. He had no history of trauma and complained of a pulling sensation behind the right knee and giving way symptoms when walking down stairs. The patient had been working as a medical technician carrying gurneys for 21 years and had no significant medical history or history of trauma, alcohol abuse, and intra-articular steroid injections. Physical examination revealed tenderness over the medial femoral condyle but no edema. The range of motion and lower limb alignment were normal. McMurray's test was negative, joint instability was not present, and early radiography was normal (), Magnetic resonance imaging (MRI) showed evidence of posterior meniscal tear without any chondral or bone marrow damage (). Surgical treatment of the posterior tear of the medial meniscus was performed. A complex tear of the posterior horn of the medial meniscus and an International Cartilage Repair Society grade II cartilage lesion (lesions involving <50% of the total cartilage thickness) in the medial femoral condyle were observed with arthroscopy (). Surgery was performed under spinal anesthesia while maintaining 70 mmHg of pressure with an arthroscopy pump, and a tourniquet was not used. Partial meniscectomy was performed with a basket forceps and a shaver without using a razor or radiofrequency device and the cartilage damage was treated with debridement. The total surgical time was approximately 20 minutes.\nThe patient complained of pain at the second postoperative week, which was managed with medication. At the sixth postoperative week, the patient felt severer pain and had the greatest difficulty in walking with straight legs, for which an increased dose of anti-inflammatory analgesics was administered. At the 12th postoperative week, an MRI scan was performed because the pain increased except for temporary relief.\nThe MRI scan revealed cartilage delamination of the medial femoral condyle that exhibited a low intensity signal on the T1-weighted image and a high intensity signal on the T2-weighted image (). Since the symptoms deteriorated during three months of medication therapy, another MRI examination was performed six months postoperatively, which showed more extensive cartilage delamination and cyst formation. An MRI scan taken nine months postoperatively showed an enlarged cyst, increased swelling around the bone, and severe cartilage delamination, all of which were the symptoms of osteonecrosis (). Thus, unicompartmental knee arthroplasty was performed (). Currently, at six months after surgery, the patient has been pain-free and returned to work. |
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 (). |
The 55-year-old, Turkish female patient experienced generalized tonic clonic seizures which started 2 years previously and had become persistent during the last 3 months, despite antiepileptic treatment. In addition, the patient had complained of speech defects, forgetfulness, perception deficit for 2 months, cognitive disorders and a weakness in the right side of the body for the 2 days prior to admission. The patient had history of an operation in her left maxillary area due to basal cell carcinoma 7 years previously and then history of radiotherapy due to relapse 2 years later the operation. She had treated with a total dose of 56 Gy radiation, administered in 15 fractions to her left maxillary region, and she had no chemotherapy history.\nDuring neurological examination it was found that the patient experienced confusion and disorientation. However bilateral papilledema was detected on neurological examination. In addition, the patient had right hemiparesis. Her muscle strength grade was 3 (active movement against gravity) in the right side of her body. A cranial CT scan showed hypodense lesions in the left frontal lobe (3 × 4 cm) and in the left temporal lobe (6 × 4 cm). No significant edema was observed around the lesions, which compressed the left lateral ventricle and did not show contrast enhancement (). Cranial MR imaging showed in the left frontal region 3 × 4 cm and in the left temporal region 6 × 4 cm lesions, which were hypointense in T1 (), hyperintense in T2-weighted images. These lesions observed with mild peripheral contrasting. They made us think about cystic masses. An EEG showed reduced bioelectrical activity in the left frontal and left temporal regions. A course of antiepileptic treatment was organized for the patient. The patient, who was using 2 × 500 mg Sodium valproate, was given dual antiepileptic therapy, starting with 3 × 100 mg Phenytoin. In addition, steroid treatment was begun. However, despite this treatment, the patient experienced loss of consciousness, a generalized tonic-clonic seizure, an increase in right hemiparesis. Her muscle strength grade became 2 (active movement with gravity eliminated). As the result of these, the patient was taken to surgery. She underwent a left temporal craniotomy. Transcortical cystic fluid was reached. The content of the cyst was aspirated. In the left frontal region, craniectomy was performed to a certain degree and the cystic fluid was aspirated.\nUnder microscopic examination of the cyst fluid, blood elements, an amorphous substance consisting of fibrinoid and hyaline material, low number of histiocyte and lymphocyte cells were observed. In the examination of material taken from the walls of the cyst and surrounding brain parenchyma, perivascular lymphocyte infiltration and macrophages were observed and hemosiderin loaded macrophages were found. These findings made us think of reactive gliosis. Also there were no evidence of neoplastic cells in the examination of cyst fluid, cyst wall and surrounding brain parenchyma.\nIn the early post-operative period, significant improvements were observed in the patient's consciousness, speech and right hemiparesis. Her muscle strength grade became 4 (active movement against gravity and resistance). The patient, whose follow-up still continues at our clinic, has not been experienced any postoperative seizure or neurologic deterioration. In postoperative follow-ups using images made for control purposes, it was observed that both cystic structures got smaller ( and ). |
A 62-year-old man was admitted to our hospital for the treatment of rectal tumor incidentally found by rectal examination during a routine medical checkup. The patient had no previous history of malignancy. Colonoscopy revealed a type II rectal tumor of 2 cm in diameter located 5 cm proximal to the anal verge and a submucosal tumor of 1 cm in diameter approximately 1.5 cm proximal to the rectal cancer. In addition, a small adenomatous polyp was observed near the rectal cancer (Fig. ). The biopsy of the rectal tumor was suggestive of moderately differentiated adenocarcinoma. The biopsy of the submucosal tumor was not performed because it was thought to be included within the region planned for surgical resection against the rectal cancer. Transrectal ultrasonography suggested the invasion depth of rectal cancer was the deep layer of the submucosa but not the muscularis propria (Fig. ). Abdominal CT showed there was no evidence of metastasis to regional lymph nodes or distant organs (data not shown). Barium enema examination suggested a small tumor with an irregular surface and a smaller submucosal tumor with a smooth surface located at the anterior wall of the rectum (Fig. ). MRI showed that the rectal cancer was located at the anterior wall of the rectum without invasion into the prostate (Fig. ), and diffusion-weighted imaging (DWI) that showed a high signal intensity was accumulated into the rectal cancer (data not shown). Results of laboratory blood tests, including tumor markers, were within normal ranges. Collectively, we preoperatively diagnosed cStage I rectal cancer and performed laparoscopic intersphincteric resection (ISR).\nMacroscopic analysis of resected specimens revealed a 16 × 15-mm type II rectal cancer with an irregular surface, a 10 × 10-mm submucosal tumor located 15 mm proximal to the primary rectal cancer, and a 10 × 7-mm adenomatous polyp located 20 mm proximal to the primary rectal cancer (Fig. , ). Histopathological analysis revealed that the primary rectal cancer was moderately differentiated adenocarcinoma with severe lymphovascular invasion: pT1 (submucosal invasion depth 3500 μm), pN0, pM0, ly1, v3, and pStage I. Immunohistochemical analysis using the stainings of D2-40 and Victoria blue was performed to evaluate lymphatic and vascular invasion (Fig. –). The submucosal tumor was composed of moderately differentiated adenocarcinoma proliferating within the muscularis propria. Moreover, numerous tumor emboli within vascular, but not lymphatic, vessels were observed in regions surrounding the submucosal tumor (Fig. –). We diagnosed the submucosal tumor to be an IM of the primary rectal cancer based on the following observations: (1) distinct location from the rectal cancer, (2) the gross appearance of the submucosal tumor without intraepithelial cancer extension, (3) the same histological type as the primary rectal cancer, and (4) tumor emboli within vascular vessels observed in regions surrounding the submucosal tumor as well as the primary rectal cancer. Three weeks after the operation, the patient was discharged without any event. The stage of the rectal cancer was stage I, but the patient elected to undergo adjuvant therapy because IM is one of the poorer prognostic factors in esophageal and gastric cancers [–]. Adjuvant chemotherapy (UFT + LV) was administered for 6 months postoperatively. The patient has been followed for more than 4 years without any signs of recurrence.\nIM is often observed in esophageal cancer but quite rarely in rectal cancer. IM of the esophageal cancer was first reported by Watson in 1933 [], and the frequency of IM has been reported to be about 10–15 % in advanced esophageal cancers [–]. The prognosis in esophageal cancer with IM was poor because of higher frequencies of lymph node and distant metastases [–]. In rectal cancer, lymphovascular invasion beyond the primary lesion is termed to be microscopic distal intramural spread (DIS). According to previous studies, DIS occurs in 10–40 % of rectal cancer, is significantly associated with lymph node and distant metastases, and is a risk factor for local recurrence and poor prognosis [–]. When DIS occurs, it is usually within 2.0 cm of the tumor [–]. As a result, a 2-cm distal margin has become acceptable for resection of rectal cancer. IM in esophageal cancer has been interpreted to be caused by lymphovascular invasion into the submucosal layer. In the present case, histological findings demonstrated invasion of the rectal cancer into the submucosal layer (T1) with severe lymphovascular invasion, a submucosal tumor consisting of cancer cells within the muscularis propria, and the tumor emboli within vascular vessels surrounding the submucosal tumor. Therefore, the submucosal tumor was assumed to represent IM via vascular invasion of tumor cells. To the best of our knowledge, this is the first report of T1 rectal cancer with IM.\nThe management of rectal cancer has become increasingly complex. Presently, three major curative surgical interventions are available: local excision, sphincter-preserving surgery, and abdominoperineal resection. Indications for local excision that preserves anal sphincter anatomy and function include small T1 lesions. However, the use of local excision is limited by an inability to assess regional lymph nodes and uncertainty of oncologic outcome. According to guidelines issued by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) in 2010, the criteria for identifying curable T1 colorectal cancer after endoscopic resection were well/moderately differentiated of papillary histologic grade, no vascular invasion, submucosal invasion depth less than 1000 μm, and tumor budding grade 1 (low grade) []. The local recurrence rate in patients with T1 rectal cancer following resection is in the range of 4–14 % at 5 years [–]. In the present case, sphincter-preserving surgery (i.e., laparoscopic ISR) was considered to be adequate considering the distance of submucosal invasion depth and severe lymphovascular invasion. The prognosis of esophageal cancer with IM is exceedingly poor with a survival rate of 9 % at 5 years and a median survival time of 0.7 years [], which made IM one of the poor prognostic factors. Although there is a lack of consensus regarding treatment strategies, IM in rectal cancer may be a poor prognostic factor as in esophageal cancer. In the present case, postoperative adjuvant chemotherapy was done due to the patient’s desire. Regarding the strategy of rectal cancer with IM, further studies are required to facilitate the development of treatment strategies for rectal cancer with IM. |
A 25 year-old man was admitted to the emergency department in our hospital due to status epilepticus. He had developed epilepsy at the age of 12 months. Despite taking anti-epileptic medications, the seizures were not controlled. He underwent right temporal lobectomy at the age of 20 (). Although right corpus callosotomy was performed after 2 years, he continued to suffer from seizures. The refractory epilepsy was of a generalized tonic-clonic nature, and occurred 4-5 times a day, each episode lasting 4-5 minutes. The patient could not independently perform activities of daily living because of pre-existing mental retardation, but showed no motor function impairment. He was brought to the emergency department due to status epilepticus. When he arrived at our hospital, he continued to experience generalized tonic-clonic seizures. He was treated with intravenous anti-epileptics and mechanical ventilation was performed after intubation. On hospital Day 3, he regained consciousness and could blink his eyes when directed. However, it was noted that he suffered from complete quadriplegia under the Medical Research Council (MRC) classification for most muscle groups. There were no signs of external trauma on physical examination and no evidence of trauma, such as fracture or dislocation, on plain radiography of the cervical spine (). His condition was diagnosed as Todd's paralysis and further work-up was not considered. On hospital Day 7, motor power showed a total score of 4 on the ASIA motor scale in the lower limbs and 0 in the upper limbs. MRI of the cervical spine was performed and showed high signal intensity in C1 of the cervical spinal cord, without changes in the surrounding tissue or bone (). A diagnosis of CCS was made and steroid pulse therapy was started. On hospital Day 19, the patient was successfully weaned off mechanical ventilation and no respiratory distress was noted. He was transferred to the rehabilitation unit one month after admission. At that time, the motor power of all 4 limbs had a score of 45 on the ASIA motor scale, 13 in the upper limb and 32 in the lower limb. Neurologic level could not be assessed on the ASIA impairment scale because his cognitive impairment precluded the sensory level examination. He scored 9 on the modified Barthel Index (MBI) and managed his bladder with an indwelling catheter. After one month of rehabilitation management, his overall score on the ASIA motor scale improved to 73, 30 in the upper limb and 43 in the lower limb. He was able to stand up from the sitting position. Although he was able to walk with an anterior walker for about 50 meters, moderate assistance of a caregiver was needed. He urinated by valsalva and diaper voiding. |
A 44-year-old obese refugee female, with an unclear past medical and surgical history, presented to the emergency department of a rural private hospital with severe dyspnea and chest pain. The patient reported progressively increasing chest pain and cough in the prior three months, with a remarkable deterioration three days prior to admission. Chest radiograph showed complete opacification of the left hemithorax with labs illustrating a significant drop in hematocrit.\nThe patient deteriorated acutely with respiratory distress and was intubated. A bedside echocardiography showed mediastinal compression with a left-sided large pleural effusion. A chest tube was inserted draining 800 cc of dark blood. The patient's systolic blood pressure was undetectable at that moment. The patient went into a cardiopulmonary shock as a result of the severe hemorrhage.\nAfter stabilization of the patient, a chest CT angiography showed a large 14 × 12 × 8 cm hypervascularized mass in the apex of the left hemithorax occupying more than two-thirds of the thoracic cavity with near total collapse of the left lung. In addition, large blood clots were seen consisting with left hemithorax, with secondary contralateral mediastinal shift ().\nDue to financial and technical limitations in the rural hospital, the patient had to be stabilized prior to transfer to a university hospital for embolization. The decision was made to proceed immediately with a thoracoscopy to evacuate the clots and obtain biopsies. A bulky dark purple mass in the apex of the thorax was visualized arising from the parietal pleura with total collapse of the left lung. After obtaining the biopsies, two liters of clotted blood were evacuated resulting in the clearing of the left costophrenic angle on chest X-ray. The bleeding stopped spontaneously after clot evacuation requiring no additional surgical intervention. It is worth noting that there were no vascularized adhesions besides the primary tumor. Hence, the source of the hemithorax was attributed primarily to the bleeding mass.\nA dramatic improvement in hemodynamic and respiratory parameters was observed allowing the intubated patient to be transferred the next day to a university hospital and undergo embolization. After extubation, repeat chest CT angiography showed marked reduction in tumor vascularization (). Under general anesthesia, a left posterolateral thoracotomy was performed in combination with the removal of the second, third, and fourth ribs. In addition, a thoracoscope was inserted, in a rendezvous technique, allowing better visualization of the apex and control of the left subclavian artery that was providing the major source of the mass' vascularization. The mass was resected with an estimated blood loss of 500 cc (). The postoperative course was uneventful, and the patient was discharged on day 7 with significant amelioration in the left lung. On one-year follow-up, the patient showed no sign of recurrence. |
The patient was a 63-year-old woman who was seen by a local physician for pain in the epigastric region that started back in December 2006. An abdominal CT scan revealed pancreatic cystic lesions and pancreatic duct dilatation, and the patient was referred to our hospital for further examination on December 27. The patient had a history of hyperlipidemia for which she was being treated, but no history of pancreatitis or abdominal trauma, and no notable family history. The patient did not smoke or drink alcohol. Examination results on admission were as follows: height, 157 cm, weight, 40 kg, and body temperature 37.2°C. The patient was alert and her abdomen was soft and flat with no palpable masses. The patient had tenderness in the epigastrium but no rebound or guarding.\nHer blood chemistry revealed a slight elevation of the pancreatic enzymes amylase and elastase 1. While no other evidence of inflammation could suggest active pancreatitis, a slight elevation of the tumor marker CA19-9 was detected.\nAbdominal ultrasonography (US) revealed a multilocular cystic lesion of 45 mm in length with node-like projections in the body of the pancreas. The main pancreatic duct was noticeably dilated from the body to the tail. The pancreatic parenchyma was overall atrophic, and her echogenicity was moderate. Comorbidity with chronic pancreatitis was suspected. An abdominal CT revealed a cystic lesion with a relatively thick septum-like structure in the body of the pancreas. A solid component with slight contrast enhancement was noted inside the cyst. Magnetic resonance cholangiopancreatography revealed a multilocular cystic lesion in the body of the pancreas, and continuity with the main pancreatic duct that was slightly dilated more distally was suspected (fig. ). Endoscopic US revealed a multilocular cystic lesion (26 mm long) in the body of the pancreas. A dilated main pancreatic duct communicating with this lesion was noted. There were extensive node-like raised lesions with papillary development from the cyst to the main pancreatic duct. Like the findings of US, the pancreatic parenchyma was atrophic and echogenicity was moderate, again alluding to comorbidity with chronic pancreatitis. Masses other than the cyst were not seen in the pancreatic parenchyma, which included the area around the main pancreatic duct proximal to the cyst. Endoscopic retrograde pancreatography (ERP) did not reveal marked abnormalities in the papillae or an irregular stricture of the main pancreatic duct in the area between the pancreatic head and body. The distal portion of the pancreatic duct was dilated (fig. ). An ERP catheter and catheter for brush cytology were unable to pass the stricture. Pancreatic juice cytology was class I, and malignancy was not detected.\nThese images revealed a multilocular cystic lesion with internal nodes and A dilatation of the main pancreatic duct. A diagnosis of a combined type IPMC was first considered. Though cytology revealed no malignancy, and examinations such as endoscopic US failed to detect obvious masses, ERP revealed an irregular ductal stricture in the portion of the pancreas head proximal to a cystic lesion. Therefore, comorbidity with small pancreatic ductal carcinoma was suspected. Nearby vascular invasions or distant metastasis were not noted. Distal pancreatectomy was then performed in February 2007.\nSurgical findings were as follows: the pancreas was hard throughout, and a multilocular cystic lesion of 4 cm in length was noted in the body of the pancreas. At the site where an irregular ductal stricture proximal to the cystic lesion was noted preoperatively, the pancreatic tissue was hard and mass like, so resection was performed more proximally. A rapid pathological diagnosis of the surgical margin during surgery revealed evidence of PanIN, and further resection was performed twice. The surgical margin was positive, and so total pancreatectomy was ultimately conducted.\nHistopathological findings were as follows: diffuse lesions corresponding to PanIN-2 to PanIN-3 [carcinoma in situ (CIS)] were noted primarily in the main pancreatic duct (fig. ). Multiple intraepithelial papillary lesions were noted in a multilocular cystic lesion and the dilated main pancreatic duct (fig. ). The irregular stricture of the pancreatic duct in the head of the pancreas was severely fibrotic, and papillary growth of intraepithelial lesions (corresponding to PanIN-2 and CIS) was noted (fig. ). In addition, numerous small pseudocysts were found around the stricture. Immunostaining indicated a positivity for MUC5AC and MUC6, partial positivity for MUC2, and negativity for MUC1.\nPostoperatively, the patient developed secondary diabetes mellitus and required insulin treatment. The patient also required high doses of pancreatic enzyme supplements but did not experience tumor recurrence after being followed up for approximately 5 years. |
A 43-year-old female was admitted to hospital with a complaint of bleeding from the right medial ocular angle. She had had a long history of capillary hemangiomas, as described below.\nShe had developed capillary hemangiomas of the right upper eyelid at the age of 4 and of the right buccal region at the age of 9. Both of those lesions were surgically excised at the time of development. She had also developed a right orbital tumor at the age of 13, which was monitored without any treatment. She presented at the age of 34 with a complaint of right proptosis with ocular pain due to the right orbital tumor, which was confirmed to be an orbital capillary hemangioma after being pathologically diagnosed from an endoscopic biopsy at that time. In the biopsy sample, a lot of dilated capillaries were observed in the mucosa (fig. , arrows), indicating that the lesion was a capillary hemangioma/malformation, but not infantile hemangioma. Radiation therapy and surgical excision were considered but rejected due to a risk of visual loss since the lesion was too close to the optic nerve. Fortunately, the right proptosis with ocular pain had almost disappeared 2 months later with no treatment other than the biopsy. She was then observed without any treatment for years.\nHer best-corrected visual acuity was 1.2 OD and 1.5 OS, and the intraocular pressure was 12 mm Hg in both eyes. Slit-lamp examination revealed no abnormalities except the superficial lesions of the capillary hemangioma of her right eye. No abnormalities were found in the retinas of either eye.\nThe hemangioma presented both superficial and deep orbital components. The superficial lesion was seen at the right medial ocular angle, that is, on the upper/lower eyelids, conjunctiva and expanding into the subconjunctival space. It appeared as superficial tortuous blood vessels, and the conjunctiva appeared violet/blue in color (fig. ). The deeper lesion lay posterior to the orbital septum and was detected using MRI with low signal intensity on T1-weighted images versus high signal intensity on T2-weighted images with internal signal void (fig. , arrows) and gadolinium enhancement.\nThe patient was instructed to apply an ophthalmic solution of timolol maleate 0.5% twice daily. The superficial lesion gradually regressed, as shown in fig. , and had almost disappeared after 1 year of treatment (fig. ). The deeper lesion had also reduced in size, with maximal MRI axial dimensions of 16 × 11 mm (fig. ), decreasing to 12 × 8 mm (fig. , arrow) after 1 year of treatment. No apparent recurrence of bleeding in her eye was observed. No local or systemic adverse effects were noted. |
A Caucasian, 27-year-old female was being followed up during her second pregnancy. Her past medical and obstetric history was unremarkable. This was her second pregnancy; her older child from the first pregnancy was well. There was no family history of renal diseases or congenital abnormalities. She was not on treatment with any medications. A dating ultrasound scan was performed at 15 weeks of gestation showing a single live foetus.\nThe pregnancy advanced uneventfully. The anomaly ultrasound scan at 20+2 weeks of gestation showed evidence of duplex right kidney with dilatation of the upper moiety. The ultrasound scan was repeated at 23+6 weeks of gestation with the same findings. The dilatation of the upper moiety was measured at 10.8 mm. The right kidney was in normal position and there was satisfactory parenchymal differentiation. The left kidney, the ureters, and the bladder appeared normal. The amniotic fluid index was normal throughout the pregnancy. A follow-up scan at 32+1 weeks of gestation showed the right duplex kidney with resolution of the dilatation previously seen. The foetal growth was optimal. No other abnormalities were detected in the antenatal scans.\nShe delivered a male infant via normal vaginal delivery at 39+2 weeks of gestation. The infant was born in good condition without any perinatal complications. An ultrasound scan () was performed at 12 days of age. This scan showed features consistent with an uncomplicated right duplex kidney measuring 6.1 cm. The left kidney had a single collecting system and was measuring 5.2 cm. Both kidneys were visualised within the renal fossae and had normal parenchymal differentiation. There was no pelvic dilatation and the ureters were not visible in either of the kidneys. The bladder looked normal. Clinically, the infant was asymptomatic with normal blood pressure and renal function. There were no other evident congenital abnormalities.\nThe infant had a follow-up ultrasound scan at 3.5 months of age. During that scan, it was difficult to visualise the right kidney which was not within the renal fossa but in a higher position behind the liver. MRI () was performed at 4.5 months of age to determine the locus of the right kidney and possible associated abnormalities. It became evident that the right kidney was lying posteriorly and superiorly to the liver, below the diaphragm. There was no suggestion of duplex system and no features consistent with herniation were demonstrated. The size and the differentiation of both kidneys were normal. The diaphragm was intact and apart from the movement of the right kidney, there were no other abnormalities seen. There was no history of trauma.\nA DMSA scan () was performed at 6.5 months of age which showed normal differential renal function; 52% on the right kidney and 48% on the left kidney were without any evidence of scarring. There was equal function in the upper and the lower poles of both kidneys with no evidence of duplex system. The infant had normal renal function and blood pressure and grew along his centile lines. |
A 43-year-old right-handed man presented to the emergency room, brought in directly from a hospital in Mexico by air ambulance. The medical records accompanying the patient stated he had suffered an upper respiratory tract infection 3 weeks previously, subsequently developing ascending weakness that eventually required intubation and mechanical ventilation 7 days from the onset of symptoms. Further history of the patient revealed that it was his second occurrence of GBS and that he had experienced a complete recovery after the first insult 12 years previously. The patient's family did not choose a hospital close to the United States-Mexican border because they wanted the patient to be seen by the neurologist who treated him during the first occurrence.\nOn arrival, initial vital signs were stable. The patient was heavily sedated, and his physical examination established a GCS score of 3 (1/1/1), fixed and dilated pupils, unresponsive deep tendon reflexes, and flaccid extremities in all four limbs. Initial CT scan of the head and stat EEG returned normal. On repeat evaluation, the pupils regained some activity, but remained highly fluctuating in terms of their size and reactivity to light.\nAfter the initial assessment, the patient was promptly admitted to the intensive care unit. Due to the confounding factor of sedation, a formal assessment of consciousness could not take place for 3 days. Once the designated time had passed, the patient displayed an ability to nod in response to questions. The patient was inquired whether he had retained sensation, to which he responded with a nod, thereby officially establishing a “locked-in” state.\nFamily reported that the patient did not receive any treatment in Mexico, as they could not afford either the IVIG or the plasma exchange. On day 2 of arrival (approximately 10 days after the onset of symptoms), plasma exchange was initiated. Due to the fact that Adventist Health White Memorial only carries medical records up to 8 years, the initial episode of GBS that occurred 12 years previously was not available for review. However, from the clinician's own records, in addition to the family's detailed history, it was determined the patient had the same course on the previous occurrence, albeit unknown whether or not the first episode was triggered by a URI or diarrheal illness. Based on the same notes, EMG and nerve conduction test was done after the first presentation and showed reduced conduction velocities as well as absence F waves and H waves. However, the first insult involved therapy in the form of both plasma exchange as well as IVIG. It was only after a full year of therapy and physical rehabilitation the patient returned to his previous baseline and experienced a full recovery. Since then, the patient led a normal professional and personal life until the recurrence. Of note, he did not receive any vaccinations that could have potentially triggered the recurrence in the previous 12 years.\nLaboratories included a positive ganglioside antibody. They were measured prior to and after the plasma exchange. Before exchange, GM1 Antibody IgG was 251, and 1 week after exchange, it was 88. Similarly, GM1b Antibody IgG was 255 before plasma exchange, and 1 week after it was 121. All other ganglioside antibodies were within normal limits. Ganglioside antibody testing was not available commercially at our hospital 12 years ago. Unfortunately, nerve conduction studies were not preformed during the relapse. Otherwise, all chemistry, renal function tests, liver function tests, and coagulation panels were all within normal limits.\nAfter a month long stay in acute unit with 2 rounds of plasma exchange (total of 10 exchange sessions), the patient was transferred to an acute rehabilitation unit with a tracheostomy and a gastric feeding tube in place. On departure from acute rehabilitation, he was able to mouth words, his upper extremity strength was 2/5, and his lower extremity was 1/5. There was no reflex loss, no sensory loss, or no bowel/bladder incontinence.\nAt the 6-month follow-up, he was able to sit up and swallow. The tracheostomy collar had been discontinued, and his upper extremity strength was 4/5, and lower extremity strength was 3/5.\nAt the 14-month follow-up, he was able to lift both upper extremities above his shoulders and reach the back of his head. In addition to the above, he was able to stand up on his feet and take a few steps with the help of a walker. The patient also was able to speak normally, and his swallowing function had returned to normal. All in all, signifying a gradual and steady road to recovery. |
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 seven-year-old male patient with multiple enchondromatosis was admitted to our clinic with complaints of left forearm and wrist deformity, length discrepancy between his upper limbs, and limited forearm rotation.\nIn the patient's physical examination, there was a significant length discrepancy between both upper extremities. Ulnar deviation of left forearm and wrist was observed. The supination and pronation of forearm and radial deviation of wrist were limited when compared to right extremity. Enchondromatosis lesions at the distal ulna were seen on radiographic evaluation. Ulna was short and deformed; distal ulna did not articulate with the distal radius and did not meet the carpal bones. Carpal bones replaced to ulnar side. The left ulna was found to be 2 cm shorter than right ulna.\nTo correct the deformity and shortening of ulna, osteotomy was performed to metaphyseal region of proximal ulna and unilateral external fixator was placed. After three days of operation, distraction osteogenesis was started and 1 mm (4 × 0.25) lengthening was performed daily. After the total of 2 cm distraction, lengthening was discontinued. Two months waiting for consolidation, external fixator was removed. During the distraction and consolidation the patient continued to use his hand in his daily activities and continued an exercise program to maintain the active and passive range of motion. There were no complications in this period, except for superficial infection at the bottom of the pin.\nIn the followup of the patient the elongation of the ulna had the corrective effect of the radius deformity. Restriction of radial deviation of the wrist and forearm rotation too much decreased. Two years later ulnar deformity and shortening recurred again and also radial head dislocation occurred in the patient. Ulnar osteotomy and distraction osteogenesis were applied again and elongated by 2 cm.\nAs a result of 3 years of followup the length of discrepancy between radius and ulna and deformity were significantly decreased. 1 cm length difference continued in ulna when compared with the healthy side. Preoperative, intraoperative, and postoperative clinical and radiographic images are shown in . |
A 21-year-old woman was admitted to the gynecology ward of Mbarara Regional Referral Hospital (MRRH) with primary amenorrhea, failure to conceive and painful coitus. All these had affected her marriage of three years to a point of divorce. On evaluation she was found to have a normal female genotype with well-developed secondary sexual characteristics. Pelvic examination revealed a vaginal dimple with no palpable uterus (Fig. ). An abdominal ultrasound scan revealed presence of both ovaries with a streak like or rudimentary uterus. The rest of the pelvic organs were normal. A preoperative diagnosis of vaginal agenesis due to MRKH syndrome was made. A decision to do surgery of creating a new vagina by using a modification of the McIndoe procedure was decided. Counseling of the patient about the surgical procedure with emphasis on the expectations was done. We explained to the patient that the procedure would improve her sexual life but would have no effect on her ability to conceive which she accepted and consented to the operation. Bowel preparation using soap enema plus overnight fasting was done prior to the operation. After induction of anesthesia, the patient was put in lithotomy position. The vulva was cleaned with antiseptic solution then draped. A urethral catheter of size 16 was inserted into the bladder. A transverse incision was made on the vaginal dimple to open into the rectovesical space. Bunt dissection was continued until a length of about 9 cm and 3 cm in width was achieved. A methylene blue dye was introduced into the bladder to make sure that there was no accidental bladder injury and a finger was also introduced into the rectum to ensure that there was no rectal injury.\nTwo full thickness hair free folds of skin measuring 12 by 6 cm in length and width were harvested from each lateral side of the abdominal wall starting from the anterior superior iliac spines. We used the lateral side instead of the skin over the inguinal ligament as done in the McIndoe method because our patient was too skinny for us to get adequate length and width of skin in this area. The folds were prepared by first immersing them in normal saline then the subcutaneous fat from each of the folds was removed using a sharp scissor. The assistant closed the sites from which the grafts were harvested using nylon 2/0 sutures interrupted vertical matrix as the lead surgeon prepared the grafts.\nUnlike in the McIndoe method were the skin flaps are folded on a vaginal mold/form, here we used the cylinder of a 60 ml bladder syringe to act as a stent for the grafts in place of the vaginal form due to lack of the foam rubber to make a vaginal form (Fig. ). The tip of the syringe was cut off before it was inserted. The skin grafts were folded on the cylinder of the syringe with the epidermal sides lying on the cylinder using interrupted vicryl 3/0 sutures. The excess lengths of the grafts were trimmed off.\nThe graft with its cylinder was then carefully inserted into the newly created rectovesical space after achieving hemostasis. In order to secure the graft in place, the cylinder of the syringe was fixed to the labia majora on either side using a nylon 2/0 suture unlike in the McIndoe method where the labia are sutured in the midline. The cylinder stent was maintained for 10 days to keep the neo-vagina patent. The urethral catheter was also kept in for the same duration to ease the patient’s voiding and to also rest the bladder and urethra to guard against pressure necrosis that could be caused by the prolonged pressure on the urethra by the cylinder hence causing a fistula. A low residue diet was prescribed for the patient to prevent constipation and hard stools. She was also put on oral antibiotics and analgesia to prevent post surgical infection and pain for about 5 days. We used antibiotics, which were readily available in the hospital (Ceftriaxone and metronidazole). The labial stitches anchoring the cylinder stent were removed on the 10th postoperative day on the ward. She was examined and there was no any postoperative complication like infection, graft rejection or bleeding (Fig. ). A methylene blue test was done before the Foley catheter was removed to ensure that there was no fistula formed as a result of pressure necrosis by the cylinder on the urethra. After removal of the cylinder stent she was taught self-serial dilatation using a condom rolled on to a candle to prevent stricture of the neovagina. She was advised to do this self-dilatation for at least 3 months.\nShe was discharged with a patent neovagina and the skin donor sites had healed after removal of the skin sutures. She has been followed up every 2 months for the last 8 months after operation and on examination the neovagina is patent (Figs. , and ) and she has resumed sexual intercourse, which has really improved her marital life. |
A 59- year-old right-handed man was referred to our clinic for sudden and brief movements of his trunk. The movements started almost 10 months prior to his presentation. The movements most frequently started from the right side of his back, either lower back or middle back area and moved to the other areas in his back (either right side, left side or both). They would propagate to the lower and upper body parts. He could trigger the movements by pushing over his back at the level of his iliac crest where he reported to have some discomfort. Also sitting with his legs unsupported triggered a more severe set of jerks characterized by flexion of the upper trunk and neck and exhaling and grunting repeatedly. The movements were variable in terms of frequency, intensity and the muscle groups involved. When he was asked to stop the movements, he was able to partially control the movements, but he reported that, “if I try to hold them, it becomes painful.” In addition to the pain and discomfort in the neck and head area, the patient was bothered by the fact that the movements were noticeable by other people. In the beginning, his movements were less frequent and less intense, but they gradually got worse in terms of frequency, amplitude and the initiation sites got more diverse and numerous.\nDuring the evaluation at our clinic, the frequency of his jerky movements differed greatly, between multiple jerks per minute to rarely having one over 10 min.\nThe history supported a diagnosis of functional movement disorder due to unexplained episodes of improvement and worsening of symptoms and the symptoms not following any known neurologic pattern. On examination, movements demonstrated evidence of distractibility, inconsistency (various muscle groups with various patterns of contraction) and suggestibility (by pushing over a random area on the back symptoms were induced). MRI cervical and lumbar spine demonstrated degenerative spine disease which could not explain the movements initiating from multiple thoracic and non-thoracic muscle groups. An EEG study was normal. Movements were captured during the study and no EEG correlation was evident.\nSurface EMG was recorded from right and left pectoralis major, supraspinalis, elevator scapulae, thoracic and lumbar paraspinals, triceps and biceps. The movement started with right pectoralis contraction with almost simultaneous contraction of left pectoralis (there was some variability, with some movements having up to 15 ms of delay). Between 20 and 30 ms later there was a contraction of the supraspinalis, triceps and the biceps. The muscles of the back had some more variability, but it was important to note that in all the trials, there was initially a contraction of the lumbar paraspinals (in some cases at the same time as the right pectoralis, in other cases up to 30 ms later), followed by thoracic paraspinals going against a rostro-caudal propagation ().\nIn regard to the Bereitschaftspotential, we observed a BP when the patient was asked to perform voluntary movements, but BP was absent prior to the involuntary movements ().\nFollowing the physiologic study, he elaborated further on the discomfort in his back and reported that he has a feeling of tension being built up in his middle back immediately before most of his movements. He reported slight relief of the tension in his back following the jerky movement. A diagnosis of tic disorder was made based on the combined clinical and neurophysiological data. The patient showed some improvement with decreased frequency of his tics after starting guanfacine. |
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. |
Our patient is a 35-year-old female who presented with a painful, tender right groin lump for a 6-week duration. An ultrasound revealed a thin-walled fluid collection medial to the femoral vessels (Fig. ). She was diagnosed with a femoral hernia and offered a repair of the hernia. Due to an improvement in symptoms since onset and clinic visit and in anticipation of the upcoming summer, she opted for elective repair. Unfortunately, her symptoms worsened prior to her surgery date resulting in an expedited operation. The patient was taken to the operating room for repair of her hernia. An incision was made overlying her groin bulge. She was found to have an obvious hernia sac below the inguinal ligament which was dissected from the femoral vessels and pubic tubercle. Due to the small size of the defect, <1 cm, the sac and contents were unable to be reduced into the abdomen. The decision was made to ligate the sac at the level of the defect. After ligation and upon examination, the distal tip of the appendix was found to be within the hernia sac and transected. The decision was made to extend the skin incision laterally in anticipation of accessing the peritoneal cavity. The external oblique, internal oblique and transversalis layers were incised in the direction of their respective fibers. The cecum was identified and brought out of the incision. A window was made at the base of the appendix which was ligated and the completion appendectomy performed. The mesoappendix was then separately ligated. The cecum was returned to the abdomen and the three muscle layers were closed individually. Due to a small amount of spillage, the decision was made to perform a primary repair of the femoral defect. Prolene suture was used to perform the herniorrhaphy, approximating the inferior portion of the inguinal ligament to cooper’s ligament inferiorly. The patient tolerated the procedure well and was discharged to home the same day. The final pathology confirmed acute appendicitis. The patient reported mild abdominal bloating at her 2-week postoperative visit that resolved by her 4-week postoperative visit. |
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 41-year-old woman gravida 2 para 1 with a body mass index of 25 presented with menorrhagia, pelvic pain, and dysmenorrhea. Her past medical history was unremarkable. Her past surgical history was pertinent for a bilateral tubal ligation in 1991. After examination by her general gynecologist, she was found to have an enlarged uterus. No additional preoperative testing was performed. In November 1996, she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The frozen section diagnosis revealed a uterine stromal tumor with rare mitotic figures. The final pathology diagnosed an International Federation of Gynecology and Obstetrics (FIGO) stage IA endometrial stromal sarcoma extending to the outer one third of the myometrium []. The fallopian tubes, ovaries, and uterine serosa were negative for malignancy. The uterus weighed 647 grams and measured 12.9 × 12 × 7 cm. Her postoperative course was uneventful and she required no further therapy. She continued her followup care under the management of her general gynecologist and remained without evidence of disease for two months.\nA surveillance computer tomography of the abdomen and pelvis performed in January 1997 showed three 4-5 mm nodular densities in the right lower lobe of the lung. The densities were too small to biopsy and no comparison films were available. The patient was asymptomatic and therefore was managed conservatively. The lung densities remained stable in size until August 1997 when one density was found to have increased to 15 × 14 mm. A lung biopsy of the largest lesion was suspicious, but not diagnostic for a malignancy. The enlarged lung density was thought to clinically represent recurrent disease and the patient was referred to a medical oncologist in her area who recommended cytotoxic chemotherapy. The patient declined chemotherapy and desired a second opinion.\nAfter referral to our medical center in November 1997, she was started on a regimen of megestrol 40 mg twice daily with monthly intramuscular injections of leuprolide 7.5 mg. Complete resolution of her lung nodules occurred in response to this regimen by January 1998. She remained on megestrol and a 3.75 mg dose of leuprolide until the date of last followup in June 2006. Now over 10 years after her initial surgery, she remains without evidence of disease. |
A 49-year-old man presented at our emergency room (ER), complaining of pain localized to the posterior left thigh, started about 2 hours after an accidental side split (hip flexed and knee fully extended) by falling down the stairs. His past medical history was significant for an episode of ophthalmic artery thrombosis for which the patient was taking aspirin daily. At physical examination, while the left anterior thigh was nontender at palpation, the posterior thigh presented as swollen, tense and painful to light touch from the gluteal fold down to 2 cm proximal to the posterior aspect of the knee. Muscle strength of the inferior limb was recorded: knee extension was 5/5 while knee flexion could not be assessed due to pain; ankle plantar flexion, ankle eversion and great toe flexion were all registered to be 5/5. Ankle dorsiflexion and great toe extension were 5/5. No sensory deficit were recorded. Dorsalis pedis and posterior tibial pulses were present as well. About thirty minutes after the ER admission ankle dorsiflexion and great toe extension were reported to be 0/5. At the following physical examination numbness was reported on the dorsal and plantar aspects of the left foot. A CT angiography was promptly carried out () and reported positive bleeding of the femoralis profundis artery giving indications to readily perform an angiography that resulted in no vessel to embolize. On the basis of the abovementioned clinical workup and the persistent clinical presentation, we made the diagnosis of compartment syndrome of the posterior tight; A CT angiography was promptly carried out () and reported positive for a jet of the femoralis profundis artery giving indications to readily perform an angiography that resulted in no vessel to embolize. On the basis of the abovementioned clinical workup and the persistent clinical presentation, we made the diagnosis of compartment syndrome of the posterior tight; approximately 8 hours after the initial injury, our patient was taken to the operating room to operate an emergency fasciotomy. The patient was placed in prone position to have better access to his left thigh; a posterior incision was performed starting at the gluteal fold and prolonged distally down to approximately 8 cm proximal to the popliteal fossa. A complete fasciotomy and release of the posterior compartment was performed by cutting longitudinally the overlying fascia (). Approximately 500 mL of hematoma were forcefully ejected out of the surgical excision at the release of the posterior intracompartmental pressure. The exposed muscles appeared dark red but presumably viable while the long head of biceps femoris, semitendinous and semimembranous were completely avulsed from the ischial tuberosity. The sciatic nerve was identified along with the posterior femoral cutaneous nerve of the thigh () and both were isolated and preserved. Any active vessel hemorrhage was rapidly blocked. Then we proceeded to suture back in place the above-mentioned tendons on the ischial tuberosity using 2 bone anchors, specifically, Corkscrew® FT suture Anchor 5,5mm x 16,3mm with two #2 Fiber Wire Arthrex® (Naples, Florida, USA)(). The surgical excision was copiously irrigated with saline solution and sutured while leaving the fascial layer open. Postoperative care was aimed at performing fresh blood and plasma transfusions; at clinical inspection the patient reported an immediate pain relief. On the 3rd postoperative day (POD), sensation on the plantar aspect of the foot had returned while the sensation on the dorsum of the foot had improved markedly, with the patient reporting just paresthesia over the toes. Motor strength was assessed as 5/5 in ankle plantar flexion, ankle eversion and great toe flexion while 4/5 for ankle dorsiflexion and great toe extension. Postoperative anticoagulation therapy was administered daily, and for the following 30 days, by subcutaneous injections of 4.000 UI enoxaparin. The patient was discharged on the 5th POD with the following indications: wheel-chair use, avoid weight-bearing for 4 weeks and vitamin B12 complex for a month. At six-week follow-up the patient could successfully stand up with the aid of crutches. Full weight-bearing was achieved 8 weeks postoperatively. At five-month follow-up our patient showed full ROM of the hip and the knee while sensation was reportedly complete: the Perth Hamstring Assessment Tool score [6] was 65 when assessed at this time. |
A 5-year-old healthy Brazilian girl was referred to the Pediatric Dentistry Clinic at the Dental School of Araçatuba, São Paulo State University (UNESP), for detailed evaluation of her oral condition. According to the report of her mother, the primary maxillary left teeth had erupted differently from the other child's teeth. The mother also reported that her daughter's affected teeth had a yellowish color and were rapidly destroyed by caries and fractured often accompanied by pain and gingival swelling.\nThe patient's mother also reported that during pregnancy she had taken medication for high blood pressure control (Enalapril®). Except for this fact, the pregnancy and the birth occurred uneventfully. There was no history of tooth or genetic anomalies in the family. The child's general health was good and no congenital or acquired disease was reported. However, the girl had a urinary infection in the first three days of life, which was treated with Amoxicillin®.\nExtraoral examination revealed no facial asymmetry, but a vascular birthmark (haemangioma) on the right side of her face (). Intraoral clinical examination revealed a relatively caries-free mouth with normal occlusion, soft tissues and developing dentition except for the maxillary left quadrant (–).\nOn the left side of the maxilla, the central incisor and the first and second molars were missing as well as the primary right central incisor. According to her mother, the teeth were extracted by a dentist 6 months before the girl was referred to the clinic. The residual root of the left lateral incisor was present and was indicated for extraction. The left canine was previously restored with composite resin and it was less affected compared to the other teeth. It is likely that part of the permanent left first molar had an altered aspect because the primary second molar had been previously extracted. This clinical finding was not presented at the first appointment and it was observed at the third appointment.\nThe panoramic radiograph, which was taken 6 months before the girl was referred to our Clinic at the Dental School of Araçatuba, revealed the presence of primary teeth and the germs of permanent teeth, including the permanent second molars, except in the maxillary left quadrant. In the affected area, it was possible to observe the primary right central incisor, which was extracted straight away. The root of primary left lateral incisor was also present. In addition, the primary left canine presented reduced radiodensity and showed wide open apex and abnormally wide pulp chambers and canals in comparison to unaffected teeth. Germs of permanent teeth from the maxillary left quadrant and also the germ of the permanent right central incisor presented a "ghost like" appearance, showing that this condition had crossed the midline. Dental development appeared age-appropriate. Normal thickness of enamel and dentin in primary and permanent dentitions was observed in the other quadrants, except for the permanent mandibular left first molar, which showed some alterations in its crown, probably a developmental anomaly (). This radiographic finding has to be investigated in the future controls.\nAfter extraction of the root of the maxillary left lateral incisor, the affected edentulous quadrant was rehabilitated with a temporary maxillary partial acrylic denture (). Prosthetic rehabilitation of patients is important to maintain mastication and phonation, to improve esthetics and to prevent overeruption of opposite teeth. The girl has been followed up periodically (once a month) to observe if there will be eruption of the "affected teeth" and to monitor the growth and development of the maxillary and mandibular arches. |
A 22-year-old male was intubated and admitted to the intensive care unit of Sultan Qaboos University Hospital, Oman, in March 2014 after being involved in a motor vehicle accident with multiple injuries, which included his lower limb, ribs, and maxillofacial fractures. Facial bone computed tomography (CT) showed lower anterior dentoalveolar fracture with lingual displacement, bilateral Le Fort I fractures of the maxillae, and medially displaced and fractured right condylar neck [].\nAs emergency management, the patient underwent closed reduction of the dentoalveolar fracture and open reduction and internal fixation (ORIF) of the bilateral maxillary fractures under general anesthesia along with orthopedic surgical repair. Three days later, the patient underwent ORIF of the right condylar fracture. Following the completion of the ORIF, severe intraoperative bleeding was encountered from the posterior medial aspect of the condyle. All local measures of packing failed to arrest the bleeding, and the patient underwent emergency angiography to identify and treat the possible source of bleeding, which was anticipated to be from the right internal maxillary artery. However, the angiogram did not show any major source of bleeding in relation to the internal maxillary artery, but identified a large DA of the extracranial part of the right ICA []. The vascular surgeon attempted surgical repair of the identified DA. However, due to the additional intracranial extension of the lesion this was difficult []. At this time, no active bleeding was found from the surgical site of the right mandibular condyle. Accordingly, a decision was taken to arrange for repair using an endovascular arterial stent, thus avoiding ligation of the ICA. The wound was thus closed in layers.\nSix days later, through the femoral approach, the patient underwent endovascular insertion of a 50 × 6 mm self-expandable covered arterial stent with no distal carotid embolic protection, which resulted in complete resolution of the vascular lesion with no complications []. At nine months follow-up, the patient showed satisfactory dental occlusion and mandibular movements with no vascular or cranial abnormalities. |
A 52-year-old male patient was referred to the Dental Hospital of Kyung Hee University from a local clinic for the extraction of his left third molar. He had suffered some discomfort during mastication and dull pain on his left lower posterior area beginning about 10 days earlier. On intraoral examination, the overlying mucosa of the left impacted third molar was intact. The shape and texture of the gingiva surrounding the second molar were relatively normal. Neither tenderness nor pus discharge via gingival sulcus was observed during the palpation on the left lower posterior area. Percussion was positive on the second molar, but no mobility was observed. No cervical lymphadenopathy was detected on his left submandibular area. His medical history was noncontributory, revealing controlled hypertension for the past 5 years.\nPanoramic and periapical radiographic examination were performed under the clinical diagnosis of pericoronitis. Conventional radiographs showed an ill-defined periapical rarefaction coinciding with the external root resorption related with the follicular space of the impacted third molar. However, there was no any etiologic factor on the left lower second molar such as dental caries or periodontitis (). CBCT examination was performed in order to evaluate the relationship with the mandibular canal and apical radiolucency of the left lower second molar. The CBCT scan described external root resorption on the distal root and extensive bony lysis over the apex of the second molar from the follicular space of the impacted third molar (). The initial radiographic impression was pericoronitis with an advanced lytic bone lesion involving the periapical region of the adjacent root.\nHe underwent a surgical extraction of his left lower third molar. Despite the continous treatment for 3 months, there was delayed extraction wound healing assuming a surface osteitis.\nAfter one year, he presented to our dental hospital with a complaint of paresthesia in the lower chin area. Intraoral examination revealed that the extraction wound was quite well healed and covered by intact, normal-appearing mucosa on his left mandibular retromolar region. Neither tenderness nor pus discharge was observed during palpation of the extraction wound. No cervical lymph node enlargement was detected in his left submandibular area.\nPanoramic radiograph and CBCT scan revealed an ill-defined bony destructive lesion with perforation of the buccal and lingual cortical plates. This lesion extended from the distal root of his left second molar to the ascending ramus and involved the cortical outline of the mandibular canal inferiorly (). The radiographic impression suggested osteomyelitis, and a primary intraosseous malignant tumor was also suspected. Partial sequestrectomy was performed under the tentative diagnosis of osteomyelitis, and a biopsy specimen was obtained for a histopathologic examination. Two specimens were drawn, one was the teeth with attached soft tissue and the other was a brown soft tissue. Microscopic examination revealed infiltrative growth of the neoplastic squamous cells. The tumor cells formed irregular epithelial islands with celluar atypia, nuclear hyperchromatism, pleomorphism, and mitosis ().\nContrast-enhanced CT scan found a heterogeneously enhanced soft tissue mass in the left retromolar region with extensive bone destruction. MR images revealed adjacent soft tissue involvement, extending laterally into the buccinater and masster muscle, with invasion into the medial pterygoid muscle and masticator space. The tumorous mass showed low signal intensity on the T1 weighted image, while it was detected to have a high signal intensity on the T2 weighted image. Gadolinium-enhanced MRI showed an ill-defined mass with internal heterogeneous enhancement ().\nOn the findings of CT and MRI, the cervical lymph nodes were found enlarged. As a result, positron emission tomography (PET) and a bone scan were considered to be necessary for evaluating the entity for a primary malignant lesion or long metastatic lesion. According to the results of PET using 18F-fluorodeoxyglucose (FDG), a focal hypermetabolic mass showing a 10.9 standardized uptake value (SUVmax) was detected on the retromolar region of his left mandible (). Furthermore, a hypermetabolic lymph node showing an SUVmax of 5.0 was also observed on his left cervical area. In addition, a Tc99m-MDP bone scintigram revealed an increased uptake of radionuclides in the left mandibular angle area, but no evidence of bone metastasis except the degenerative change of other joints. The patient underwent radiation therapy for three months before surgical intervention. Under general anesthesia, the patient underwent partial mandibulectomy and selective neck dissection. The surgical defect was also reconstructed by surgical plates and a radial forearm flap. The histopathologic examination of the surgical specimen proved that the tumor, measuring about 4 cm×3.5 cm×3 cm, invaded the cortical bone of the mandible and surrounding skeletal muscles. The tumor cells formed an atypical epithelial cell nest with hyperchromatism and pleomorphism, while the overlying oral mucosa had no connection with the tumor. Scetions of a regional lymph node showed no tumoral cells. The histological diagnosis was moderately differentiated squamous cell carcinoma most likely of central origin. No lymphatic metastasis was detected; however, tumor cells were very close to lingual and buccal resection margins. In conclusion, the diagnosis of PIOSCC was confirmed radiographically and histopathologically. Up to the present, there has been no evidence of local recurrence or distant metastasis during the six-month postoperative follow-up period. |
A 36 years, 10 month old female patient presented to Department of Orthodontics with a chief complaint of generalized spacing in upper and lower front region of the teeth and irregular arrangement in posteriors of the upper arch. Extra oral examination revealed the patient with an average facial form with symmetrical face, mild convex profile, posterior divergence and competent lips. During smile, both upper and lower incisors were visible within her age limits []. Occlusal examination Showed upper retained deciduous canine with bilateral ectopic eruption of canine buccally between 1st and 2nd premolar teeth []. Clinical and radiographic evaluation show it's a case of complete transposition,[] where crown and root of the respective teeth are found parallel in their transposed position []. Interestingly she doesn't have any other dental anomaly or developmental missing tooth except bilateral occurrence of complete canine transposition. Root morphology was altered with external root resorption in the distal aspect of the mid root section was seen in the upper left 1st premolar tooth. Class I molar relation was seen in the right side. She underwent extraction of left side upper 1st molar, both maxillary 3rd molar and right side lower 3rd molar due to gross decayed condition 5 years back. Further, heavily restored amalgam fillings in relation to the lower left 1st molar and right 2nd molar. Grade II mobility[] and class III gingival recession,[] was seen in both lower central incisors. Cephalometric analysis showed a class I skeletal pattern with proclination of both upper and lower incisors with 0.5 mm over jet and overbite relationship [].\nConsidering the class III gingival recession of both the lower central incisors, free gingival graft was planned initially before orthodontic treatment to improve the periodontal status. Free gingival graft of 8 mm × 5 mm was taken from the donor site of palatal tissue in relation to upper left 1st molar region. Graft was placed such that to increase the width of attached gingiva rather than for recession coverage of the lower incisors []. Fixed orthodontic treatment was started with extraction of both retained deciduous canines in the upper arch with 022 Roth prescription along 0.012 niti wire. Since it's a case of complete transposition, maxillary canine and 1st premolar brackets were interchanged with 1st premolar moved mesially in the deciduous canine position. First premolar was recontoured as canine and canine as premolar respectively. After 3 months, brackets were fixed in the lower arch. Leveling and aligning was done up to 0.019 SS × 0.025 SS in both arches. Orthopantamogram was taken and bracket was repositioned in relation to 14, 21, 23, 24 and 2nd molar banding was done []. Recontouring and restoration was done in relation to 11, 13 and 23. Occlusal settling was completed and space in the 26 region was maintained for prosthesis replacement. After final debonding fixed bonded retainer was placed in both upper and lower arch. A removable Hawley type retainer was also placed in the upper arch [Figures -]. Finally, a three unit metal ceramic fixed prosthesis was done in relation to 26 region. |
A 63-year-old female initially presented with a past medical history of diabetes mellitus, peripheral neuropathy, Charcot neuroarthropathy, coronary artery disease, lymphedema, hypertension, and rheumatoid arthritis. She underwent an attempted tibio-talo-calcaneal fusion with external fixation for management of a Charcot joint about the rearfoot and ankle. She did not report a previous infection with the initial surgery. As she tried to progress her weight bearing status 3 months after the initial surgery, varus deformity about the rearfoot and ankle developed within a period of 2–3 weeks. On initial presentation she was unable to weight bear but could stand on the affected extremity. She displayed significant edema to the extremity secondary to lymphedema but no open wounds were present or clinical signs of infection. Initial radiographs revealed resorption of the talus with nonunion of the ankle and subtalar joint with severe varus deformity noted to the heel that was rigid (A, B, and C). The first stage of surgical management of this condition consisted of obtaining a bone biopsy and three bone cultures. The pathology report documented chronic osteomyelitis. All three bone cultures revealed Staphylococcus epidermidis. At this time the patient was placed on parenteral antibiotic therapy. A second staged procedure was performed 10 days after the initial bone biopsy and additional cultures were taken. A talectomy at this time was performed with placement of an antibiotic impregnated spacer and closure of the wounds with application of a well-padded splint (). The patient then returned to the operating room 6 weeks later for removal of the antibiotic spacer and repeat bone cultures. The cultures were negative for bacterial growth and the patient returned to the operating room 7 days later for a revisional tibio-calcaneal fusion with a blade plate and application of a multiplane external fixator (A and B). The external fixator was removed 12 weeks later and the patient was placed into a non-weight bearing cast for 4 weeks with the application of an external bone stimulator and then progressed into a walking cast for another 4 weeks. The patient then resumed full ambulation with a custom high-top shoe and double upright brace. She has no further progression of deformity and has maintained an ambulatory status for the last 6 months, despite the absence of complete trabeculation across the arthrodesis site (A and B). Closer observation is warranted in this case scenario. |
Patient was an 8-year-old boy referred to our center with massive upper gastrointestinal bleeding. The patient was found to have splenomegaly. He went through multiple evaluations including endoscopy and underwent band ligation for progressive esophageal varices. The patient had no history of neonatal blood exchange and umbilical venous catheters during infancy. No finding suggestive of portal venous thrombosis was observed in Doppler sonography. All the experiments indicated normal hepatic function. Due to recurrent bleeding and signs of hypersplenism and bicytopenia (thrombocytopenia and anemia), CT scan in venography phase was performed, which presented suspicious findings in splenic vein. Patient's CT angiography of the abdomen revealed splenomegaly (), dilation and tortuosity of spleen hilum veins and veins lining the esophagus and stomach (), and dilation of coronary and left renal veins (). Haziness was observed throughout the mesenteric fat of the spleen hilum and splenic vein pathway. However, the size and density of the pancreas were normal. Additionally, lipase and amylase levels were also normal both in initial evaluations and in subsequent follow-ups. Given the portal hypertension symptoms and the history of cytopenia and splenic vein thrombosis, complementary evaluations were made considering PNH. Flow cytometry of peripheral blood was carried out on white blood cells in which CD55 and CD59 were reported as 90% positive. Gallbladder as well as intra- and extrahepatic biliary ducts were seen as normal. Splenorenal shunt was observable through left renal vein and splenogastric shunt was visible because of the tortuosity and dilation of gastric veins and enlargement of coronary vein. Regarding the clinical status of the patient, such as recurrent bleeding and failure to respond to band ligation in the specified time, the patient was scheduled for surgery. He underwent laparotomy under general anesthesia and in sterile conditions. The laparotomy findings were as follows: normal liver in inspection and palpation. There were plenty of omental adhesion bands surrounding the spleen. The spleen was larger than usual. Dilated veins surrounding the spleen and stomach and esophagus were observed. To release adhesions surrounding the spleen, the splenic vessels ligations were cut. Splenectomy was completed. It is worth noting that, due to signs of hypersplenism and the presence of splenic thrombosis, diagnostic assessments were done prior to surgery on MPS including ET and PV. JAK2 mutation was checked and reported as negative. Aspiration and bone marrow biopsy were also performed which reported bone marrow as normocellular and reactive. During the one-year follow-up the patient did not go into relapse and control endoscopies showed improvement of esophageal varices. In the assessments that followed hereditary deficits of pro S, pro C and Antithrombin III were checked for and reported as negative. The normal values are added to . |
A 46-year-old Dominican woman presented to emergency room with complaints of five hours of vomiting and profuse diarrhea in summer 2011. Symptoms started within 3 hours after eating chicken sandwich and salad, which were prepared at home. While frequency of vomiting decreased, she reported diarrhea, which later occurred and was too often to count. Subsequently, her urine output decreased. The patient denied fever or blood in the stool. She had previously been healthy and was not taking any medications. She had no known allergies. Her last travel to Dominican Republic or outside the US was more than 3 years ago. She lived with her husband and son. She consumed alcohol occasionally and did not smoke or use illicit drugs. Her family and friends who had the dinner together had been well. She had no history of similar symptoms in the past. She denied recent use of antibiotics or hospitalization. She had gastric bypass surgery in 2005 and abdominoplasty in 2007. At presentation, she was afebrile with pulse rate of 103 beats/minute. Her blood pressure was 89/52 with orthostatic changes. Her mucous membranes were dry; the remainder of the examination was unremarkable. Laboratory test results were significant for anionic gap metabolic acidosis with acute kidney injury and severe hypokalemia. There was no leucocytosis. Liver enzyme tests showed mildly increased aminotransferases. The laboratory data at presentation are presented in . The patient was admitted to the critical care unit due to acute renal failure with severe electrolyte abnormalities. Human Immunodeficiency Virus test was negative. She had central line placement for close monitoring of central venous pressure. She had a total stool output of 40 liters by the end of 5 days. Later, her stool color changed to green. Stool ova and parasites and Clostridium difficile toxin were negative. Computed tomography scan of abdomen showed normal bowel pattern without any dilated loops of bowel and unremarkable pancreas (). She later recalled eating cheese brought by relatives from Dominican Republic 1 day prior to the onset and at the dinner, which occurred 3 hours prior to the onset of diarrhea. Initial stool cultures were suggestive of Aeromonas; therefore, the patient was started on trimethoprim/sulfamethoxazole. Despite antibiotic treatment, there was no significant improvement of her diarrhea. Later, identification of organism from stool culture showed Vibrio cholerae O1 serovar ogawa strain. The Vibrio cholerae was resistant to trimethoprim/sulfamethoxazole; therefore, the antibiotic was changed to ciprofloxacin. Diarrhea resolved in 5 days with normalization of her renal parameters. She received 3 units of blood transfusion in view of her anemia. She developed abnormal liver function tests during the hospitalization and work-up revealed unremarkable hepatitis serology. The cause of the deranged liver function tests was probably secondary to medications and subsequently improved at the time of discharge. The patient was discharged after 7 days of hospitalization. Her caregivers were instructed about standard precautions. The case was reported to the New York State Department of Health and the US Centers for Disease Control and Prevention. |
A 14-year-old male patient was referred for suspicion of a mandibular cystic lesion in the site of tooth number 37 where the lesion was incidentally discovered. Clinically, the patient presented no signs of infection, no pain, and no history of swelling. Radiographically, it extended from the distal part of 36, englobing the root of 37 and the crown of 38, invading the body of the mandible within the limits of the buccal and lingual cortices without perforation, and extending apically close to the inferior alveolar canal ().\nFollowing administration of local anesthetic, an intrasulcular incision was made on teeth number 36, 37, and in the site of 38, extending distally on the anterior border of the ramus with continuous contact with the bone. Full-thickness flap was reflected to gain access to the underlying bone. A bony window was drawn extending at least 5 mm more than the originally radiographically predetermined size of the lesion using the OT7 tip mounted on the piezoelectric device. This extension of the bone window will secure a latter repositioning of the lid on a healthy stable bone. The used tip was directed in a beveled orientation through the healthy external cortical plate down to the cancellous bone, as denoted by the reduced resistance to pressure. The beveled bony lid was freed with an angulated bone chisel using a gentle luxation with progressive movements in order to avoid any possible fracture (). The bony lid was thus removed and placed in a sterile saline solution. The underlying lesion was visualized and enucleated using curettes and sent for pathology as a routine procedure. Careful complete removal of the lesion was achieved, ensuring a total absence of any soft tissue remnant inside the bone cavity that was rinsed repeatedly with intraoral Betadine® (povidone-iodine). After wisdom tooth extraction, the removed bony lid was repositioned in situ. Digital pressure was used trying to move the lid in all directions, thus ensuring its proper repositioning in its original place and optimizing its stability ().\nNevertheless, it was secured with a collagen tape (CollaTape®) that acted as an extraplugging material. The flap was sutured in place in a tension-free manner using a 4.0 resorbable vicryl suturing material. Postoperative medication included Augmentin® 625 mg, BID for 7 days, ibuprofen 400 mg, TID for 3 days, and a chlorhexidine mouthwash (0.12%), TID for 2 weeks. Healing was uneventful as reported by the patient with limited swelling and reduced pain.\nA routine 8-month cone beam computed tomography (CBCT) was done. It revealed an almost complete radiographic bone healing at the previously diseased site ().\nInterestingly, no buccal bone resorption was noted nor any ridge collapse. |
A 54-year-old male patient presented with febrile sensation and anterior chest wall pain with an erythematous ulcerative plaque in the right parasternal area that had become aggravated over a month despite antibiotic treatment prescribed at a local clinic. A swab culture was done, which led to the identification of Citrobacter koseri. The patient was admitted to the general ward for further workup and initiated on intravenous (IV) ciprofloxacin (400 mg every 12 hours).\nThe patient had undergone right upper lobectomy and thymectomy 35 years ago via posterolateral thoracotomy followed by adjuvant radiotherapy. A chest computed tomography scan revealed chronic empyema with a right apical calcified sac with an air-fluid level and chest wall abscess, for which continuity to the pleural space could not be excluded ().\nAn elliptical skin incision was made around the fistula orifice at the second and third intercostal spaces (ICSs) along the right side of the sternum at the costosternal junction. After removing the infected bony chest wall, we entered the empyema cavity and evacuated the pus and necrotic materials. A sump drainage tube was inserted into the cavity for subsequent irrigation and drainage.\nTreatment with IV antibiotics was continued, and daily chest tube irrigation with 1 L of taurolidine-mixed purified water was performed for local infection control. Subsequently, a pleural fluid culture study was performed every 5 days, and no bacterial growth was observed. However, the patient remained febrile for 36 days after the initial operation; thus, we delayed the second stage of the operation. After discontinuing the irrigation using the chemical agent, the patient was afebrile and in a suitable condition for thoracomyoplasty. The first stage of the operation included full thoracotomy and resection of the second to fifth ribs. The thoracic cavity was entered and inspected through the fourth ICS periosteal bed. Severe visceral pleural adhesion to the chest wall was seen inferior to the fifth ICS level, and the cavitary empyema wall superior to fourth ICS level was dissected using a rongeur and Mayo scissors to confirm the previously inserted intracavitary sump drain. A serratus anterior (SA) muscle flap was harvested and transposed inside the chest through the ICS and sutured on the anterior and posterior chest wall to obliterate the apical dead space.\nThe second stage of the operation was performed 14 days later for definitive closure of the surgical wound. The interval between the stages of surgery provided adequate time to assess the viability of the SA flap and the sufficiency of space obliteration, as well as to confirm a negative microbiology report to ensure that there would be no local recurrence of infection. Here, a pedicled vertical rectus abdominis myocutaneous (VRAM) flap was utilized to fill in the right anterior chest wall soft tissue and skin defect from the first exploratory thoracotomy operation. The SA flap transposed in the previous operation was identified in the field, which appeared fresh with a healthy blood supply. The VRAM flap preparation and coverage were carried out by a plastic surgeon. The flap was passed through the subcutaneous tunnel to reach the space where the pericardium was exposed ().\nThere were no postoperative complications. The Jackson-Pratt drain was removed on postoperative day 12, and the patient was discharged home on postoperative day 21. He was then followed up at the outpatient clinic until 17 months postoperatively; there was no recurrence of infection, and no impairment of activities of daily living (). |
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. ). |
The patient was a 36-year-old Southeast Asian man who was an employee of a multinational corporation. At the time of the accident, he had been working as a dimensional control surveyor for module production at the construction of an offshore plant for 7 months at a Korean shipyard.\nHe caused an accident on the premises of the shipyard on December 4, 2012, at around 2 p.m., by crashing into a concrete wall after colliding with a motorcycle parked on the street. He presented to the emergency department of a nearby university hospital with the help of the company health officer. No conspicuous physical symptoms were observed except for mild tenderness on the right upper arm, but he had no memory of the period immediately before and after the accident. He had been wearing his safety belt, and, according to the statement of a worker who witnessed the accident, he was driving at a speed of ≤ 30 km/h, which is the speed limit on the premises. The accident itself was negligible, but he was unconscious at the time of the accident and he recovered consciousness only after a worker at the site knocked on the window approximately 5 min after the accident.\nThe results of a blood test, radiography of the right upper arm, and brain computed tomography (CT) did not reveal any abnormalities. The patient refused to undergo a more detailed examination to determine the cause of his loss of consciousness (LOC), and he was discharged without further treatment. The patient revisited the university hospital 3 days later, and no abnormalities were detected with the neurological examination conducted at the outpatient care of the neurosurgery department. Although the patient did not have any LOC-associated medical history, the medical team of the company decided to limit his work involving safety-sensitive activities such as driving and working at a height, in confined spaces, and with electricity, because of the risk of recurrence. He was referred to the Department of Occupational and Environmental Medicine of our hospital on December 31, 2012, for an assessment of fitness for work.\nThe following facts were communicated in the interview held on the day of his presentation. The patient had been working at a Korean shipyard as an employee of a multinational corporation since May 2012. As a dimensional control surveyor, he was responsible for module production, process management, and quality control in a liquefied natural gas plant. He started work between 7 and 8 a.m., and worked 9 hours a day, excluding a lunch break, and spent about 40% of his working hours at the site. His on-site activities consisted mainly of visiting the module production sites dispersed across various workplaces within the shipyard and collecting the production process data by using a laser scanner. Upon returning to the office, he would reconstruct the 10–15 datasets collected during his visits by using an elaborate 3-dimensional data computer program, and he used the 3-dimensional data to check whether the major module structures or complicated piping arrangements were produced within the error ranges admissible by the design. He then corrected the design drawing based on the detected production errors deviating from the permitted ranges, and had the work verified by the dimensional control manager. He spent 40–45% of his total working hours in the office, and all module production sites were within a distance of several kilometers. The shipyard premises contained traffic signs specifying a speed limit of 30 km/h. Because of the traffic caused by the transport of material and heavy equipment, it took approximately 5–10 min to move from one module to the next, and he spent about 15% of his working hours moving around by car. He alternated between 8 working weeks without a break and 2 off-work weeks in his home country, and he did not engage in overtime or shiftwork.\nHis baseline physical characteristics were as follows: height, 180 cm; weight, 112 kg; body mass index (BMI), 34.6 kg/m2; blood pressure, 145/95 mmHg; body temperature, 36.5°C; pulse, 63 beats/min; and respiratory rate, 22 breaths/min. He had been consuming medication for hypertension for a year without any other notable medical history; he did not smoke or drink.\nA blood test, peripheral blood smear examination (PBS), urine test, electrocardiography, and treadmill test were conducted to detect any possible medical condition that may have been the cause of LOC. The blood test revealed a fasting blood glucose level of 108 mg/dL; the test values for glycated hemoglobin and total red blood cell count as well as the levels of hemoglobin, hematocrit, blood electrolytes, blood urea nitrogen, and creatinine were all normal. The results of the PBS and urine examinations as well as electrocardiography did not reveal any abnormalities. No abnormalities were observed during the exercise portion of the treadmill test; however, the test was discontinued 2 min and 10 s after it began, when his systolic blood pressure exceeded 200 mmHg. Electroencephalography (EEG) and temporal lobe epilepsy magnetic resonance imaging (TLE-MRI) were performed to detect any possible neurological cause of LOC. The EEG and TLE-MRI readings did not reveal any abnormalities that were likely to cause epilepsy or syncope, but we decided to perform a more detailed examination for sleep disorders when we observed short sleep latency on the EEG result.\nWhen the patient presented again to our hospital on January 14, 2013, we performed another interview that was focused on sleep problems in addition to detailed anthropometrics and ESS. His neck circumference (NC) measured 46 cm (18.1 inch) and ESS was 13 points (Table \n). He usually went to bed between 11 and 12 p.m. and woke up at around 6 a.m. In his home country, his wife had complained about his snoring, and he used to hold his breath during sleep and subsequently needed to gasp for breath. As he reported that he took a nap for 20–30 min to prevent sleepiness in the afternoon hours after lunch, PSG was performed to determine whether he had a sleep disorder.\nThe PSG performed in our hospital on January 30, 2013, yielded the following results: sleep latency, 25 min; sleep efficiency, 88.6%; total sleep time, 388.5 minutes out of a total recording time of 438.5 minutes (Figure \n, Table \n). The sleep latency of rapid eye movement (REM) was 114 minutes, and the sleep architecture showed a substantially increase in stage N1, decrease in stage N2, and decrease in stage R. Frequent respiratory events and arousals were observed when he was sleeping in a supine position, but these were rare when he slept in a lateral decubitus position. Particularly, the respiratory events increased, and the recorded minimum blood oxygen saturation was 70% in REM sleep. The apnea-hypopnea index (AHI) was measured as 84.5, indicating severe sleep apnea.\nOn the basis of the results of the interview and tests, we concluded that it was very likely that the accident was caused because of OSA while the patient was driving, and we recommended that the patient resume working only after the OSA was alleviated through continuous positive airway pressure (CPAP) or surgical intervention.\nRelying on the results of the assessment of fitness for work, the company temporarily suspended the patient from work and decided to reinstate him to his usual duties when his OSA was alleviated. The treatment period for OSA was estimated to last for 2–3 months, and it was decided that the patient would receive the treatments in his home country, and his reinstatement to work would depend on the results of a reassessment of fitness for work. |
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 64-year-old man visited our hospital with penile pain and voiding dysfunction. The patient had received a paraffin injection procedure performed by non-medical personnel (a friend) for penis enlargement 35 years previously in Japan. After the injection, he had experienced sexual dysfunction due to a buried glans penis, penile curvature during erection, and intravaginal penetration impairment. Voiding dysfunction was also present, with urine spotting and loss of urine flow due to preputial ring stenosis caused by a paraffin granuloma. He visited the hospital due to having experienced exacerbated voiding dysfunction over the course of 6 months, associated with pain of the pelvis and penis. He was not able to engage in any sexual activity at all. His past history indicated that he had received a colorectal polyp removal procedure a year previously. He had been diagnosed with hypertension 5 years ago and was currently taking aspirin. No specific findings were obtained from a general blood test, urinalysis, liver function test, hepatitis test, syphilis test, or a serum test for AIDS. We did not find any causative factors, such as prostatic hyperplasia, urethral stricture, or neurological diseases related to voiding dysfunction. On his physical examination, the penis foreskin injected with paraffin had the shape of a penis glans, making it impossible for posterior retraction to denude the glans penis, and the actual penis glans was not palpable, as it was completely embedded in the paraffin granuloma. The urinary meatus was also not confirmed. The preputial and penile shaft skin around the injection displayed a typical appearance of paraffinoma, and no bilateral inguinal lymphadenopathy was found ().\nIn the magnetic resonance imaging findings, the penile paraffinoma induced a heterogeneous signal that was observed from the glans as well as from the distal part of the penis. The more or less increased enhancement of the urethra and urethra spongiosum in addition to the buried penis glans was assumed to be an inflammatory change ().\nA phalloplasty was performed using a scrotal flap following paraffin granuloma removal under spinal anesthesia. The volume of the resected paraffinoma was 8.5×6.0×5.5 cm, and its weight was 195.7 g (). A histopathologic examination showed variably sized globules separated by sclerotic stroma and associated with inflammation ().\nAt present, 3 months after the procedure, no findings of recurrence have been observed and the patient's sexual function has normalized, in addition to the resolution of voiding dysfunction (). The patient scored a total of 24 out of a possible score of 25 on the International Index of Erectile Function-5 at 4 weeks postoperatively, indicating that he had no problems regarding sexual function. |
A male child aged 1 year and 9 months was brought to our center by the caregivers with history suggestive of accidentally swallowing a computer battery cell at home 4 h before. The parents provided the history of living in a one-roomed dwelling of a slum, which also served both as a computer hardware assembling and repairing workshop of the father and, usually, was cluttered with computer accessories. History suggested that the child had ingested a battery cell while playing in the vicinity of the dismantled spares of computer sets and started retching, vomiting, coughing and choking and turned pale soon after swallowing something. The caregivers had an unsuccessful attempt at retrieving the object. The father had brought along with him a sample of the battery cell to support the suspicion, which resembled a five rupees coin with smooth edges.\nA high-risk informed consent was taken after counseling the caregivers for the procedure, explaining in detail the risks with the advantages and disadvantages involved in anesthesia and the course of actions of further interventions. In the preliminary history and clinical examination, the child had dehydration and mild stridor, but showed no batter marks on the body to exclude a case of child abuse. X-ray PA view of the chest and neck was performed immediately in the emergency room, which confirmed the impaction of the foreign body [].\nThe toddler was rushed to the observation room of the emergency services at our center. A fluid line was promptly started with Ringer lactate and a bolus dose of hydrocortisone and ceftriaxone was administered with adequate precautions, while the preparation was pursued to shift the child to the emergency operation theater. A pediatrician was called without delay to assess the clinical status, including hemodynamic stability of the child.\nThe pre-operative logistics was in favor of general anesthesia on the anticipation of use of rigid endoscope if flexible endoscopy fails and a tracheostomy in case of respiratory distress. The child was intubated orally by the anesthesiologist and the pediatric flexible esophagoscope was negotiated. The battery cell was noticed to be impacted in the cricopharynx, which is the most common site of impaction for foreign bodies.\nBecause of limited edematous and congested space, instrumentation was difficult and the single battery slipped repeatedly due to smooth surface, but was removed safely without trauma to the surrounding structures. An infant feeding tube was inserted immediately under direct supervision. On inspection, the foreign body was found to be discolored, with corrosion of one surface, as we could remove it before it could cause severe reaction to the tissues [Figures and ].\nThe child was kept in the pediatric intensive care unit to observe for immediate complications like dysphagia, odynophagia, mucositis causing stridor and aspiration in cases of delayed intervention. A nasogastric tube feeding was initiated 4 h after this non-invasive procedure. The post-operative period was uneventful. Antibiotics, steroids and anti-inflammatory drugs were given as a 5-day course and a nasogastric tube was left in situ for a week, after which the patient could swallow well before discharge. The toddler recovered uneventfully in the immediate post-operative period. The child was followed-up for the last 1 year and was free of long-term complications. Institutional ethics committee approved the publication of this report.\nForeign bodies in the esophagus are a routine emergency dealt by the otolaryngologist in daily practice. More the delay in extraction of the leaking battery cells, greater is the damage due to liquefaction necrosis of mucosa and the chance of stricture and pressure necrosis. A Taiwan study noted that 21.6% of the children accidentally ingested button batteries. There were no major complications after endoscopic removal.[] In the Turkish retrospective study on the ingested foreign bodies in children having endoscopic removal, the relative risk was >1 for button batteries.[] In the Taipei Veterans General Hospital Poison Control Center, of 25 patients with button battery ingestion, it was noted that impacted cell needed immediate esophagoscopic removal.[] At the department of Radiology, Klinikum Rudolf Virchow, Charlottenburg, FRG, button-type batteries ingested were removed from the esophagus and the upper gastrointestinal tract of 13 children by means of the FE-EX “OGTM-technique.” In all cases, the button cells were easily detected and retracted under fluoroscopic control with the magnet without post-operative setback.[] Litovitz in his review of 56 cases advocated immediate removal of cells to prevent further complications and use of nasogastric tube to prevent strictures.[] Still, the researchers are of the opinion that the management of ingested foreign bodies in children is not standardized.[]\nIn the present case, the accidental battery cell impaction was referred to a teaching hospital emergency within 4 h. The kid was examined and diagnosis was confirmed promptly. The narrow inlet of cricopharynx was the site of impaction for this type of larger foreign bodies. Primary outcome measure was immediate endoscopic removal with non-invasive technique as the utmost priority to prevent known secondary complications by the prompt extraction.\nThe strength of the study is that the case of foreign body impaction had undergone optimum management within the resource constraint set up of eastern Indian tertiary care hospitals. Further, the case has been reported with precise details, including the follow-up. To the horizon of our knowledge, no previous study had been reported of children with computer battery cell in the cricopharynx of a toddler in eastern India. We had the limitation of reporting the case little later than expected.\nForeign bodies are dealt with by different authors differently, but the basic method is prompt endoscopy and atraumatic removal. Early removal prevents complications. Long-term follow-up is mandatory to see for late sequel.\nHistory should be taken in detail to rule out battered baby syndrome. Further, controversies move around the logistics of general anesthesia, use flexible or rigid endoscope and a tracheostomy in case of respiratory distress.\nFuture research directions should move around research collaboration in this part of the country for the underlying mechanisms of foreign body ingestions by socioclinical research. The caregivers need to be educated on the art of rearing of children by continuing parent education to prevent all the domestic and peridomestic accidental occurrences. They should be taught on the early identification of ingested foreign bodies, and the optimum intervention is by prompt endoscopic removal of foreign bodies under general anesthesia as the safe and effective method in children to prevent erosion and perforation of the gastrointestinal tract. Longer the duration of impaction, more are the chances of delayed complications. Training of the primary health care staff with clinical audit are needed for handling such emergencies without referring them to other centers, which can save morbidities with long-term complications. |
RC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.\nOn postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis (Figures and ). On hospital day 27, the patient underwent a final exploratory laparotomy with intraoperative findings of persistent collapsed bowel loops distal to the new anastomosis. The collapsed distal segment was resected, and an ileocolic anastomosis was created. On gross examination, the entire distal ileum was thickened without stricture (Figures and ). The pathology of the distal ileum showed submucosal fibrosis with hyalinization of the lamina propria and atherosclerotic changes in the adjacent vessels. After the second revision, the patient progressed as expected with return of bowel function and tolerance of diet and was later discharged on hospital day 38. Our presented patient continues to do well on the outpatient follow-up. |
A 40-year-old right hand dominant male patient presented with pain in the left hand due to a fall on the out stretched hand. He had pain and tenderness over the base of the first ray. A bony fragment was felt over the dorsum of the hand near the anatomical snuff box. Movements of his thumb was only restricted in the terminal range.\nPlain radiographs of the left hand showed a coronal fracture of the trapezium, with the base of the first metacarpal impacted in between the two fragments. A reduction was attempted in the emergency room under intravenous sedation, which showed the fracture geometry more clearly in the immediate postreduction radiographs. CT scan was asked for better evaluation [Figures and ] which confirmed the coronal split fracture of the trapezium with articular involvement. There was a major volar fragment and a dorsal fragment [].\nUnder general anesthesia and tourniquet control the fracture was exposed through a dorsoradial approach. The fracture was well visible through the tear in the capsule. The fragments were reduced and held with a reduction clamp. Our original plan was to fix the fragments with a 2.7 mm screw, passed from the dorsal fragment. However, tightening of the screw to get compression resulted in fragmentation of the dorsal fragment. Hence the fragments were fixed with two, 1.6 mm Kirschner wires []. To keep the joint reduced and to maintain the articular congruity, the joint was stabilized further with a joint spanning mini fixator. The K wires and the external fixator were removed at 6 weeks, and the patient was sent for hand physiotherapy where he was started with an active and active assisted range of movements [].\nAt 1-year follow-up radiographs showed normal articular relationship of the trapezium with the base of first metacarpal and scaphoid. The anatomic relationship of the bases of the first and second metacarpal was also maintained. He had a complete range of motion of the left thumb, when compared to the uninjured side. His grip strength was normal. |
The patient was a 72-year-old male with previous medical history of atrial fibrillation on apixaban, hypertension, hyperlipidemia, and prior basal cell carcinoma status post resection who presented with headache. The patient reported earlier on the day of presentation he awoke around 6:00 AM with a diffuse throbbing headache, approximately 5 out of 10 in intensity. He initially tried to manage it conservatively, but he began to vomit and decided to present to an outside emergency room. At the outside facility a dry computed tomography (CT) of his head was performed which demonstrated an acute left subdural hematoma (Figure ). He was subsequently given prothrombin complex concentrate (PCC) and transferred to our facility.\nOn further history the patient endorsed a history of similar headaches in the past that would last for days and were associated with pulsatile tinnitus. He was neurologically intact on initial examination. Given the history of pulsatile tinnitus a diagnostic angiogram was performed to rule out any underlying vascular malformation. This was negative. A magnetic resonance imaging (MRI) of the brain with and without contrast was also performed and was negative for any underlying metastatic lesion.\nThe patient remained neurologically with improved headaches. The patient was sent home after serial imaging was completed and stable. He was brought back electively for left-sided middle meningeal artery embolization approximately two weeks later. After the completion of this procedure he was discharged home the following day after repeat imaging was obtained and again stable (Figure ).\nHe returned the following evening with a transient episode of speech difficulty that resolved on arrival to the emergency room. Head imaging obtained was unchanged. His levetiracetam dosage was increased to treat seizures and he was sent home with plans to follow up with him in clinic later in the week. The following day he presented again with the same complaints. Head CT at that time again was stable (Figure ), however, given his persistent symptoms and unresolved subdural hematoma, surgical intervention was performed.\nThe patient was transported to the operating room and induced under general anesthesia. He was positioned supine and prepped and draped in sterile fashion. A 4 cm left frontal incision was made and a small craniotomy was performed. The IRRAflow system was primed and tunneled into the incision. The dura was opened and the IRRAflow catheter was then placed in the subdural space. The IRRAflow system was turned on, and subdural hematoma was noted to be draining through the catheter into the collection system. The wound was then closed in standard fashion.\nPost-operatively the patient awoke from anesthesia without issue and was monitored closely in our neurocritical care unit. Daily CT scans were acquired and are displayed below (Figure , ). His pre-operative speech deficits resolved following placement of the catheter. On postoperative day three the subdural had nearly fully resolved and he was discharged home from the intensive care unit. The patient has been seen in clinic twice since discharge with imaging studies. There have been no signs of recurrence at this time. |
This 58 years old non-indigenous man had been homeless since his early thirties. He developed schizophrenia in early adulthood and retreated from mainstream life to live under a suburban bridge for the next 26 years, with minimal contact with the medical or psychiatric system. By the age of 55 years old his schizophrenia had “burnt out” but he was experiencing increasingly severe low back pain and leg weakness from degenerative lumbar spine disease. This significantly impacted his mobility and resulted in more frequent ED presentations. By mid-2016, his back pain and leg weakness rendered him unable to mobilise over any significant distance and his presentations to hospitals escalated further. Over the years he had also developed other health problems: severe COPD and hepatic disease due to heavy cigarette and alcohol use respectively and bladder cancer. Despite these issues and very limited mobility he was repeatedly discharged back to live under the bridge after brief hospital admissions. By late 2016, he was wheelchair bound and moved into the Perth Central Business District where homeless services such as food vans were in closer proximity but the risk of assault was considerably greater. He continued to present frequently to hospital asking for assistance with housing and his medical issues, especially his back pain and leg weakness. He scored 14 on the VI-SPDAT questionnaire in August 2016, which reflects high vulnerability.\nHospital use by this 58 years old patient for the 29 months period January 2015 to July 2017 is summarised in with the associated costs of ED presentations and inpatient admissions. They cost almost $250,000 over the 29 months period; 69 ED presentations costing $45,264 and the 84 hospital bed days adding up to $202,860 (based on IPHA R19 estimates). This does not include other admission costs such as investigations or medications.\nIn July 2016, the hospital Homeless Team connected this patient to the 50 Lives 50 Homes project. He was prioritised for housing due to his high vulnerability and frequent hospital admissions. Through the efforts of his caseworker, he was housed in a friendly aged care hostel facility in early August 2017 and has had no ED presentations since. Regular follow up visits have been made by Homeless Healthcare to him at his new accommodation as part of the After Hours Support Service provided as part of the 50 Lives project. Having lived on the streets for nearly half his life, there have been many adjustments, for example he had spent so long out of mainstream life that he needed instructions to use a TV remote control. Whilst it is early days and premature to compute a cost-benefit analysis in relation to this case study, as discussed in , the unit cost of ED presentations and inpatient admissions far outweighs the costs associated with case worker support and housing. |
A 20-year-old right-hand-dominant and otherwise healthy female student presented with protrusion of the left upper back and left periscapular pain that occurred after sport activities. Ten months previously, the patient had been seated in the left rear passenger seat in a car that was hit in the left side by another car. Further details such as the posture and the arm position of the patient at the time of the accident were uncertain. At the time of the car accident, the patient visited an orthopedic clinic where a surgeon diagnosed left shoulder contusion without any abnormal radiographic findings. The left arm was kept in a sling for 2 months, as left arm elevation caused severe pain in the upper back. After sling removal, the patient returned to basketball, which generated continuous dull pain around the left scapula. She presented at our clinic because her mother had noticed the deformity of her back.\nThe patient had no relevant family or medical history. There was no neurological deficit in the left shoulder and arm. The left scapula was slightly higher than the contralateral scapula and exhibited atypical medial winging with the arm at the side. The distance between the spinal process and medial scapular border was shorter on the left side than the right side at the inferior angle level, but these distances were almost the same at the scapular spine level (). Contraction of the scapular stabilizing muscles was good. There was a palpable bony protuberance without tenderness on the ventral side of the ISA. The limitations of the active ranges of motion of the left shoulder compared with the right shoulder were 25° for total elevation, 15° for external rotation, and none for internal rotation and horizontal adduction; however, there were no limitations of the passive ranges of motion. The winged scapula became prominent at 0–45° of active flexion, while it disappeared when the patient flexed the left arm while consciously attempting to depress the scapula (). The winged scapula did not emerge when the patient pushed on a wall at chest level. Radiographs showed a small bony fragment in the ventral side of the ISA, with a narrow space between the fragment and the scapular body (). Computed tomography revealed a bony protrusion extending from the medial scapular border to the bony fragment, with a narrow gap between the protrusion and the fragment (Figures –).\nThe patient was instructed to avoid elevating the left arm for 2 months and then performed reinforcement exercises of the SA such as the scapular push-up and the bear hug using an elastic band for 2 months. At examination 4 months later, the periscapular pain and the winging of the scapula with the arm at the side and in active flexion had resolved. The push-on-the-wall test at waist level was negative, and the range of motion of the left arm was the same as the unaffected side, except for a 15° limitation in external rotation. Although the radiographic findings were the same as at the first visit, computed tomography demonstrated bony union (Figures and ). The patient was permitted to use the left arm without restrictions.\nAt the time of the final follow-up 10 years of postinjury, the patient reported that there was an occasional painless click and a sporadic floating feeling of the scapula with initial active flexion of the arm. However, there was no pain or any disturbance to the patient's activities of daily life and work as a physical therapist. The patient's colleague confirmed the disappearance of the winged scapula associated with shoulder movement. The DASH score was 0, and the Constant score ratio compared with the right shoulder was 100% [, ]. |
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 55-year-old man presented to the ED with the main complaint of a severe headache. Additional symptoms included dizziness and nausea. He denied any trauma. He stated that the headache started earlier that day and that headaches were uncommon for him.\nA physical exam of the patient revealed a well-appearing male without neurological deficits. The patient was calm and cooperative. Due to the main presenting symptom of headache, a CT head and a CT angiogram of the head and neck were ordered to look for a potential cerebrovascular cause, such as bleed or aneurysm.\nAlthough no cause of the headache was discovered, there was an incidental discovery of a 1.2 cm nodular opacity in the superior segment of the left lower lobe with features suggestive of a peripheral PAA. Non-emergent CT angiography of the chest was recommended for further evaluation. After treatment with fluids and pain medication, the headache improved, and the patient was discharged home.\nThe patient returned three months later for a CT angiography of the chest. On imaging, a 1.2 x 1.0 x 1.1 cm enhancing structure in the superior segment of the left lower lobe was seen arising from the subsegmental branch of the left lower lobar pulmonary artery, most consistent with a PAA (Figure ). No draining vein was identified, which would have suggested AVM. Pulmonary angiography was recommended for confirmation and treatment.\nThe patient returned the following week for intervention. Under ultrasound guidance, access was gained to the right common femoral vein via a four French micropuncture kit and transitioned to an eight French vascular sheath. Using standard guidewire and catheter, a five French pigtail catheter was advanced through the right atrium and ventricle and into the main pulmonary trunk. Pulmonary manometry was performed yielding normal pulmonary arterial pressures. A seven French destination sheath was then advanced into the central main pulmonary artery. Main pulmonary angiography demonstrated normal pulmonary branching anatomy with normal perfusion of the left lung. The left lower lobe aneurysm was visualized. The catheter was advanced into the left pulmonary artery and pulmonary angiography was performed at a steep obliquity to help delineate the anatomy and provide a road map (Figure ). A selective catheter was then used to select the lower lobar artery, superior subsegmental branch. Gentle hand angiography demonstrating an 11 mm fusiform aneurysm that correlated with the CT findings confirmed no draining vein, proving this to be a true PAA rather than an AVM (Figure ).\nThe catheter was advanced into the aneurysm and coil embolization was performed using a 13 mm x 24 cm detachable coil. Completion angiogram demonstrated no significant residual filling within the aneurysm with maintained perfusion in the peripheral branches (Figure ). The catheter was retracted into the main pulmonary artery and manometry revealed no change in pulmonary arterial pressure. All catheters wires were removed and hemostasis was achieved with manual pressure. The patient tolerated the procedure well. After six hours of observation, the patient was discharged home without complication. |
A 79-year-old female presented to the emergency department with 2 weeks of left jaw pain and swelling as well as left facial weakness and droop. As seen in , an MRI with IV contrast revealed a 1.5 × 1.5 × 1.8 cm heterogenous, low-intensity, peripherally enhancing lesion located in the deep lobe of the left parotid gland, abutting the posterior aspect of the left lateral pterygoid muscle. It demonstrated likely pathologic involvement of the facial nerve within the parotid gland and in the region of the stylomastoid foramen. She was subsequently referred to our office and was found to have weakness of the marginal branch of the facial nerve and diminished gag reflex.\nDue to high malignancy suspicion, a left total parotidectomy with facial nerve resection was performed as well as facial nerve reconstruction. The tumor was noted to be very firm and was encountered deep in the parotid gland, extending to the deep muscles in the neck but not adherent to any surrounding structures. The margins were distorted during the excision. Surgical pathology included 2 tumor excisions exhibiting spindle cell morphologies and 5 lymph nodes labeled benign. The first parotid excision was 2.5 cm and showed extensive calcification and hyalinization. The second was 1.9 cm, surrounded nerve bundles, and was noted to have focal necrosis. Diagnosis was a sarcoma ex pleomorphic adenoma with the sarcomatous component being consistent with a leiomyosarcoma.\nThe patient began external radiation 2 months postoperatively to the left total parotidectomy tumor bed using generous margins and tracing the path of the left facial nerve back to the stylomastoid foramen. Lymph nodes were not included since the surgical specimens were negative and spindle cell sarcomas do not generally metastasize to lymph nodes. Left facial droop improved over the course of 6 weeks of 30 radiation treatment fractions. Six months after surgery, PET scan of the head and neck showed no abnormal hypermetabolic foci within the head and neck region to suggest metastatic disease. Nonspecific bilateral hilar hypermetabolic densities were appreciated, so a repeat CAT scan 3 months later was recommended. At a one-year postoperative followup, the patient had no complaints and only marginal facial nerve palsy was noted on exam.\nWhile vacationing in Florida, the patient presented to the local hospital with 2 days of symptoms including ataxia, diplopia in the right eye, and bilateral hand numbness. MRI revealed a homogenously enhancing mass in the left paramedian inferior pontine region of the brainstem measuring about 9 × 9 mm. Chest CT also revealed a lobulated 5.2 × 2 cm mass along the peripheral portions of the right upper lobe. The brainstem and lung masses were assumed to be metastatic sarcoma from the left parotid. She was not deemed a surgical candidate and was recommended to undergo palliative radiation therapy, but she preferred hospice care just 18 months after first experiencing symptoms.\nThe parotid specimen was prepared on H&E and immunohistochemical stained slides, shown in . Observations included the following: identifiable foci of pleomorphic adenoma with presence of benign glandular/tubular structures identified within a predominantly acellular hyalinized and focally calcified nodular area. There was also variably differentiated spindle-shaped cellular proliferation extensively involving periparotid soft tissues including perineural and perivascular invasion, as well as invasion of the parotid parenchyma. The lesion showed fascicular to storiform growth comprised of elongated cigar-shaped nuclei. There was increased mitotic activity including atypical mitoses and focal necrosis. The IHC stains were variably reactive for smooth muscle actin, smooth muscle myosin heavy chain, desmin, and calponin but negative for pan-cytokeratin, S100 protein, CD34, and ALK1. This is consistent with leiomyosarcoma. While there was focal moderate nuclear pleomorphism, the nuclear morphology was relatively bland lacking features of a histologic high-grade neoplasm. Diagnosis is a sarcoma ex pleomorphic adenoma with the sarcomatous component being consistent with a leiomyosarcoma. The absence of epithelial malignancy precludes a diagnosis of carcinosarcoma. The specimen was defined as histologic grade 2, including perineural and perivascular invasion with tumor extension into periparotid soft tissue. 12 lymph nodes were examined and 0 were noted for malignancy. Thus, the stage of the tumor was T1N0M0. |
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. ). |
We present the case of a 33-year-old Caucasian male patient. During periods of clinical stability, he used to work with high performance. He has no siblings, practically no social life and few leisure interests. He smokes 20 cigarettes a day and denies regular consumption of recreational drugs or alcohol, although he admits to the occasional use cannabis, which has triggered episodes of behavioural disorders. He has spent long periods off work due to his psychiatric condition, which has led to the loss of his current job.\nHe refers no psychiatric family history. Somatic history shows obesity and gynecomastia.\nPast psychiatric history: he was first diagnosed with bipolar type I disorder in 2003, at the age of 20 years, and was admitted to a psychiatric unit for the first time in 2006. From the clinical perspective, he suffers a very unstable condition with a poor and slow response to treatment and frequent relapses involving startling manic symptoms and severe behavioural disorders. Besides, he has experienced severe drug-induced side effects, the most remarkable being extrapyramidal symptoms, sedation, weight gain and dyslipidaemia. Because of the numerous and troublesome adverse effects, the patient has become reluctant to take medication, which has led to irregular treatment adherence and frequent relapses. Altogether, he has been admitted 18 times since 2006, with an average of twice a year. Thirteen of these admissions were to the acute unit of the Department of Psychiatry in Zamora Hospital, making a total of 256 days. The remaining 5 admissions were to the convalescence unit of the same department, involving a total of 41 days. This is strong proof of the great complexity and difficulty in achieving clinical stabilization of the patient. Moreover, keeping the patient in the inpatient care unit became an almost constant need from the months of November 2014 to March 2015, due to the combination of poor clinical response and the numerous side effects of the medication.\nThe patient was conscious and well oriented, but showed partial insight. He suffered from reduced cognitive capacity, with cognitive slowing, inattention and distractibility. His mood oscillated from euphoria and grandiosity to irritability and dysphoria, which made his personal approach inappropriate. He exhibited pressure of speech, with racing thoughts and, occasionally, flight of ideas, which caused his communication to be incoherent. He felt restless, with episodes of psychomotor agitation and frequent verbal and physical aggressiveness, disruptive behaviour, and no sense of social distance. He had global impressions of severe insomnia, although he did not complain about it because he did not feel tired. He denied experiencing hallucinations or delusional thoughts, but revealed clear megalomaniac feelings and expressions.\nAn electroencephalographic record conducted in March 2006 showed normal bioelectric brain activity. In May 2012, the results of a simple contrast computed tomography scan reported no abnormal findings.\nThe poor and short lasting response to pharmacological treatment has led the patient to undergo different drug trials, combining mood stabilizers (lithium, valproic acid and carbamazepine), antipsychotics and benzodiazepines. Haloperidol and atypical antipsychotics such as risperidone, olanzapine, paliperidone, quetiapine, aripiprazole or asenapine have been tested, the latter specifically indicated for the treatment of moderate to severe acute mania associated with bipolar disorder. Poor efficacy and tolerability (including weight gain, metabolic disorders, sexual dysfunction and persistent sedation) were present throughout most of the antipsychotic treatment. This situation became more apparent during the months of January, February and March 2015, when the patient was admitted on an almost continuous basis ().\nOne of the reasons for antipsychotic treatment failure is poor compliance secondary to tolerability issues. In fact, the patient’s family suggested it as a possibility and, therefore, the first readmission was attributed to this problem. However, this probability was ruled out by supervising medication intake during the admissions.\nAccordingly, a pharmacogenetic study was requested in March 2015, after performing a theoretical drug interaction analysis to assess the different pathways involved in the metabolism of the prescribed drugs and to identify the enzymes’ corresponding drug substrate. The genes eligible for genotyping analysis were identified according to this complex theoretical analysis. In this case, we conducted a molecular analysis of gene variants CYP2B6 (*6 ), CYP2C9 (*2,*3 ), CYP2C19 (*2,*3,*17 ), CYP2D6 (*2, *3,*4,*5,*6,*7,*8,*9,*10,*12,*14,*17,*29,*41, XN ), CYP3A4 (*1B ), CYP3A5 (*3 ) and MDR1 (3435 C>T ) (). The DNA sample was obtained from peripheral blood extraction and the analysis was performed using a Compaq MagnaPure system. CYP2D6 genotyping was performed using microarrays (Infinity, AutoGenomics, Palex, Spain) after PCR amplification. For other genes, a real-time PCR method was used, alongside fluorescence resonance energy transfer (FRET)-probe assays to define fusion curves.\nThe pharmacogenetic study showed a possible decrease in the expression of MDR1 transport protein/multidrug resistance protein (heterozygous genotype carrier of allele T of 3435 C>T of MDR1 gene). A genotype associated with low efficiency of CYP2B6 (G/T), CYP2C9 (*1/*2) and CYP3A5 (G/G) was also identified. By contrast, CYP2D6 (alleles *1/*41), CYP2C19 (*1/*1) and CYP3A4 (A/A) were identified, which gives cause to expect an efficient metabolism of the enzymes encoded by these genes.\nAfter several months of near-constant admissions and different drug trials, the lack of clinical response led to a complex polypharmacologic treatment plan (). Guided by the theoretical interaction assessment and the results yielded by a pharmacogenetic analysis, the treatment regimen was modified:\nClonazepam, which can interact with carbamazepine and olanzapine via 2B6 (altered in this patient) and 3A4, was changed to lorazepam, which is not metabolized via the CYP 450 pathway. This was later discontinued.\nPaliperidone was then suspended due to low tolerability, partly caused by low expression of the efflux transporter MDR1 alteration, which increase bioavailability and brain levels of paliperidona.\nOlanzapine was also discontinued due to lack of response and side effects, mainly sedation and weight gain. This could be related to MDR1 and 2C9 alteration in this patient, as well as to interaction with carbamazepine and nicotine via 1A2.\nCarbamazepine was stopped because of its adverse effect profile (sedation, liver function impairment) and global induction of hepatic metabolism, in this case olanzapine and clonazepam metabolism induction.\nThe lithium dosage was maintained at 1,600 mg/day.\nAripiprazole was started at a medium-dose of 15 mg/day.\nAfterwards, as the patient started to show signs of a depressive episode, he was started on bupropion, which he took for several months at a dose of 300 mg/day.\nThe ultimate goal was to improve the metabolic profile associated to polypharmacy and thereby the efficacy of the treatment, also reducing its side effects, especially weight gain, sedation and apathy.\nDuring the two months following modification of the treatment regimen, a progressive overall clinical improvement became apparent, as well as a reduction of side effects.\nFive months after starting progressive medication changes based on the pharmacogenetic study, a more simplified treatment () was found to be effective in relieving the patient’s symptoms: he regained euthymia, recovered his normal functional behaviour and mental organization, and showed more initiative and an improvement in cognitive performance.\nSimilarly, irritability and insomnia disappeared.\nIn terms of healthcare resource consumption and overall recovery of functionality, the patient has not required any further hospital admissions; he is living with his parents and has become more involved in both household and social activities. |
We present a case of a 30-year-old primigravida who developed seizures and short-term loss of consciousness just few minutes after normal vaginal delivery of a healthy male child. She had although complained about on and off severe headaches since last 10 days, for which no specific cause related treatment was initiated. Her baseline hematological work-up and vitals including blood pressure were within the normal limits during the antenatal and natal periods.\nThere was no past as well as antenatal history of trauma, fever, fits, or blurring of vision. Her past medical history did not reveal any comorbid medical conditions and she had not had any similar episodes in the past.\nA further detailed personal history revealed that there was no evidence of substance abuse or any sort of addictions. On examination, she had a pulse of 80 beats per minute, mildly elevated blood pressure of 140/90 mm of mercury, respiratory rate of 22 breaths per minute. Her blood parameters were within normal limits too, hemoglobin level was measured to be 14 gm/100 mL. A fundoscopic examination was within normal limits. Neurological examinations revealed that the patient had developed left-sided hemiparesis and aphasia and was managed with conservative medical therapy.\nFollowing seizure and loss of consciousness, a preliminary baseline noncontrast CT [] scan of head was performed, it showed changes of early infarct involving bilateral cerebral hemispheres, with the infarct being randomly interspersed and not belonging to any specific vascular territory. There was minimal subarachnoid hemorrhage in the right frontal and perisylvian region. These findings led to a thought of venous infarct and hence an magnetic resonance (MRI) scan was done to rule out any possibility of cerebral venous thrombosis. MRI findings corroborated the CT findings of acute infarct [] and SAH []. It confirmed the infarct but the etiology still remained unclear as the MR venogram was absolutely normal []. With no renal derangement and the baby being bottle fed, she underwent a 3D CT angiography of the head and neck vessels to evaluate for any aneurysmal bleed. The observations from the CT angiography were remarkable as it showed severe narrowing of bilateral internal carotid arteries, just distal to bifurcation of both common carotid arteries []. With the patient being young and having no definite identifiable causes for severe narrowing of bilateral internal carotid arteries, we inferred it to be an extremely rare presentation of bilateral ICA hypoplasia. This was further confirmed by the measurement of the bony petrous part of bilateral internal carotid canals [] measuring approximately 2.5 mm on right side and 2.8 mm on left side. The cerebral circulation comprised of multiple collaterals having been developed predominantly from bilateral external carotid arteries and the vertebrobasilar arteries. A retrospective color Doppler study [] and noncontrast MR angiography [] were done for corroborating our findings. On follow-up, the patient after 1 month showed no significant improvement in her clinical condition and she had residual neurological deficit as a result of previous vascular insult.\nThere is no consensus about the optimal therapeutic strategy, perhaps due to the rarity of this clinical entity. Extreme search of literature did not reveal any appropriate management strategy. The role of lower segment cesarean section (LSCS) versus vaginal delivery is controversial and its outcome are not known. |
An 11-year-old male patient presented with abnormal contour of the abdomen and both flanks in January 2009 (). The abnormal contour was first noted by the parents at the age of 5 years and gradually increased in size without any additional manifestations or other similar masses in his body. He did not have any other medical abnormalities, had not had any surgeries prior to this, and there was no familial history of obesity nor abdominal tumors. There was no abnormal prenatal nor neonatal history. There was no history of any abdominal trauma, drug administration, or hospitalization. Previous referral to pediatric endocrinology and genetic counseling showed normal hormonal profile and no abnormality detected in genetic studies.\nFurther clinical examination revealed multiple masses of the anterior abdominal wall, both flanks, and upper thighs. The ill-defined masses caused a generalized obesity in the trunk superficial to the muscles. They were not related to the skin, nor did they have any pigmentation or ulceration. There was no lymph node enlargement nor skin sagging. To determine the extent of the masses, a computed tomography (CT) scan was performed. It showed diffuse subcutaneous fatty infiltrations to the anterior abdominal wall, both loins and upper thighs with no bony deformities of the pelvis. According to the CT findings, the masses had infiltrated the subcutaneous tissue with no muscular, intraperitoneal, or retroperitoneal extension and this was confirmed by ultrasound. An incisional biopsy was done preoperatively and revealed subcutaneous lipomatosis with no malignancy. The weight of the boy was 44 kg (80th centile) according to his age.\nConsidering the patient’s age, the extent of involvement, absence of predisposing factors, and normal laboratory examination, he was diagnosed with diffuse abdominal lipomatosis. He did, however, feel weighted down by his bulky trunk and complained of isolation from his peers and difficulties in routine daily activities. After a discussion with the family, surgery was planned for him. We considered an excisional surgery for all the diffuse abdominal lipomatosis with an abdominoplasty Approach.\nThe operation was done in 2 stages; first stage: under general anesthesia, tumescent solution was injected, and a full abdominoplasty incision was made. Dissection of the abdominal flap was performed up until the costal margin with release of the umbilicus. A lobulated mass was found with an incomplete capsule superficial to the rectus sheath (). Removal of most of the anterior and flanks lipomatosis was performed, and followed by abdominoplasty, umbilicoplasty, hemostasis, and wound closure in 2 layers (). The total size of the resected masses was 3500 gm, approximately 8% of the patient’s total body weight. Pathological evaluation revealed fibrotic dermis overlying diffuse lesions of variable-sized lipomatosis with no atypia or malignancies. The recovery was uneventful in the postoperative period and suture removal was performed after 10 days ( and ).\nThree years after the initial surgery, the patient showed no local recurrence. Due to residual masses in the flank area and upper thighs, we planned liposuction on both flanks and thighs with abdominal scar revision. An additional 1300 mL was aspirated in the liposuction and 425 gm excised with the scar revision.\nAt the 36-month follow-up, the patient showed excellent results, with restored symmetry to the abdomen, flanks, and thighs ( and ). There was no permanent hypesthesia. No areas of growth were evident within and along the margins of resection. The patient started to practice sports within a group and the family was very satisfied. Satisfaction was assessed by our clinical psychologist who interviewed the patient and his parents before and after the procedure especially with the change in the social habits of the patient, being more interested in socializing with his peers. |
A 59-year-old Japanese female with no significant medical history presented to our hospital with a right breast ulcer with foul odor and bleeding in August 2015. She initially became aware of her breast lump in the summer of 2014, and the lesion started bleeding at the beginning of 2015. However, she did not recognize the seriousness of her symptoms, and delayed her first medical consultation for approximately 1 year. Pathological examination of the lesion confirmed a diagnosis of invasive breast cancer, and extensive imaging studies revealed multiple metastases of ipsilateral lymph node, lung, liver, and bone. She was clinically diagnosed with stage IV disease.\nThe patient originally lived with her mother, brother, and sister in Odaka District. Due to evacuation orders following the FDNPP accident, she relocated to a relative's residence 200 km away from the district, together with her brother and mother, while her sister evacuated separately from them. Although the patient moved back to Minamisoma City by herself in the middle of 2014, the mandatory evacuation orders issued to Odaka District continued to be in effect, and she began residing alone in one of the temporary housing shelters for evacuees built in the habitable zone of Minamisoma City. She reported that she did not frequently talk about her health concerns to her family or friends at this time, although she remained in general contact with them.\nDespite inception of chemotherapy in September 2015, her general condition gradually deteriorated. In October 2016, she slipped and hit her pelvis on the floor, and became incapable of standing up. As a result, she was hospitalized. Although computed tomography (CT) did not reveal any fractures in her pelvis or right femur, she continued to be bedridden due to persistent pain, possibly caused by the metastatic lesion in her right femur, which was simultaneously detected by the CT. Her chemotherapy was discontinued. Although she disclosed her wish to die at home in November 2016, this appeared challenging to achieve because she was still residing alone in the confined conditions of the temporary housing shelter.\nOur team then contacted her sister, who lived apart from the patient, and explained the necessity of family caregiving to enable her wish for palliative homecare.\nAs a result, the sister decided to not only live together with the patient, but also return to their prior residence in Odaka District. Although her condition had further deteriorated at the time of her discharge in December 2016, the patient did not report any concerns about moving back to her homeland.\nA multidisciplinary team in our hospital, consisting of a home doctor, nurses, and a community health worker, provided her with health and social services (eg, rental service of nursing care bed) in Odaka District, where there were still no hospitals operating full-time since the disaster. In the course of palliative care management, we carefully listened to her sister, who was the primary caregiver for the patient, at every home visit, and gave her psychological support, and information about illness and services available to her. The patient did not make a single ER visit or hospital transfer, and died in January 2017 at her original residence in Odaka District. Bereavement support was not provided to the family members, including the patient's sister. |
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