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A case of a 16 year old female patient who suffered from first grade open multi-fragment fracture of the tibia (AO42-C2) due to a complicated horseback riding accident is presented in this case report.\nOn admission the patient had extensive soft tissue swelling and a first grade open fracture was detected. Initial radiological assessment showed a multi-fragmentary tibia shaft fracture (AO42-C2) with a long intermediate segment (). We decided in favor of temporary external fracture fixation concept due to the extensive soft tissue swelling. Intraoperative we encountered some difficulties achieving a satisfactory alignment of the bone due to a hypermobility of the intermediate segment, however because of the extensive soft tissue swelling internal fixation was not feasible. In the end a satisfactory alignment and reduction could be achieved by an extended position of the lower limp and application of longitudinal traction. Postoperative the patient was treated with strict confinement to bed and additional physical treatments like RICE (rest, ice, compression, elevation) in order to prevent further soft tissue swelling. There was no evidence of a compartment syndrome.\nIt is inherent to the system that external fixation of the hypermobile intermediate fragment is difficult and despite complete immobilization the postoperative radiological assessment showed a secondary dislocation of the hypermobile fragment (). Coherently we encountered insufficient detumescence; therefore we decided to an early change of procedure. In respect of the difficulties encountered during the first surgery we decided in favor of intramedullary nailing of the tibia, to minimize the risk of malunion or deformity in our female patient we utilized the suprapatellar approach.\nThe patient was positioned supine on the radiolucent table. First the external fixator was removed while maintaining axial tension on the injured leg. Hereafter the knee was positioned in an extended position on a sterile pillow and subsequently the knee was flexed approximately 15° (). Then the image intensifier was positioned so that visualization of the knee and tibia including the articular surface of the proximal tibia in both AP and lateral views were possible. Afterwards a 2 cm longitudinal skin incision about 3 cm proximal to the superior pole of the patella was made () and followed by a deep incision of the quadriceps tendon, longitudinal just above the superior pole of the patella. The knee was entered through the suprapatellar pouch. Blunt dissection was used to loosen the patella in order to facilitate placement of the protection sleeve. To achieve optimal alignment especially in proximal and metaphyseal fractures of the tibia it is important to accomplish an ideal positioning of the nail by choosing the right entry point. Hereafter the handle (consisting of the handle, outer protection sleeve and inner trocar) was carefully inserted into the joint by gliding through the femoropatellar groove (). After reaching the tibia the trocar was removed and the centering sleeve inserted. Before placing the guide wire optimal positioning of the centering sleeve in accordance with the entry point was confirmed through the image intensifier (). Now the guide wire was inserted about 10 cm intramedullary under imaging in both AP and lateral views. Afterwards the handle was temporarily fixated onto the femoral condyles using a guide wire (). Then the drill bit was placed over the guide wire and the intramedullary canal was opened. Now a reaming rod replaced the guide wire and subsequently the fragments of the multifragmentary fracture were aligned onto the reaming rod. Optimal placement of the reaming rod in the distal tibia was confirmed under imaging (). The nail was placed over the reaming rod and inserted in semiextended position (15° flexion of the knee). However the radiological control showed an apex anterior malreduction. Therefore a temporary Poller wire was utilized while aligning the fracture as supplementary procedure in order to achieve satisfactory alignment of the bone (), now accomplishing a good alignment of the fracture and achieving optimal fracture treatment. Blocking screws were applied in the proximal and distal end of the nail. Reduction and fixation were confirmed both radiologically and clinically ().\nPostoperatively our patient was treated with partial weight bearing of 20 kg for 6 weeks. The would healing was regular and timely and follow-up for clinical and radiological assessment was scheduled at 6 weeks, 3 months and 6 months postoperatively. Pain free weight bearing of 20 kilograms was achieved 6 weeks after the surgical treatment and gradually increase of the weight bearing was allowed. No signs of both pain during increased weight-bearing occurred and anterior knee pain were detected at any time. Full weight bearing and physiological range of motion was reached 10 weeks after the surgery. Radiological assessment showed proper consolidation of the fracture (). A full recovery and resumption of regular activities of the daily life and sport was accomplished 4 months after surgery.\nWe recommend to place a sterile pillow under the knee to achieve a flexion of approximately 10-15° in order to get a perfect exposure of the suprapatellar entry. From there on no further movement of the lower leg during nailing is necessary.\nDuring the incision it is important to split the quadriceps tendon in midsubstance. Afterwards use your finger to carefully feel for the retropatellar nook in order to be sure to be inside the femoropatellar joint.\nIt is important, once inside the joint, to just use careful blunt dissection in order to avoid damage to the cartilage.\nIn order to avoid damage to the cartilage it is important to carefully insert the handle into the joint by gliding through the femoropatellar groove () until it reaches the tibia. A solid connection between the handle and the tibia has to be confirmed through the image intensifier (lateral view).\nOnce placing the guide wire it is important to know that the centering sleeve has a concentrical and excentrical option. If the first placement of the guide wire through the concentrical option is not perfect than you can use the excentrical option to place a second guide wire in the optimal position and afterwards remove the initial guide wire.\nIt is important to accomplish an ideal positioning of the nail by choosing the right entry point which is in line with the axis of the intramedullary canal and with the lateral tubercule of the intercondylar eminence (AP view) as well as at the ventral edge of the tibial plateau (lateral view)().\nDuring reaming in preparation for the intramedullary nailing it is important to minimize the risk of secondary damage to the cartilage by connecting the suction to the protection sleeve to prevent reaming material from entering the joint.\nBefore definite placement of the nail it is important to remove the handle.\nPoller screws or Poller wires are helpful and often necessary tools during reposition and reduction of metaphyseal tibia and femur fractures. |
A 38-year-old male, an agricultural laborer by occupation, presented to us with a history of multiple warts (verruca vulgaris) all over his body for the past 25 years and a recent increase in the size of four, cauliflower like hyperkeratotic fleshy lesions; the first, arising from the skin of the right post-auricular region measuring 6 × 3 cm; the second from the right parietal region of the scalp measuring 8 × 6 cm; the third lesion 4 × 2 cm in the vertex of the scalp 2 cm medial to the second lesion; and the fourth, a 5 × 3 cm lesion in the left temporal region of the scalp []. He was a diabetic (type 2) controlled on oral hypoglycemic drugs and was seropositive to hepatitis B surface antigen, but was otherwise well-preserved. He had attempted various native topical remedies for the same, despite which the lesions continued to progressively increase and worsen over the past 10 months, with associated foul smelling discharge and occasional bleeding episodes. There were multiple warts of various sizes and shapes scattered all over his body, predominantly involving his trunk, palmoplantar regions, and genitalia which had been static over time. There was no significant cervical adenopathy. He has no significant past medical or family history. A computed tomography (CT) scan of the head and neck revealed the extent of the lesions and also found all four of them to be confined to the skin of the scalp []. The patient was taken up for a wide excision of all the four lesions of the scalp lesions after a biopsy confirmation of VC. The extensive skin defects following the wide excision were reconstructed with large split skin grafts. Despite a macroscopic clear margin of 0.8-1 cm, the final histopathology of the right parietal lesion and the left temporal region lesions showed microscopic tumor to be extending up to the resected margins. The tumor cells were found to be positive for HPV infection as was confirmed by polymerase chain reaction (PCR) and by immune-positivity to p16 [Figure –]. The patient refused a repeat surgery and was hence offered adjuvant radiotherapy for better local control. He received 60 Grey of external beam radiotherapy to the entire scalp using intensity-modulated radiotherapy technique. He tolerated the treatment well with dramatic resolution the warty lesions as well [] and continues to be disease free for close to 2 years following completion of treatment. |
An Indian girl, 12 years old, was referred to Department of Pedodontics and Preventive Dentistry of Dental College, for inspection of a painless swelling in the mandibular left primary molar region since 6 months. Past dental history revealed that she had undergone incomplete endodontic treatment with the same tooth a year ago. Her oral hygiene was good and was overall in good health. Extraoral examination revealed, a diffuse, bony nontender swelling on left side of jaw extending from corner of mouth to angle of mandible. While, intraoral examination revealed a grossly carious and mobile left primary second molar tooth (). Panaromic radiograph showed a round unilocular radiolucent lesion, 1.8 × 2 cm in diameter, below the left second primary molar (), displacing the successive permanent second premolar apically. A closer examination of the radiograph revealed that the border of the lesion appeared corticated and was smooth and well-defined. Occlusal radiograph revealed buccal cortical plate expansion extending from distal aspect of permanent mandibular left lateral incisor to mesial aspect of permanent mandibular left second molar and revealed an interesting finding that the successive premolar was displaced and aligned buccolingually in the cystic cavity ().\nFrom history and clinical examination a provisional diagnosis of radicular cyst associated with them andibular left primary second molar was made which could be due to either secondary caries or the medicament used duri ng endodontic treatment. Differential diagnosis included periapical granuloma or dentigerous cyst.\nPrimary left second molar was extracted under local anesthesia and cystic cavity was exposed. Cystic lining was removed as much as was accessible and sent for histopathological examination (). The successive permanent second premolar was also extracted because of its improper alignment. After thorough curettage of cystic lining, the premolar was placed back into the cystic bony cavity with proper alignment and a primary closure was attempted following debridement and hemostasis. During the entire procedure, care was taken to handle the periodontal surface as gently as possible with frequent immersion in normal saline solution. Surgical exploration confirmed that the cyst was not associated with permanent tooth. Postsurgical period was uneventful and short band and loop space maintainer was given after removal of the sutures to maintain the space ().\nHistopathological features were consistent with provisional diagnosis of radicular cyst. Histological examination revealed the cystic cavity to be lined by a nonkeratinized stratified squamous epithelium with mixed Inflammatory infiltration. The patient returned once every 3 months for regular checkup. At 6 months follow-up, tooth had almost aligned vertically and was on the path of eruption (). At 18 months postsurgery, the OPG revealed good amount of bone formation (). The patient is on a regular follow-up. |
A 24-year-old male presented to the hospital with multiple episodes of hemoptysis for 24 hours. He had no significant past medical history. CT scan of the chest showed multiple pulmonary nodules with the largest lesions in the right upper lobe of the lung and right hilum (Figure ). A bronchoscopy and biopsy of the hilar lymph node showed a necrotic focus of metastatic choriocarcinoma. Beta human chorionic gonadotropin (hCG) in the blood was 12,431 mIU/ml (reference range for males <15 mIU/ml). CT scan of the abdomen also showed multiple soft tissue lesions in the mesentery but no testicular or retroperitoneal masses. The primary site of the tumor was elusive; an ultrasound and MRI of the scrotum also did not reveal any masses. Upon further inquiry, the patient mentioned he had noted swelling in his right testicle a few weeks prior to the presentation which he believed was from intense work-out that he is required to do as a part of his job, and did not seek care for it since it was not painful and resolved in a few days on its own. Two days into his admission he developed a severe headache and intractable vomiting; an MRI of the brain showed multiple enhancing metastases throughout the brain (Figure ). He was started on combination chemotherapy regimen with bleomycin, etoposide, and cisplatin (BEP) and also underwent a short course of whole-brain radiation therapy. With each cycle of chemotherapy, he would have a good response with beta hCG trending down immediately following the chemotherapy, but it would rise in the time his next cycle was due. Considering the laggard response in beta hCG, he also underwent right orchiectomy to possibly eliminate the sanctuary site. Pathology of the right testicle showed a 5 mm focus of fibrosis but did not show any evidence of the tumor. Imaging after four cycles of BEP chemotherapy did show some response, but he continued to have a heavy burden of disease. He was being considered for high-dose chemotherapy with rescue autologous stem cell transplantation, but before this could be set up, his disease progressed rapidly with beta hCG reaching 32,784 mIU/ml. He was started on second-line chemotherapy with paclitaxel, ifosfamide, and cisplatin. Unfortunately, while undergoing this regimen he had a massive pulmonary hemorrhage leading to acute respiratory distress syndrome (ARDS), and eight months after his diagnosis, he died from complications of his disease. |
A 52-year-old male, chronic alcoholic and smoker presented to the emergency department with acute abdominal pain. The serum amylase level was elevated and a diagnosis of acute pancreatitis was made. The patient was managed conservatively and was satisfactorily discharged after a two week-stay in hospital. The patient developed abdominal pain again after 2 months and presented to the outpatient department at another institute where a diagnosis of acute on chronic pancreatitis was made. The patient was referred and when he presented to us he was ambulatory and complained primarily of vague upper abdominal pain with no signs of peritonitis. He also complained of occasional episodes of vomiting and weight loss. He was carrying a report of an endoscopic ultrasound (EUS) done elsewhere, films of which were not available. The EUS report showed a 3×3 cm pseudocyst in the region of neck of pancreas with possible communication with dilated main pancreatic duct (MPD). The pseudocyst was compressing the distal common bile duct (CBD) causing moderate biliary dilation. At our institution, he was further evaluated with a transabdominal USG and a contrast enhanced CT (CECT) to look for the severity and extent of disease. The USG () showed the portal vein as anechoic but with no color flow within and also showed communication between the cyst and portal vein. The CECT showed the pseudocyst () in the pancreatic neck and completely thrombosed portal vein and its branches () which was misinterpreted as dilated CBD on EUS. There were multiple periportal collaterals and areas of necrosis in segment V and VII of liver which showed subtle peripheral enhancement and were considered as cholangiolar abscesses. There was suggestion of communication of the pseudocyst with the MPD.\nMRI was performed to investigate a possible communication of the pseudocyst with the MPD and to further characterize the liver lesions. It showed the pseudocyst at the neck of the pancreas with communication with the dilated MPD. The cyst was seen just above the spleno-portal confluence with a defect in the posterior wall and a possible direct communication with the portal vein. The portal vein showed a signal characteristic consistent with fluid i.e. homogenously hyperintense on T2-weighted imaging and hypointense on T1-weighted imaging. There was some plaque-like material along the wall of the main portal vein and its branches which showed hyperintense signal on T1-weighted imaging and hypointense on T2-weighted imaging (, ). On post contrast images there was no opacification of the portal vein (). These features did not correlate with the expected signal character of the thrombus but rather confirmed the presence of fluid within the portal vein similar to that in the pseudocyst with the plaque-like material along the wall showing the character of residual lysed thrombus. There were non-enhancing areas of necrosis in segments V and VII of the liver and thrombus in the distal part of the superior mesenteric vein and splenic vein. The CBD was normal in caliber and there was no intrahepatic biliary dilation. Thus a diagnosis of rupture of pancreatic pseudocyst into the portal vein with lyses of the portal vein thrombus and associated liver necrosis was made. The MRI findings suggested this diagnosis thus obviating the need of any invasive diagnostic modality. Since the main complaint of the patient was generalized abdominal pain and distention which was well controlled with regular medication, a decision to continue with conservative treatment was taken and the patient was kept on close follow up and review. The patient did well thereafter with no significant increase or development of complaints on 6-month follow up. The patient is still on regular follow up and doing well. |
A 34-year-old female who has no previous clinical illness presented in 2000 with a large irregular mass, estimated clinically to be around 5 × 6 cm by physical examination, involving the right breast while she was lactating. There were no other signs or symptoms. FNA was done to rule out breast cancer, and the specimen showed few foamy macrophages and rare clusters of ductal cells, with focal secretory lactational changes. Based on that, it was determined that the specimen was negative for malignancy. The tumor continued to grow, and in June 2004, FNA of the right breast was repeated and showed large staghorn-shaped sheets of uniform ductal cells with no cytologic atypia along with myoepithelial cells. There were fragments of fibrotic stroma and bare nuclei scattered in a bloody background, and so, a diagnosis of fibroadenoma was made. Two months later, the patient underwent excision of the tumor in another healthcare facility. Examination of the slides showed an overgrowth of epithelial and stromal components in pericanalicular and intracanalicular patterns with irregular large cystic spaces showing protruding leaf-like structures (). The stromal cells showed plump elongated slightly dysmorphic nuclei with occasional prominent nucleoli. Other areas showed significant cellular growth of the stromal spindle cells which appeared to be arranged in long intersecting fascicles and growing in herringbone pattern (). Within the spindle cell growth, extracellular mucin was noted. One focus showed an exclusive spindle cell growth which was moderately atypical with plump elongated hyperchromatic nuclei. Numerous mitosis was found, up to 20 in 10 high power fields in this focus. Entrapped epithelial ductal elements were occasionally seen in other areas exhibiting ductal epithelial hyperplasia. These features were consistent with malignant phyllodes tumor with stromal fibrosarcomatous overgrowth. The patient subsequently underwent mastectomy as the margins were focally involved. During the procedure, a mass measuring around 3-4 cm was found in the most posterior aspect of the breast and there was some indication that it may have invaded the pectoralis major muscle. All the breast tissue, the tumor, and some of the muscle fibers were removed. On gross examination, there were multiple tumor masses in the inner lower and outer upper quadrants, the largest being 3 cm. On microscopy, there was proliferation of atypical spindle and elongated plump cells with pleomorphic nuclei and occasional prominent nucleoli. Extracellular mucin was also identified. The atypical stromal cells formed herringbone fascicular growth pattern reminiscent to fibrosarcoma and numerous mitosis averaging around 14 mitosis in 10 high power fields. No residual phyllodes tumor elements were identified. The tumor nodules had a well-demarcated margin with focal infiltration of surrounding breast and adipose tissue. No lymphovascular invasion, necrosis, or heterologous differentiation was seen. All surgical margins and muscle fibers were not involved by the tumor. The skin and nipple did not show any involvement either. All these histological features were identical to those identified in her previous lumpectomy except that there was more pronounced atypia and no residual epithelial component of phyllodes tumor identified. No lymph nodes were identified. A year later, the patient began to suffer from acute bouts of pancreatitis and was admitted several times for this. In March of 2006, abdominal CT was performed and showed a heterogenous low attenuation soft tissue mass involving the head and body of the pancreas and was extending upwards. The celiac vessels and its branches were going through this mass but did not show any significant narrowing. There was obvious atrophy of the pancreatic tail and dilatation of the pancreatic duct. The mass was in contact with the anterior aspect of the inferior vena cava (IVC) with no clear fat plane in between (). Biopsy of the pancreatic mass showed uniform proliferation of elongated spindly cells which had coarse chromatin and mild to moderate nuclear pleomorphism. Some cells had plump hyperchromatic nuclei. Numerous mitotic figures were identified (). The background showed variable amounts of collagen and stroma with focal areas of myxoid appearance. Immunohistochemical staining showed strong positivity for vimentin; however, the cells were negative for actin, S100, and cytokeratin (). These findings were consistent with metastatic fibrosarcoma of the pancreas secondary to her primary breast lesion. Due to the location, extent, and nature of the condition, the case was deemed unresectable. Chemotherapy was initiated; and in the little chance that the tumor shrunk enough, the possibility of resecting the metastasis would be entertained. In January 2007, the patient presented to the ER with severe epigastric pain, where she collapsed, was hypotensive, and subsequently admitted. On examination, a tender mass in the epigastric area was felt. Urgent CT of the abdomen and pelvis with and without contrast showed a pseudoaneurysm in the splenic artery measuring around 3.5 cm. There was also expansion of the retroperitoneal mass and blood in the intraperitoneal cavity. There was heterogenous enhancement in the liver most probably indicating liver infarct. In addition, there were areas of the IVC which had markedly thinned wall and areas suspicious for active bleeding, especially from the proximal splenic artery (). The pancreatic fibrosarcoma had grown and eroded branches of the celiac artery with bleeding pseudoaneurysm along with infarct of the liver, spleen, and adjacent organs. The patient continued to be hypotensive with abdominal distention due to severe intra-abdominal bleeding and developed multiorgan failure and hemorrhagic shock leading to her death. |
A 58-year-old man presented with paralysis and pain in the left leg, and a mass was found in his thigh. Because of the growth of the mass and the worsening of his symptoms, the patient visited a neighboring hospital. Computed tomography confirmed the presence of a femoral arterial aneurysm. He visited our hospital for more detailed examinations and medical treatment. Physical examination revealed a pulsatile mass with a diameter of 8 cm in the left thigh. The patient had no history of trauma, previous operations or interventions. He had medication-controlled hypertension. Multidetector computed tomography performed in our hospital revealed a large DFA aneurysm with an intraluminal thrombus (Fig. ). An image diagnosis of a DFA aneurysm was made. There was no evidence of aneurysms or occlusive lesions in the other arteries. Surgical intervention was planned because of the large size of the aneurysm, the high risk of perforation and the worsening symptoms.\nThe surgery was performed through a longitudinal groin incision. The sartorius muscle was preserved by splitting it along the muscle fibers. The DFA aneurysm was 5 × 10 cm in size. The proximal neck of the aneurysm was isolated 2 cm distal to the bifurcation. The deep femoral vein was found to be adhered firmly to the aneurysm. The common femoral artery, superficial femoral artery, superficial femoral vein and deep femoral vein were recognized and preserved (Fig. a). After clamping the DFA proximal and distal to the aneurysm, we opened the sac and found a massive thrombus. Aneurysmectomy and revascularization of the distal DFA with an artificial blood vessel graft were performed (Fig. b). The operation lasted for 416 min, and the operative bleeding was 690 ml. Pathological examination of the specimen revealed atherosclerosis in the vascular wall and confirmed that it was a true aneurysm.\nFollowing surgery, the patient's symptoms improved gradually. A follow-up multidetector computed tomography scan showed good blood flow in the graft, superficial femoral artery and popliteal artery (Fig. ). The patient had an uneventful postoperative recovery and was discharged without complications. |
A 50-year-old man had a history of an operation for lumbar herniated disc at the age of 37 and hypertension since the age of 42 that was controlled with medication. He visited a nearby clinic because of epigastric pain and dysphagia that started 3 months earlier. He was referred to our hospital because of gastroscopic findings of extrinsic compression.\nThe initial physical examination revealed normal heart and lung sounds, a flat and soft abdomen, and no tenderness on palpation. No superficial lymph nodes were palpable. Hematological and biochemical findings were normal. Gastroscopy performed at our hospital revealed a submucosal tumor with a smooth surface at the 9 o'clock position in the lower esophagus (). Barium esophagogram showed extrinsic compression from the lower esophagus to the gastroesophageal junction (). Good expansion and smooth mucosa were noted. Endoscopic ultrasonography showed a cystic mass in the esophageal wall extending from the lower esophagus to the cardiac region of the stomach (), with the suspected presence of viscous fluid inside the cyst. Computed tomography (CT) showed an iso-enhanced dumbbell-shaped mass (3.5 × 3 cm) with a smooth surface and homogeneous content, which extended from the lower thoracic esophagus to the cardiac region of the stomach (). Magnetic resonance imaging showed a mass that was hyperintense and moderately hyperintense on T1- and T2-weighted imaging, respectively, with and without fat suppression (). Although gastrointestinal stromal tumor and leiomyoma were also suspected, the patient was diagnosed as having EDC based on imaging findings and underwent laparoscopic resection.\nIntraoperatively, the mass was soft and elastic and had a smooth surface in the lesser curvature of the stomach near the cardiac region and along the esophagus when approached from the mediastinum by partially dissecting the crus of the diaphragm. The mass was carefully resected along the esophagus in the abdominal cavity toward the mediastinum. At the resection site, normal mucosa was left in some areas, but in other areas resection extended through all layers. Using a 3-0 synthetic absorbable suture, the surgical site was closed under intraoperative esophagoscopic observation to ensure proper closure and prevent esophageal stricture due to suturing. Cystic fluid in the resected specimen was mucous and reddish brown, with no cellular components (). Histopathological findings revealed that the cyst consisted of two layers of smooth muscle and the inside of the cavity was lined with pseudostratified columnar epithelium (). These findings, with no evidence of malignancy, led to the definitive diagnosis of EDC. The postoperative course was unremarkable, and the patient resumed a normal diet on postoperative day 4 and was discharged on postoperative day 10. |
A 30-year-old man sustained an anterior dislocation of the right shoulder along with a GT fracture () in the last week of April 2020 after being hit on the shoulder by a stick in a local street fight in a town located 150 kilometers from the main city. This region was served by general primary physicians in primary health services who are only equipped to treat common diseases; as a result, the local doctors provided the patient with a sling, no X-ray imaging or further management for the dislocation was performed. The patient was unable to travel because of the lockdown restrictions and sought our opinion only after a delay of 3 months with symptoms of severe pain with a visual analog scale (VAS) score of 8 points (out of a maximum of 10 points) and restricted use of the affected limb. His functional ability to use the injured limb was limited because he had severe pain and a restricted shoulder range of motion of −10° of external rotation, L4 vertebral level of internal rotation, and 50° of forward flexion. Computed tomography imaging did not reveal any glenoid bone loss. He was operated on after his COVID-19 status was confirmed to be negative under full personal protective equipment precautions as was the protocol for all surgeries. He underwent open reduction through a deltopectoral approach. During surgery, the following difficulties were encountered: (1) reduction of the GT was not possible without debulking the lateral part of the proximal metaphysis of the proximal humerus as ossification and fibrosis restricted the anterior reduction of the GT and (2) the lesser tuberosity (LT) was not visible even with a medial retraction of the conjoint tendon because of severe medial displacement of the proximal humerus. Hence, a coracoid osteotomy was performed that enabled the conjoint tendon to be retracted further medially and allowed the exposure of the LT and the attached subscapularis. The entire subscapularis had to be detached (later repaired) to allow the reduction of the humeral head to the glenoid. We also released the posterior capsule from the glenoid in order to reduce the head on the glenoid. However, the head kept slipping out anteriorly with even the slightest of rotation of the arm and was found to be unstable because of the severe contractures. Ultimately, the chronicity of the neglected dislocation resulted in severe contractures around the head; hence, two K-wires were used to fix the acromion to the humeral head () in order to keep the humeral head stable in the glenoid cavity. The GT was dissected from the surrounding fibrosis and fixed to the humerus with the help of suture anchors. The neglected status of the injury led to an increased surgery duration (3.5 hours) because extensive capsular release, entire subscapularis release, proximal metaphysis debulking to reduce the GT, and K-wire fixation to stabilize the head were required. There were also two instances of uncontrolled bleeding that necessitated packing the wound for 15 minutes until the bleeding subsided. The coracoid tip that had been osteotomized was reattached to its base with the help of cerclage sutures through the tip and the remaining coracoid bone. Postoperatively, there was no neurovascular deficit or any other complication, and both the K-wires were removed at 4 weeks. This case was more complicated than the other case (case no. 2) of neglected shoulder dislocation because the displaced GT fracture resulted in a loss of lateral restraining forces on the humeral head, causing it to displace far too medially. The patient’s pain (VAS score) and external rotation improved from 8 points and −10° preoperatively to 3 points and 55° at 6 months of follow-up. Further, the forward flexion increased from 50° preoperatively to 80° at 6 months of follow-up, and internal rotation improved from L4 to the T12 vertebral level. The 6-month follow-up X-ray showed persistent subluxation of the humeral head ( and ), and the patient reported mild pain (VAS score 2/10). |
A 21-year-old man developed right lower quadrant pain, nausea, and a single episode of vomiting after an otherwise uneventful jump off the back of a pickup truck. The pain and nausea spontaneously resolved with rest. In the days following, an intermittent, spontaneously resolving, right inguinal bulge was reported with associated nausea and radiating pain into the right scrotum. There was no scrotal swelling or skin changes. The patient has no prior abdominal surgeries and their medical history was unremarkable.\nThe patient presented a week after the initial incident to a local emergency room after repeated episodes. Hernia was initially suspected but ruled out by multiple surgeons and a radiologist after an unimpressive abdominal/genital exam and negative CT imaging with IV/enteric contrast and negative Valsalva. The patient was diagnosed with a musculoskeletal injury to the lower abdomen, prescribed conservative management, and advised to follow up with primary care if no improvement was noted.\nInguinal and scrotal sonography were performed prior to the subsequent primary care visit with no evidence of inguinal hernia and other unimpressive findings. The patient had mild increased fullness to the right inguinal region, but significant tenderness limited comprehensive examination. A repeat CT was ordered, with instructions to the patient and the radiology staff to have the patient perform 30 mins of physical activity to achieve reported changes prior to image acquisition. Patient reported difficulty achieving adequate changes at imaging and the interpretation was again unimpressive for herniation or any soft tissue bulge.\nThe patient was instructed on specifics to acquire adequate dichotomy images of before and after aerobic activity. General Surgery was again notified with the patient provided images, which were deemed sufficient to pursue exploratory inguinotomy (Figures -). Intraoperatively the patient had an indirect inguinal hernia sac and was diagnosed with a communicating inguinal hydrocele. The sack was removed and the defect repaired 12 weeks after initial presentation. The patient recovered well and returned to normal activity four weeks postoperatively with a relief of symptoms. |
A 48-year-old woman was admitted to our hospital with a mass in the pelvic space that was detected on abdominal ultrasonography (US). She had no past or family history of note. She had mild numbness in the right leg. Enhanced abdominal computed tomography (CT) revealed a 65 × 50 mm, solid, well-defined, heterogeneous mass in the right lateral pelvis space (). Magnetic resonance imaging of the tumor revealed heterogeneous hyperintensity on T2-weighted images (). The preoperative diagnosis was a gastrointestinal stromal tumor or a neurogenic tumor in the right lateral pelvic space. We performed laparoscopic extirpation of the tumor as follows.\nWe placed the patient in the lithotomy position under general anesthesia and inserted a ureter stent into the right ureter to prevent intraoperative injury. Next, we placed a 12 mm trocar with camera at the umbilicus using the open method. We then placed four 5 mm trocars at the bilateral upper and lower quadrants. The camera showed that the mass lesion (approximately 70 mm in diameter) covered the retroperitoneum in the right lateral pelvic space. We divided the right ureter and exposed the external iliac artery and vein. The tumor was located close to the right internal iliac artery and vein. We carefully isolated the tumor from the surrounding tissue using a THUNDERBEAT handheld system (Olympus Corporation, Japan). We dissected the obturator artery and vein to secure the surgical field. We resected the branches of the internal iliac vein as they were firmly adhered to the tumor. We carefully dissected the tumor from the surrounding tissues using both sharp and blunt maneuvers. The tumor was located at the dorsal side of the right sciatic nerve and was firmly adhered to the nerve (). We suspected the mass to be a neurogenic tumor arising from the right sciatic nerve. The tumor was carefully isolated from the right sciatic nerve and freed from the surrounding tissues. We enlarged the umbilical incision to 4 cm and inserted a Smart Retractor (TOP Corporation, Japan). We removed the tumor through the enlarged incision covered by the Smart Retractor. No spillage occurred. After complete extirpation of the tumor, we preserved the right sciatic nerve in the right lateral pelvic space (). Finally, we inserted a drain into the pouch of Douglas. The total operative time was 330 min, and total blood loss was 126 mL.\nOn inspection, the specimen was a firm, elastic, 70 × 50 mm mass with a capsule (). In section, the mass was yellow and white in color, with a solid consistency. Pathological examination showed a fibrous capsule and a palisade arrangement of spindle-shaped cells originating from the Schwann cells (). We observed extensive degenerative change in the tumor. We made a pathological diagnosis of benign schwannoma.\nThe patient recovered well, but mild sciatic nerve palsy of right foot remained. She has continued rehabilitation training with a therapeutic orthosis. |
Patient A. M. R. 22-year-old, leukoderma, female, attended the Dental Polyclinic with referral for evaluation of possible lesion in a mandibular body region, left side, identified by radiographic examination of the jaws. The patient reports that she had been undergoing orthodontic treatment for about 3 years. The patient agreed to submit to the appointments and norms of the institution through the informed consent term.\nDuring the anamnesis, the patient did not present any changes in the systems revision or underlying disease. She also did not report any painful symptomatology or phlogistic sign in the lesion region, denying any previous surgical intervention at the site. On an extraoral physical examination, there was a slight facial asymmetry in the lower third of the face. On intraoral physical examination, there was a slight volume increase on the left side region of the mandibular body and angle, suggesting expansion of the cortical bone. Absence of oral mucosal continuity solution was observed as well as other alterations.\nComputed tomography (CT) scanning revealed a hypodense multilocular lesion in the left mandibular body (first molar region), compromising the mandibular ramus, and extending the mandible head region and coronoid process on the same side [].\nAn incisional biopsy of the lesion was performed, in which a descriptive report of central lesion of giant cells was obtained. The microscopic report of the incisional biopsy indicated that histological sections stained by hematoxylin and eosin showed areas constituted by vascular proliferation in a loose stroma amid the presence of chronic inflammatory infiltrate with predominance of plasma cells and the presence of multinucleated giant cells with nuclei arranged in an orderly fashion peripherally and others with central nuclei [].\nTo conclude the diagnosis, the patient underwent complementary laboratory tests to distinguish histopathologically similar pathologies similar to CGCL.\nDue to the size of the lesion, the age of the patient, morbidity, possible damages to nearby noble structures and economic factors, a less invasive treatment was chosen when compared to the bone resection.\nAccording to the protocol proposed by Terry and Jacoway, the conservative treatment was based on intralesional injections of triamcinolone (10 mg/ml) associated with lidocaine 2% and epinephrine 1:200,000. The infiltrations were 2 ml of solution every 2 cm of radiolucency of the lesion.[] Weekly applications were carried out for 6 consecutive weeks, once a week.\nAfter 5 months, new imaging tests were performed, where the lesion reduction was observed, almost in its entirety [].\nAfter 4 years of therapy, there was an increase in bone density in the region, with total remission of the lesion and absence of clinical and radiographic signs of relapse []. |
A 61 year old Caucasian male was transferred from an outside facility for respiratory failure and acute renal failure. On arrival, the patient had been intubated at the outside facility so he was moved to the intensive care unit. Two days after admission, hemoptysis was noted from the patient’s endotracheal (ET) tube. A computed tomography (CT) scan of the chest was performed and demonstrated a left upper lobe bronchial obstruction with associated atelectasis, bilateral pleural effusions and mediastinal lymphadenopathy (LAD). The obstruction at the time was assumed to be related to an endobronchial malignancy due to fullness of the hilum per radiology. A bronchoscopy was performed the next day. This documented an endobronchial mass in the posterior segment of the right upper lobe, a mass obliterating the entire orifice of the posterior left upper lobe with active bleeding. Biopsies were obtained from the lung masses as well as bronchial washings from both lungs. Pathology revealed a non-small cell lung carcinoma (NSCLC) with squamous cell type from the right upper lobe biopsy and atypical squamous metaplastic mucosa with fibrin material from the left upper lobe biopsy.\nOne week later, the patient underwent a video-assisted thoracoscopic surgery (VATS) procedure with pleural stripping and drainage of the right sided effusion to check for a source of malignancy. Cytology of the effusion was negative for any malignant cells. Pleural biopsy demonstrated fibrinopurulent exudate, marked inflammation, necrosis and hemorrhage without any evidence of malignancy.\nCT scans of the abdomen, pelvis and head were performed for staging of disease. A chronic, left atrophic kidney was found but otherwise scans were negative for malignancy. A bone scan was also performed and was negative for metastatic lesions.\nHe was extubated successfully and continued on hemodialysis for his renal failure thought to be related to hypotension and one working kidney. At discharge, he was transferred to a rehabilitation facility with an appointment for a local oncologist near his home to begin treatment.\nApproximately one month after discharge, he returned to our hospital for hemoptysis. A repeat CT scan of the chest was done and showed no change in the size of the mass documented in the left upper lobe but did show improvement in the consolidation and atelectasis documented two months prior. It also revealed gynecomastia of the right breast without obvious masses. The patient had a biopsy by interventional radiology (IR) of the lingula. Pathology showed a non-small cell lung cancer of squamous cell type. After almost complete resolution of the patient’s hemoptysis, a bronchoscopy was repeated due to a positive biopsy of the right upper lobe on previous admission but no mass documented on CT scan of the chest. Repeat bronchoscopy demonstrated sharp carina, irregularity of the anterior segment of the right upper lobe, and abnormal mucosa of the left main bronchus towards the lingula. Biopsies were taken of the abnormal mucosa of the left upper lobe and bronchoalveolar lavage (BAL) was taken of the right upper lobe. An endoscopic bronchial ultrasound (EBUS) was performed as well and a biopsy was taken of an L4 lymph node that was enlarged on visualization. Pathology demonstrated non-small cell carcinoma squamous cell type of the biopsies of the left upper lobe irregularity and a negative cytology of the BAL from the right lung.\nThe patient was discharged home and had decided to continue further follow up with our office for treatment. Given the delay in treatment, a PET scan was ordered prior to beginning treatment. PET showed a left pulmonary hilar lesion with an SUV of 18.8 (), a right precarinal lymph node with calcification and SUV of 4, right breast retroareolar uptake with an SUV of 2.8 () and an atrophic left kidney. On questioning, the patient had complaints of a right breast mass for approximately one week. On examination, a mass could be felt in the right breast in the retroareolar region and was approximately 3 cm in size. Before treatment could begin for his lung cancer, a biopsy of this mass was obtained in IR. Pathology from this biopsy demonstrated a neuroendocrine carcinoma with a Nottingham score of 8 (glands = 3, nuclei = 2, mitoses = 3), grade III. The tumor consisted of sheets of crowded cells with hyperchromatic, pleomorphic nuclei with high nuclear cytoplasmic ratio (NC ratio), scant cytoplasm, easily seen mitoses (). Immunohistochemical staining results showed: CD56 - strong positive, synaptophysin - strong positive, p63 - moderately positive, nuclear, diffuse, CK5/6 - negative and TTF-1 - negative. These results were most consistent with a high grade small cell carcinoma of the breast. This biopsy was compared to the patient’s previous biopsies and there was no resemblance noted in any of the samples. No in-situ component was identified in the biopsy specimen. In light of the PET scan being negative for any other metastatic sites of disease, this was labeled as a primary small cell carcinoma of the right breast with a simultaneous diagnosis of Stage IV NSCLC of the lung.\nThe patient received radiation therapy (RT) to the right breast concurrently with chemotherapy using carboplatin and etoposide. He completed RT to the right breast in one month with a total dose of 5000 cGy and a tumor boost to the right breast of 1000 cGy in 5 days. Due to hemoptysis at presentation and recurrence at a future date, it was decided to give RT to the left upper lobe of the lung to prevent further and possible fatal hemoptysis. He completed this radiation in 56 days with a total dose of 6660 cGy. As of now, the patient has completed 5 cycles of carboplatin/etoposide and is doing well. CT scan of the chest has shown resolution of the breast mass and volume loss of the left upper lobe without malignancy or new disease. The breast mass has resolved on examination. |
A 45-year-old female presented with a painful swelling at the flexor aspect of forearm. In his history, she was aware of the swelling for 1 year, but the numbness was only present for the last 2 months. On clinical examination, there was a painful solid mass 3–4 cm in length, little sensitive to pressure, mobility restricted in both directions. Percussion over the mass produced a Tinel's like sensation along the median nerve. No history of significant trauma was recalled. The patient experienced mild numbness in the distribution of the median nerve in the palm, but no motor weakness or muscle atrophy was detected. No cutaneous pigmented lesions were found. The patient reported she first palpated a nodule 2 year ago that grew up very slowly to the current size, but becoming painful since last 2 months.\nAn ultrasound (US) examination revealed a 4 cm long, well-circumscribed mass in close proximity to the neurovascular bundle of the flexor aspect of the forearm. On MRI examination, lesion had a relatively homogenous low signal, slightly lower to the flexor tendon of forearm, on T1 images. On T1 fat-suppressed images, increased gadolinium enhancement was noticed at the periphery of the mass with a nonenhancing low signal central area. No peritumoral edema was present and a line of fat surrounded the tumor. Based on the long history of the patient, and the clinical, US, and MRI features, the diagnosis of a nerve sheath tumor arising from the median nerve was supported and the patient was scheduled for excisional biopsy.\nA longitudinal incision centered over the tumor bulk at the distal part of flexor aspect of forearm was performed []. The tumor was situated below the flexor tendon of forearm. The tumor had an eccentric position and was firmly attached to the median nerve. The decision to preserve the median nerve and perform a marginal tumor excision was undertaken. The epineurium was longitudinally incised and the soft tumor mass dissected from surrounding nerve fascicles [Figures and ]. The mass was encapsulated and removed totally []. Immediately postoperatively the patient not experienced any sensory loss and weakness of the muscles innervated by the median nerve.\nThe histopathology result demonstrated an ovoid tumor measuring 3.5 cm × 4 cm. The center of the mass was solid and firm. Histologically, the characteristic features include the presence of alternating Antoni A and Antoni B areas. Antoni A area is composed of spindle-shaped Schwann cells arranged in interlacing fascicles. There may be nuclear palisading. In between two compact rows of well aligned nuclei, the cell processes form eosinophilic Verocay bodies []. Mitotic figures may be present. Antoni B area consists of a loose meshwork of gelatinous and microcystic tissue. Large, irregularly spaced, thick-walled blood vessels are noted in Antoni B area. These may contain thrombus material in the lumina. Immunohistochemistry shows S-100 stain was positive. The final pathology report was consistent with schwannoma. At 6 months follow-up the wound is well healed with no pain upon palpation. The patient returned to full labor work as a farmer. |
A 74-year-old female known case of Type II diabetes mellitus, primary hypertension and deep venous thrombosis (DVT) of the left leg on tablet warfarin, was admitted to our hospital for the evaluation of upper gastrointestinal bleed. The patient had no complaints of any visual problems before this admission and had complaints of mild global headache on and off for the past 4–5 months. There was no history of sudden worsening of her headache associated with visual deterioration in the past. After 5 days of admission to the hospital, the patient complaints of rapidly worsening eyesight which was not associated with any change in the character of her headache.\nClinical and neurological evaluation revealed visual acuity of perception of hand movement in the left eye at 3 feet distance and only perception of light in the right eye. Pupils were bilaterally 04 mm and reacting to light. Rest of the systemic and neurological examination was unremarkable. Perimetry for visual field defects could not performed due to the poor visual acuity of the patient. The visual evoked potential was not recordable. Endocrinological evaluation did not reveal any hormonal disturbances.\nMultiplanar contrast enhanced MRI revealed approximately 30 mm × 25 mm × 24 mm mass lesion in the sellar and suprasellar region. This mass lesion was seem to displace the optic chiasm superiorly, and pituitary could not be separately visualized from the lesion []. There was no evidence of apoplexy on the MRI. Axial fluid-attenuated inversion recovery sequence revealed bilateral optic tract edema (right > left) []. No other abnormalities were noted on MRI.\nIn view of the rapid deterioration of the vision and MRI findings of bilateral optic tract edema, injection dexamethasone 4 mg IV QID was started for the patient and the patient was planned for trans nasal transsphenoidal excision of the tumor. Since the patient had deranged international normalized ratio (2.10), she could not be taken up for surgery immediately which carried a high risk of bleeding in the intra- and post-operative period. After 3 days of administration of injection dexamethasone, the patient had improvement in her vision. The patient was not willing for any surgical intervention because of her age, comorbidities, and significant risk of bleeding in her case because of the medications for DVT. She has been kept on follow-up for visual complaints. |
A 68-year-old Caucasian female patient presented in our Department with abdominal pain and a concomitant 15 kg weight loss over the past 6 months that was unintentional. The pain was mainly located in the epigastrium. She also had symptoms of dehydration, due to persistent postprandial vomiting, during these months. Her medical history included hypertension and diabetes mellitus. Her physical examination was normal and her blood results and an abdominal ultrasound were within normal range.\nOn admission, a nasogastric tube was inserted and the fluid and electrolyte balance was corrected by parenteric infusion of crystalloid fluids. Two days later, the patient was subjected to gastroscopy which showed mild inflammation of the lower esophageal mucosa and gastritis. The instrument could not pass further from the third part of the duodenum, due to extraluminal pressure on the duodenal wall. Gastrografin swallow confirmed the obstruction of the third part of the duodenum with proximal dilation of the stomach and duodenum (Fig. ).\nComputerized tomography (CT) scan of the upper and lower abdomen excluded the possibility of a tumor or an annular pancreas to be the cause of the compression of the duodenum. The subsequent CT scan showed an acute angle of 15° (Figs. and ) between the superior mesenteric artery and the aorta.\nThus, based on the history, the unintentional weight loss may have induced the compression of the third part of the duodenum. In this case, the clinical and the imaging findings of the patient concluded the diagnosis of SMA syndrome.\nFollowing extensive discussion with the patient and her family, she opted for surgery rather than conservative management. She was unwilling to try nasojejunal feeds or total parenteral nutrition (TPN) in the interim.\nTherefore, after obtaining informed and written concern, the patient was subjected to laparotomy. The first and second parts of the duodenum were not dilated and hypertrophied as expected, due to acute onset of the syndrome. The duodenum was obstructed at the point where the superior mesenteric artery crossed the third part of the duodenum (Fig. ). These findings confirmed the diagnosis of SMA syndrome.\nDue to patient’s hemodynamic instability intraoperatively, Strong’s procedure was performed with lysis of the ligament of Treitz and mobilization of the duodenum (Fig. ).\nThe postoperative course was not uncomplicated. There was evidence of gastric outlet obstruction and persistent ileus. The patient had a nasogastric tube that drained about 1.5 l of bilious material per day. She was then subjected to upper gastrointestinal endoscopy to rule out other pathology that may demonstrate external pressure on the third portion of the duodenum.\nIn addition, repeated difficulties with intravenous line placement, electrolyte abnormalities and falling serum albumin levels indicated that Strong procedure had failed and the patient’s condition necessitated again surgical intervention.\nA week after the first operation, she was subjected to new laparotomy where a side to side gastrojejunostomy was performed. The postoperative course was now uncomplicated and she was admitted after 2 weeks.\nAfterwards, a barium meal a month later showed postoperatively unobstructed passage of the contents from the stomach to the jejunum. |
A 39-year-old woman with a history of abdominal wall endometriosis presented to our clinic complaining of urgent urination and an emerging inguinal mass. She had a CS due to a breech presentation in 1994. She noticed a mass in the CS scar with cyclic pain in 1999. The mass was excised and diagnosed as abdominal scar endometriosis histologically. The margin was free and no further treatment was given after surgery. In 2004 a similar mass with cyclic pain was detected in the scar again. The mass grew gradually and was diagnosed as recurrent abdominal wall endometriosis without further treatment. She also developed urgent urination and dysuria during her menstrual period. In the last 4 months she noticed masses emerging in the bilateral inguinal area with mild pain.A physical examination showed a solid 6 cm × 5 cm mass without a clear borderline near the symphysis pubic in the previous longitudinal scar. Two enlarged lymph nodes with diameters of 2 cm and 1 cm in the right groin, and one lymph node with a diameter of 1 cm in the left groin were detected. Serum CA125 was 22.1 U/ml. Computed tomography (CT) scans showed that the mass had invaded the bladder and that the inguinal lymph nodes were enlarged (Figure ). Cystoscopy showed that the mass had penetrated the roof of the bladder near the membrane (Figure ). Malignant transformation of abdominal wall endometriosis was highly suspected before surgery.During laparotomy, it was seen that the mass had invaded the whole abdominal wall to the peritoneum and the roof of the bladder was also involved (Figure ). There was no endometriosis detected in the pelvic cavity. A frozen section pathological analysis was done and malignant disease was confirmed. Therefore, the woman underwent extensive surgery including: partial bladder excision, hysterectomy, bilateral adnexectomy, omentectomy and lymph node excision. The inguinal lymph nodes, pelvic lymph nodes and para-aortic lymph nodes were all enlarged (Figure ).Pathological examination gave a diagnosis of clear cell carcinoma in a background of endometriosis with metastasis to the bladder and the lymph nodes (Figure ). There were 8/8 positive bilateral inguinal lymph nodes, 18/21 positive pelvic lymph nodes and 6/6 positive para-aortic lymph nodes.\nThe patient recovered uneventfully but refused further treatment after three cycles of chemotherapy with carboplatin and paclitaxel. She sought traditional Chinese herbal medication. Ten months after chemotherapy, tumor recurrence was detected in the pelvic cavity and the patient died of the disease two months later.\nMalignant transformation of endometriosis is quite rare, affecting 1% of women suffering from endometriosis. The most common sites of malignant transformation of endometriosis are the ovaries. About 20% of cases occur in extragonadal sites including the rectovaginal septum, colon and vagina []. The malignant transformation of endometriosis in the abdominal wall is a rare event and less than 30 cases have been reported in the literature.\nSampson [] proposed three criteria to diagnose a malignant transformation of the endometriosis: demonstration of both neoplastic and benign endometrial tissue in the tumor, histological type of tumor compatible with endometrial origin and no other primary site identified. Scott [] added a fourth criterion of transition between histological benign endometriosis and carcinoma, which was defined as atypical endometriosis with cytological or architectural atypia in the endometriotic glands []. These criteria were based on the characteristics of malignant transformation of ovary endometriosis. Only a few cases of malignant abdominal wall endometriosis have fulfilled all four criteria []. All cases of malignant transformation of abdominal wall endometriosis in the literature had a history of surgery that caused the iatrogenic dissemination of the endometrium and a histological type of tumor compatible with an endometrial origin and no other primary site was identified [,-].\nMalignant transformation of endometriosis in the abdominal wall can invade all layers of the abdominal wall and grow as large as 10 cm in diameter []. However, there is no report of bladder invasion in the literature. In the present case, the mass arose near the symphysis pubis just above the roof of the bladder. When the neoplasm grew and invaded the wall of the bladder, the patient developed bladder-stimulating symptoms. CT scans clearly showed the bladder invasion since the margin between the mass and the wall of the bladder was visible. Cystoscopy confirmed bladder metastasis because the involvement of the bladder wall and mucosa can be identified clearly.\nLocal invasion is one important biological characteristics for malignant transformation of endometriosis in the abdominal wall; however, it can also spread through the lymph system. Three other cases with lymph metastasis have been reported in the literature (Table ). For the four cases, the average latency was 16.75 years. The carcinomas had a wide range of local invasion to all layers of the abdominal wall with a diameter of at least 5 cm. Three of the four cases had a histological type of clear cell carcinoma and one had mixed endometrioid and serous carcinoma. Pre-surgical evaluation and diagnosis of lymph node dissemination is difficult. Lymph metastasis was missed in both preoperative magnetic resonance imaging (MRI), surgical exploration and postoperative CT in cases 1 and 3. During the repair of the surgical wound, a 5-cm lymph node was found near the right external iliac artery in case 1. In case 3, postoperative positron emission tomography with computed tomography (PET-CT) using 18-fluorodeoxyglucose showed the involvement of two left iliac nodes. In case 2 and our case, a bilateral inguinal mass with metastasis was detected before surgery and confirmed by an imaging scan. Only in our case, was a systemic lymph dissection conducted. The lymph invasion clearly demonstrated that the path for the lymph metastasis in the malignant transformation of endometriosis in the abdominal wall was from the inguinal lymph nodes to the para-aortic lymph nodes through the pelvic lymph nodes. This pathway is consistent with the route of lymph fluid reflux in the lower abdominal wall. Symptoms of emerging inguinal mass together with local physical examination and imaging scan might be valuable for detecting primary lymph nodes metastasis before surgery.\nThe diagnosis of malignant transformation of abdominal wall endometriosis is still a challenge for gynecologists. There are no characteristic symptoms and markers during malignant transformation. Imaging can detect endometrioma and its fast growth. Malignant transformation is only suspected when the tumor has a solid or mixed component. In the present case, the patient developed urgent urination and an inguinal mass, which could be a sign of tumor invasion. Therefore, malignant transformation and metastasis were highly suspected before surgery. Accordingly, we were able to make a detailed plan and prepare for extensive surgery.\nThe best treatment for malignant transformation of endometriosis in the abdominal wall is unknown. Radical surgery with a wide resection is believed to be the primary treatment []. Chemotherapy based on carboplatinum and radiotherapy have been proposed without any evidence of improved prognosis. In all four cases with lymph metastasis, radical therapy together with hysterectomy salpingo-oophorectomy and lymph node excision were the standard treatment. Chemotherapy was administered to cases 1 and 3. Our patient had chemotherapy and used traditional Chinese herbal medicine. Cases 1 and 3 had limited or isolated unilateral iliac lymph node metastasis (one lymph node in case 1 and two in case 3). These two patients had no sign of recurrence over the short time of the follow-up. While case 2 and our case had extensive lymph nodes metastasis, these two patients died of the disease within one year. Extensive lymph node involvement indicated the late stage of the disease with multiple metastases. This might also correlate with a poor prognosis. |
A 22-year-old male patient visited the King Khalid University Dental Clinic for the replacement of anterior missing teeth. He attributed the loss of teeth to road traffic accident 6 months back. He also complained of moderate pain and clicking in the left temporomandibular joint. Patient provided the history of admission in a tertiary referral hospital subsequent to accident to have treatment for mild concussion from neurophysician and also a maxillofacial surgeon. On examination it was observed that the patient had lost maxillary central and lateral incisors on both sides (). The patient reported no change of posterior occlusion after accident. There was no mobility of adjacent teeth. Temporomandibular joint (TMJ) examination revealed that left and right lateral pterygoid muscles were tender to palpation. The maximum opening of the mouth was within normal range, with no restriction of lateral mandibular movement. The single click was observed on the left side of TMJ; no deviation or deflection of mandible occurred upon opening. Occlusion evaluation showed the protrusive and nonworking side contacts on left side (). Digital occlusal evaluation was also performed with T Scan III; it confirmed the existence of protrusive and balancing side interference. The occlusion time recorded was within normal range (0.52 seconds). Protrusive and left lateral disocclusion time were 0.86 seconds and 1.79 seconds, respectively. The right lateral disocclusion time recorded was 0.74 seconds. The protrusive and left lateral disocclusion times were substantially prolonged. The panoramic and intraoral periapical radiographs showed nothing significantly abnormal in TMJ and adjacent teeth. On complete evaluation of clinical signs, symptoms, and clinical examination, it was diagnosed as loss of maxillary anterior teeth with the associated temporomandibular joint disorder.\nThe treatment objectives were to replace the missing maxillary central and lateral incisors along with eliminating existing occlusal interference to rehabilitate the TMJ. Treatment options to replace the missing anterior teeth were discussed with the patient and his parents. Though the implant supported fixed prosthesis was ideal treatment, due to socioeconomic factors, conventional tooth supported fixed partial denture treatment plan was finalized.\nThe bilateral canines were used as abutments for the prosthesis. Thorough clinical and radiological evaluation was done for the abutments; no pulpal, periapical, or periodontal pathology was observed. The abutments showed no pain on percussion or pathological mobility. The sulcus depth around them was within normal limits. Bilateral canines had a favourable crown root ratio, root configuration, and periodontal ligament area to support the missing four anterior teeth. Another important factor in favour of the tooth supported fixed partial denture was that, though the tooth loss was due to road traffic accident there was no associated large soft tissue or bone defect in the residual ridge of missing teeth.\nDiagnostic casts were made from alginate impression, mounted on a semiadjustable articulator with the help of face bow transfer. Both abutments were prepared as full veneer porcelain fused with metal retainers (Figures and ). Provisional fixed partial denture was fabricated with indirect-direct technique. The provisional restoration was critical to evaluate esthetics and phonetics and get patient perspective on planned fixed partial denture (). The provisional restoration was also helpful in establishing proper anterior guidance. The anterior guidance was evaluated with T Scan to adjust the protrusive disclusion time at 0.6 seconds. The occlusion refinements were made to eliminate the nonworking side contacts too by reestablishing proper canine guidance. The patient was recalled after 24 hours to evaluate the patient opinion, gingival health, and comfort. The patient was continuously monitored for 6 weeks for alleviation of pain in the TMJ. The provisional restorations with acceptable anterior guidance, esthetics, phonetics, and comfort need to be replicated in permanent restoration. The alginate impression was made with provisional restorations, poured in dental stone, and mounted on the articulator with the face bow transfer. The customized incisal guidance table was fabricated with autopolymerizing acrylic on the semiadjustable articulator (). The working dental cast was made from additional silicone impressions of the prepared abutment teeth. It replaced the earlier dental casts in the semiadjustable articulator. Customized incisal table helped replicate the precise anterior guidance that was evaluated in the patient. The Polyvinyl siloxane putty index was made over the provisional restorations. It was helpful in making the final restoration with similar tooth contour, shape and labial surface. The final porcelain fused with metal restoration was cemented over the glass-ionomer type I luting cement after requiring occlusion refinements (). The patient was recalled after 1 week to evaluate the residual cement, gingival health, and occlusal integrity. The patient was recalled and monitored for six months with in-between intervals of one month for prosthesis and TMJ evaluation. The patient showed complete recovery from the TMJ pain. |
An otherwise healthy 18-month-old boy was brought in the emergency department by his parents due to possible button battery ingestion. The parents suggested that the incident took place at their home no more than half an hour prior to their arrival. The child was asymptomatic and alert. He did not show any signs of discomfort, dyspnea drooling, or pain.\nClinical evaluation did not reveal anything significant. Vital signs were normal and oxygen saturation was >96%. Evaluation of the oral cavity did not show any mucosal damage or any other signs of ingestion of a foreign body. Auscultation of the lungs was normal and the abdomen was soft at palpation with no signs of distention or tenderness.\nThe child was immediately referred for a radiographic evaluation. A foreign body located in the stomach that simulated a button battery or a coin was found in the anteroposterior X-ray. Immediately, a second lateral X-ray was taken that revealed the characteristic “step-off” sign, indicative of a button battery. It is created due to the different diameters on the flat and convex sides of the battery.\nAt that time the father arrived to the emergency department and supplied an identical battery to the one that was supposedly ingested by the child. This was a 20 mm diameter 3 V lithium battery (CR2025). The increased diameter of the battery and with the 3 V current that it creates led us to the decision to hospitalize the child and follow up his condition.\nHe was put in “nil per os” diet and intravenous hydration. At the second hour of hospitalization the child had two consecutive vomiting episodes without showing any discomfort or change to his mood or clinical condition thereafter. Despite the above, we decided to change our approach and a gastroscopy was scheduled.\nDuring endoscopy, the battery was found in the antrum alongside the greater curvature of the stomach, with its negative pole in contact with the gastric mucosa, and was removed in a basket ().\nA thorough inspection of the area revealed multiple superficial and deep erosion of the mucosa. Upon completion, we examined the battery itself and we found that the battery was significantly corroded ().\nThe patient's postoperative period was uneventful and he was discharged on the second postoperative day. Follow-up 15 days and 2 months after the event was normal. |
A 41-year-old Turkish woman pregnant for the fourth time with a past history of Graves' disease was referred to our emergency department with a diagnosis of respiratory arrest. She was unconscious and had been intubated. Her blood pressure and pulse rate were 160/90 mmHg and 120 beats/minute, respectively. Her body temperature was 36.5 °C. She also had a full goitrous thyroid gland with bilateral exophthalmos. From the history of the patient, it was learned that she had been diagnosed with Graves' disease one year before after consulting a general surgeon for respiratory difficulty and swelling of the neck. She was also positive for Pemberton's sign, which is the presence of facial plethora with both arms raised []. Her difficulty in breathing was thought to be due to her large goiter and a total thyroidectomy was planned for surgical treatment. She had started to use antithyroid drugs to become euthyroid before surgery. In addition, she was oligomenorrheic and did not know that she had conceived. She continued to use propylthiouracil 50 mg every six hours together with propranolol HCl 40 mg/day throughout the first four months of her pregnancy. Her respiratory difficulty resolved partially during that time. After she found out that she was definitely pregnant, she suddenly stopped taking her medications without consulting a physician and did not take them thereafter.\nShe was not followed regularly by an obstetrician during her pregnancy and was fine in the second trimester despite some mild respiratory problems. However, at the beginning of the third trimester, her respiratory difficulty worsened and one day before the respiratory arrest, she visited an obstetrician for respiratory distress. At that time, her fetus was still alive and found to be at the 27th week of gestation on sonography. She was given oxygen therapy and sent home. The next day, she was readmitted with severe respiratory distress together with stridor and she suffered respiratory arrest in the hospital. Using direct laryngoscopy, she was intubated with difficulty because of upper airway edema. After resuscitation, she was referred to us and her baby was found to be no longer alive. The patient was admitted to the intensive care unit for further evaluation and management. Initial maternal free triiodothyronine (T3), free thyroxin (T4), and thyroid-stimulating hormone (TSH) values were 17.6 pg/mL (1.80-4.71), 3.79 ng/dL (0.80-1.90), and 0.07µ IU/mL (0.400-4.0), respectively. Thyroglobulin was 184 ng/mL (0.73-84) while antithyroid peroxidase (TPO) antibody was 420 IU/mL (10-40) and antithyroglobulin antibody was 60 IU/mL (20-35). The patient was diagnosed with thyroid storm and treatment with propylthiouracil 150 mg every eight hours, propranolol HCl 40 mg/day, dexamethasone 0.5 mg/day, saturated solution of potassium iodide four drops every eight hours was started. An 1100 g female ex fetus was delivered vaginally after labor induction. After 48 hours in the intensive care unit, thyroid hormone levels started to decrease and she was extubated and transferred to our ward for further monitoring. The patient was discharged 10 days later with maintenance doses of propylthiouracil 200 mg every 8 hours and propranolol HCl 80 mg/day. |
A 51-year-old male patient with diabetes was admitted to the division of pulmonology with the chief complaints of fever and hemoptysis. A chest computed tomography scan was performed for the evaluation of persistent fever and recurrent pleural effusion, and it showed pulmonary embolism at bilateral multiple segmental arteries and segmental infarction of the involved lung segments. Based on the results, echocardiography was additionally performed and revealed isolated pulmonary valve infective endocarditis with severe pulmonary regurgitation.\nAfter the diagnosis was made, the patient was treated with antibiotics, followed by echocardiography. The echocardiography showed progression of pulmonary valve thickening and right heart failure. We performed pulmonary valve replacement with a #24 Sorin tissue valve. The postoperative course was uneventful and the patient was followed up at the outpatient clinic regularly with anticoagulation.\nAfter 6 months, he was brought to the emergency unit presenting with a high fever (>39℃) and general weakness that had lasted for 3 days. He was treated with antibiotics including vancomycin, imipenem, and rifampin. Methicillin-sensitive Staphylococcus aureus (S. aureus) was isolated from his blood culture, and the echocardiography showed a hypoechoic movable mass on the prosthetic pulmonary valve () and the pressure gradient of the prosthetic pulmonary valve was 16.2 mmHg (maximum pressure gradient)/9.4 mmHg (mean pressure gradient). Follow-up echocardiography showed a worsened pressure gradient of the prosthetic pulmonary valve. We did a redo-pulmonary valve replacement under the impression of prosthetic valve infective endocarditis.\nThe prosthetic pulmonary valve leaflet was thickened with infected tissue (). After removal of the infected prosthetic valve, a secure portion for the new prosthetic pulmonary valve replacement was hard to find because of the risk of pulmonary vessel wall injury. Moreover, complete debridement of the remaining infected tissue seemed impossible. Thus a valved graft was made by placing a 21 mm tissue valve in the middle of a 22 mm Vascutek artificial graft (). After completely obliterating the proximal portion of the pulmonary arterial lumen with simple suturing for isolation of probable remnant infected debris, the valved graft was used to perform the redo-pulmonary valve replacement similar to the Rastelli operation with right ventricular outflow tract reconstruction ().\nImmediate postoperative echocardiography showed intact prosthetic pulmonary valvular function with a peak pulmonary valve pressure gradient of 34 mmHg and a mean pulmonary valve pressure gradient of 16 mmHg. Follow-up echocardiography was performed on postoperative day #19, and the peak pulmonary valve pressure gradient was 20.71 mmHg, while the mean pulmonary valve pressure gradient was 11.14 mmHg. No more microorganisms were isolated from his blood culture. The patient is currently being treated with anticoagulant (coumadin), presenting no respiratory or cardiovascular symptoms during follow-up in outpatient clinic for 2 years after surgery. The last echocardiography was performed at 15 months after surgery; it showed intact prosthetic valve function with a peak pulmonary valve pressure gradient of 19 mmHg and a mean pulmonary valve pressure gradient of 10 mmHg. |
A 71-year-old female was diagnosed with colon cancer, and had the operation of sigmoid colon cancer resection in the year 2011. After 1 year of the surgery, the patient underwent percutaneous vertebroplasty of L3 because of the pain of the low back which was caused by L3 vertebral metastasis. Then, 1 year later, the patient presented with complaints of severe pain in her lower back and left leg that had become progressively more severe and was made even worse by ambulating and sitting up. Magnetic resonance imaging (MRI) showed the L3 vertebral body had been completely involved by osteolytic vertebral metastasis and the compression of the dural sac and nerve root from pathologic fracture fragments and tumor tissue were common findings on presentation (Fig. A and B). The sharp pain could not be relieved even though the patient had taken dihydroetorphine hydrochloride tablets. These patients with limited life expectancy and poor general physical condition are ineligible for an invasive surgery. Therefore, the minimally invasive technique was defined at a multidisciplinary medical staff meeting, and approved by the Medical Ethics Committee of our hospital simultaneously.\nAfter obtained the informed consent from each participant, we performed the first percutaneous transforaminal endoscopic spinal decompression and palliative resection of metastases in the left side. After the first surgery, symptoms of pain radiating to the left leg were satisfactorily relieved, the visual analog scale (VAS) score decreased from 8/10 preoperatively to 1–2/10. Approximately 4 months after this therapy, the patient complained that radicular pain of the right leg was persistent existing. MRI showed the dural sac and right nerve root was compressed by spinal metastases (Fig. C and D). So, the second operation of percutaneous transforaminal endoscopic spinal decompression and palliative resection of metastases was performed in the right side. The patient accepted an operation of selective lumbar arteries chemoembolization before the minimally invasive surgery a week ahead of schedule.\nChoose the right side of the operation as an example. This procedure was performed with the patient under local anesthesia in the prone position on a radiolucent table and under the guidance of C-arm fluoroscopy. The skin entry point was located 8 cm from the midline and the procedures of puncture and localization were according to the PELD technique.[ A trephine was used for foraminoplasty to facilitate cannula insertion by removing ventral part of the articular process. Then an endoscope was inserted through the working cannula. Continuous feedback was obtained from the patient during the entire procedure so as not to cause damage to any neural structures. The TESSYS endoscopic system was used for the procedure. In the rear of the intervertebral space, the residual annulus fibrosus and elevated posterior longitudinal ligament, part of pathologic fracture fragments and tumor tissue could be observed under endoscopic visualization. The tumor had invaded the posterior border of L3 and L3-4 intervertebral space as well as compressed the dural sac and nerve root (Fig. A). All the tissues that caused the dural sac and nerve root compression were grasped and removed carefully with endoscopic forceps by adjusting the observation angle of the working cannula (Fig. B), and then a radiofrequency electrode was used to coagulate bleeding. These 2 procedures were operated to remove the compression tissue alternately, just like the mulberry leaf was swallowed up gradually by a silkworm. The criterion of complete decompression was the dural sac and the nerve root should be observed freely movable with the changes of irrigation pressure (Fig. C). At the end of the procedure, the spinal canal, intervertebral space, and foramen were visually inspected while the working cannula and endoscope were removed gradually. The tumor tissue which was taken down should be sent for pathological examination after the operation (Fig. ).\nThe minimally invasive surgery was performed successfully without clinical complications. The patient's postoperative course was notable for immediate pain relief within 1 hour, and she was able to walk 500 M without a brace or ambulatory assistance device 1 day later. Pain severity in her back and lower limbs greatly decreased from VAS10/10 to 2/10 during the 6-month follow-up, and the use of analgesic opiate was suspended. Because of the aggressive growth of the malignant tumor had metastasized to the whole body, the patient died of respiratory failure 6 months after the second minimally invasive surgery. |
The patient, a 28-year-old Japanese woman, had been under periodic follow-up since her childhood for tuberous sclerosis, and underwent right nephrectomy for AML at the age of 17; she continued to be under follow-up for immediate detection of AML developing in the remaining left kidney. During the course of follow-up, the patient developed sudden abdominal pain and needed emergency hospitalization because of decreased serum Hb level. Laboratory examination at admission revealed a serum Hb level of 7.3 g/dL and serum Cre of 0.9 mg/dL.\nAbdominal CT revealed a fairly large-sized tumorous lesion situated primarily in the left retroperitoneum and containing a huge aneurysm-like hemorrhage. The left renal artery was dilated to nearly the size of the aorta (). While a part of the normal kidney parenchyma was identified (), most of the remaining organ was occupied by the AML and constituents of the hematoma secondary to rupture, that conspicuously impinged on and displaced the abdominal viscera (, ).\nAn abdominal angiography revealed marked distension of the left renal artery, and it was difficult to visualize the mass clearly and to accurately delineate the vascular supplies to the normal kidney parenchyma, even by left renal arteriography (infusion rate, 7 mL/sec; total dose of the contrast medium, 35 mL) (). Based on these findings, we carried out embolization of the aneurysm-like bleeding site with metallic coils () and of the rest of the bleeding sites with gelatin sponge particles upon identifying the blood vessels supplying the normal renal parenchyma, with concomitant CTSA (). Angiography performed after the embolization procedure demonstrated satisfactory visualization of the normal renal parenchyma and the remaining embolized tumor vasculature ().\nAt half a year and about 5 years after the embolization, CT scans showed marked contraction in the size of the tumor and hematoma, with no evidence of any fresh hemorrhage (, , , and ). The CT obtained at 5 years post embolization, nevertheless, demonstrated an increase in the size of the AML arising from the left kidney (, ). In regard to the renal function, the serum Cre level was 1.5 mg/dL at the time of discharge and remained practically constant thereafter, except for one instance of worsening when the patient developed septicemia of uterine origin during the 4th year post operation. The serum Cre level has remained in the 3 to 3.5 mg/dL range, and the patient has not needed initiation of dialysis therapy. |
A 3 year-old male, neutered, domestic shorthair cat was presented with a 2 week history of severe regurgitation of all ingested food. The cat had a history of a voracious appetite and regurgitation of solid food since being acquired as a kitten, but was able to consume liquid meals without regurgitating until 2 weeks prior to presentation.\nThe physical examination revealed a poor body condition score (BCS 2/9) and a 4 cm firm tubular structure in the ventral neck, believed to be within or associated with the esophagus. The remainder of the examination was unremarkable. As a result of the cat’s fractious nature, it was necessary to induce general anesthesia for further evaluation. Thoracic radiographs showed severe distention of the entire cervical and intrathoracic esophagus to the level of the heart base with heterogeneous soft tissue opaque material surrounded by a thin gas rim (). Differentials for the radiographic findings were constriction due to a vascular ring anomaly (VRA), most commonly a persistent right aortic arch, a mural defect or benign esophageal stricture.\nComputed tomographic angiography (CTA) was performed in order to confirm and classify the suspected VRA and to determine if surgical correction would be possible. The esophagus cranial to the heart base was almost entirely filled with heterogeneous soft tissue, gas and mineral opaque material. At the level of the heart base, the esophagus was focally and concentrically narrowed by the trachea and aorta on the right and the main pulmonary artery on the left. The site of constriction was apparent at the anatomic level of the ligamentum arteriosum; however, the ligamentum arteriosum could not be specifically identified on CTA. The aortic arch and proximal descending aorta were located just to the right of midline, with the distal descending aorta positioned immediately ventral to the thoracic spine. A bicarotid trunk and right subclavian artery were present, and branched from the aortic arch in close succession. The left subclavian artery branched aberrantly from the proximal descending aorta. Additionally, the origin of the aberrant left subclavian artery from the aorta was markedly dilated and then abruptly narrowed distally to a normal diameter; this finding is known as Kommerell’s diverticulum. Although the aberrant left subclavian artery created a dorsal indentation in the intrathoracic esophagus, it did not appear to be the primary cause of the constriction. Three-dimensional reconstruction of the CTA confirmed a type III VRA.\nEsophagoscopy was performed and multiple compact trichobezoars were removed. The esophagus remained dilated cranial to the level of the constriction and pulsation of the major vessels against the wall of the esophagus was observed at the level of the luminal narrowing (see video in the Supplementary material). Evidence of mild-to-moderate esophagitis, presumably due to stagnation of trichobezoars and putrefaction of food, was observed cranial to the constriction. It was possible to advance the endoscope past the constriction and no gross abnormalities were noted in the stomach.\nFollowing recovery from anesthesia, the cat was able to drink water and eat a canned food slurry without complication or regurgitation. Surgical ligation and transection of the vascular ring anomaly with concurrent endoscopic balloon dilatation of the esophageal stricture was recommended as the treatment of choice. The owner elected not to pursue further treatment at that time. The cat was discharged with instructions to continue feeding a canned food slurry in an upright position.\nThe owner was contacted prior to submission and reported that the cat was doing well with multiple small feedings of canned food and had not regurgitated since discharge. |
A 53-year-old man presented with acute chest pain and shortness of breath for 12 h was admitted to our hospital. He had a history of hypertension and diabetes mellitus and underwent mechanical aortic valve replacement for hypertension associated chronic severe aortic valve regurgitation 18 months ago. The blood tests on admission are shown in and most laboratory parameters deviated from the normal range. The bedside echocardiography confirmed the normal function of the mechanical aortic valve with an ejection fraction of 50%. The patient was examined by CT angiography (CTA) after he was stabilized by medical treatment and it showed a simultaneous ascending aortic dissection extending to descending aorta and PAD combined by aortopulmonary fistula ().\nAfter we informed the families of the patient regarding the different treatments and related risks, including coronary artery involvement in aortic root dissection, renal malperfusion, heart failure, and especially complications associated with secondary cardiac surgery, the families and patient demanded surgical treatment.\nEventually, surgery was performed with median sternotomy and cardiopulmonary bypass was established via the intubation of the right atrial and right axillary artery, which was also used for selective cerebral perfusion in aorta arch replacement. The aorta root replacement and proximal anastomosis were performed first combined by removing the coronary arteries and reattaching them on the Dacron graft; in the meantime, the aortopulmonary fistula was closed with continuous 5-0 monofilament suture. Then, the hemiarch replacement and open distal anastomosis were completed under deep hypothermic circulatory arrest (nasopharyngeal temperature: 24°C). The surgery time was 474 min, cardiopulmonary bypass time was 185 min, cross-clamp time was 79 min, and deep hypothermic circulatory time was 23 min. The patient was transferred to the intensive care unit for further treatment and monitoring postoperatively. In the early period, there were no signs of unstable hemodynamics, respiratory insufficiency, and neurological disorders, and the ventilator weaning was performed 2 days after surgery. However, the patient was reintubated 10 days post-operatively due to dyspnea and methicillin-resistant Staphylococcus aureus was detected in sputum culture. Aspergillus was also detected in sputum culture 17 days postoperatively. Although vancomycin and fluconazole were used, the patient died of infectious shock 1 month after surgery. |
A 5-year-old boy was referred to the Pediatric Surgery Department with complaints of a large mass in the abdomen for the past 4–5 months. There were no other associated complaints such as nausea, vomiting or abdominal pain. Preanesthetic evaluation revealed no previous surgeries or hospitalization, no medication, no history of any other chronic illness or associated congenital anomalies. Airway examination was normal. Per abdomen examination revealed a tense, distended, nontender abdomen wall with a large solid mass on palpation, which seemed to occupy most of the abdomen []. Radiological evaluation revealed a large 30 cm × 20 cm tumor arising from the right kidney with no intravascular extension. He was posted for excision and surgical staging of the tumor. Preoperative investigations revealed a normal hemogram and normal electrolytes. Renal function tests were also within normal limits.\nThe patient was taken up for surgery after arranging adequate units of blood and taking informed high-risk consent from the parents. The child was taken into the operation theater (OT) after premedication with midazolam. After establishing basic monitoring and decompressing the stomach with a nasogastric tube, the patient was induced in a slight head up position to decrease respiratory embarrassment due to the abdominal mass. A central venous catheter was inserted into the right internal jugular vein anticipating a large amount of blood loss and fluid shifts.\nThe abdomen was then opened and revealed a large vascular mass arising from the right kidney []. The tumor was gradually dissected and removed over the next 1 h. Hemodynamic stability in terms of oxygenation and perfusion was maintained with isotonic crystalloids initially and later with packed red blood cells. There was no drastic hypotension noted and the operation seemed to progress uneventfully till the mass was removed from the abdomen. As the surgeons prepared to close the abdomen, suddenly a ventricular tachycardia (VT) rhythm was noted on the monitor, which was initially confused with electrocautery interference, but was confirmed after asking surgeons to stop. Absence of the carotid pulse confirmed a pulseless VT and chest compressions were started while the defibrillator was charged. The patient was revived with return of normal cardiac rhythm after 10 min of resuscitation following the pediatric advanced life support algorithm. He was given 3 DC shocks (2 J/kg), 2 doses of epinephrine (10 mcg/kg), and calcium gluconate (100 mg/kg). A femoral arterial blood gas (ABG) sample was sent while the surgeons rapidly closed the abdomen. The patient was urgently shifted to the Pediatric Intensive Care Unit (PICU). The blood gas sample revealed hyperkalemia (6.8 mEq/L) and hypocalcemia (7 mg/dl). The electrocardiogram (ECG) now showed a sine wave pattern. Anti hyperkalemic measures were instituted in the form of glucose insulin infusion over 10 min, salbutamol nebulization and soda bicarbonate (2 mmol/kg). The patient required inotropic support in the form of dopamine (10 mcg/kg/min) and norepinephrine (0.5 mcg/kg/min). Repeat sample of ABG revealed persistent hyperkalemia and the patient was planned to be put on urgent hemodialysis (HD). Due to hemodynamic instability and high inotropic requirement, the patient could not tolerate HD and arrested again in the PICU. He was transiently revived and the HD was stopped. However, due to resistant hyperkalemia, not at all responding to conventional modes of treatment, patient recurrently went into VT. After numerous attempts at resuscitation, the patient could not finally be revived and was declared after briefing and sensitizing the parents to the prognosis. |
A 55-year-old male patient presented to the emergency department after sustaining a fall from 4-meter height. Patient attempted to break his fall and landed on his outstretched left hand. After the fall, the patient had severe pain and deformity of his left forearm. Initial assessment revealed a hemodynamically stable and cooperative patient but in distress due to severe pain. His left upper extremity had an obvious deformity in the forearm, with swelling and restricted range of motion due to pain. The patient also had a 3 cm wound on the dorsolateral side of his elbow.\nRoentgenograms showed a comminuted fracture of the ulnar shaft at the proximal and middle third junction with 35° of angulation along with a posteriorly dislocated nonfractured radial head and a fractured lateral humeral epicondyle (). Furthermore due to the presence of the wound the fracture was classified as an open fracture. Computed topographic scan with 3D reconstruction was done to understand the injury more ().\nPatient was transferred the same day to the operative room for treatment. The wound was copiously irrigated with minimal debridement needed. Traction was first applied and it was sufficient to reduce the radial head and align the ulnar fracture. Open reduction of the ulnar fracture helped attain a better reduction and the fracture was fixed using a laterally applied 3.5 mm locked compressive plate (LCP) and ensuring a fixation of at least 6 cortices both proximally and distally. The fractured lateral humeral epicondyle was then reduced and fixed using 2 cannulated 3.5 mm partially threaded screws. The radial head stability was then evaluated and was found to be stable.\nThe postoperative period was uneventful and the patient was discharged home on day 3 postoperatively with a clean noninfected wound. The elbow was immobilized with a long posterior arm splint for 7 days. The elbow was then held in an articulated elbow brace and physical therapy was started. Active and passive range of motion exercises were started and at 6-week follow-up visit the patient was pain-free and showed full elbow extension, flexion to 140, supination to 90, and pronation to 80 degrees.\nRadiographs done at 3-month follow-up visit revealed a healing ulnar and humeral fracture with a radial head in its adequate position (). Patient at 6-month follow-up had full extension, flexion to 130°, supination to 90°, and pronation to 80° (). Based on Broberg and Morrey scale [], the end result was excellent. |
This was a case report of a 5-month-old male infant who was admitted as an emergency case to a secondary care hospital with acute onset of high-grade fever and respiratory distress. The chest X-ray showed bilateral extensive consolidation involving mainly the lower lobes of the lungs. He was placed on broad spectrum antibiotics and bronchodilatory inhalers, in response to which he showed no clinical improvement over a period of 2 days. Therefore, and in view of his deteriorating clinical status, he was urgently transferred to our hospital for further management.\nUpon arrival, the infant was in respiratory distress requiring 4 L/min of oxygen to keep his oxygen saturation above 90%. Further examination of the infant revealed dysmorphic features such as low set ears, generalized muscular hypotony, and delayed psychomotor development. Additional questions on patient history identified that at the age of 5-months the child had accidentally ingested paraffin oil administered by his 3-year-old brother. This prompted consideration of a probable diagnosis of acute exogenous LP. Computed tomography (CT) scan [] revealed extensive bilateral consolidations in the lower lobes. Bronchoscopy was performed which did not reveal any significant anatomical abnormalities or foreign bodies. The BAL aspirate was opalescent with a supernatant halo of fat and showed an increased number of macrophages. BAL was sent for microbiological studies including Gram staining, Ziehl-Neelsen staining, and bacterial and fungal cultures. The microbiological results were all negative. The cytologic study showed numerous foamy macrophages with intracytoplasmic and extracellular droplets of fat with a positive histochemical confirmation of acute LP with Oil Red O stain. (Oil Red O is a fat-soluble dye used for staining of lipids and triglycerides.) Total lavage was not performed as it was considered too risky in view of the critical status of the patient and the signs of hypoxia he demonstrated during the procedure.\nA corticosteroid therapy regimen was introduced which led to an improvement of his general condition. The infant remained in our hospital for a total of 5 months showing gradual clinical improvement. Before discharge an additional bronchoscopy and BAL was performed that showed a clear aspirate with no supernatant fat and fewer lipid-laden macrophages. Further, an additional CT scan was performed which showed persistent findings with minimal improvement []. 7-years after the incident, the patient was admitted for a complete workup. He underwent spirometry, which revealed a forced vital capacity (FVC) equal to 85% of predicted value, a forced expiratory volume in 1 s (FEV1) of 79% of predicted value. FVC and FEVI values over 80% of predicted value are considered normal. FEV1/FVC ratio was 81%, which was within the normal range (approximate range: 75-80%) for healthy adults. The reversibility test was negative. The patient could not undergo further pulmonary function testing (lung volume, diffusing capacity of lung for carbon monoxide). BAL revealed far fewer lipid-laden macrophages, while the CT scan showed resolution of the consolidations, but evidence of residual interstitial findings []. |
A 27-year-old man with a past medical history of Crohn's disease presented in the Emergency Department with a complaint of a right hip pain for one month that has been worsening. The patient said that he visited his primary care physician weeks prior and was referred for physical therapy. The patient was compliant with physical therapy and received cyclobenzaprine; however, his pain did not improve. During examination, the patient pointed that the pain was localized to the right flank and right hip crest, sharp in nature, and intermittently radiating to the right lower quadrant. The patient reported that although he was able to bear weight, the pain was exacerbated with movement. The patient reported no fevers or chills, as well as no redness, or swelling, over the hip joint. The patient also had been having three to four soft bowel movements per day and reported that this is his baseline. The patient did not have any black stools, bright red blood in stools, nausea, or vomiting. Review of systems was also negative for dysuria, hematuria, and penile discharge (Figure ).\nThe patient was diagnosed with Crohn's disease at age 11 years old and has been on ustekinumab 90mg every eight weeks for the last three years. The patient reported that he had a flare four months prior because he ran out of ustekinumab for three months due to the inability to cover the cost. The patient also had known small bowel resection and simultaneous appendectomy six years ago. The last colonoscopy the patient had was four years prior to the presentation and did not show any acute findings.\nAt presentation, the patient had a sublingual temperature of 99.8 F, with a blood pressure of 141/78 mmHg, a pulse of 130 beats per minute, a respiratory rate of 18 breaths per minute, and oxygen saturation of 100% on room air. On physical examination, the patient was not in acute distress. The abdominal examination revealed tenderness over the right lower quadrant, involuntary guarding, and hyperactive bowel sounds. Examination of the hip joint showed no redness, edema, or tenderness. No limitation in anterior hip flexion, lateral hip flexion, or internal rotation. Also, the costovertebral angle was not tender on percussion. Mild tenderness noticed on the external rotation of the right hip and the psoas sign was positive. Cardiovascular and pulmonary examinations did not produce significant findings. Laboratory investigations showed white blood cells of 15 x 103/cu mm, hemoglobin 7.6 g/dL, MCV 73.5%, MCHC 32.0%, platelets 457 x 103/cubic mm, reticulocyte count 1.3%, ESR 118 mg/L, C-reactive protein (CRP) 58 mg/L.\nGiven the suspicion for psoas abscess, blood cultures were sent and the patient was started on ampicillin and sulbactam. CT of the abdomen with and without oral and intravenous contrast was performed. This showed marked inflammation of the terminal ileum with the fistulous connection between the terminal ileum and the right psoas major, which was markedly edematous and inflamed, containing an abscess. A smaller abscess in the right iliacus muscle was also described. After the CT findings were reviewed, general surgery was consulted and antibiotics changed to metronidazole, cefepime, and vancomycin. Finally, interventional radiology performed abscess drainage. |
Altered mental status and severe headache developed in a 54 year old female, previously diagnosed with acute myeloid leukemia, four weeks after admission for high dose chemotherapy followed by matched unrelated donor stem cell transplant. Following her conditioning chemotherapy, which consisted of busulfan and fludarabine and subsequent bone marrow transplant, she developed a nodular pneumonia thought to be fungal in nature but culture negative by bronchoscopy specimens. During this time, the patient was on tacrolimus for graft versus host disease prophylaxis. This was started 25 days prior to the onset of mental status changes. Tacrolimus levels were maintained in a therapeutic target range of 10–15ng/ml during this time frame. On day 27 of the admission, she complained of severe headache which was followed by confusion. Also of note, the patient developed accelerated hypertension in the 48 hours surrounding the episode of confusion. Neither visual disturbance nor seizure activity was noted. Prior to this event, the patient was fairly normotensive with a systolic blood pressure range of 120–130 mmHg. At the peak of confusion, she was noted to have blood pressure of 188/90 mmHg. Calcium channel blocker therapy was then started and normotension was achieved.\nCranial T2-weighted MRI showed increased FLAIR and signal in the left and right cerebellar hemispheres that did not enhance or show restricted diffusion. There was also increased flair signal in the left and right posterior parietal occipital cortex consistent with posterior reversible leukoencephalopathy. Tacrolimus was discontinued and mycophenaolate mofetil was initiated. Within 24 hours of discontinuation of the tacrolimus, the neurologic symptoms began to resolve and the patient was again normotensive. Subsequent to this, she did develop grade II graft versus host disease of skin requiring high dose steroids and sirolimus was then added to the regimen. Because of the concern for potential worsening of the nodular pneumonia, steroid taper was initiated as soon as clinically feasible. Ultimately, she recovered and was discharged from the hospital in stable condition, with resolution of all neurologic findings. |
This is a 57-year-old male with end-stage renal disease due to post-streptococcal glomerulonephritis with a history of living related donor renal transplant in 1984 into his right lower quadrant. The allograft then developed transplant nephropathy and he began dialysis in 2015 and was relisted for red o kidney tx. In 2018, the patient received an HLA and ABO compatible kidney transplanted to his left iliac fossa. Subsequently, his original renal transplant became incarcerated through an incisional hernia, and a transplant nephrectomy was then performed.\nThe patient initially presented to our transplant clinic for evaluation and workup of hematuria and persistent, activity limiting, right lower quadrant pain, not associated with nausea or vomiting. Due to the development of multiple skin malignancies on Tacrolimus his immunosuppression regimen at the time included Everolimus and prednisone. On physical examination, he was noted to be moderately tender to palpation in the right lower quadrant over the previously transplanted kidney, with no obvious bulge.\nHis workup was included but not limited to basic labs (CBC, CMP and UA), a renal transplant ultrasound, and a CT of the abdomen and pelvis. The CT scan revealed herniation of the right-sided donor kidney through an incisional hernia ( and ).\nGiven the patient's persistent, activity limiting pain, the decision was made to proceed to the operating room for right transplant nephrectomy and primary repair of incisional hernia.\nThe nephrectomy was performed right lower quadrant, previously transplanted kidney scar. Dissection was carried down to the subcutaneous tissue where it was found that the transplanted kidney was incarcerated through the external oblique fascia (). The dissection continued and revealed a 3 × 3 cm fascial defect that resulted in the incarceration of the transplanted kidney. The fascia was then enlarged, and dissection was carried out into the retroperitoneum. The transplanted kidney renal vessels and ureter were exposed and stapled off above the patient external iliac vessels.\nGiven the small size of the fascial defect, and the patient being on Everolimus, the decision was made to repair the hernia primarily with 1-0 PDS suture in an interrupted fashion without tension. The wound was then closed in three layers using 2-0 absorbable sutures and the skin closed with staples.\nThe patient’s postoperative course was complicated by poor wound healing, subcutaneous seroma abscess that required drainage and antibiotics. His mTOR inhibitor was stopped to aid with wound healing and reduce risk of further complications. |
A 2-month-old boy who previously underwent surgical correction for intraventricular defect started to present frequent episodes of inconsolable crying, associated with neck extension, stiffening of the arms and trunk, sometimes followed by swallowing and vomiting.\nSymptoms were attributed to GERD, and therapy with PPI started. However, no improvement was noticed. In the following weeks, episodes became even more frequents with exacerbation of symptoms. His mother video recorded an attack (), which showed the presence of flexion spasms, presence of intractable GERD was suggested and the child eventually underwent fundoplicatio.\nNo improvement was noticed: Persistence of symptoms and occurrence of spasms of the arms during acute episodes finally suggested diagnosis of West syndrome. IS was then confirmed by EEG while MRI was negative. Despite starting of appropriate therapy at 8 month of age, clinical signs of mental retardation were present.\nAlthough IS is a rare disorder, diagnosis is usually not hard: The age of patients is peculiar and a careful patient history with a complete neurological evaluation are usually sufficient conditions to suspect the disease. Traditionally, differential diagnosis of IS does not contemplate GERD ().\nWe have described the cases of three infants presenting with classical clinical findings attributable to IS who were initially diagnosed, and consequently treated, as having GERD. In all patients, irritability, spasms and crying were considered signs of gastrointestinal complaints rather than to psychomotor development regression.\nTo our knowledge, this is the first report of IS misdiagnosed as GERD.\nWe would like to underline that our patients presented classical signs of IS, and a more precise physical examination would have also revealed a psychomotor development regression. These findings were very consistent with IS that usually begins between age of 4 and 8 months and are characterized by brief symmetric contractions of neck, trunk and extremities. Spasms occur during sleep or arousal and have tendency to develop while patients are drowsy or immediately on awakening. These findings should always drive paediatricians to request for EEG, in which pattern most commonly associated with IS is hypsarrythmic.\nWe have tried to examine the reasons underlying such an exceptional misinterpretation.\nConsidering that both IS and GERD have not been changed their clinical presentation among past years, we believe that our report could be consider as the consequence of an extraordinary attention around GERD in the last decade.\nIn confirmation of this statement, Barron et al. have recently demonstrated that PPI use in paediatric population increased steadily from 1999 to 2004 in the United States ().\nWe could speculate that a possible danger of such an attention towards GERD in children could be the erroneous attribution to GERD of symptoms clearly associated with other conditions like in patients we have described. Interestingly, it has already been shown that most of the symptoms classically related to GERD have revealed to be inconsistent with the clinical suspicion. In fact, only less of 10% of the symptoms conventionally associated with GER episodes (crying, regurgitation, feeding refusal, back arching, wheezing, coughing and hoarseness) are truly related to episodes of gastroesophageal reflux (GER) when detected with combined pH monitoring and impedance measurement (). Similarly, Orenstein et al. () did not find any difference in efficacy between lansoprazole and placebo for symptoms attributed to GERD in infants.\nWe have already suggested that these symptoms, if not associated with other major complaint as growth failure or psychomotor development regression, should be simply considered part of the physiological behaviours of infants, rather than pathological events (). Unfortunately, most paediatricians dealing with irritable infants still seem to be more prone to start with anti-reflux therapy rather than to educate parents on how to cope with infant crying as a part of anticipatory guidance. In our experience, this unjustified and ineffective approach may confuse the family, leading at the end to food refusal in the baby, with an impact on growth ().\nOn the other hand, this particular attention to GERD in children may reduce attention towards other peculiar clinical conditions, like in cases we presented. We would like to underline that IS should be always considered in every infant presenting with symmetric spasms and psychomotor development regression.\nIn conclusion, we have described for the first time three cases of children affected by IS initially misdiagnosed with GERD. We believe that it could be the result of a peculiar overestimation of clinical signs attributable to GERD, beard from a flourishing specific literature in the past years, leading to overdiagnosis of GERD in healthy infants and to lack diagnosis of other specific clinical conditions like in cases we have presented.\nIn particular, IS long-term overall prognosis is poor, and mainly among those patients with long time from onset to treatment, cyptogenetic IS and age of onset <4 months, thereby prompt diagnosis is mandatory to start proper therapy.\nWe would suggest to consider GERD only in those patients with high risk rate for developing GERD like children with cerebral palsy, in those with surgery complications after oesophageal atresia and/or in any child with very evocative GERD symptoms, such as hematemesis and or chronic vomiting with growth failure. |
A 58-year-old Hispanic female with a history of hypertension and hyperlipidemia was brought to the emergency department for an altered mental status. On admission, the patient was hemodynamically stable. She had a nonfocal initial neurologic exam. Her laboratory findings were consistent with hypoxemia, acidosis, and mildly elevated leukocytosis. A 12-lead ECG revealed sinus tachycardia with lateral ST segment elevation; due to these findings, the patient underwent emergent cardiac catheterization, which revealed normal coronaries.\nA noncontrast CT scan of the head demonstrated a right subacute temporal lobe infarct and multiple scattered infarcts in all vascular territories raising the possibility of embolic phenomenon. Further clinical course was complicated by right popliteal and superficial femoral vein thrombosis and bilateral segmental pulmonary embolism. The patient also had a transient right radial artery occlusion.\nHer initial contrast-enhanced transthoracic echocardiography (performed after the cardiac catheterization) and subsequent transesophageal echocardiography (TEE) revealed a large left ventricular mass with a wide base, attached to the anterolateral free wall. The mass had poorly defined edges and several mobile components. There were no other significant structural and functional cardiac abnormalities noted. Detailed TEE analysis (, Supplementary video in Supplementary Material available online at ) confirmed a presence of a 42 × 10 mm thrombus arising from the lateral wall and extending into the left ventricular outflow tract.\nEvidence of multiple arterial and venous clots in addition to the large cardiac thrombus raised the suspicion for inherited thrombophilia. The coagulability workup was performed and came back positive for protein C and S deficiency, with activity of 26% (normal range: 84–171) and 18% (normal range: 54–132% for females) for proteins C and S, respectively. At that time, the patient had normal liver function and vitamin K level and was not on any vitamin K antagonist therapy. Renal function was normal and the patient did not have any evidence of disseminated intravascular coagulation.\nThe patient underwent a surgical cardiac thrombectomy to prevent further systemic embolization. An elongated mass attached to the lateral wall and connected to anterior mitral leaflet was removed (). No valvular changes or lateral wall regional wall motion abnormalities were observed. Pathology confirmed an organizing arterial thrombus without evidence of infection. The patient did well after surgery and was treated with oral anticoagulation (Warfarin, bridged with intravenous Heparin) and discharged to skilled nursing facility with no further cardiac or vascular complications. |
A 56-year-old female patient from Tamil Nadu presented in October 2016 with generalized weakness, vomiting, and massive lymphedema of the left upper limb. She was in distress, unable to bear the weight of her arm, and was admitted in a cot with a specially designed contraption to rest her left upper limb weighing 31 kg. She had made a similar one at home for this purpose.\nHer history revealed that she had undergone modified radical mastectomy for carcinoma left breast in January 2002. Postoperatively, she underwent adjuvant chemotherapy and radiotherapy to her chest wall and axilla. She was seen in the Lymphedema Services of the Palliative Medicine Division and was taught the necessary precautions to be observed and exercises to be done. The risks involved in noncompliance were clearly communicated to her in her own language.\nSince June 2002, she developed edema of the left upper arm and pain in the anterior chest wall. She was on regular follow-up and was disease free. The size of the left upper limb increased progressively by the year 2012, along with pain. The pain was a concern for which she was forced to seek medical help and did get relief from local hospital close to her home. By February 2016, her affected arm measured 120 cm in circumference at elbow region. She was offered salvage surgery by several plastic surgeons necessitating 7 to 10 sittings. She declined the suggestions and continued her life as a hard-working homemaker. Married with two children, she never received support for her work or assistance for physiotherapy, and finally she neglected it. To supplement their family income, she worked as a full-time system analyst in a transport company where a customized table was made for her affected limb to rest and she used the affected hand to type. At home, she had similar contraptions to rest her arm while sitting and when on the bed. She used to climb stairs, dress, and cook all by herself.\nBy October 2016, she was at her wits end, reaching the dead end of endurance, and desperately wanted to get rid of her limb, and pleaded for the same, and this was the only means to improve her quality of life. She did not have any comorbidities and was scheduled for left shoulder disarticulation.\nShifting her to the theatre was a laborious process, and it necessitated two trolleys and a “team” to coordinate the process []. She was given uneventful general endotracheal anesthesia and interscalene brachial plexus block under ultrasound guidance []. Central venous pressure (CVP) was monitored in addition to standard ASA monitoring. Intravenous fluids were given to maintain CVP between 4 and 6 cm H2O. The intraoperative period was uneventful. The upper limb was completely removed through disarticulating at the left shoulder joint and it weighed 31 kg (40% of her initial weight).\nPostoperative analgesia was provided with a rather unique method. An elastomeric pump having a “Y-” shaped outlet tubing with two ports was used, each capable of delivering 1.04 ml/h 0.5% ropivacaine and administered to the brachial plexus (nerve sheath catheter analgesia) and the wound itself []. This infusion was continued for 5 days, and the patient was pain free throughout (mean numerical pain rating score 3). There was no requirement of additional analgesia. She was started on amitriptyline to preempt phantom limb pain. She was pain free and cheerful with a beaming smile during the postoperative period []. She was discharged on the 5th day. On follow-up 3 weeks later, the site had healed well by primary intention, with no stump or phantom pain and no phantom sensation either. |
A 35-year-old female patient was presented to our center for TV replacement due to stenosis. At the age of 11 years, the patient suffered from endocarditis supported by a small ventricular septal defect. At that time, the ventricular septal defect was closed and a mechanical tricuspid valve (SJM, 28 mm) implantation and epicardial single chamber pacemaker implantation due to concomitant third degree AV block without escape rhythm were performed. At the age of 17 years, the abdominal pacemaker was replaced, due to battery depletion (Biotronik). Six months later, a second surgery followed with replacement of the dysfunctional mechanical valve for a 27 mm Porcin-Baxter biological TV. Another PM replacement (Medtronic) was performed at the age of 27 years, again, due to battery depletion. At the age of 30 years, the abdominal pacemaker was explanted and a two chamber transvenous ICD (Medtronic Egida DR) was introduced, as the patient suffered a syncope during documented sustained ventricular tachycardia. The ICD lead was implanted passing the tricuspid valve into the right ventricle. Six years later, severe TV stenosis developed, caused by an ICD lead, that stuck to the posterior leaflet of the biological valve and ventricular myocardium, and the TV had to be replaced a third time. To avoid future TV dysfunction due to lead related complications, we discussed several options with the patient. These included first TV replacement in combination with epicardial pacemaker leads and a subcutaneous ICD (S- ICD, EMBLEM™ Boston Scientific) or alternatively placing a pacing lead in the coronary sinus in combination with an S- ICD. As the patient disagreed on both options, despite a higher risk of TV dysfunction by placing another transvenous ICD lead through the TV, we discussed another option and opted for a lead sparing replacement of the TV. The TV ring was cut open on both sides beneath the original ICD lead, and the TV prosthesis was excised. A new bioprosthetic valve was implanted, leaving the ICD lead outside the ring of the new TV prosthesis. As the lead was stuck to the former TV annulus and posterior ventricular wall, no further fixation of the lead was needed. The new valve (SJM biological 28 mm) was implanted using 14 Coreknots (Figures , , ).\nThe postoperative course was unremarkable, and the patient was dismissed on the 11th postoperative day/postoperative day 11. Follow-up after 4 months showed a well functioning TV prosthesis without stenosis or regurgitation and no deterioration in pacing or sensing parameters. No artifacts or other hints to a lead dysfunction were recorded (Table ). |
A 19-year-old female traffic accident victim was presented with multiple open bilateral fractures to the lower extremities with joint dislocation, massive skin and soft tissue defects, and multiple soft tissue contusion. Wounds on both lower extremities were covered with VSD (Vacuum Sealing Drainage). The tibiofibular and ankle joints on both lower limbs were fixed using external fixators. Knee joints’ passive motion on lower limbs was normal. The active movement was limited to a motion range of about 20 degrees due to pain. Muscle force was grade IV. Ten days later, wound exudation of both lower limbs decreased, granulation tissue grew fresh, and large areas of tendon, bone, and joint got exposed. Because of mandible fracture reduction and internal fixation, tracheotomy and indwelling tracheal cannula and artificial nose lead to the inability of spontaneous sputum excretion, and the condition requires long-term bed rest. Moreover, the operation time of DIEP combined with ALTP flap is significantly prolonged, which will definitely increase the risk of postoperative pulmonary complications. After comprehensive consideration, the operation was performed at different times. The skin on the right leg had a circular defect and the tibia was exposed. An anterolateral thigh flap (16 cm×7 cm) was designed from the opposite thigh for covering the tibia and soft tissue defects of the right leg (). The vascular pedicle was anastomosed to the anterior tibial artery, and the donor site was directly sutured. Cutaneous deficiency on the right leg was repaired by skin grafting from the left thigh.\nTen days later, the blood supply to the skin flap and skin graft area on the right lower limb was good, most of the 2nd toe on the left foot was necrotic, palmar skin defect was observed on the 1st metatarsal joint, and the joint capsule was exposed. The 3rd metatarsal bone had dry necrosis, without surrounding soft tissue. The necrotic tissues were removed. After bone cement removal from the left leg, the defect area of the skin and soft tissue was about 23 cm×10 cm. The fibular artery appeared to be of good texture. However, the anterior tibial artery was located at the proximal tibial stump, with poor texture. A skin flap of the same size was designed on the abdomen () and sutured to the skin defect area of the left leg. The trunk of the right inferior epigastric artery was anastomosed to the internal pressurized blood vessel reserved at the left pedicle (). The left inferior epigastric artery was anastomosed to the peroneal artery and the vein to the peroneal vein. Seven days later, an anterolateral thigh flap was designed on the right thigh to cover the wound of the left dorsum of the foot combined with a skin graft (). The branch of the posterior tibial artery was anastomosed to the descending branch of the lateral circumflex femoral artery of the flap. The vein was anastomosed to the vein of the descending branch of the lateral circumflex femoral artery with the posterior tibial artery. The blood supply to the flap was good. All flaps were sutured to the skin edge at the recipient site without tension. All donor sites were closed directly in one stage. After 9 months of follow-up, the flaps survived well, with a satisfactory appearance. Donor sites on both thighs and abdomen healed well. The lower limbs were saved successfully (). |
The patient was a 68-year-old man presenting with induration and swelling of the left submandibular region. His past medical history and familial history were unremarkable. At the age of about 25 years, he had noticed a small induration with an irregular surface in this region, but it was left untreated because of a lack of subjective symptoms. However, it also showed no tendency to improve, and then the swelling gradually worsened.\nAt the time of his first visit to our department, except for the induration and swelling in the left submandibular region, there were no abnormal findings in the ear, nose, throat, head, and neck. CT revealed nodular shadows with marked calcifications in the left submandibular region and the upper mediastinum (). No significant abnormalities were noted in the laboratory examinations. Preoperative FNAB of the left submandibular lesion was performed three times but revealed no evidence of malignancy.\nBecause of the uncertain diagnosis, surgery was performed. After a skin incision of the left submandibular region, an irregularly surfaced firm mass in the deep submandibular space was revealed (). First, open biopsy of a portion of the mass was carried out for intraoperative histopathological diagnosis of frozen sections. It revealed calcification with no evidence of malignancy. Following this diagnosis, tumor resection was performed. The tumor could be easily dissected from the surrounding tissue and removed, since it did not adhere to the hyoid bone, pharyngeal submucosal tissue and hypoglossal nerve. This nerve and the marginal submandibular branch of the facial nerve were identified and preserved.\nGrossly, the resected tumor was a 4 cm × 3 cm × 3 cm solid mass and showed marked calcification and ossification on sections (). Histopathologically, diffuse proliferating spindle cells with eosinophilic cytoplasm were present in a tangled and crossed arrangement in and around the calcification and ossification. A histological transition was observed between the smooth muscle tissue and calcification. Immunohistochemically, the spindle cells were stained intensely with α-SMA and h-caldesmon, consistent with smooth muscle cells (). These findings led to a definitive diagnosis of leiomyoma with calcification and ossification. His postoperative course was uneventful and no recurrence and no significant complications have been observed.\nHowever, a definitive diagnosis of the mass in the upper mediastinum () has not been obtained, it was considered most likely to be leiomyoma with calcification. Finally, the patient did not wish to undergo its resection immediately because he had no symptoms and the resection would be more invasive. |
A 71-year-old Saudi male patient with a 10-year history of hydatid disease involving the right kidney, retroperitoneum and right inguinal subcutaneous tissue, treated years earlier by a course of albendazole 400 mg daily for 2 months followed by partial nephrectomy, presented with multiple episodes of sudden attacks of shortness of breath and dull abdominal pain for the past 10 months. The attacks were severe enough to require multiple emergency room visits and admissions. The patient did not recall any significant history of trauma or lung infection. There was no history of chronic cough or chronic constipation. He had a significant past medical history of chronic kidney disease, diabetes mellitus, hypertension, renal stones and ischemic heart disease, for which he had undergone percutaneous coronary intervention 2 years earlier, and was started on antiplatelet therapy. The patient had also experienced several thrombotic events affecting his lower limbs in the form of “trash feet,” which were managed at that time without complications.\nAbdominal examination was unremarkable except for a painless, soft swelling over the right inguinal region. Additionally, his routine blood tests and hydatid titer were within normal limits. Chest X-ray (Fig. ) showed absence of a right diaphragmatic shadow, with bowel loops projecting over the lower chest above the level of the liver. A small pleural effusion was also present. For further evaluation of the condition, computed tomography (CT) scans of the chest and abdomen were performed and clearly demonstrated the presence of multiloculated cystic lesion at the upper pole of the right kidney, as shown in Fig. . The lesion was abutting the crus and the dome of the right hemidiaphragm. Further, a large diaphragmatic defect was seen at the posteromedial aspect with herniation of bowel loops and accompanying fat into the chest cavity. Subsequently, collapse of the lower lobe of the lung was evident.\nTen years earlier, magnetic resonance imaging and CT of the abdomen were performed in an outside hospital and demonstrated that the diaphragm was intact. There was also a larger retroperitoneal multiloculated lesion that abuts the crus of the right hemidiaphragm as well as its dome, notably at the posteromedial aspect. A smaller similar lesion was seen within the right kidney, as illustrated in Fig. .\nBased on his clinical situation, the decision was made to repair his DH, hopefully through a laparoscopic approach.\nThe operation started as a diagnostic laparoscopy where major portions of the small bowel, omental fat, and ascending and transverse colon were found to be partially herniating through two diaphragmatic defects, located posteromedially. The defects were separated from each other by a delicate septum with a total defect size of about 10 × 15 cm, and neither had a hernia sac, as shown in Fig. . The diagnosis of right-sided adult Bochdalek hernia was established, and hernial components were successfully reduced back into the abdominal cavity. However, the absence of a posterior anchoring point of the diaphragm made approximation of diaphragmatic edges or mesh implantation difficult to accomplish laparoscopically. Therefore, the approach was changed to posterolateral thoracotomy, where the two orifices were connected to each other, creating a 10 cm defect. The hernia was repaired with Gore-Tex DualMesh (15.0 cm × 19.0 cm × 2.0 mm oval) using a bridging technique fixed with Prolene 0 non-absorbable sutures, as demonstrated in Fig. . Postoperatively, the patient was transferred to the intensive care unit and kept intubated. Two days postoperatively, he developed deterioration in liver function, demonstrated in the form of elevated aspartate and alanine aminotransferases reaching 2400 and 2000 IU/L, respectively. CT scan was done and showed perfusion changes; however, hepatic and portal veins and hepatic arteries were all patent, with no evidence of biliary dilatation. Liver enzymes returned to baseline after a few days. The patient was discharged from the hospital in good condition on postoperative day 20.\nCurrently, 2 years postoperatively, the patient is symptom-free, with significant improvement in terms of his original complaints. |
Male, 26 years old, with a history of penis shaft silicone liquid injection (). After 3 years, he came to our Plastic Surgery Division with the main complaint of a hardening swollen penis with recurrent infection and recurrent lymphadenitis in both inguinal regions. The patient had difficulty urinating because of a protruding mass into the penis and feeling pain upon morning erection. The penis elicits severe pain when erecting for sexual intercourse. The physical examination revealed that the skin on the distal region of his penis was swollen with a diameter of roughly 5 cm when not erect, with the consistent expression of a circular solid mass. The patient already had an incision at the distal area of a circular paraffinoma mass to release the pressure on the glands by another paramedic and cannot urinate because of the infection of the incision area. The patient was referred to our division with a catheter and infection surrounding the gland area due to the excision. The patient was scheduled for paraffinoma mass excision and defect closure with FTSG. Excision was performed from the penile-pubic junction proximally to the distal shaft up to 0.3 mm from the glands (). The depth of excision did not cross the dartos fascia. The graft was taken from the left inguinal region and closed primarily using 5–0 polyglactin braided and 5–0 polypropylene sutures. The FTSG was placed on the raw surface area of the penile shaft in a spiral or circular pattern in a single graft sheet (). Using a 5–0 vicryl suture, the skin graft is connected at the coronal margin of the glans penis, pubic skin edge, and between the skin grafts. Quilt sutures from the FTSG to the dartos fascia were used to ensure the skin graft could not move or be crippled. The penis was a fixation with the dressing in an erect position. We used a silicone foley catheter because the patient was on bed rest for 2 weeks to ensure the skin graft would take and get other drugs such as antibiotics, analgesics, albumin, and vitamins. The patient was treated with HBOT as an adjunctive therapy. After five sessions of 2.0 ATA HBOT, the graft took successfully (). The follow-up at 6 months showed promising results; the patient only complained of slight itching in the postoperative area, which was treated with moisturizer at the donor and recipient sites. There was no infection, and the patient’s IIEF-5 score of 26 indicated no erectile dysfunction. The patient was happy with the result. |
Written informed consent was obtained to report the case. A 34-year-old G2P1 pregnant woman diagnosed with AS presented at the obstetric outpatient clinic at 18 weeks of gestation. She experienced back pain when she was 25 years old; these symptoms made walking difficult during her first pregnancy at 31 years old. Following her first vaginal delivery, she was able to walk although pain persisted to a lesser degree than during pregnancy. Radiography revealed osteosclerosis of the posterior surface of cervical vertebrae and osteoarthritis of the right hip with joint space narrowing (Figure ). The initial diagnosis of AS was made at 33 years of age.\nPain was managed by the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. After the present pregnancy was diagnosed, only acetaminophen continued to be administered, but pain increased during the present pregnancy. She complained of right hip pain, with a visual analog scale (VAS) score of 7/10. A dosage of 5 mg of oral prednisolone was administered daily from 18 weeks of gestation, and thereafter, the symptoms temporarily improved to 0/10 on the VAS. Unfortunately, the symptoms relapsed at 31 weeks of gestation. At 32 weeks of gestation, she complained of restricted neck mobility with difficulty gargling, restricted lumbar mobility that caused difficulties in bending her back, and restricted right hip joint mobility with a limitation of 10º of abduction, which also affected internal and external hip rotation. Peripartum management was discussed and planned by obstetricians and anesthesiologists. Given that only hip abduction and rotation, but not flexion, were limited, it was considered that an attempt of vaginal delivery would be possible when spontaneous labor occurred. However, if an emergency cesarean section (CS) was necessary during labor owing to other obstetric complications such as nonreassuring fetal status, special anesthesia management may be required because of the possible failure of spinal anesthesia due to calcified spinal ligaments and difficult tracheal intubation and airway management for general anesthesia. In such cases, the preparation of awake fiberoptic intubation or supraglottic airway device insertion should be considered.\nAt 38 weeks of gestation, the patient was admitted to our hospital because of membrane rupture. Labor analgesia was not provided. Oxytocin administration was required due to prolonged second stage of labor. Vacuum delivery with episiotomy left of the midline, which was opposite to the restricted right hip joint, was performed due to fetal bradycardia at birth. A healthy baby with a weight of 3358 g was successfully delivered. Both mother and neonate had a good postpartum course. Prednisolone and NSAIDs were started after pregnancy. |
A 26 year-old man attended our ophthalmic ward in April 2017 with intermittent bleeding of the right eye, from which there was also strong odor. The patient was a heavy smoker but had no other underlying conditions. He had no history of drug-use. From his medical history it was noted that the patient had undergone a right ophthalmectomy 24 years previously due to retinoblastoma, and implantation of an artificial right eyeball in 2014 (timeline shown in Additional file ).\nOn admission, his pulse rate was between 80 and 100 beats/min. His body temperature and respiratory rate were both normal. Physical examination showed narrow conjunctival sac in right eye and the exposure of ocular prosthesis, which was discharging a yellow-green secretion along with a strong odor. The visual acuity of left eye was 0.3, and the intraocular pressure was 15 mmHg. All other characteristics of the left eye were normal. A auscultation did not show any abnormality in the lungs, and no signs of carotid murmur were found. Interestingly, laboratory investigations did not reveal abnormal inflammatory markers such as leukocytosis or any increase in neutrophils or C-reaction protein. According to clinical and laboratory investigations, infectious endocarditis was not suspected. The patient had no history of other immunosuppressive conditions, except smoking and a retinoblastoma 24 years previously. The patient did not report any direct contact with animals; however, he did work in a clothing factory so would have been contact with wool and cowhide for one month of the year. Three months had elapsed between the patient last coming into contact with wool and cowhide and the appearance of clinical symptoms. Considering the results of these investigations, partial artificial eye infection, especially anaerobic organism infection, was suspected.\nImaging workups were completed, which included chest x-ray, transthoracic echocardiography and eye magnetic resonance imaging. As shown in Fig. , eye magnetic resonance imaging revealed that the tissue surrounding the right eye prosthesis as well as the soft tissue of the lacrimal gland area were swollen, whereas the left eye appeared normal. Inflammatory disease in the right eye was therefore suspected. According to chest x-ray and transthoracic echocardiography, no obvious abnormalities in the lungs or heart were observed.\nBefore surgery, a few specimens of the right eye secretions were collected to be cultured, but no bacteria were isolated, possibly because most of the secretions had been absorbed by the artifical eye making it yellow-green in appearance. After removal of the right artificial eye with debridement (5 days after admission), both the artificial eye and specimens of the eye secretions were sent for bacterial culture under aerobic and anaerobic conditions. No bacterial growth was detected from the ophthalmic secretions, but cultures were obtained from the artificial eye. Sparse growth of β-hemolytic cocci and heavy growth of small, non-hemolytic, translucent colonies were observed on Columbia agar plates supplemented with 5% sheep blood (BioMérieux, Marcy l’Etoile, France) under aerobic conditions after 48 h. And the latter colonies only grow close to the hemolysis zone of the former one. Under anaerobic conditions, only the small, translucent colonies were detected from the artificial eye (as shown in Fig. ). Of the two colony types, the β-hemolytic cocci were confirmed as Staphylococcus aureus, whereas the small, translucent colonies stained positive in a Gram stain and occurred singly, in pairs, or in short chains (Fig. ). Catalase and oxidase reactions of the unknown colonies were negative and phenotypic characterization using the Vitek2 GP system (BioMérieux) was inconclusive. However, Matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry revealed a match with Helcococcus ovis DSM 21504 T DSM (log score: 1.637) according to the Brucker Maldi-Biotyper database. Identification of this organism was confirmed by 16S rRNA gene sequencing. BLAST analysis of the partial 16S rRNA gene sequence derived from our isolate (1492 nucleotides, deposited in the GeneBank database under accession number MG188744) showed 98.9% identity (15 nucleotide differences) with the 16S rRNA gene sequence of H. ovis s840–96-2 deposited in the GenBank database under accession number NR027228 by Collins and coworkers [] in 1999 when this species was first described.\nAntimicrobial susceptibility testing (AST) of both strains was performed. The disk diffusion method was carried out and with the exception of penicillin, erythromycin and clindamycin, S. aureus isolated from this case was susceptible to all other drugs including cephalosporins and fluoroquinolones. AST for Helcococcus was performed using the CLSI broth microdilution method on Mueller-Hinton II broth (BD Diagnostics, Heidelberg, Germany) supplemented with 3% (vol/vol) lysed horse blood (Oxoid, Wesel, Germany) and 0.001% (wt/vol) pyridoxal HCl (Sigma–Aldrich, Munich, Germany) incubated at 37 °C in 5% CO2 for 24 h [, ]. Streptococcus pneumoniae ATCC 49619 served as a quality control. Then, we changed the method and performed an E-test on blood agar, with S. aureus ATCC 29213 as the quality control (for reference only). The MICs (μg/L) of the drugs for this strain are reported in Table . Since no antimicrobial testing guidelines are currently available from the Clinical and Laboratory Standards Institute (CLSI) for Helcococcus, the MICs were determined in reference to the CLSI guidelines for S. aureus []. According to the CLSI [, ], this strain was susceptible to penicillin, ampicillin, teicoplanin, ceftriaxone, vancomycin, and linezolid.\nAfter admission, the patient received levofloxacin eye drops 4 times per day until being discharged from hospital. After surgery, the patient was initially treated with intra-venous cefotaxime (2.25 g/250 ml NaCl, 1/day) and ornidazole (500 mg/day) for 1 week. Two weeks after admission, the patient recovered and was discharged from hospital. Six months later, the patient returned to the hospital to finish implantation of the artificial right eyeball and no signs of infection were detected. With the patient’s consent, we collected samples from the skin around both eyes for aerobic and anaerobic culture, but only normal skin flora were detected, such as coagulase-negative Staphylococcus. After surgery, the patient was in good health and was discharged from the hospital. |
A 28 year-old lady who was had previous 3 children (Gravida 3, Para 3) presented 6 months after cesarean section with history of severe pain and blood discharge during menstruation from the previous transverse supra-pubic scar, in between the menstrual cycles she complained from pus discharge from the same site of the scar. The patient had no dysuria with normal color urine, no frequent urination, and the defecation was normal.\nThe patient had history of previous 2 cesarean sections, the past medical history was negative for any chronic illnesses, and the cycles were regular with no history of dysmenorrhea.\nThe cesarean section was done at the 37th week of gestation as an emergency surgery because she had previous 2 scars and developed severe uterine contractions, she delivered a healthy male baby weighing 3.6 Kg.\nThe drug history was negative and the family history was negative for any relevant genetic information or psychosocial abnormalities.\nOn physical examination she had normal vital signs, the patient was afebrile, with no pallor, and the body mass index was 28.\nAbdominal examination revealed a localized tenderness at site of previous cesarean section scar with a 1*1 cm opening at the central part of the scar which was discharging blood during pressure over the lower abdomen. There was no urine discharge from the scar. Vaginal examination by the speculum was normal.\nThe complete blood count was normal with normal hemoglobin and white blood cells count, the urinalysis was also normal. The patient was sent for abdominal ultrasound which showed no abnormalities.\nFrom the clinical scenario we suspected endometriosis as the provisional diagnosis as many patients present after cesarean section complaining from cyclical bleeding at the site of the scar. The patient received medical treatment in the form of GnRH agonists for three months with little improvement and the symptoms recurred after that.\nThe second option was surgical intervention, the operation was performed under general anesthesia, the scar was excised and there was an abnormal fistulous tract which was connected to the uterus and the endometrial cavity at the site of the previous uterine scar which was sutured by a non-absorbable suture material (Silk) at the time of previous surgery (, ).\nComplete excision of the tract was done with removal of the previous sutures, removal of the necrotic tissue was done, refreshment of the edges was performed, the uterus was re-sutured using a slowly absorbable suture material, irrigation of the wound was performed with warm normal saline, and then the abdominal wall was closed ().\nThe operation was done by a gynecologist and a general surgeon.\nThe immediate post-operative condition was smooth and satisfactory with no immediate complications. Follow up the patient was done for 8 months with no post-operative complications with normal regular menstrual cycles. |
A 26-year-old man, educated in an engineering field, from a city in North of Iran was referred to School of Dentistry of Tehran University of Medical Sciences by an oral and maxillofacial surgeon (OMFS) for oral pathology consultation in winter of 2010. He complained of continuous dull pain in the upper left region of his face from 2 months ago and visual disturbances in recent weeks. The upper left second and third molars had been extracted by a dentist one month ago, assuming that the pain was of dental origin. As expected, the pain persisted and healing of the extraction site was not normal. Therefore, a more serious process was suspected and the patient was referred to an OMFS for further examination. He performed an incisional biopsy and sent it to a general pathology service for histopathologic examination. The microscopic diagnosis was “adenomatoid odontogenic tumor” which did not match the clinical and radiographic findings. The surgeon decided to ask for a second opinion and sent the documents to our center for consultation.\nClinical examination revealed a bony hard swelling of the left posterior region of maxilla. Intraorally, nontender buccal and palatal expansion of the alveolar ridge at the same area was observed. Also, the extraction site of the second and third molar was filled with an irregular exophytic ulcerated mass which bled easily on palpation []. No other intra- or extra-oral sign was observed; the remaining head and neck examination and general physical evaluation were unremarkable and no significant event was noted in the medical history.\nPanoramic radiographs demonstrated an ill-defined unilocular radiolucent lesion in the left posterior region of maxilla and the left maxillary sinus was totally obliterated. Computed tomography scan showed extension of the lesion medially and vertically to the nasal septal bone and the inferior orbital rim, respectively [].\nMicroscopic examination of the slides revealed a neoplastic tissue with scattered benign appearing cords and nests of epithelial cuboidal or columnar cells with peripheral palisading in a myxoid to highly cellular mesenchymal background mostly composed of plump stellate and ovoid to spindle cells. Nuclear hyperchromatism, pleomorphism, and scattered mitotic figures were identified in some areas as well as giant and bizarre cells and the tumor was diagnosed as “ameloblastic fibrosarcoma” accordingly [Figures and ].\nNo evidence of regional lymphadenopathy or distant metastasis was found and a segmental resection of the maxilla along with wide excision of the surrounding soft tissues was performed. Histopathologic examination of the whole specimen confirmed the diagnosis of AFS. All surgical margins were free of tumor infiltration. However, adjuvant radiotherapy was also performed in order to ensure a better outcome. The patient was under close follow up and after 6 months, rehabilitative prosthetic treatment was started. At present, after 2 years, the patient is free of any recurrence and in a good health status [Figures and ]. |
A 36-year-old G3P2 patient with a history of two previous caesarean sections was admitted for an elective repeat cesarean section at 39 weeks of gestation. The routine preprocedure preparation was uneventful and an indwelling bladder catheter was placed without difficulty. Upon peritoneal entry, the bladder was noted to be significantly distended despite the fact that urine was confirmed in the urinary drainage bag. In an attempt to empty the bladder, a new 12 G Foley catheter was placed, followed by a rigid silicone catheter, but the bladder remained distended. In order to have a better view of the pelvic organs, fetal extraction and uterotomy closure were decided.\nPersistence of bladder distension might have resulted from a urinary tract injury at initial catheterization. To investigate this hypothesis, 400 mL of methylene blue was injected through the urinary catheter. The bladder volume did not change and no methylene blue was noted intraabdominally. After this negative test, most of the 400 mL of methylene blue flowed back into the urinary bag and the remaining blue-colored urine came in intermittent streams. A rectal digital examination did not reveal any injuries.\nCystoscopy confirmed a distended bladder and two patent ureteral meatus. No trace of methylene blue was identified within the bladder. At the end of the cystoscopy procedure, a fold was noted on the posterior wall of the bladder neck (see ). This fold was initially thought to be iatrogenic. Insertion of the cystoscope inside this fold revealed a dilated peristaltic tubular structure containing methylene blue. This finding confirmed that the urinary catheter entered this ectopic ureter, and not the bladder. In order to avoid this fold and empty the bladder, a urinary catheter was placed under direct visualization. The postoperative course was uneventful and antibiotic prophylaxis was administered for 48 hours.\nMagnetic resonance imaging showed a left ureteral duplication with chronic renal pelvic dilatation of the superior calyceal system and associated cortical atrophy. The right kidney had a proximal bifid ureter (see ). |
A 69-year-old, diabetic, South Asian male presented to the emergency department of Hamad Medical Corporation (HMC) in October 2019 with sudden onset generalized abdominal pain more pronounced in the right lower quadrant and hypogastric region. He also had associated nausea and fever. On initial examination, he was afebrile and vitally stable and abdominal examination revealed tenderness in the right lower quadrant and suprapubic area with rebound tenderness. The remainder of his review of systems and physical exam was unremarkable. Computed tomographic (CT) examination of the abdomen showed multiple ileal diverticulae with focal wall thickening of the distal ileum and surrounding fat stranding and air loculi along the wall of the distal ileum suggestive of ileal diverticulitis with localized perforation (). He was admitted and managed conservatively with IV fluids and antibiotics and kept nil per orem. His symptoms subsided, and he was discharged three days later.\nTwo days after discharge, the patient returned to the emergency department with abdominal pain like the initial presentation but worse in intensity. A repeat CT with oral contrast revealed evidence of distal ileal perforation ().\nThe patient was taken for a laparoscopic exploration, and extensive peritonitis was noted; therefore, the procedure was converted to a laparotomy. We noted a perforation in the ileum 50 cm from the ileocecal valve on the mesenteric aspect of the bowel with a purulent exudate covering the terminal ileum (). The terminal ileum was resected, and a double-barrel ileostomy was created. His recovery was uneventful, and he was discharged on postoperative day 6. Histopathological examination of the resected bowel revealed 3 diverticulae with diverticulitis along with ulceration. Enteroscopic examination through the stoma showed multiple diverticulae up to 50 cm within the proximal limb (). Three months postoperatively, his stoma was reversed after resecting 50 cm of proximal terminal ileum which included all diverticulae. Postoperative course was uneventful, and the patient made a full recovery. Final histopathology revealed diverticular disease in the resected portion of the ileum with no evidence of diverticulitis. |
A 63-year-old female patient, 168 cm height and 53 kg weight on referral, suffered the following (chronical) diseases. She was diagnosed with a papillary thyroid carcinoma in 1989, which was treated by resection and radiotherapy. In the following years, she developed a stenosis of the esophagus. Because of this disease, repeated aspiration led to several episodes of respiratory insufficiency due to pneumonia and purulent pleurisy, which was treated by pleurectomy. Furthermore, she developed a restrictive ventilation pattern and a recurrent nerve palsy. Consequently, the patient was treated by percutaneous endoscopic gastrostomy and tracheostoma two decades before referral. She was put on home ventilation although not completely dependent on the ventilator. Her mobility decreased a lot and from 10 years before referral she never left the bed or nursing chair due to a secondary depression, and over this time, she nearly stopped talking. As a consequence, her mandible was nearly fixed, and she could not open her mouth over a maximum of 20 degrees at referral. Six years before referral, the left axis vertebralis was stented and developed furthermore stenosis of the internal axis carotis on both sides. In the meantime, arterial hypertension and secondary lactase deficiency were diagnosed. With the intention to alleviate the swallowing of saliva, the esophageal stenosis was dilated in a secondary hospital. On October 11, the patient was referred to the University of Erlangen due to a decreasing general condition. Unfortunately, a fistula between the esophagus and tracheal membrane had occurred in the upper third of the trachea which corresponded to the former field of radiotherapy. The patient was examined by several chiefs and consultants of Ear, Nose and Throat, Thoracic Surgery, Pulmonology and Medical intensive care unit at the University of Erlangen and she was deemed too unstable for open surgery. The inability to open the mouth and the recurrent nerve palsy gave rise to the judgment that a minimal invasive orthograde approach would be impossible to accomplish.\nOn October 26, the patient was referred to our hospital on the surgical intensive care unit. At this point, she was suffering from pneumonia by 4-multiresistente gramnegative Pseudomonas aeruginosa in the right lung. She was put on veno-venous extracorporeal membrane oxygenation (vv-ECMO) with a partial thromboplastin time of 60 seconds in a preseptic status (). This approach was chosen as an optional lung replacement due to the expectation that this procedure would be extremely difficult as a final last option. In addition, she was ventilated through a tracheostoma with low ventilation forces ().\nA thoracic computed tomography on October 27, 2016, confirmed a big fistula of the tracheal membrane of at least 3.5 cm length (). The tracheal cannula ended shortly beneath the lower limit of the mediastinal fistula.\nThe decision to try endobronchial stenting was made based on the plan to close the fistula with a pedicled omentum majus replacement through the diaphragmal opening of the esophagus. This surgical plastic needed an abutment and a secured continuous airway replacement above the tracheostoma level.\nThe procedure was performed on October 28, 2016. At that time, vv-ECMO began to be partly ineffective due to rising septical issues. To keep the vv-ECMO running, a high volume input of physiological saline was needed. Due to the fact that the oral approach would only allow a small flexible bronchoscope to guide instruments via seldinger technique in the upper third of the trachea, it was clear that the approach for this upper part of the trachea had to be performed through the percutaneous tracheostoma in a retrograde manner. After trying different Dumon and one-hybrid self expandable metalic y-stent, the plan was to changeover to a more floppy Freitag stent (FS). The whole procedure was accompanied by a mandatory additional ventilation (besides vv-ECMO) through a nasal jet catheter (Accutronic) or a special double-lumen endotracheal tube exchange catheter (DLET) (Cook Medical Company, Bjæverskov, Denmark; Ref. No C-CAE-11.0-100-DLT-EF-ST) which was always put on the back of all endobronchial materials as a border to the dorsally located fistula. This ventilation line was introduced either orally or through the tracheostoma and placed distally below the main carina.\nThe successful retrograde stenting was performed in four steps (I–IV).\nWith the help of regular bronchoscopes, jagwires, jet-catheters, and DLETs in different combinations, the manually compressed “y” of the FS was successfully pushed downward on the main carina (–).\nAt the level of the lower tracheostoma, the frontal surface of the stent was cut with at least 1 cm opening in the longitudinal axis. The stent surface was reduced ~40% in the sagittal axis. By this modification, a new stoma for a regular tracheal cannula was created. The lower new edge of this stoma was fixed subcutaneously ( and ).\nTo secure a patient endobronchial airway above the level of the percutaneous stoma in order to bridge the whole fistula up to the level of the vocal cords, a jagwire was introduced through the mouth into the trachea which were running out of the new FS stoma, leaving the dorsal membrane of the cut FS behind. Over this jagwire, this above-mentioned soft-tip stiff DLET was introduced for more stability and dragged out of the new stoma of the cut FS. Then, the distal jagwire was introduced into the oral orifice of the FS by bending up a curve. At that point of time, the oral part of the FS was still outside the body. By bending the FS outward at the level of percutaneous stoma and pulling the jagwire at both ends – one end was below the level of percutaneous stoma, the other was beyond the mouth – the FS flipped with its upper part over the soft-tip stiff DLET into the upper third of the trachea (–). As the DLET came downward from the mouth, the whole fistula was bridged by the FS up to the level of the vocal cords (). At the end, the upper edge of the new FS stoma was fixed subcutaneously (). A FS 11 cm in length (110–25–40) and an inner diameter of 13 mm was then placed successfully retrograde into the trachea and completely bridged the big fistula.\nA regular tracheal cannula was introduced for ventilation (–).\nDue to the fact that a lot of physiological saline was needed to keep the vv-ECMO running, the lungs were not aerated at that point of time. Over several days, the spontaneous breathing work increased and the vv-ECMO support was reduced, and the lungs became re-aerated again. The patient woke up again and could communicate with her family by writing and her eyes. Unfortunately, the infections continued to be very severe, and the spontaneous work of breathing never exceeded a tidal ventilation of 170 mL per breath. The reduction of intravenous saline injection was limited due to the mandatory but reduced vv-ECMO support. After 2.5 weeks of weaning approaches, the patient along with her family decided actively to reduce the vv-ECMO support, even with the risk of death. She unfortunately died on 18 November 2016 due to pulmonary infection. |
A 64-year-old gentleman presented with a 5-year history of an enlarging right cheek mass. He reported that the lesion was not bothersome at first but that it had been growing slowly over time. He presented because the mass had grown so much in size that it was obscuring his inferior visual field to the point that he was unable to see beneath his cheek on the right side. He denied numbness or tingling of the face, facial pain, weight loss, or difficulty with chewing. He had no other bumps or masses and no other complaints. His past medical history was significant for hypertension, hyperlipidemia, coronary artery disease with 3 myocardial infarctions and percutaneous coronary artery stenting, and an inguinal hernia repair. He walked with crutches for a left ankle fracture that he sustained as a youth. He was a previous cigar smoker but denied alcohol or illicit drug use. His father had BCC of the face, and his sister had breast cancer. Physical examination was significant for a 7 cm by 5 cm right cheek mass with extensive vascularization and central ulceration (see ). The lesion involved the skin and soft tissues of the face and extended to the buccal mucosa of the right cheek but was mobile and did not appear fixed to the maxilla. He had numbness on the right side of his face in the distribution of cranial nerve V2. There was no palpable facial or cervical neck lymphadenopathy.\nNoncontrast facial bone computed tomography (CT) scan revealed a mass-like subcutaneous lesion abutting the anterior aspect of the right maxilla, maxillary sinus, and inferior orbital rim and base of nasal bone, measuring about 5.5 cm in length by 5 cm in width by 4.5 cm in anterior to posterior dimension (see ). No definite bone erosion or remodeling was demonstrated. No enlarged lymph nodes were evident in the field of view. Posterior-anterior and lateral 2-view chest X-ray was benign. Ultrasound guided fine needle aspiration of the mass revealed BCC of nodular type, staged as clinical T2N0M0, Stage II.\nHis case was discussed at multidisciplinary tumor board and the consensus was that up-front surgical monotherapy would involve a large full thickness resection of the skin of the face, likely with a frozen section of the infraorbital nerve, a full thickness resection through the cheek including removal of the buccal mucosa, and a radial forearm free flap reconstruction. Given his major medical comorbidity of coronary artery disease with multiple previous myocardial infarctions, there was concern that he may be medically unfit for such an extensive surgical procedure. Moreover, the patient was concerned about his postoperative recovery period and ultimate facial cosmesis following such an approach. Alternatively, he was offered combined modality therapy with once daily oral vismodegib 150 mg, followed by definitive radiation therapy once the response to vismodegib had either dramatically slowed or plateaued, reserving surgery for salvage. He was agreeable to this plan and vismodegib was initiated.\nOverall, he tolerated the vismodegib very well and denied any muscle spasms, hair loss, weight loss, fatigue, nausea, decrease in appetite, or diarrhea. His only new complaint after 4 months of therapy was a minor decrease in taste which did not affect his appetite, ability to eat, or weight. Within 2 weeks of taking vismodegib, he noticed a decrease in the size of his lesion, and on physical exam it decreased to 6 cm by 4 cm. At 6-week follow-up, the lesion was 5 cm by 3 cm, and at 10-week follow-up it measured 4 cm by 3 cm. After approximately 14 weeks of vismodegib, the rate of reduction in the size of the lesion decreased, so the decision was made to proceed with definitive radiation therapy. The patient was maintained on vismodegib until the initiation of radiation therapy, resulting in approximately 4 months of drug therapy in total that resulted in an objective clinical response of greater than 50% reduction in the size of the lesion (see ). Prior to starting radiation therapy, he underwent repeat facial bone CT scan which revealed that the lesion had decreased in size to 2.7 cm in largest dimension (see ).\nHe then underwent CT simulation, in which he was positioned supine with a head and neck thermoplastic immobilization mask with a radioopaque wire placed around his residual lesion. His radiation therapy prescription was 50 Gy in 20 fractions of 2.5 Gy per fraction to the gross residual lesion (gross tumor volume, GTV) plus margin accounting for both local microscopic spread (clinical target volume, CTV) and interfraction setup variability (planning target volume, PTV) delivered daily, Monday through Friday, for a total of 4 weeks. He was treated with a 0.5 cm daily skin bolus using 3-dimensional conformal radiation therapy (3DCRT) with a 4-field technique involving right anterior oblique, left anterior oblique, anterior superior oblique, and anterior inferior oblique field arrangements. shows representative views and dose distributions of the radiation therapy plan on his CT simulation scan. relates target volumes to dose coverage and also shows representative doses to nearby critical structures. He tolerated radiation therapy very well with the expected toxicities of grade 1 fatigue that did not limit his daily activities and grade 2 moist skin desquamation in the area of the nasolabial fold that was improved with over-the-counter moisturizer and topical antibiotic cream.\nAt 3-month follow-up after the completion of radiation therapy, it was noted that he had a persistent 1.5 cm firm nodule in the right nasal-alar groove with overlying vasculature. Based on physical exam alone, it was difficult to determine if this nodule was scarring versus residual malignancy. Due to its firmness, size, and location, it was not amenable to fine needle aspiration, so the patient was taken for wide local excision, 2.5 cm by 5 cm, with intermediate closure. During the procedure, an elliptical incision was performed in the right cheek and the BCC in the right nasolabial fold was excised, resulting in a 2.5 cm by 5 cm defect which was then closed. He did not require reconstruction. Pathology from the wide local excision revealed only focal residual BCC with negative surgical margins. Overall, he tolerated the treatment very well and complained only of minor skin tightness and nasal congestion following his surgery. At 2-month follow-up after his surgery, he was doing very well, was clinically without evidence of disease, and had excellent facial cosmesis and functional capacity (see ). |
A 74-year-old male patient was admitted to our hospital in March 2017 to undergo liver resection to treat a malignant hepatic lesion diagnosed with CT and PET and a fine-needle biopsy positive for squamous carcinoma. The hepatic tumour discovered during follow-up for a previous bladder cancer submitted to endoscopic surgery three years before measured 22 mm in diameter and was located in the VIII Couinaud's segment [] of the liver in association with three smaller hypodense liver lesions with a focal dilatation of peripheral biliary tree ().\nThe case is discussed with radiologists, oncologists, and pathologists of our hospital. Even if the lesion had been the single site of disease; due to the proximity/doubtful infiltration of the lesion to the biliary tree, we decided to submit the patient to an explorative staging laparotomy and possible palliative surgery.\nOur internal protocol states that during the preadmission every patient who is a candidate for a liver resection is subjected to a routine liver function test with ICG to determinate the most appropriate surgical procedures []: 0,5 mg/Kg ICG are routinely injected intravenously up to seven days before surgery to evaluate the ICG retention rate at 15 min (R15). In our case 45 mg of ICG was intravenously administrated to test hepatic function, ten days before the surgery (patient R15 = 8.9).\nThanks to the ICG property of being fluorescent with the light emitted from the photodynamic eye of the laparoscopic system in our possession, it is possible to visualize the lesion during the surgical procedure. To this target, timing of administration and dose of ICG are key points.\nSeveral studies have demonstrated that the effective dose of ICG depends on the timing of injection; in particular, if the function liver test had been performed more than 7 days before surgery it would have been necessary to administer an adjunctive dose (0,1 mg/Kg) the day before []. In this case, it was necessary to administrate an adjunctive dose of ICG the day before the surgery (9 mg of ICG injected intravenously). After laparotomy, exploration of the abdominal cavity, and exposure of the liver, we easily confirmed the superficial lesion in the VIII Couinaud's segment. The liver surface has been analysed with the fluorescent imaging system. The fluorescing tumour has been clearly identified and defined on the liver surface, as shown in . We have also identified that a large area of fluorescent parenchyma that gets from the peripheral of the lesion up to the portal pedicle such as the neoplasia would interest the right biliary tree in the form of neoplastic lymphangitis (). This datum was not preoperatively known.\nA right hepatectomy would have been the oncologically correct surgical procedure due to the infiltration of right biliary duct. Considering the probable metastatic nature of the lesion, the absence of a clearly primary lesion, the age, the comorbidities, and the small size of residual liver, we have decided to perform an atypical segmental resection of S8 associated with cholecystectomy and lymphadenectomy of the hepatic pedicle nodes, including the area of impaired biliary excretion.\nAt the histological examination, the lesion, the lymph nodes of the hepatic pedicle region, and the right biliary branch, respectively, resulted in hepatic metastases from squamous cell carcinoma and sites of metastatic location. As expected the resection margin was interested by neoplasia.\nIn particular, the histological examination showed the following:Macroscopical exam: the neoplasia, in a site, appears to be in contact with the resection margin Microscopical exam: parenchymal hepatic section that showed metastatic localization of squamous carcinoma moderately differentiated. The neoplasia interest the surgery resection margin.\nIn this case, fluorescent imaging has revealed a fluorescing ring around the hepatic metastasis (). The fluorescence of the cholestatic area was shown on the cut surface (). |
The patient's clinical history started when she was 13 years old and presented with a generalized tonic–clonic seizure, which lead to a magnetic resonance imaging (MRI) of the brain with the subsequent diagnosis of multiple intracerebral CVs: a left frontal intraparenchymal one (35 mm in diameter) and a left posterior temporal one, both within the parenchyma (23 mm in diameter), and an intraventricular one (30 mm in diameter). Despite the best medical treatment, the epilepsy was not well controlled and the patient had up to three to four epileptic attacks per week. This case was discussed several times at our multidisciplinary meeting, as well as with the patients and the parents. The final decision was to remove the largest and the apparently symptomatic CV, and this decision was guided by a video-EEG (electroencephalogram). The left frontal CV was removed at the age of 14 years, with epilepsy symptoms being temporarily improved. Unfortunately, after 10 months, she started to complain of epilepsy again, with a clinical absence type behavior, pointed for temporal lobe origin type of seizures. Thus, a few months later, the left posterior temporal lesion was removed as well. The second operation gave very good medical results in terms of seizures control. The episodes dropped to one or two focal seizures per year. The third lesion, the intraventricular one, was followed up with a yearly MRI scan. At the age of 21, because the lesion had increased in size (∼8 mm) and because of the patient's desire, we decide to remove it using a transcranial interhemispheric approach. The operation was uncomplicated, and the patient was discharged home a week after the procedure. At that stage, no other lesions were present, and in the following 10 years, the follow-up MRI scans did not show any recurrence or new CVs. When she was 32 years old, on the yearly follow-up scan, a newly developed lesion was identified. This lesion, suspicious for CV, was small (6 mm) and located within the septum pellucidum. Because of its small size, the location, and the absence of symptoms, a conservative treatment option was followed. Unfortunately, the lesion doubled in size in the following 18 months and therefore the patient was very adamant about having it removed (\n). We were a bit reluctant because the patient was completely asymptomatic and had not had any epileptic attack for 10 years. Upon neurologic examination, she presented no issues. Finally, we took the decision to remove the lesion and we started to discuss how to approach it. We were wondering whether to use the same interhemispheric approach with the possibility of encountering scar tissue or if it was better to use a new surgical route such as a transcortical one. Finally, we decided to use something completely different and we opted for a transcortical endoscopic approach.\nWith the patient in the supine position through a single burr hole, placed slightly more laterally in relation to Kocher point, a purely endoscopic approach was performed and the lesion was completely removed (\n). A rigid endoscope was used and guided by the neuronavigation. Upon inspection, the lesion (\n) presented with two veins attached to it (one rostral and the other caudal). The removal began with the coagulation and dissection of the septum pellucidum superior to the CV location. After accurate coagulation and section of the caudal vein, using endoscopic forceps allowed the creation of a “pedunculated” CV. The insertion of an endoscopic rongeur in the space between the peel-away cannula and the endoscope allowed keeping the CV in place, avoiding its fluctuation in the ventricles. This maneuver allowed the exposition and easy dissection of the rostral vein, which, eventually, was coagulated and cut. The CV was then freed from the surrounding tissue and finally removed. An external ventricular drainage was precautionary left in the right ventricle just for 24 hours.\nThe histological examination revealed multiple dilated and congested vascular spaces lined by the endothelium, confirming the diagnosis of a CV.\nThe postoperative course was uneventful, and the patient was discharged home 2 days later. Serial follow-up MRI scans did not show any new or recurrent lesion at 5 years follow-up. |
A 62-year-old male with a medical history of hypertension, poorly controlled diabetes, and stroke with residual mild cognitive impairment and expressive aphasia presented to the hospital complaining of abdominal pain, vomiting, and ambulatory dysfunction for the last two days. He had a preexisting mid-metatarsal amputation of the left foot and was on aspirin 81 mg daily. He stated that he felt generally weaker than normal and was unable to ambulate in the ED. A noncontrast CT of the head was negative on presentation, and he was subsequently admitted for the management of dehydration secondary to suspected viral gastroenteritis. His nausea and vomiting improved shortly after admission. However, on the first day of hospitalization, the patient was being assessed by the medicine team as well as physical therapy and was found to be leaning backward and to the right when standing or attempting to ambulate. His family confirmed at this time that he had been doing this at home for a few days and had experienced several falls recently.\nGiven these findings, the neurology service was consulted and he was assessed on his second day of hospitalization. He was noted to have left-sided dysmetria. A CT angiogram of the head and neck showed a congenitally hypoplastic left vertebral artery and otherwise patent vertebrobasilar system with multifocal intracranial stenosis in the anterior circulation bilaterally. MRI of the brain was performed and confirmed a large area of acute/subacute infarct in the right cerebellar hemisphere without mass effect (Figure -). MRI at that time also showed restricted diffusion in a miniscule region of the AP on the right (Figure ). Echocardiogram performed showed an LVEF (left ventricular ejection fraction) of 60%, no regional wall motion abnormalities, normal wall thickness, and grade 1 diastolic dysfunction with trace aortic regurgitation. On day 5 of hospitalization, the patient became acutely more nauseous again and was noted to have projectile bilious vomiting. The nausea and vomiting lasted from minutes to hours and occurred with or without movement, typically following a meal. Notably, his neurologic examination was unchanged from the previous one, and the abdominal examination was unremarkable. The patient was sent for an abdominal X-ray obstruction series, which was negative. Subsequently, he was sent by the primary team for a repeat MRI of the brain to assess for worsening or a new infarct. The MRI was read as “stable” by the radiology service (Figure -). He was initially treated with ondansetron 8 mg every six hours as needed, which was ineffective. The neurology service was reconsulted for input regarding the intractable nausea and vomiting. He also had concomitant hiccups. The MRI was reviewed by the neurology service, and it was apparent that the stroke in the AP had extended (Figure ) and explained his APS. The stroke etiology was felt to be likely secondary to vessel-to-vessel embolization due to chronic atherosclerotic disease and less likely. The patient was monitored on telemetry for several days without any events or abnormalities noted.\nHe was started on a scheduled antiemetic regimen of metoclopramide 10 mg four times daily and ondansetron 8 mg every eight hours. Within one day, the nausea and vomiting was under control, and the patient was able to eat again without difficulty and was successfully discharged to rehabilitation. |
A 54-year-old male patient was diagnosed with pancreatic cancer and suffered from intractable, severe epigastric pain with a score of 5 to 8 out of 10 on the Numeric Rating Scale (NRS). Furthermore, the abdominal pain was not responsive to opioids and other medications.\nTherefore, we planned to perform celiac plexus neurolysis and reviewed the patient's anatomy on the abdominal CT image with contrast to determine the target point, ideal depth, and insertion angle through CT simulation. The celiac trunk was located at the T12 vertebral body level. At this level, the classic conventional transcrural approach via "walking off" the vertebral body was simulated, but the needle pathway was impeded by the kidney on the right side and by the aorta on the left side (). Then, we simulated the transdiscal pathway through the T11-12 intervertebral disc. The pathway was drawn from the target point to the lateral side of the right superior articular process of the T12 vertebra and extended to the skin.\nThe point at which the pathway crossed the posterior skin surface was designated as the needle insertion point (I). The distance from the midline spinous process of the T12 (S) to the needle insertion point was measured against the scale printed on the axial CT image (IS: 3.6 cm). The angle between the proposed needle pathway and the midline was designated as the needle insertion angle (*) (). The distance between the target point and the anterior margin of the vertebral body was measured, and the anteroposterior (AP) diameter of the vertebral body was also measured. The proportion of these two values was used to estimate the proper depth of the needle in the fluoroscopic image.\nIn the operating room, the patient was placed in a prone position, and we identified the T11-12 intervertebral disc space. In this case, the predetermined insertion angle was 18 degrees on the right side. Therefore, we rotated the fluoroscopy tube 18 degrees to the right side. The insertion point was the lateral margin of the superior articular process of the T12, and it was marked 3.6 cm to the right of the midline. After anesthetic infiltration was deepened in a fan fashion, the skin was punctured with a 16 g needle, and a 20 g Chiba needle was introduced through the 16 g needle. After contacting the disc, the fluoroscope was rotated to the lateral position. We inserted the needle through the disc while checking the tip position with the AP and lateral fluoroscopic images. After penetrating the disc, the 20 g Chiba needle was advanced up to the predetermined depth, which was 2/3 of the AP diameter of the vertebral body from the anterior margin of the vertebral body. Frequent fluoroscopic images for both the AP and lateral views were used to guide the needle when advancing it in the correct plane. While advancing the needle, we checked the loss of resistance using saline to penetrate the crura of the diaphragm. Contrast was injected to confirm the proper spread; the contrast flow showed a smooth curvilinear contour corresponding to the anterolateralaortic space, and it silhouetted the runoff of the celiac artery. On the AP view, the contrast spread across the midline. On the lateral view, the needle penetrated the disc, and its tip was located at 2/3 of the AP diameter anterior to the vertebral body. Then, 15 ml of 2% lidocaine followed by 15 ml of 99% ethyl alcohol was injected for neurolysis ().\nThere were no adverse events during the procedure. The patient tolerated the entire procedure well and did not complain of pain related to the procedure. The next day, during follow-up, the patient reported an abdominal pain score of 2 to 3 out of 10 on the NRS. After 1 week, the patient expressed great satisfaction with the results and was discharged. |
The patient was a 76-year-old male with past medical history significant for open cholecystectomy over ten years ago and coronary artery bypass graft less than one month prior to presentation. He was admitted for small bowel obstruction and initially treated nonoperatively. The patient failed to progress and was taken to the operating room for exploratory laparotomy with lysis of adhesions and resection of a 4.5 cm segment of ischemic small bowel with stapled anastomosis. Washout was completed and abdomen was closed.\nInitial postoperative course was uneventful other than the development frequent loose stools secondary to Clostridioides difficile infection diagnosed by stool toxin assay on postoperative day #6. Until this point, he only had a 24-hour perioperative antibiotic coverage. He was then started on oral vancomycin with plans for discharge the next day. However, he rapidly decompensated the next morning and was found to be septic with diffuse peritonitis and spillage of enteric contents from the midline incision. The patient was emergently taken for repeat exploratory laparotomy. Upon inspection, the entire staple line of the anastomosis had dehisced and over four liters of loose enteric contents were evacuated. The proximal limb continued to briskly secrete an abnormally large amount of enteric contents. The area was further resected with new stapled anastomosis. Enteric contents obtained from the proximal end were tested and found positive for Clostridioides difficile toxin, confirming the diagnosis of Clostridioides difficile enteritis. Final pathology of small bowel resection found severe transmural ischemia.\nThe patient's proceeding hospital course was complicated by prolonged ventilatory-dependent respiratory failure on vasopressor support. A large fluid collection was identified with concern for possible abscess not amenable to percutaneous drainage which required surgical drainage on hospital day #18 although this fluid was found to be serous with no infection. With persistent anemia requiring multiple transfusions, he underwent endoscopy on hospital day #28 where a bleeding gastric ulcer was identified and cauterized. The patient eventually progressed and was transferred to a skilled nursing facility on hospital day #42 with physical deconditioning requiring further physical therapies. Due to continued poor oral intake and malnutrition, he underwent percutaneous endoscopic gastrostomy tube placement three days after discharge but was otherwise lost to follow-up. |
Fully informed consent for publication of clinical information relating to this case was obtained from the patient.\nThe patient was a 68-year-old man who was examined at our hospital's emergency outpatient department after his face was struck by the steering wheel during a traffic accident. The emergency room doctor performed computed tomography (CT), which showed no abnormalities of the internal organs or brain. That same day, he was referred to our department for the treatment of contusions of the lips and oral cavity. No abnormal findings in his medical history or family history were noted. When he arrived at the hospital, he was in pain and bleeding from the contusions, but there were no signs of nerve paralysis or infection. The contusions of the lips and oral mucosa were debrided and sutured.\nThe CT performed in the emergency department showed no fractures anywhere. However, it showed a cavity in the lingual side of the mandible from the right anterior to the premolar region. CT in hard tissue mode showed a high-density line, suggesting cortical bone on the margin of the cavity in the lingual side of the mandible (). The lingual cortical bone was recessed from the lingual side to the buccal side and, at the most recessed point, was contiguous with the buccal cortical bone (). There was no continuity between the apex of the adjacent #27 and the cavity in the lingual side of the mandible, and a high-density line suggested the presence of bony tissue between the apex of #27 and the cavity in the lingual side of the mandible. There was no continuity between the cavity in the lingual side of the mandible and the mandibular canal. CT in soft tissue mode showed that the inside of the cavity in the lingual side of the mandible had similar soft tissue density (CT number, 40–70 Hounsfield units (HU)) to the sublingual glands (CT number, 40–60 HU) and was contiguous with the sublingual glands (). Based on these CT findings, our presumed diagnosis was a Stafne bone defect.\nIn 3 months after the first examination, magnetic resonance imaging (MRI) was performed to examine the tissue inside the cavity in the lingual side of the mandible. The area exhibited greater hyperintensity than the muscle and similar signal intensity to the sublingual gland tissue on T1-weighted and T2-weighted images and was filled with soft tissue contiguous with the sublingual glands. Short T1 inversion recovery images showed no signs of tumors or inflammation in the surrounding area. A final diagnosis of a Stafne bone defect was established based on the presence of a cavity in the lingual side of the mandible from the right anterior to the premolar region that was filled with salivary gland tissue connected to the sublingual gland tissue (Figures and ). Subsequently, regular imaging was performed, and the patient was followed up.\nAbnormal findings had not been observed 12 months after the first examination. |
A 70-year-old female patient was hospitalized because of known cholangitis. She had previously undergone cholecystectomy because of the cholelithiasis. Physical examination revealed tenderness of the lower quadrants of the abdomen. As part of the clinical work-up, the patient underwent an abdominal computed tomography, which demonstrated colonic distension and small bowel ileus with focal narrowing and obstruction of the transverse colon (). Mechanical obstructive ileus was suspected, and a colonoscopy revealed luminal erosion and stricture of the transverse colon. Microscopic examination of multiple blind biopsies showed erosion and vascular congestion with no evidence of malignancy. A whole body scan to evaluate the presence of metastatic lesions did not show any abnormal fluorodeoxyglucose uptake. The patient was diagnosed with colonic malignancy, and right hemicolectomy was performed.\nOn gross examination, the resected specimen displayed infiltrative submucosal lesions that involved the whole circumference and resulted in colonic stricture (). Histologically, the colonic mucosa was intact except for focal erosion, and the muscular layer was markedly hypertrophied at the stricture site. Further microscopic examination revealed that a benign glandular structure of gastric origin invaded the erosive colonic mucosa. These glands showed a downward growth pattern toward the submucosa and the muscular layer, gastric differentiation, and focal cystic dilatation (). Additionally, we identified an adenocarcinoma that originated in the heterotopic gastric glands in the submucosa and muscular layers. The adenocarcinoma foci were composed of glands as well as isolated tumor cells and clusters with focal mucin production and were moderately to poorly differentiated (). The tumor was distributed through the colonic wall and pericolic soft tissue. Immunohistochemically, both the heterotopic glands and adenocarcinoma showed positive results for cytokeratin (CK) 7 and MUC5AC and were negative for CK20, CDX2, and MUC2 (, ). On the basis of these findings, heterotopic gastric mucosa in the transverse colon and development of invasive adenocarcinoma were diagnosed and staged at pT3, pN1b (2/43), pMx according to the 7th edition of the Cancer Staging Manual of the American Joint Committee on Cancer. |
The patient's clinical history started when she was 13 years old and presented with a generalized tonic–clonic seizure, which lead to a magnetic resonance imaging (MRI) of the brain with the subsequent diagnosis of multiple intracerebral CVs: a left frontal intraparenchymal one (35 mm in diameter) and a left posterior temporal one, both within the parenchyma (23 mm in diameter), and an intraventricular one (30 mm in diameter). Despite the best medical treatment, the epilepsy was not well controlled and the patient had up to three to four epileptic attacks per week. This case was discussed several times at our multidisciplinary meeting, as well as with the patients and the parents. The final decision was to remove the largest and the apparently symptomatic CV, and this decision was guided by a video-EEG (electroencephalogram). The left frontal CV was removed at the age of 14 years, with epilepsy symptoms being temporarily improved. Unfortunately, after 10 months, she started to complain of epilepsy again, with a clinical absence type behavior, pointed for temporal lobe origin type of seizures. Thus, a few months later, the left posterior temporal lesion was removed as well. The second operation gave very good medical results in terms of seizures control. The episodes dropped to one or two focal seizures per year. The third lesion, the intraventricular one, was followed up with a yearly MRI scan. At the age of 21, because the lesion had increased in size (∼8 mm) and because of the patient's desire, we decide to remove it using a transcranial interhemispheric approach. The operation was uncomplicated, and the patient was discharged home a week after the procedure. At that stage, no other lesions were present, and in the following 10 years, the follow-up MRI scans did not show any recurrence or new CVs. When she was 32 years old, on the yearly follow-up scan, a newly developed lesion was identified. This lesion, suspicious for CV, was small (6 mm) and located within the septum pellucidum. Because of its small size, the location, and the absence of symptoms, a conservative treatment option was followed. Unfortunately, the lesion doubled in size in the following 18 months and therefore the patient was very adamant about having it removed (\n). We were a bit reluctant because the patient was completely asymptomatic and had not had any epileptic attack for 10 years. Upon neurologic examination, she presented no issues. Finally, we took the decision to remove the lesion and we started to discuss how to approach it. We were wondering whether to use the same interhemispheric approach with the possibility of encountering scar tissue or if it was better to use a new surgical route such as a transcortical one. Finally, we decided to use something completely different and we opted for a transcortical endoscopic approach.\nWith the patient in the supine position through a single burr hole, placed slightly more laterally in relation to Kocher point, a purely endoscopic approach was performed and the lesion was completely removed (\n). A rigid endoscope was used and guided by the neuronavigation. Upon inspection, the lesion (\n) presented with two veins attached to it (one rostral and the other caudal). The removal began with the coagulation and dissection of the septum pellucidum superior to the CV location. After accurate coagulation and section of the caudal vein, using endoscopic forceps allowed the creation of a “pedunculated” CV. The insertion of an endoscopic rongeur in the space between the peel-away cannula and the endoscope allowed keeping the CV in place, avoiding its fluctuation in the ventricles. This maneuver allowed the exposition and easy dissection of the rostral vein, which, eventually, was coagulated and cut. The CV was then freed from the surrounding tissue and finally removed. An external ventricular drainage was precautionary left in the right ventricle just for 24 hours.\nThe histological examination revealed multiple dilated and congested vascular spaces lined by the endothelium, confirming the diagnosis of a CV.\nThe postoperative course was uneventful, and the patient was discharged home 2 days later. Serial follow-up MRI scans did not show any new or recurrent lesion at 5 years follow-up. |
An 89-year-old fit female with a history of chronic back pain and an appendectomy during her youth completed using a McBurney incision presented with a one-day history of spontaneous pain in her right flank without any fever, chills, or other symptoms. At the time of her admission, she was not in distress, she was not febrile, and her vital signs were within normal values. On clinical examination, there was swelling with a red area measuring 12 cm × 4 cm and tenderness of the right flank around her appendectomy scar. Crepitus could be felt diffusely on her right and left flanks and the periumbilical and epigastric regions upon palpation. Blood test showed the presence of mild inflammation, with a CRP value of 7 mg/l (within normal values) and an elevated white blood cell count of 18 G/l. The rest of the laboratory results were normal. Emergency ultrasonography was unhelpful because of air interference. An abdominal CT scan () showed diffuse subcutaneous abdominal emphysema extending to the pelvis on the left side that was more pronounced on the right inguinal fossa with a bowel loop in contact with the abdominal wall. An emergency laparotomy centered on the McBurney incision showed feces and pus within the subcutaneous compartment. Furthermore, at the level of the aponeurosis of the external oblique muscle, an inflammatory diverticulum could be seen fistulizing between the lumen of the sigmoid colon loop and the necrotic subcutaneous tissue. We subsequently diagnosed intraoperatively a subcutaneous abscess and emphysema with an enteroparietal fistula caused by a ruptured sigmoid diverticulum in an incisional hernia. The necrotic tissues were excised, and the punctiform sigmoid colon fistula was closed. Revision of the rest of the sigmoid showed important adhesions between the sigmoid colon and the parietal peritoneum of the right flank and between the caecum and the sigmoid colon, respectively. The sigmoid colon also showed diffused diverticulosis with no inflammation. The cutaneous and subcutaneous tissues were left open and dressed with a negative pressure-assisted closure device on postoperative day 1. The patient received intravenous antibiotherapy for two weeks with quinolones and a third-generation cephalosporin at first which was then switched to aztreonam due to an allergic reaction. Bacteriological studies showed polymicrobial digestive bacteria (i.e., Escherichia coli, Streptococcus equinus, and Enterococcus). Subsequently, there was good clinical and biological evolution. At two weeks postoperation, she was reoperated on for closure of the wound. She was discharged from the hospital three weeks after her initial surgical intervention with the indication to continue antibiotics for a total of four weeks. |
The patient was a 14-year-old girl. We obtained informed consent from the patient and her parents for the publication of her data in this scientific study. She belonged to the athletic club of her junior high school. While sprinting in a relay race, she suddenly experienced left buttock pain and difficulty walking. The next day, she visited her nearby hospital and was diagnosed with an avulsion fracture of her left ischial tuberosity. The orthopedist continued to observe her without any treatment; however, 11 months after the injury, her pain had not improved, and the fracture did not achieve union. Therefore, she was referred to our department for further treatment.\nAt her first visit to our hospital, she was found to have local tenderness on her left buttock just above the ischial tuberosity. She could not sit for 10 minutes due to pain at the same point as the tenderness. Her hip and knee joints showed no restricted range of motion. There was no difference in the thigh and calf girth between both her legs. No abnormal neurologic finding was noted in both legs.\nRadiographic images revealed the transposition of the bone fragment, which was 12 mm at the time of the injury () and had now increased to 23 mm, and the fragment had enlarged (). Bone scintigraphy showed intense uptake in both sides of the nonunion site, ischial tuberosity, and bone fragment ().\nShe was diagnosed with nonunion following the avulsion fracture of her left ischial tuberosity, and surgical treatment was performed one year after the injury. The surgery was performed in the prone position under general anesthesia. An incision of about 10 cm was made along the gluteal crease. After lifting the gluteus maximus, the nonunion site was exposed. The unstable bone fragment was connected to the sciatic bone with capsule-like fibrous tissue, from which about 1 ml of bloody synovial fluid was withdrawn by a puncture. After removing the tissue around the bone fragment, it was fixed with two 6.5 mm-diameter cannulated cancellous screws. Then, the hamstring tendon was fixed to the ischial tuberosity with three 2.3 mm-diameter suture anchors ().\nFrom postoperative day 1, range of motion exercises of the hip and knee joints were allowed. During the first 4 weeks, any weight bearing on her left leg was prohibited. Thereafter, one-third partial weight bearing (PWB) was allowed, and the load was raised every 2 weeks in the following increments: 1/2 PWB, 2/3 PWB, and full weight-bearing. Jogging was started 3 months after the surgery when the radiographical bony union was recognized. We measured her hamstring strength before and after surgery in 90 degrees of knee flexion () using a handheld dynamometer. Her hamstrings strength in 90 degrees of knee flexion on the affected side had improved to over 97% of that on the unaffected side 6 months after the surgery, and a strength of more than 85% was maintained even after the frequency of rehabilitation decreased. Nine months after the surgery, she could run at full speed and had returned to a competitive level of athletics. At the most recent follow-up, 3 years after the surgery, she had continued athletic activity in high school, without any pain (). |
A 42-year-old female presented to the Emergency Department with a complaint of left lower quadrant abdominal pain and cramping that she reported began 2 days prior. Pain onset was followed by bloody stools, both of which resolved the following day aside with only some residual nausea. Abdominal cramping recurred early on in the morning of admission. The patient denied any ingestion of potentially contaminated water or unusual food. The patient history was also negative for recent surgeries, travel, or sick contacts. The patient reported no family or personal history of inflammatory bowel disease and had no other concerns aside from the left lower abdominal pain and bloody stools.\nUpon examination, her vital signs revealed an elevated heart rate of 118 and a slight elevation in blood pressure at 134/88. Her abdominal exam showed normal bowel sounds and a soft abdomen but with mild diffuse tenderness. No rebound or guarding was noted.\nLaboratory testing was largely unremarkable. CT abdomen pelvis with intravenous contrast revealed findings consistent with an ileocolic intussusception (). A tubular structure was seen within the lumen of the intussusception which was determined to be a distended appendix potentially serving as the lead point. No indication of obstruction or bowel perforation was seen, but there was a small amount of intraperitoneal fluid. All organs were unremarkable aside from a non-obstructing stone seen in the right kidney.\nThe patient was admitted to general surgery for further evaluation and management. It was discovered that right colon and distal ileum had intussuscepted into the transverse colon, but it was unable to be reduced laparoscopically and therefore the procedure was converted to open laparotomy. After converting to an open procedure and mobilizing the colon, it was noted that a very long segment of colon had intussuscepted with a firm mass and lead point that had travelled into the transverse colon. The bowel was manually manipulated back to its original placement, at which point the base of the appendix appeared to be thickened and fibrotic, likely serving as the lead point for the intussusception. She also had a Meckel's diverticulum that was resected and sent to pathology. The patient was discharged the following day. Pathology revealed low-grade appendiceal mucinous neoplasm. A follow-up CT scan 6 months later revealed no evidence of disease. |
A 26-year-old, a male who is an auto driver by profession presented with a relapse of alcohol dependence. The patient was treated for alcohol dependence in a private hospital, and he was abstinent for last 4 years till 2 months before. He also a complaint of hearing voices for the 4 months but it did not disturb him much. Patient complaint of excessive anxiety and restlessness 2 months ago following the demise of his relative. He started consuming alcohol and within 4 days he developed tremor, insomnia, craving for alcohol which qualified him for a relapsed episode. He was admitted to hospital and detoxified. During the stay, complaint of hearing of voices getting more prominent following deaddiction treatment. After the admission, he complaint of hearing multiple people talking among themselves about him. He used to talk back to them but could never control it. He also used to get irritated on silly matters and cry like a helpless boy with an expression of suicidal ideation to get relief from the agony of hearing derogatory voices. He continued to be abstinent from alcohol after 2 weeks of discharge, but the hearing of voices got worsened which was quite unexpected even in the presence of olanzapine 20 mg and quetiapine 25 mg. His cognition was well preserved with Mini-Mental State Examination score of 27. Due to the atypical course of illness, we sought a neurological consultation, who suggested for magnetic resonance imaging (MRI) brain and electroencephalogram (EEG). Out of our surprise, MRI report revealed the presence of an arachnoid cyst in right middle cranial fossa compressing temporal lobe. EEG did not reveal any paroxysmal discharge. Other investigations such as total and differential count, blood sugar, thyroid function, urine routine, liver and renal function tests were within normal range. Hence, neurosurgical consultation was asked for. They suggested mannitol to reduce intracranial pressure and phenytoin to prevent focal seizure. Surgical intervention was discussed with the patient. With anti-edema measures, the patient was significantly improved from hallucination. |
A 26 year-old man attended our ophthalmic ward in April 2017 with intermittent bleeding of the right eye, from which there was also strong odor. The patient was a heavy smoker but had no other underlying conditions. He had no history of drug-use. From his medical history it was noted that the patient had undergone a right ophthalmectomy 24 years previously due to retinoblastoma, and implantation of an artificial right eyeball in 2014 (timeline shown in Additional file ).\nOn admission, his pulse rate was between 80 and 100 beats/min. His body temperature and respiratory rate were both normal. Physical examination showed narrow conjunctival sac in right eye and the exposure of ocular prosthesis, which was discharging a yellow-green secretion along with a strong odor. The visual acuity of left eye was 0.3, and the intraocular pressure was 15 mmHg. All other characteristics of the left eye were normal. A auscultation did not show any abnormality in the lungs, and no signs of carotid murmur were found. Interestingly, laboratory investigations did not reveal abnormal inflammatory markers such as leukocytosis or any increase in neutrophils or C-reaction protein. According to clinical and laboratory investigations, infectious endocarditis was not suspected. The patient had no history of other immunosuppressive conditions, except smoking and a retinoblastoma 24 years previously. The patient did not report any direct contact with animals; however, he did work in a clothing factory so would have been contact with wool and cowhide for one month of the year. Three months had elapsed between the patient last coming into contact with wool and cowhide and the appearance of clinical symptoms. Considering the results of these investigations, partial artificial eye infection, especially anaerobic organism infection, was suspected.\nImaging workups were completed, which included chest x-ray, transthoracic echocardiography and eye magnetic resonance imaging. As shown in Fig. , eye magnetic resonance imaging revealed that the tissue surrounding the right eye prosthesis as well as the soft tissue of the lacrimal gland area were swollen, whereas the left eye appeared normal. Inflammatory disease in the right eye was therefore suspected. According to chest x-ray and transthoracic echocardiography, no obvious abnormalities in the lungs or heart were observed.\nBefore surgery, a few specimens of the right eye secretions were collected to be cultured, but no bacteria were isolated, possibly because most of the secretions had been absorbed by the artifical eye making it yellow-green in appearance. After removal of the right artificial eye with debridement (5 days after admission), both the artificial eye and specimens of the eye secretions were sent for bacterial culture under aerobic and anaerobic conditions. No bacterial growth was detected from the ophthalmic secretions, but cultures were obtained from the artificial eye. Sparse growth of β-hemolytic cocci and heavy growth of small, non-hemolytic, translucent colonies were observed on Columbia agar plates supplemented with 5% sheep blood (BioMérieux, Marcy l’Etoile, France) under aerobic conditions after 48 h. And the latter colonies only grow close to the hemolysis zone of the former one. Under anaerobic conditions, only the small, translucent colonies were detected from the artificial eye (as shown in Fig. ). Of the two colony types, the β-hemolytic cocci were confirmed as Staphylococcus aureus, whereas the small, translucent colonies stained positive in a Gram stain and occurred singly, in pairs, or in short chains (Fig. ). Catalase and oxidase reactions of the unknown colonies were negative and phenotypic characterization using the Vitek2 GP system (BioMérieux) was inconclusive. However, Matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) mass spectrometry revealed a match with Helcococcus ovis DSM 21504 T DSM (log score: 1.637) according to the Brucker Maldi-Biotyper database. Identification of this organism was confirmed by 16S rRNA gene sequencing. BLAST analysis of the partial 16S rRNA gene sequence derived from our isolate (1492 nucleotides, deposited in the GeneBank database under accession number MG188744) showed 98.9% identity (15 nucleotide differences) with the 16S rRNA gene sequence of H. ovis s840–96-2 deposited in the GenBank database under accession number NR027228 by Collins and coworkers [] in 1999 when this species was first described.\nAntimicrobial susceptibility testing (AST) of both strains was performed. The disk diffusion method was carried out and with the exception of penicillin, erythromycin and clindamycin, S. aureus isolated from this case was susceptible to all other drugs including cephalosporins and fluoroquinolones. AST for Helcococcus was performed using the CLSI broth microdilution method on Mueller-Hinton II broth (BD Diagnostics, Heidelberg, Germany) supplemented with 3% (vol/vol) lysed horse blood (Oxoid, Wesel, Germany) and 0.001% (wt/vol) pyridoxal HCl (Sigma–Aldrich, Munich, Germany) incubated at 37 °C in 5% CO2 for 24 h [, ]. Streptococcus pneumoniae ATCC 49619 served as a quality control. Then, we changed the method and performed an E-test on blood agar, with S. aureus ATCC 29213 as the quality control (for reference only). The MICs (μg/L) of the drugs for this strain are reported in Table . Since no antimicrobial testing guidelines are currently available from the Clinical and Laboratory Standards Institute (CLSI) for Helcococcus, the MICs were determined in reference to the CLSI guidelines for S. aureus []. According to the CLSI [, ], this strain was susceptible to penicillin, ampicillin, teicoplanin, ceftriaxone, vancomycin, and linezolid.\nAfter admission, the patient received levofloxacin eye drops 4 times per day until being discharged from hospital. After surgery, the patient was initially treated with intra-venous cefotaxime (2.25 g/250 ml NaCl, 1/day) and ornidazole (500 mg/day) for 1 week. Two weeks after admission, the patient recovered and was discharged from hospital. Six months later, the patient returned to the hospital to finish implantation of the artificial right eyeball and no signs of infection were detected. With the patient’s consent, we collected samples from the skin around both eyes for aerobic and anaerobic culture, but only normal skin flora were detected, such as coagulase-negative Staphylococcus. After surgery, the patient was in good health and was discharged from the hospital. |
A 35-year-old female patient was presented to our center for TV replacement due to stenosis. At the age of 11 years, the patient suffered from endocarditis supported by a small ventricular septal defect. At that time, the ventricular septal defect was closed and a mechanical tricuspid valve (SJM, 28 mm) implantation and epicardial single chamber pacemaker implantation due to concomitant third degree AV block without escape rhythm were performed. At the age of 17 years, the abdominal pacemaker was replaced, due to battery depletion (Biotronik). Six months later, a second surgery followed with replacement of the dysfunctional mechanical valve for a 27 mm Porcin-Baxter biological TV. Another PM replacement (Medtronic) was performed at the age of 27 years, again, due to battery depletion. At the age of 30 years, the abdominal pacemaker was explanted and a two chamber transvenous ICD (Medtronic Egida DR) was introduced, as the patient suffered a syncope during documented sustained ventricular tachycardia. The ICD lead was implanted passing the tricuspid valve into the right ventricle. Six years later, severe TV stenosis developed, caused by an ICD lead, that stuck to the posterior leaflet of the biological valve and ventricular myocardium, and the TV had to be replaced a third time. To avoid future TV dysfunction due to lead related complications, we discussed several options with the patient. These included first TV replacement in combination with epicardial pacemaker leads and a subcutaneous ICD (S- ICD, EMBLEM™ Boston Scientific) or alternatively placing a pacing lead in the coronary sinus in combination with an S- ICD. As the patient disagreed on both options, despite a higher risk of TV dysfunction by placing another transvenous ICD lead through the TV, we discussed another option and opted for a lead sparing replacement of the TV. The TV ring was cut open on both sides beneath the original ICD lead, and the TV prosthesis was excised. A new bioprosthetic valve was implanted, leaving the ICD lead outside the ring of the new TV prosthesis. As the lead was stuck to the former TV annulus and posterior ventricular wall, no further fixation of the lead was needed. The new valve (SJM biological 28 mm) was implanted using 14 Coreknots (Figures , , ).\nThe postoperative course was unremarkable, and the patient was dismissed on the 11th postoperative day/postoperative day 11. Follow-up after 4 months showed a well functioning TV prosthesis without stenosis or regurgitation and no deterioration in pacing or sensing parameters. No artifacts or other hints to a lead dysfunction were recorded (Table ). |
A 45-year-old male presented newly developed pain, coldness, and numbness of the right upper extremity. The pain gradually increased and he said that he could not move his right hand and fingers for about 1 hour. He never had such complaint before. He denied having been exposed to any trauma and he had no previous history of cardiac, vascular, rheumatological, and neurological diseases and intervertebral herniation. The right arm was cold and right hand and fingers were cyanotic on inspection. The axillary artery could be palpated whereas the pulse of the brachial artery was found to have disappeared below the level of antecubital fossa. Radial and ulnar pulses could not be palpated. Cardiac and lung auscultation was normal and lower extremity and left upper extremity arteries could be palpated. Electrocardiogram showed a normal sinus rhythm without any other abnormal finding. Initial workup included total blood count and blood urea, creatinine, liver enzymes, and routine ELISA panel all of which were found within normal limits. Arterial flow dynamics were evaluated using a pocket-ultrasound device. A normal triphasic waveform was audible above the level of the brachial artery whereas the waveform was biphasic below that level and inaudible at the level of ulnar and radial arteries. Based on these findings, the initial diagnosis was acute thromboembolic occlusion of the right brachial artery. An initial 5000 U of intravenous heparin was given. The patient was immediately taken to the operating room for thrombectomy. Interestingly, ischemic symptoms suddenly improved during the preparation for the operation. The cyanosis degraded and radial and ulnar pulses became palpable. The patient said that his arm and hand have been almost completely relieved and warmed. The operation was canceled. Computed tomography angiography was considered for differential diagnosis of aortic dissection. However, the patient denied giving consent for use of intravenous contrast medium when he was informed about the risk of contrast nephropathy and hypersensitivity. The patient was initiated on intravenous heparin infusion (1000 IU per hour). Symptoms suddenly reappeared six hours later, but this time the cyanosis of the right arm was more severe. The patient gave consent for the radiographic evaluation and contrasted tomography was performed. Contrast enhancement was found normal on proximal segments of the right upper extremity arterial bed; however, it was found to have totally disappeared just above the level of ulnar-radial artery bifurcation. While the patient was being immediately taken to the operating room, symptoms suddenly disappeared again; cyanosis degraded and the hand became warmed while his distal pulses became palpable, again. Local anesthesia was made with subepidermally applied lidocaine 10% and a longitudinal incision was made over the antecubital fossa. The brachial artery was explored deep in the fossa and was seen anomalously perforating the bicipital aponeurosis. It was found constricted by both bicipital tendon and bicipital aponeurosis (). The aponeurosis and surrounding tissues were removed using sharp dissections and the artery was liberalized (). Because the radial and ulnar pulses were palpable and the ischemic signs and symptoms totally disappeared, further intervention was not performed. Postoperative course was uneventful. The patient had no more recurrence of symptoms and was discharged on the day after the operation. |
A 13-year-old boy was referred for management of left microbial keratitis by a general ophthalmologist. The patient had presented with 3 days history of painful left eye associated with loss of vision. Prior to this acute symptom a month earlier he was treated by a local doctor for suspected viral conjunctivitis in both the eyes that settled after 10 days. Subsequently, the patient noted gradual reduction of vision in both the eyes with painful knee joints. As the left eye became painful and red in the last 3 days the patient reported to the nearby ophthalmologist.\nOn examination he had best spectacle corrected vision of 20/80 OD and FC 1 m OS. Slit-lamp examination revealed disciform keratitis with normal corneal epithelium in the right eye []. There were no cells in the anterior chamber nor were any keratic precipitates. The left eye revealed very swollen corneal stroma in the form of a large disc almost involving the entire cornea associated with a small ragged epithelial defect in the para-central part of cornea [, arrow]. The edge of the epithelial defect had a faint whitish infiltrate. The anterior chamber showed a small hypopyon with numerous cells in the anterior chamber.\nBased on the finding, a diagnosis of bilateral disciform keratitis was made with suspected bacterial keratitis in the left eye. As the patient was already using moxifloxacin eye drops 0.5% in the left eye and was feeling better, corneal scraping was not attempted. The patient was admitted and treated with prednisolone 1% eye drops 6 times a day in the right eye. The left was treated with moxifloxacin (0.5%) eye drops every hour and atropine (1%) eye drops 3 times a day. He was also put on oral acyclovir (400 mg) twice daily. The patient was referred to a rheumatologist for the knee joint pain.\nThe patient was found to have inflammatory arthritis of both the knee joints and arthritis of the right ankle joint. His ESR was 90 mm/h. He was found to be positive for HLA B27. A diagnosis of Reiter's syndrome was made by the rheumatologist and the patient was treated with oral NSAID. The oral acyclovir was stopped.\nWithin 3 days of treatment the epithelial defect healed with disappearance of the infiltrate and hypopyon in the left eye. The moxifloaxcin drops were reduced to 4 times daily and prednisolone eye drops were started 6 times daily in the left eye. Over the next 10 days the corneal lesions reduced gradually and the patient was discharged home. The steroid drops were tapered gradually. The appearance of both the cornea 2 weeks after presentation is shown in Fig. and .\nIn the last checkup 6 weeks later his best corrected vision was 20/20 in both the eyes. Both the cornea appeared normal. |
Written informed consent was obtained to report the case. A 34-year-old G2P1 pregnant woman diagnosed with AS presented at the obstetric outpatient clinic at 18 weeks of gestation. She experienced back pain when she was 25 years old; these symptoms made walking difficult during her first pregnancy at 31 years old. Following her first vaginal delivery, she was able to walk although pain persisted to a lesser degree than during pregnancy. Radiography revealed osteosclerosis of the posterior surface of cervical vertebrae and osteoarthritis of the right hip with joint space narrowing (Figure ). The initial diagnosis of AS was made at 33 years of age.\nPain was managed by the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. After the present pregnancy was diagnosed, only acetaminophen continued to be administered, but pain increased during the present pregnancy. She complained of right hip pain, with a visual analog scale (VAS) score of 7/10. A dosage of 5 mg of oral prednisolone was administered daily from 18 weeks of gestation, and thereafter, the symptoms temporarily improved to 0/10 on the VAS. Unfortunately, the symptoms relapsed at 31 weeks of gestation. At 32 weeks of gestation, she complained of restricted neck mobility with difficulty gargling, restricted lumbar mobility that caused difficulties in bending her back, and restricted right hip joint mobility with a limitation of 10º of abduction, which also affected internal and external hip rotation. Peripartum management was discussed and planned by obstetricians and anesthesiologists. Given that only hip abduction and rotation, but not flexion, were limited, it was considered that an attempt of vaginal delivery would be possible when spontaneous labor occurred. However, if an emergency cesarean section (CS) was necessary during labor owing to other obstetric complications such as nonreassuring fetal status, special anesthesia management may be required because of the possible failure of spinal anesthesia due to calcified spinal ligaments and difficult tracheal intubation and airway management for general anesthesia. In such cases, the preparation of awake fiberoptic intubation or supraglottic airway device insertion should be considered.\nAt 38 weeks of gestation, the patient was admitted to our hospital because of membrane rupture. Labor analgesia was not provided. Oxytocin administration was required due to prolonged second stage of labor. Vacuum delivery with episiotomy left of the midline, which was opposite to the restricted right hip joint, was performed due to fetal bradycardia at birth. A healthy baby with a weight of 3358 g was successfully delivered. Both mother and neonate had a good postpartum course. Prednisolone and NSAIDs were started after pregnancy. |
A 75-year-old female non-smoker who was diagnosed with lung adenocarcinoma and underwent lower right lobectomy (pT1N0M0, stage IA) 18 years prior to our report complained of an intermittent mild fever and cough for two months and was admitted to our hospital. She was affected by CRF as a result of hypertension and had undergone HD three times a week and hemofiltration twice a month for the past nine years. A computed tomography (CT) scan of the chest showed a mass in the upper lobe of the right lung near the mediastinum and multiple small nodules in the bilateral lung (Fig ). Positron emission tomography (PET)-CT revealed that the mean standard uptake value of the mass was 4.5, the uptake of the multiple nodules elevated, and the abdominal uptake value was normal. Tumor relapse was confirmed based on these results. Because of her advanced age, poor PS, CRF requiring HD, and the toxicity of chemotherapy, chemotherapy was inappropriate for this patient. An EGFR DNA sequencing analysis was performed on her tumor tissue, which was obtained 18 years ago, revealing an L858R mutation in exon 21. The patient gave written informed consent and started oral gefitinib treatment at a dose of 250 mg daily. We then performed a PK analysis of gefitinib.\nSeven days after the initiation of a daily 250 mg dose of gefitinib, we obtained blood samples in heparinized tubes at zero, two, four, six, eight, and 10 hours after administration on the days in which the patient did not receive HD. Additional blood samples were drawn at 25 and 29 hours (the times before and after HD the next day). Plasma was isolated by centrifugation at 3000 × g at 4°C for 10 minutes within one hour of collection. The plasma was then transferred to screw-cap polypropylene tubes and frozen at −80°C until further analysis. The gefitinib concentration in the plasma samples was determined using validated high-performance liquid chromatography coupled with tandem mass spectrometry in the Clinical Pharmacology Research Center Laboratory of Peking Union Medical College Hospital (PUMCH), as previously reported.\nAs shown in Figure , the peak plasma concentration of gefitinib occurred six hours after administration, with a peak of 456 ng/mL on non-HD days and 463 ng/mL on HD days. Twenty-four hours after administration, the plasma concentration of gefitinib decreased to 386 ng/mL. The plasma concentration of gefitinib was 376 ng/mL before HD and 463 ng/mL after HD. Two weeks after the initiation of daily 250 mg gefitinib administration, the patient received hemofiltration. We then performed a PK analysis of gefitinib before and after hemofiltration. The plasma concentration of gefitinib was 499 ng/mL before hemofiltration and 766 ng/mL after hemofiltration.\nOne month after the start of daily administration of 250 mg gefitinib, the patient's symptoms improved and thoracic CT scans showed that the tumor had reduced in size. This evaluation demonstrated a partial response of her disease. Eight months later, the tumor increased in size and the patient died of metastasis of the tumor one year after treatment with gefitinib. No severe adverse effects were reported during gefitinib administration. |
This 43 year old lady presented with a firm left sided swelling in the neck. Staging CT and MRI of the neck were performed to assess operability. The scans showed a mass arising in the left lobe of the thyroid extending to the superior mediastinum. Multiple lymph nodes were visualized in the left cervical chain encasing the carotid sheath. At operation the left lobe of the thyroid was enlarged and adherent to the strap muscles, oesophagus and trachea, with retrosternal extension. A tubular mass of tumour was found to be invading the IJV and most of the associated venous complex in the upper neck extending up the common facial vein at the margin of the mandible. Tumour extended into the lumen of the deep lingual vein and other veins associated with the superior thyroid pedicle.\nTotal thyroidectomy with clearance of lymph nodes in levels 1,2, 3 and 4 was performed. The surgeon was able to dissect tumour free of the trachea and oesophagus but unable to conserve the left sternomastoid, left IJV, deep lingual and common facial veins, all of which were sacrificed. Pathology revealed a poorly differentiated follicular thyroid carcinoma. A mass of tumour was demonstrated in the resected IJV (Fig ). Post-operative 131I scanning showed intense 131I accumulation in the midline of the neck (Fig ).\nFollowing surgery radical dose EBRT consisting of 46 Gy given in 23 fractions over four and a half weeks was administered to both sides of the neck up to the level of the mastoid processes, followed by 20Gy to the left side of the neck. In addition she received an ablative 131I dose of 5.5GBq followed by a further 5.6GBq therapeutic dose. Thirty three months after presentation, she developed cavernous sinus thrombosis with a tumour deposit in this area on MRI plus multiple lung and bone metastases. She received EBRT to the base of the skull with good symptomatic relief and remains asymptomatic but with disease 53 months after initial presentation. |
A 75-year-old female pedestrian was hit by a motor vehicle. Examination by the emergency medical service crew found her heart rate 130/min, systolic blood pressure 84 mmHg, initial oxygen saturation 78% without supplemental oxygen. On the way to our hospital, an emergency physician got into the ambulance, established two intravenous lines and started fluid resuscitation. He noticed that her lung sounds were decreased on both sides.\nUpon admission to our resuscitation bay, she had developed cardiac arrest but still breathed spontaneously. While undergoing cardiopulmonary resuscitation, we detected a pelvic fracture on palpation and found no fluid accumulation in the thoracic or abdominal cavities with ultrasound. We then performed a resuscitative thoracotomy in order to clamp the descending aorta and perform direct cardiac massage because we expected that the cause of cardiac arrest was bleeding from the severe pelvic fracture. At the time of the thoracotomy, the stomach and greater omentum prolapsed out of the body and spontaneous circulation was immediately recovered. We also found that the descending aorta and heart were not collapsed, and the heart was beating strongly. Although we were puzzled why the aorta and heart did not collapse despite the expected severe bleeding, we moved on to manage the pelvic fracture.\nWhile placing a pelvic C clamp to stabilize the pelvic ring and pelvic packing to control bleeding from the retroperitoneal space, we temporarily closed the thoracotomy incision to control wound surface bleeding without clamping the aorta. In spite of these treatments, she gradually became hemodynamically unstable, so resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed. A contrast computed tomography (CT) scan was performed of the head, chest, and abdomen, which revealed multiple trauma, including traumatic subarachnoid hemorrhage, left diaphragm rupture, multiple rib fractures, and a severe pelvic fracture (Fig. ). After confirming the absence of a basal skull fracture, a nasogastric tube was inserted, but it was unable to reduce gastric contents. To control hemodynamic instability, we performed a transcatheter arterial embolization (TAE) of the internal iliac artery and transformed the patient to the intensive care unit (ICU).\nDespite treatment of the severe pelvic fracture with a pelvic C clamp, pelvic packing, and TAE, her hemodynamic instability continued. We considered that the persistent shock was caused by an injury other than pelvic fracture, so we decided to explore the abdominal and thoracic cavities because of the presence of the diaphragmatic injury. As we were unable to maintain adequate hemodynamics in spite of administering massive transfusion protocol and continuous epinephrine infusion, we introduced arterio-venous extracorporeal membrane oxygenation (ECMO). Under ECMO support, an emergency operation was performed with a two-pronged approach with a laparotomy and thoracotomy. Exploring the thoracic and abdominal cavities, we detected only the diaphragm rupture and prolapsed stomach. There was no other obvious intraabdominal organ or thoracic injury. We closed the diaphragm rupture site and chose an open abdominal management to avoid abdominal compartment syndrome. Despite these treatments, the patient died shortly after returning to the ICU. We think that the cause of death was a combination of hemorrhagic shock, traumatic coagulopathy, and post cardiac arrest syndrome caused by the tension gastrothorax. |
A 72-year-old male patient with stomach cancer and S-phase colon cancer received ileostomy along with gastrectomy and proctocolectomy for cancer removal, followed by concentrated observation treatment in the intensive care unit, during which, dyspnea occurred suddenly. After intubation and artificial venting by a respirator, respiration-related symptoms were improved and spontaneous respiration became possible after removing the respirator. However, dysphagia occurred, and he was admitted by the department rehabilitation medicine in the present hospital for comprehensive rehabilitation treatment. Although the patient did not have a past history of high blood pressure or diabetes, he had a history of drinking alcohol 4 times a week and smoking for 40 pack years, and was taking warfarin due to atrial fibrillation. He had a history of receiving percutaneous transluminal coronary angioplasty due to angina pectoris. According to a physical exam, no particular finding was observed other than weakness of the whole body.\nThe patient had received a continuous nutrition supply through total parenteral nutrition for more than 2 months since the first onset, and changed nutrition supply to tube feeding through nasogastric tubing after being hospitalized by the present hospital, followed by continued exercise promoting tongue's posterior movement and laryngeal elevation through occupational therapy. After that, VFSS was conducted to analyze the possibility of oral nutrition, during which, a large quantity of remnant epiglottis vallecula was observed without, however, a finding for aspiration so that nasogastric tubing was removed and oral nutrition was attempted through a compensation technique. Since then, however, there was a complaint of continued dysphagia during eating, and esophagogastroduodenoscope (EGD) examination was conducted through a consultation with the division of gastroenterology for a detailed cause analysis. From the EGD examination, no finding of mechanical closure of esophagus or stomach was observed. For a more accurate diagnosis, esophageal pressure manometry was conducted, which indicated normal findings for both the length of the upper and lower esophagus sphincter muscles or the resting pressure, as well as coordination of the esophagus during swallowing and fluid changes. Following that, VFSS was conducted again and a comparative analysis with the previous study images was made. The result of which led to a judgment that epiglottis was not bent back toward posterior inferior so that foods did not pass to the esophagus, Hence, an intervention was conducted where the epiglottis was physically stretched and spread in the direction of posterior inferior, using a urethral catheter. Intervention involved first implementation of the swallowing test, positioning a 16 F urethral catheter in the epiglottis vallecula, and subsequently expanding the balloon, as well as stretching and spreading of the epiglottis for 1 minute using about 5 mL of a contrast medium for balloon expansion; followed by rest for 10 seconds, which were repeated for a total of 3 times for the treatment (). Thereafter, swallowing test was again conducted to make judgment on the treatment effects (, ).\nSince then, an improvement in dysphagia symptoms was indicated with the ability of eating semisolid foods, and stretching and spreading treatment of the epiglottis was continued with progress observation. In addition, the use of a urethral catheter was accompanied by re-implementation of VFSS once a week. As a result, improvement was made to the extent of being able to eat solid foods, allowing discharge from the hospital. |
A 4-year-old female developed diarrhea and hematochezia. She was born via a caesarean section without any complications. She did not have a history of symptoms suggestive of immune dysfunction, such as prolonged fever or opportunistic infections. Her mother had Crohn’s disease (CD) since the age of 10 years and was refractory to infliximab. None of her other relatives had any symptoms of immunodeficiency or inflammatory bowel disease (IBD). At the age of 4 years and 1 month, the patient’s bowel movement increased to four times per day and was accompanied by bloody stool. She was admitted at a regional hospital and underwent colonoscopy, which showed chronic colitis. Considering her family history, she was diagnosed with ulcerative colitis, and treated with oral mesalazine and exclusive enteral nutrition using elemental formula. Although her diarrhea symptoms improved, her symptoms relapsed soon after she resumed taking food. She was subsequently referred to our hospital at the age of 4 years and 9 months for further treatment.\nAt the time of admission, she showed growth retardation with poor weight gain; her growth velocity was 2 standard deviations below average. On physical examination, she was afebrile and had stable vital signs and her laboratory data is presented in . No infectious agents were identified in the collected stool specimens; Clostridium difficile toxin was not detected in a stool sample. The duodenal mucosa appeared slightly erythematous and edematous on esophagogastroduodenoscopy. Small bowel capsule endoscopy showed mild erythema and edema throughout the small bowel. Colonoscopy revealed frank friability, marked erythema, absence of vascular patterns, and erosions throughout the rectum and sigmoid colon; these findings were similar to those of ulcerative colitis (). Her terminal ileum was also slightly edematous.\nMucosal biopsy specimens of duodenum and small colon showed increased inflammatory cells including neutrophils, plasma cells and lymphocytes in lamina propria. Crypt architectural distortions were also observed in the rectum and sigmoid colonic mucosa. Biopsy specimens from the duodenum and terminal ileum revealed foamy macrophages with intracellular granules (). Periodic acid-Schiff staining and Ziehl-Neelsen staining were performed to exclude infectious disease caused by intracellular parasites such as Mycobacterium avium complex. The samples were positive for periodic acid-Schiff staining (), but negative for Ziehl-Neelsen staining, suggesting that M. avium complex infection was unlikely. We suspected T. whipplei infection and performed electron microscopy, which showed rod-shaped bacillary bodies within a macrophage measuring 1 μm in size (). Furthermore, we performed polymerase chain reaction (PCR) using DNA from the duodenal mucosa and primers specific to whipplei DNA [,]. A specific PCR product of 160 base pairs that corresponds to T. whipplei 16S ribosomal RNA gene was detected (). A definite diagnosis of WD was made. Laboratory tests for the evaluation of immunodeficiency, which frequently causes WD, including human immunodeficiency virus (HIV) antibody tests, CD4 T-cell count, lymphocyte-stimulation test, and natural killer T-cell activity test, were negative. We performed whole exome sequencing of DNA isolated from the blood cells of the patient and her parents to identify any underlying genetic diseases, including primary immunodeficiency diseases or monogenic IBD; no known specific mutations associated with these diseases were identified.\nShe was treated intravenously with ceftriaxone (50 mg/kg per day) for 2 weeks, followed by oral therapy with sulfamethoxazole-trimethoprim (40 mg/kg per day). Diarrhea and hematochezia improved within a few days, and growth retardation recovered at 12 months after treatment initiation. Additional follow-up at 12 and 24 months showed improved mucosa edema in the small bowel and colon (). In the follow-up biopsy after 12 months of treatment initiation, T. whipplei was not detected by electron microscopy and the PCR did not amplify T. whipplei DNA specific amplicon. She continues taking oral therapy with sulfamethoxazole-trimethoprim without any symptoms. |
A 69-year-old male patient presented to his local hospital with insidious onset of chest pain for the past 10 days. He was hemodynamically stable without features of cardiogenic shock. As initial investigations detected elevated D-dimer levels, computed tomographic pulmonary angiography was performed to rule out pulmonary embolism that was excluded, but incidental findings of a Type A aortic dissection were seen. Subsequent computed tomography aortogram depicted a Type A aortic dissection originating in the ascending aorta, involving the innominate artery, and extending to the aortic bifurcation. The proximal ascending aorta and aortic root were not involved. All visceral arteries were seen to arise from the true lumen. Despite the subacute presentation, signs of chronicity were seen on imaging, including a thick and straight dissection flap alongside a dilated false lumen with outer wall calcification (\n). On echocardiography, biventricular size and function were preserved with no valvular abnormality documented.\nThe patient had undergone bilateral sequential lung transplantation 15 years prior for α-1-antitrypsin deficiency. A clamshell incision had been used for access with CPB via central cannulation. The patient had regularly attended the lung transplant outpatient clinic since his original discharge, having developed a degree of immunosuppressant-induced nephropathy and hypertension.\nThe patient underwent urgent operative repair through median sternotomy (oscillating saw) with attention to minimize trauma to the pulmonary allografts during dissection. Due to involvement of the innominate artery, the left axillary artery was cannulated via a 8-mm synthetic graft, and venous return was established with a percutaneous right femoral venous cannula. Pulmonary artery and left apical venting were used to avoid dissection near the right hilum. Under moderate hypothermia, circulatory arrest was instituted with bilateral selective antegrade cerebral perfusion.\nInterestingly, the primary intimal tear was located in proximity to the site of the previous aortic cannulation, with only distal progression of the flap and no involvement of the aortic root (\n). Multiple fenestrations were seen on transesophageal echocardiography in the descending thoracic aorta (\n, available in the online version). Open distal anastomosis with a Gelweave Ante-Flo graft (Vascutek Ltd., Renfrewshire, Scotland, United Kingdom) was performed. Full flow was restored through the side arm of the graft. The proximal anastomosis was performed above the sinotubular junction.\nThe ventilatory strategy employed optimized positive end expiratory pressure (PEEP) and tidal volumes of 6 to 8 mL/kg, ensuring peak pressures lower than 25 cm H\n2\n0. A combination of low tidal volume and PEEP was used during CPB to minimize atelectasis and reduce the inflation pressures required for reinflation prior to separation from CPB. Our postoperative strategy was to aim for early extubation to minimize total ventilation time.\nClose attention was given to fluid management given the risk of excess fluid to the lungs in the context of renal impairment. The CPB circuit was primed with human albumin solution to improve colloid oncotic pressure and minimize third space losses. We elected to use filtration on CPB to prevent inadvertent fluid overload and limit metabolic derangement.\nPostoperatively, extubation was performed on the first postoperative day and following an uncomplicated course the patient was discharged on the 12th postoperative day after reestablishing maintenance immunosuppressive treatment.\nHistological examination of the resected segments of aortic wall showed extensive dissection, moderate myxoid change, elastic fiber disruption, patchy fibrosis, and mild inflammation in the adventitia. |
A 57-year-old male was admitted to the emergency room after being unconscious for two days. His children reported that two days ago, the patient suddenly had dizziness and blurred vision when working in the morning and then fell to the ground and became unconscious, which lasted for approximately 6 hours. He was immediately admitted to the local county hospital. The next day, head CT diagnosis indicated low-density lesions in the bilateral thalamus. Due to limited medical resources at the local county hospital, the patient was transferred to the Department of Neurology of our hospital. A MRI examination was conducted immediately, which suggested bilateral thalamic acute infarction (). The patient had had hypertension for 4 years. The patients had no bad habits, such as smoking or drinking, no history of drugs or vaccination, and no history of exposure to toxic substances. Physical examination showed that he was in a drowsy state. Neurological examination revealed the left pupil at 7 mm and the right pupil at 5 mm (), bilateral pupil reflex to light disappeared, binocular vertical gaze palsy, bilateral Babinski signs were suspicious positive, the NIHSS score was 6 points, and the GCS score was 13 points. The haematology test revealed a low-density lipoprotein concentration of 3.31 mmol/L. Other haematology tests showed no abnormalities. The electrocardiogram was normal, echocardiography showed no abnormality, magnetic resonance angiography was normal (), and digital subtraction angiography was normal. The patient gradually recovered after a week in the hospital. During hospitalization, the patient was monitored and underwent regulation of blood pressure, anti-platelet aggregation, stabilization of plaque, improvement of circulation, elimination of oxygen free radicals and other treatments, and the clinical symptoms significantly improved. The patient was admitted to the hospital with a NIHSS score of 6 points, which dropped to 2 points after treatment. The patient was admitted to the hospital with a GCS score of 13 points, which increased to 15 points after treatment. The MMSE scale score was 20 points (illiterate).\nThe patient’s status was retrospectively reviewed one year after discharge from our hospital. The patient continued to have persistent cognitive dysfunction, memory decline, mental decline, vertical fixation paralysis, no fluency in speech and unstable emotions. |
An otherwise healthy 52-year-old man presented to the emergency room with nausea and vomiting accompanied by acute dyspnea. Two hours earlier the patient who was a recreational fisherman reported on consumption of liver and gonads extracted from a fish which he just captured at sea ().\nSeveral minutes after consumption he complained of perioral paraesthesias with worsening limb muscle weakness. Shortly after admission to the ER, the patient developed an acute respiratory failure with bradypnea. This was accompanied by bradycardia which quickly deteriorated to cardiac arrest.\nAfter a short resuscitation, including tracheal intubation and mechanical ventilation, the patient returned to sinus rhythm. On examination, shortly after patient was stabilized, signs of complete paralysis with absence of motor responses and lack of pupil reactions were noted. Patient was noted to be in deep coma with GCS of 3. At this point, possible poisoning by paralyzing agent was suspected. Patient was transferred to the intensive care unit and treated by supportive measures.\nSeveral hours after his ICU admission, patient's family approached the medical stuff with a fish claimed to be consumed by the patient just two hours prior to his hospital admission. A diagnosis of tetrodotoxin (TTX) poisoning was suggested by typical clinical manifestations and temporal proximity to consumption of TTX-containing fish. The fish remnants were photographed and were immediately analyzed by a marine biologist and by the national center of poisoning. Consequently the fish was identified as the poisonous Lagocephalus sceleratus. At this point, the patient had a complete muscle paralysis with absent deep tendon reflexes and deep coma. Due to the severity of his illness, and after an extensive literature review, a decision was made to treat the patient with a cholinesterase inhibitor. During the first 24 hours the patient received 4 doses of intravenous neostigmine 2.5 mg. Immediately after the first dose of neostigmine deep tendon reflexes could be noted along with reversal of the comatose state.\nOver the next 24 hours, the patient completed a course of 4 doses of neostigmine. During that time a dramatic improvement was observed, which included complete recovery of muscle strength and return to full consciousness. 36 hours after his hospital admission the patient was extubated and had a complete and uneventful recovery. |
The second case is a 75-year-old Irish woman with a psychiatric history of bipolar affective disorder, stable for several years on olanzapine and valproate, enabling her to lead an independent lifestyle. There was no history of cognitive impairment. She suffered from multiple medical conditions including: atrial fibrillation, type 2 diabetes mellitus, obstructive sleep apnea, and a recent mitral valve repair complicated by postoperative delirium.\nShe was admitted medically to a rural Irish hospital in November 2015 for management of a raised INR. During the admission she developed sudden onset left-sided weakness and altered levels of consciousness, as well as rigidity and one isolated temperature spike. The concern was raised that she may be or might have been suffering from neuroleptic malignant syndrome and her neuroleptics were stopped as a precaution (Table ). She was transferred to the intensive care unit (ICU) in the MMUH in Dublin with a suspicion of neuroleptic malignant syndrome or encephalopathy. Computed tomography (CT) brain imaging was normal at the time. As neuroleptic malignant syndrome was suspected, olanzapine was stopped. However, her creatinine kinase levels were normal as was her body temperature. Hence, neuroleptic malignant syndrome was deemed to be unlikely. An electroencephalogram during admission showed changes suspicious of encephalopathy and MRI imaging showed no acute abnormality. A working diagnosis of metabolic encephalopathy was established but extensive investigations yielded no cause for the encephalopathy.\nDue to prolonged altered levels of consciousness and unexplained altered mental state, the Liaison Psychiatry service was consulted in January 2016.\nOn examination, she responded with a mouthed single word greeting, but made no other attempt at verbal interactions. She inconsistently followed the examiner with her gaze, but stared out of the window for most of the examination. On physical examination she presented with waxy resistance to passive movement and psychomotor retardation. The impression was that these features were most likely related to a catatonic exacerbation of her bipolar affective disorder, in the absence of an organic explanation. She was diagnosed as having bipolar I disorder with catatonia as per DSM-5 (Table ).\nDelirium was raised as a differential diagnosis (Table ), but she had been reviewed in September 2015 by the Liaison service, when she was delirious after her valve replacement and her presentation was distinctly different on that occasion.\nShe was initially treated with intravenously administered lorazepam, but became drowsy, with a significant drop in Glasgow Coma Scale (GCS). As such the treatment was abandoned. Instead, olanzapine was cautiously reintroduced, which led to a significant improvement in her mental state within days. On follow-up review, she was mildly confused but engaged well at interview, and was euthymic with no evidence of thought disorder or movement disturbance. Subsequently she was discharged back to her own home. She was not reviewed at 6-month follow-up as she was living in a rural area and was followed up in her local service.\nOf note, in 2017, the same patient was readmitted to the MMUH ICU, from the same peripheral hospital, in a very similar state to the presentation in November 2015. Again her neuroleptics had been stopped when she was acutely unwell and she developed typical traits of acute catatonia. She was trialled on lorazepam, which she did not tolerate and reinstitution of her neuroleptics brought no improvement. The therapy was then escalated to electroconvulsive therapy (ECT), to which she had a dramatic response and significant improvement of her mental state. |
A 52-year-old previously healthy man with an 11-year history of recurrent, bilateral carpal tunnel syndrome presented with a 22-month history of severe NP in his right hand. The same condition was present on the left side, although to a lesser degree.\nThe patient had undergone multiple decompressive surgeries (two on the left side, three on the right) during the 11 years prior to the presentation. After each operation, he experienced symptom relief lasting from 6 to 9 months, followed by gradual recurrence. His last operation on his right wrist, 30 months prior to presentation, resulted in roughly 8 months of pain relief. Further surgical intervention was not recommended on pain recurrence. Various treatments were tried without satisfactory pain relief (see ). The pain was eventually deemed chronic and treatment refractory.\nThe patient described the pain as constantly present, with intensity usually ranging between 5 and 8 on a 0–10 Numeric Rating Scale (NRS). The pain was located primarily distal to the wrists, in the area of median nerve innervation. Although there were both pain and sensory symptoms beyond this, both in the hand and lower forearm, he did not describe it as radiating. The pain was associated with numbness, tingling and prickling sensations. The most striking and clinically debilitating aspect of the patient’s pain was the degree to which it was aggravated by cold, in terms of both cold allodynia and the effect of ambient temperature. He scored 22/38 on the PainDETECT questionnaire, indicating >90% probability that the pain had a neuropathic component.\nMRI of the right wrist revealed scar tissue in close proximity to the median nerve. Neurological examination found cold and light touch allodynia as well as decreased sensation distal to the wrist scars in both hands. These findings included but also went beyond the distribution of the median nerves. Findings were similar on both sides, but more severe on the right. Neurography confirmed damage to the right median nerve at the level of the carpal tunnel (the left side was not tested). Neurological examination was otherwise normal.\nThe patient was referred to us for inclusion in the NoTOPain trial which tested EGFR-inhibition in patients with chronic, treatment-refractory NP. He was randomised to receive a single dose of blinded placebo first, followed by a single dose of blinded cetuximab and then one open-label cetuximab infusion (see ).\nThe patient’s pain scores (self-reported daily, on a 0–10 Numeric Rating Scale) showed a clinically significant decrease after blinded cetuximab, but not after placebo (see ). Only the pain scores for the right hand (the most severely affected) were registered in the NoTOPain trial, although improvement was analogous on the left side.\nThe patient described the pain relief he experienced after cetuximab as having completely transformed his quality of life. Specifically, he was able to sleep right through the night, without being woken up by pain that he otherwise experienced several times each night when his hands were exposed to cold as they slipped out from under the bed covers. Being well-rested improved his concentration and capacity to work. Ability to tolerate cold meant that he no longer required warm gloves and could work outdoors in all types of weather. He was more flexible and functional in general, able to do spontaneously things he enjoyed with family and friends, no longer having to consider pain and disability. He was able to stop taking all other pain medications and no longer needed to use the transcutaneous electrical nerve stimulation apparatus at bedtime.\nMechanical allodynia was assessed during the NoTOPain trial using standardised nylon monofilaments before and after the patient was treated with blinded cetuximab. He was asked to identify the area on his right hand with maximum pain. The monofilaments, in order of increasing size and target force, were then sequentially applied there, and he was asked to indicate when the filament triggered a painful response (using a non-painful area on the opposite side as a control). Just prior to the start of the cetuximab infusion, the patient scored 7 on the 0–10 NRS for ‘pain right now’. The first filament to provoke a pathological pain response at that time had a target force of 60 g (size 5.88). The test was repeated in the same place 2 hours after the cetuximab infusion, when his pain score was 1 on the same NRS (see ). At that time, none of the monofilaments provoked a pathological pain response (the largest filament tested having target force 300 g (size 6.65)). The test was repeated again the following day, with a pain score of 2 and again allodynia was not provoked by any of the monofilaments.\nThe patient experienced near-complete pain-relief after one of the two blinded study infusions which at study closure was revealed to be cetuximab. The open-label cetuximab infusion elicited the same response. He was, therefore, prescribed the oral EGFR-inhibitor erlotinib 150 mg daily, which he started taking once pain recurrence was well-established after his last cetuximab infusion. The patient described partial, transient improvement in NP after the first dose of erlotinib but felt that it never measured up to the dramatic improvement that he had experienced after the two intravenous cetuximab infusions in the trial.\nThe question of whether lack of efficacy of erlotinib could be a dosing question was raised so after 2 weeks taking 150 mg he increased to 300 mg daily. He took 300 mg daily for a total of 6 days but stopped because he was then convinced that erlotinib in fact had no effect at all, that is, he reported that the pain was back to the levels he had before start of the trial.\nAfter a further month of pain, treatment with the oral EGFR-inhibitor gefitinib was started. He took 250 mg gefitinib daily for 3 weeks without any change in NP severity.\nHaving failed both oral EGFR-Is that had shown benefit in several patients before, afatinib was prescribed, based on the hypotheses that a germline EGFR mutation may cause resistance to erlotinib and gefitinib, or that a broader inhibition (afatinib is a pan-HER inhibitor) may reproduce the effect he had experienced after the two cetuximab infusions in the NoTOPain trial. Therefore, 6 months after his last dose of cetuximab in the trial, the patient was prescribed afatinib 40 mg daily. He began noticing improvement in his NP on day 4 of this treatment. There was a gradual decrease in pain scores over the subsequent 2–3 weeks until a new plateau was reached (see ).\nAgain, pain relief was accompanied by improved function and enjoyment of life, as indicated by Brief Pain Inventory scores (see ).\nAfter approximately 3 months, the patient’s afatinib dose was reduced to 20 mg daily in order to test if that was a sufficient dose for pain control. The patient’s impression is that afatinib is not fully as effective as he remembers intravenous cetuximab but that 20 mg daily of afatinib is virtually as effective as 40 mg, with lesser side effects. During the treatment breaks, his pain typically recurs after 3 days.\nAfatinib may inhibit EGFRs with mutations that render them resistant to erlotinib and gefitinib. The patient‘s blood was therefore analysed for germline EGFR mutations with allele-specific PCR (Cobas EGFR mutation test v2, Roche), covering 42 different mutations in exons 18, 19, 20 and 21. None of these mutations were found.\nA year after starting afatinib, the patient was offered a trial of the HER1/HER2 inhibitor lapatinib 1250 mg daily in an attempt to reduce gastrointestinal and cutaneous side effects. He took this treatment for 7 days without noticing any improvement in his NP and therefore reverted to afatinib.\nThe patient has intermittently taken tetracycline 500 mg two times per day to treat acneiform rash while under treatment with the various EGFR-Is. He has had maximum grade 2 dry skin and mucositis. His most bothersome side effect has been grade 2 diarrhoea, for which he has taken loperamide as needed, with partial effect. |
A 55-year-old male patient visited at Gyeongsang National University Hospital with a complaint of tonsil cancer. The patient was preparing to undergo concurrent chemoradiotherapy for human papillomavirus-positive cancer. He was experiencing problems with his left molar tooth, and the latter was therefore extracted before the patient underwent the next radiation therapy session (after sufficient time had elapsed). The tonsil cancer was treated with radiation therapy of 7,200 rad. However, a defect appeared in the region where the left molar tooth had been extracted (). The defect was diagnosed as a case of ORN caused by the radiation therapy, and antibiotic administration and symptomatic therapy were followed for 3 months. However, the defect size gradually increased and the necrosis region grew wider, calling for a different type of treatment.\nOn the basis of our experience with tongue reconstruction using a buccinator flap, we planned the reconstruction of the defect site using a buccinator artery-based buccal flap. After sufficiently sterilizing the defective area, the necrosis region was ground with a drill and was removed in order to view the fresh tissue. Afterwards, an incision slightly larger than the defect site was performed in the buccal mucosa (). After incising the buccal mucosa and the muscle along the upper and anterior borders, the flap was elevated in an anterior to posterior direction (). When harvesting the buccinator flap, the buccal fat layer was also harvested so that the defect site in the mandible could be obliterated (). The neurovascular pedicle (including the buccal artery, vein, and nerve) was identified (). The dissection was continued inferiorly and laterally, and lower and posterior incisions were made so that the flap could be elevated. The flap was then rotated to fill the defect site with buccal fat, and the harvested buccal mucosa was sutured to the mucosa of the defect site (). Subsequently, the donor site was sutured with primary suture. The total operating time was 90 minutes. One week after the operation, good settlement of the flap was observed (). One year later, it was found that the donor site and the recipient site were stably healed (). The patient was healed without particular discomfort, and the ORN did not progress any further. |
A 64-year-old Caucasian male who was treated over the course of 7 months for multiple intrahepatic abscesses, left portal vein and segmental hepatic arterial thrombosis ultimately underwent an extended left hepatectomy and was found to have XGC. The patient had a medical history significant for non-insulin dependent diabetes, chronic renal failure, chronic hepatitis C and coronary artery disease. He initially presented to the hospital seven months prior to his eventual surgery with diabetic ketoacidosis and at the time was found to have hypodense areas in the lateral and medial segments of the left lobe with extension to the hilum concerning for evolving phlegmon of the liver. Subsequent ultrasound of right upper quadrant revealed acute left portal vein thrombus (Fig. ). The patient was started on heparin infusion and transitioned to coumadin. He was subsequently readmitted with sepsis and underwent an attempt at image-guided drainage of the liver abscess (Fig. ) where no purulent fluid could be aspirated. A solid lesion was noted which was biopsied with final pathology noting organizing hematoma with acute and chronic inflammation.\nRepeat CT imaging revealed continued thrombosis of the left portal vein and anterior branches of the right portal vein and right hepatic artery (Fig. ). Due to persistent left intrahepatic abscess and concern for an underlying obstructive process in the left biliary system, the patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) which revealed choledocholithiasis which was removed followed by sphincterotomy and stent placement. He subsequently underwent a spyglass™ procedure which noted a left biliary tract occlusion secondary to a mass which was biopsied. Pathology, however, was noted to be benign with debris and bile crystalline material and rare fragments of fibrous tissue with biliary-type epithelium.\nAfter evaluation and review of his complicated hospital course with no clear diagnosis but high suspicion for cholangiocarcinoma, a decision was made to undergo a diagnostic laparoscopy with peritoneal washings to rule out carcinomatosis given ascites. The laparoscopy noted inflammation in segments 4 and 5 of the liver, with the gallbladder not visualized since it was covered by omentum. Several biopsies which were obtained from both the right and left liver segments including washings were negative for malignant cells. Thus, the decision was made to proceed with hepatectomy.\nPreoperatively patient reported mild right upper quadrant pain, nausea and diarrhea. He denied any fevers, jaundice or weight loss. On physical exam, his vitals were stable, the abdomen was soft and non-tender to palpation. Labs showed white blood cell (WBC) of 3.84 k/uL, hemoglobin 9.4 g/dL, aspartate aminotransferase (AST) 56 U/L, alanine aminotransferase (ALT) 63 U/L, alkaline phosphatase 261 U/L and total bilirubin 1.0 mg/dL. Tumor marker noted cancer antigen CA 19-19 at 53 U/mL (normal limit: <36 U/mL) and carcinoembryonic antigen (CEA) at 1.7 ng/mL (normal limit <2.9 ng/mL).\nIntraoperatively, the surface of the liver was noted to be quite inflamed. There were dense pericholecystic adhesions, and the gallbladder was diffusely thickened. A hard mass with surrounding inflammatory and fibrotic changes was encountered in segment IV. After mobilizing the liver and controlling all hilar structures, in addition to Doppler confirmation of right hepatic artery flow, an extended left hepatectomy was performed. The right hepatic artery was carefully dissected off the mass, and the left liver including segments 5 and 8 as well as the caudate lobe was resected (Fig. ). We were able to preserve the main bile duct. Pathology subsequently revealed XGC extending into the hepatic parenchyma (Fig. ). After an uneventful post-operative course patient was discharged to extended care facility in stable condition 8 days after his surgery. |
An 89-year-old fit female with a history of chronic back pain and an appendectomy during her youth completed using a McBurney incision presented with a one-day history of spontaneous pain in her right flank without any fever, chills, or other symptoms. At the time of her admission, she was not in distress, she was not febrile, and her vital signs were within normal values. On clinical examination, there was swelling with a red area measuring 12 cm × 4 cm and tenderness of the right flank around her appendectomy scar. Crepitus could be felt diffusely on her right and left flanks and the periumbilical and epigastric regions upon palpation. Blood test showed the presence of mild inflammation, with a CRP value of 7 mg/l (within normal values) and an elevated white blood cell count of 18 G/l. The rest of the laboratory results were normal. Emergency ultrasonography was unhelpful because of air interference. An abdominal CT scan () showed diffuse subcutaneous abdominal emphysema extending to the pelvis on the left side that was more pronounced on the right inguinal fossa with a bowel loop in contact with the abdominal wall. An emergency laparotomy centered on the McBurney incision showed feces and pus within the subcutaneous compartment. Furthermore, at the level of the aponeurosis of the external oblique muscle, an inflammatory diverticulum could be seen fistulizing between the lumen of the sigmoid colon loop and the necrotic subcutaneous tissue. We subsequently diagnosed intraoperatively a subcutaneous abscess and emphysema with an enteroparietal fistula caused by a ruptured sigmoid diverticulum in an incisional hernia. The necrotic tissues were excised, and the punctiform sigmoid colon fistula was closed. Revision of the rest of the sigmoid showed important adhesions between the sigmoid colon and the parietal peritoneum of the right flank and between the caecum and the sigmoid colon, respectively. The sigmoid colon also showed diffused diverticulosis with no inflammation. The cutaneous and subcutaneous tissues were left open and dressed with a negative pressure-assisted closure device on postoperative day 1. The patient received intravenous antibiotherapy for two weeks with quinolones and a third-generation cephalosporin at first which was then switched to aztreonam due to an allergic reaction. Bacteriological studies showed polymicrobial digestive bacteria (i.e., Escherichia coli, Streptococcus equinus, and Enterococcus). Subsequently, there was good clinical and biological evolution. At two weeks postoperation, she was reoperated on for closure of the wound. She was discharged from the hospital three weeks after her initial surgical intervention with the indication to continue antibiotics for a total of four weeks. |
A 45 year-old elite female runner developed acute anterolateral left knee pain and popping at mile 17 during a marathon. The patient reported a painful pop in her knee with extension. Pain was reported up to 10 out 10 with walking and running but relieved with rest. Past medical history, surgical history and review of systems were noncontributory. On physical exam, the patient walked with an antalgic gait. There was a visible pop on the anterolateral aspect of her patellar tendon with acute knee extension, focal tenderness to manual palpation of the anterolateral aspect of the fat pad and minimal knee joint effusion. A firm nodule could be manipulated, which was tender to palpation while the knee was in full extension. Exam was otherwise negative. An magnetic resonance imaging (MRI) was obtained and showed a well-defined intermediate to low signal intensity soft tissue nodule in the deep proximal lateral border of the infrapatellar fat pad measuring 1.3 cm by 0.9 cm. This nodule was adjacent to the inferior lateral margin of the patella, in close proximity to the anterior margin of the lateral femoral trochlea ().\nThe patient was brought to the operating room for arthroscopic biopsy and excision. An anteromedial portal was used as the viewing portal given the location of the nodule. The medial compartment was first evaluated and showed an intact meniscus and normal articular surface. The lateral compartment showed a well-circumscribed encapsulated nodule visible at the proximal lateral aspect of the patella fat pad (). A distal lateral portal was created with the assistance of an 18-gauge spine needle to avoid penetrating the nodule. The nodule was carefully removed in one complete segment with an Arthrocare (ArthroCare, Austin, TX, USA) while avoiding any damage to its overlying capsule and sent to pathology (). Additional debridement of the fat pad at the base of the nodule was performed to ensure that no residual tissue was left behind. Pathology report was consistent with the nodular form of Pigmented Villonodular Synovitis (PVNS) and described a well-circumscribed tan nodule with rusty-orange pigmentation measuring approximately 1.5 cm in the greatest dimension. The nodule was composed of mononuclear cells with discreet eosinophilic cytoplasm and round nucleus with interspersed multi-nucleated giant cells, small collections of foamy macrophages and hemosiderin deposits.\nThe patient was seen in clinic two weeks postoperatively with full range of motion with elimination of the pre-operative pop during extension. At the three months postoperative visit, the patient had resolution of her knee pain and returned to early training in preparation for a half marathon. |
A 27-year-old male patient was referred to the Department of Prosthodontics at our institution. The patient complained of facial asymmetry and poor looks due to loss of the right eye. A history of retinoblastoma, followed by exenteration of the orbit was recorded. The surgical intervention had been carried out when the patient was 5 months old; thereby the growth was retarded. The facial asymmetry was apparent as the anophthalmic defect included the right orbit and extended laterally along the outer canthus of the eye, toward the temporal region as well along the malar eminence toward the zygomatic arch. The patient underwent a computed tomography scan on basis of which a stereolithographic model was fabricated. A mock surgery on the stereolithography model [] revealed optimal bone thickness along the inferolateral orbital rim composed of zygomatic bone while the lateral aspect of superolateral rim composed of frontal bone showed moderately optimal bone in terms of thickness and density.\nA surgical stent was fabricated as per the mock preparation. After obtaining patient's written consent, implant surgical procedure was done under short general anesthesia. Two intraoral dental implants were placed depending on the availability of the bone at the defect site. A 3.75 mm × 10 mm implant was placed in inferolateral region and 3.75 mm × 8 mm implant was placed in superolateral region []. A healing period of 4 months was given following which the extra oral radiographs - posteroanterior waters and lateral cephalogram [] were made. The defect impression was made with implant components in place []. A metal framework was cast to attach it to the implant abutment with the magnetic keepers embedded in it []. The metal framework was threaded onto implant in the patients defect. The wax orbital prosthesis had the corresponding magnets embedded in it []. The wax trial was taken []. Finally, the silicone orbital prosthesis was placed in situ []. Intrinsic coloring was done to blend the silicone with the adjacent skin color.\nThe evaluation of the final prosthesis showed excellent retention and stability with facial expressions and head movement. The patient was extremely pleased with the final outcome, and there was also a marked improvement in his social interaction and self-esteem.\nHygiene maintenance instructions were given to the patient to maintain cleanliness. Cotton buds, an interspace toothbrush with soft bristles and floss were the advised cleaning aids. |
A 36-year-old African American man with a past medical history of herpes simplex virus (HSV) infection presented to the emergency department with a chief complaint of right knee pain and swelling of a couple of weeks. The symptoms began shortly after the patient returned from his trip to Minnesota where he was diagnosed with gonococcal urethritis by urine polymerase chain reaction (PCR) at a local emergency department. He had initially presented with a thick white urethral discharge and had been treated with one dose of cefixime 400 mg and doxycycline 100 mg twice a day for seven days. The patient returned to Connecticut and presumably finished his antibiotics treatment.\nOver the next two weeks, the patient developed right knee pain and swelling and sought care in an outside emergency room. He was noted to have bilateral conjunctival injection in addition to right knee synovitis. He was given ibuprofen as well as erythromycin ophthalmic ointment. The patient returned the following day to the same emergency room due to minimal relief of his knee pain and this time was given prednisone taper for five days starting with 50 mg daily. Six days later, he presented to our emergency department with ongoing right knee pain.\nUpon presentation, the patient also endorsed complaints of right ankle pain and swelling as well as left lateral hip pain. He had also complained of open sores on his penis, which per patient felt very similar to his prior HSV outbreaks. On further questioning, he noted feeling febrile but denied fatigue, weight loss, eye pain or redness, vision changes, rhinitis, ear discharge, chest pain, shortness of breath, abdominal discomfort, nausea, vomiting, diarrhea, dysuria or urethral discharge. Patient admitted to smoking about two to three cigarettes a day and drinking alcohol occasionally but denied use of illicit drugs. He has had multiple sexual partners over the past six months and did not use protection.\nOn physical examination, he was febrile (102.9°F) and tachycardic (129 beats per minute). He was found to have bilateral conjunctival erythema with normal pupil size and light reactivity. Two non-tender, sub-centimeter, and elliptical-shaped dry ulcers with erythematous base were found on the hard palate of his mouth. There were a few mildly tender, non-purulent and sub-centimeter ulcers on his penis. There was no inguinal lymphadenopathy. His right knee was extremely warm, tender, and swollen. The range of motion was also limited due to pain. He had similar warmth, tenderness and swelling over the right ankle, and tenderness was noted over the left trochanteric bursa. Sausage-shaped swelling, consistent with dactylitis, of his right second toe was noted (Figure ). Bilateral plantar surfaces were covered with hyperkeratotic hyperpigmented plaques consistent with keratoderma blennorrhagicum (Figure ).\nLab work showed leukocytosis (white cell count of 24.0/µL) and significantly elevated inflammatory markers (erythrocyte sedimentation rate [ESR] of >130 mm/hr; C-reactive protein [CRP] of 262 mg/L). Right knee arthrocentesis revealed a turbid aspirate with 23,778 white blood cell count with 88% neutrophils. Gram stain was negative.\nThe patient was empirically started on ceftriaxone for disseminated gonococcal infection and azithromycin to cover for chlamydia. He was also given valacyclovir for herpetic ulcers on his penis. Despite treatment with antibiotics, he had persistent fevers and synovitis of the right knee and ankle. Repeat gonorrhea and chlamydia PCR returned negative. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), tuberculosis, syphilis, Lyme, Anaplasma, and Babesia also returned negative. Synovial cultures from initial as well as repeat arthrocentesis remained negative. Magnetic resonance imaging (MRI) of the right knee and ankle showed joint effusion but no other underlying abnormality was found. Human leukocyte antigen B27 (HLA-B27) was positive.\nGiven patient’s lower extremity predominant oligoarthritis, conjunctivitis, recent history of gonococcal urethritis, dactylitis, a classic rash of keratoderma blennorrhagicum and HLA-B27 positivity, a diagnosis of reactive arthritis was made. He was initially treated with ketorolac without much improvement in his joint symptoms. He was subsequently placed on two alternative non-steroidal anti-inflammatory drugs (NSAIDs) one after the other (indomethacin and diclofenac). A complete resolution of left trochanteric bursa pain was achieved with the NSAIDs, however debilitating pain in the right knee and ankle persisted. Finally, oral prednisone 40 mg daily was initiated with resolution of his fever and improvement of right knee and ankle synovitis. He was discharged home on prednisone with a plan for rheumatology outpatient follow-up. His total hospital stay was 12 days.\nPatient was re-admitted to the hospital 10 days later due to persistent synovitis involving the right knee and ankle and a new-onset left knee synovitis. On further probing patient stated that he was non-adherent with taking prednisone at home. Repeat arthrocentesis again revealed aseptic inflammatory aspirate. He was started on intravenous methylprednisolone 40 mg twice a day along with sulfasalazine 500 mg twice a day. The patient's joint symptoms improved markedly over the next two days and he was discharged on oral prednisone. Unfortunately, he was lost to follow up upon discharge. |
The authors report a case of a 29-year-old Saudi woman who was G4T2P0A1L2 at 21 weeks of gestation. She was free from medical illness and she had had no previous surgical procedures. She is a housewife; she never smoked tobacco or drank alcohol, and she had no history of recent travel to endemic or pandemic areas. She was referred based on an antenatal ultrasound finding that showed multiple fetal anomalies. This ultrasound had been conducted at another hospital for evaluation and management. Her past obstetrical history was uneventful with two normal term vaginal deliveries and a history of first trimester unexplained miscarriages. She is married to a first-degree cousin working in a governmental institute; there is no history of genetic or congenital anomaly in either of their families.\nHer current pregnancy was spontaneous with no history of illicit drug use or exposure to infection or radiation. Her initial early antenatal scan diagnosis showed suspicion of possible fetal diaphragmatic hernia and required further validation which was not possible at the maternal–fetal medicine (MFM) unit at the hospital which also did not have available sonographic specialists. During her first antenatal visit at 21 weeks + 0 day of gestation, the results of her anatomy scan revealed a single viable fetus with estimated fetal weight (EFW) on 50th percentile with normal biometry measurements.\nFurther detailed anatomy scan findings revealed a male fetus with both kidneys appearing small in size, hyperechoic dysplastic, both ureters were dilated, urinary bladder looked abnormal in shape with thickened bladder wall, and umbilical cord at fetal insertion side appeared thickened. In addition, the diaphragm was seen clearly separating the chest from the abdominal compartments with no evidence of diaphragmatic hernia. Both feet were clubbed and open hands were seen with no other anomalies or any soft marker seen (see Fig. .) Based on the multiple fetal structural anomalies discovered, the couple was counseled about the scan findings and advised for further workup, such as: perinatal invasive testing; toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus, and herpes (TORCH) screening; and fetal echocardiogram to exclude syndromic or chromosomal causes. This would support reaching a better diagnosis and allow for further discussion on the options available such as the continuity of the pregnancy or termination based on the severity of the fetal condition (see Table ).\nOur patient had some social issues and was also following her condition in another institute and only revisited our center at 32 weeks and 4 days of gestation. At our center another follow-up scan revealed a single viable fetus, cephalic in presentation, anhydramnios with normal head and femoral length biometry. Unfortunately, the abdominal circumference (AC) was not taken due to the extremely distended abdominal wall that prevented any further visualization by ultrasound. The right kidney measured 3.4 × 1.1 cm with a small cyst, the left kidney measured 2.9 × 1.3 cm with bilateral hugely dilated ureter and urinary bladder (mega cyst) (see Fig. ).\nTORCH screen test results were non-reactive. Amniocentesis was performed and showed normal chromosomal results. A fetal echocardiogram allowed for limited examination due to anhydramnios; however, no obvious cardiac anomalies were noted. Lungs appeared compressed due to severely distended abdomen from the progressively enlarged urinary system, otherwise no other abnormal findings noted. The couple was counseled by the MFM team about the worsening condition from the recent scan findings and were told about the poor fetal prognosis and the high mortality rate, secondary to severe lung compression with the presence of anhydramnios which would lead to lung hypoplasia and cause fetal demise.\nIt was explained that the entire urinary system was affected with severe dilatation causing severe abdominal wall dilatation and for this reason measuring fetal AC had been difficult antenatally. Options were discussed with the couple:Termination of pregnancy to avoid obstetrical complication during labor which is fetal abdominal dystocia as it was difficult to measure the abdominal wall antenatally with the severe progressive renal system dilation with advancing gestational age versus To wait until term pregnancy while knowing the poor fetal prognosis\nFurthermore, antenatal interventions were offered to the couple including tapping of the fetal bladder and ureters prior to induction of labor and to then send the amniotic fluid sample for further genetic testing. Our patient’s case was initially discussed by a multidisciplinary team which included a perinatologist and a neonatologist before finally making a combined agreement and alignment with the couple who decided to terminate the pregnancy; a caesarian section would be preserved for maternal indication and comfort care post-delivery to born infant were also explained.\nAt 32 weeks and 5 days of gestation, tapping of the fetal bladder and ureter was performed and samples of amniotic fluid were sent for whole exome sequencing (WES) test; however, unfortunately, after waiting a few weeks for the results, no results could be determined due to a laboratory error.\nOur patient underwent induction of labor to terminate the pregnancy and delivered vaginally a male neonate with Apgar score of 2 in 1 minute and 5 in 5 minutes, weighing 1800 grams without any complications. The vital signs revealed blood pressure of 90/60, pulse 100 beats /minute, and temperature of 36 °C. Clinical examination of the newborn revealed distended abdomen and thin wrinkled skin, retracted chest, cryptorchidism, and clubbed feet; no facial anomalies were noted and the features were most likely to be suggestive of PBS (see Fig. ). The newborn died 2 hours post-delivery.\nThe placenta was sent for a histopathology examination as a part of the workup and the result revealed normal findings.\nA postmortem examination was not offered to the couple since this is not conducted in the center. The couple was counseled prior to discharge regarding future pregnancy plans, despite low reoccurrence. It was also highlighted to them the importance of having early prenatal testing in a center in which there were well-trained sonographers and a high risk in pregnancy unit available. They were also informed about the lack of result of WES test due to laboratory error and they were fine. |
A 34-year-old female who has no previous clinical illness presented in 2000 with a large irregular mass, estimated clinically to be around 5 × 6 cm by physical examination, involving the right breast while she was lactating. There were no other signs or symptoms. FNA was done to rule out breast cancer, and the specimen showed few foamy macrophages and rare clusters of ductal cells, with focal secretory lactational changes. Based on that, it was determined that the specimen was negative for malignancy. The tumor continued to grow, and in June 2004, FNA of the right breast was repeated and showed large staghorn-shaped sheets of uniform ductal cells with no cytologic atypia along with myoepithelial cells. There were fragments of fibrotic stroma and bare nuclei scattered in a bloody background, and so, a diagnosis of fibroadenoma was made. Two months later, the patient underwent excision of the tumor in another healthcare facility. Examination of the slides showed an overgrowth of epithelial and stromal components in pericanalicular and intracanalicular patterns with irregular large cystic spaces showing protruding leaf-like structures (). The stromal cells showed plump elongated slightly dysmorphic nuclei with occasional prominent nucleoli. Other areas showed significant cellular growth of the stromal spindle cells which appeared to be arranged in long intersecting fascicles and growing in herringbone pattern (). Within the spindle cell growth, extracellular mucin was noted. One focus showed an exclusive spindle cell growth which was moderately atypical with plump elongated hyperchromatic nuclei. Numerous mitosis was found, up to 20 in 10 high power fields in this focus. Entrapped epithelial ductal elements were occasionally seen in other areas exhibiting ductal epithelial hyperplasia. These features were consistent with malignant phyllodes tumor with stromal fibrosarcomatous overgrowth. The patient subsequently underwent mastectomy as the margins were focally involved. During the procedure, a mass measuring around 3-4 cm was found in the most posterior aspect of the breast and there was some indication that it may have invaded the pectoralis major muscle. All the breast tissue, the tumor, and some of the muscle fibers were removed. On gross examination, there were multiple tumor masses in the inner lower and outer upper quadrants, the largest being 3 cm. On microscopy, there was proliferation of atypical spindle and elongated plump cells with pleomorphic nuclei and occasional prominent nucleoli. Extracellular mucin was also identified. The atypical stromal cells formed herringbone fascicular growth pattern reminiscent to fibrosarcoma and numerous mitosis averaging around 14 mitosis in 10 high power fields. No residual phyllodes tumor elements were identified. The tumor nodules had a well-demarcated margin with focal infiltration of surrounding breast and adipose tissue. No lymphovascular invasion, necrosis, or heterologous differentiation was seen. All surgical margins and muscle fibers were not involved by the tumor. The skin and nipple did not show any involvement either. All these histological features were identical to those identified in her previous lumpectomy except that there was more pronounced atypia and no residual epithelial component of phyllodes tumor identified. No lymph nodes were identified. A year later, the patient began to suffer from acute bouts of pancreatitis and was admitted several times for this. In March of 2006, abdominal CT was performed and showed a heterogenous low attenuation soft tissue mass involving the head and body of the pancreas and was extending upwards. The celiac vessels and its branches were going through this mass but did not show any significant narrowing. There was obvious atrophy of the pancreatic tail and dilatation of the pancreatic duct. The mass was in contact with the anterior aspect of the inferior vena cava (IVC) with no clear fat plane in between (). Biopsy of the pancreatic mass showed uniform proliferation of elongated spindly cells which had coarse chromatin and mild to moderate nuclear pleomorphism. Some cells had plump hyperchromatic nuclei. Numerous mitotic figures were identified (). The background showed variable amounts of collagen and stroma with focal areas of myxoid appearance. Immunohistochemical staining showed strong positivity for vimentin; however, the cells were negative for actin, S100, and cytokeratin (). These findings were consistent with metastatic fibrosarcoma of the pancreas secondary to her primary breast lesion. Due to the location, extent, and nature of the condition, the case was deemed unresectable. Chemotherapy was initiated; and in the little chance that the tumor shrunk enough, the possibility of resecting the metastasis would be entertained. In January 2007, the patient presented to the ER with severe epigastric pain, where she collapsed, was hypotensive, and subsequently admitted. On examination, a tender mass in the epigastric area was felt. Urgent CT of the abdomen and pelvis with and without contrast showed a pseudoaneurysm in the splenic artery measuring around 3.5 cm. There was also expansion of the retroperitoneal mass and blood in the intraperitoneal cavity. There was heterogenous enhancement in the liver most probably indicating liver infarct. In addition, there were areas of the IVC which had markedly thinned wall and areas suspicious for active bleeding, especially from the proximal splenic artery (). The pancreatic fibrosarcoma had grown and eroded branches of the celiac artery with bleeding pseudoaneurysm along with infarct of the liver, spleen, and adjacent organs. The patient continued to be hypotensive with abdominal distention due to severe intra-abdominal bleeding and developed multiorgan failure and hemorrhagic shock leading to her death. |
A 30-year-old woman visited the hospital due to right lower quadrant pain over the period of 1 week. A laparoscopic myomectomy was performed 4 years ago because of a broad ligament leiomyoma, which was about 10 cm in size. Laboratory findings included a routine blood examination, and a C-Reactive Protein (CRP) test, with tumor markers all found to be within normal ranges. The pelvic Magnetic Resonance Imaging (MRI) scan showed some nodules at the posterior margin of the bladder that were considered to be endometriosis, and some pelvic effusion that was significant on the right side. It was also noted that there was a mass shadow at the lower right ureter (medial to the iliopsoas muscle), with distention of the lower right ureter (Fig. ). The patient also underwent computed tomography (CT) scans to enable the practitioners to observe the size of the abdominal mass and its surroundings. The CT images revealed a region occupying the middle right ureter that was considered to be a retroperitoneal aggressive fibroma, which led to severe hydronephrosis on the right kidney and upper ureter, and a right pelvic effusion (Fig. ). After more detailed examinations were conducted, there were no obvious abnormalities detected in the brain, heart, liver, gallbladder, spleen, pancreas or blood. The color Doppler ultrasound demonstrated that there was a hypoechoic mass next to the right iliac vessels that was closely related to the adjacent ureter. This resulted in severe hydronephrosis of the right kidney and a right upper ureteral dilatation (Fig. ). Ndzengue et al. [] reported a case of a pelvic desmoid tumor simulating a uterine leiomyoma recurrence. The patient that presented at our hospital had a history of uterine leiomyoma. We subsequently organized a multidisciplinary consultation to determine the next stage of her treatment plan. According to the patient’s surgical history, the next step would be determined after reviewing the results of the last surgical pathological wax, because the pathological nature of the retroperitoneal mass was uncertain.\nConsequently, a laparoscopic pelvic tumor resection with assistance from a Da Vinci robot was successfully conducted. A local peritoneal protuberance was observed in the right iliac vascular area. The parietal peritoneum was incised above the mass and it was carefully freed along the edge of the mass. The size of the tumor was about 6.0 cm × 5.0 cm × 3.0 cm. It had invasively grown and it was wrapped around the right ureter and the right ovarian arteries and veins. It was stuck to the psoas muscle and the iliac vessels. According to preoperative preparations and intraoperative conditions, a decision was made to cut off the right ureter, the right ovarian arteries and veins, and completely remove the tumor and the two masses that were located in front of the broad ligament on the right hand side of the uterus. The sizes of the masses were approximately 1.5 cm × 1.0 cm × 1.0 cm. The right ureter was anastomosed and put into a double J tube. A pathological diagnosis of an intraoperative frozen sample determined that it was a spindle cell soft tissue tumor, and the two masses were leiomyomas. Postoperative pathology tests of the pelvic mass determined that it was aggressive fibromatosis that had invaded the ureteral wall (Fig. ). The uterine surface nodules were also leiomyomas. Microscopically, the tumor cells were arranged sparsely in a spindle shape with blood vessels of different sizes found in the interstitial tissue. Immunohistochemical findings were found to be partially positive for smooth muscle actin (SMA) and desmin, and less than 5% ki-67 of positive cells were seen in the lesion. A detailed re-examination was performed 3 months after the initial surgery, to determine the structure and function of the ovaries. The transvaginal color Doppler ultrasonography was able to determine that the ovaries were normal in size with several follicular echoes. The blood supply to the right ovary was good. There were no obvious abnormalities in the uterus or pelvic cavity (Fig. ). The pelvic MRI and the CT scan of the whole abdomen determined that there were no abnormal lesions in the pelvis. Simultaneously, the endocrine function of the patient’s ovaries was found to be normal, and she was able to self-maturate after removing the double J tube. |
A 41-year-old chronic alcoholic and smoker male patient residing in western India presented with history of acute painless monocular vision loss in right eye over seconds while drinking at home. The symptoms were non-progressive since onset, and the patient sought consultation after 4 days due to lack of any improvement in symptoms. The patient was diagnosed as being hypertensive since 5 years, but was not compliant with his medications and reported bilateral parieto-occipital mild heaviness-type of evening headache since 5 years without any other symptom. There was no early morning worsening of his headache or any associated complaints of vomiting or visual blurring over the last few years. There was no previous history of any focal neurological deficits, transient ischemic attacks, amaurosis fugax, ischemic heart disease or diabetes, or similar history in family members. General examination did not reveal any subcutaneous nodules or any other positive finding. Both pupils were of equal size and normally reacting to light and accommodation. He was able to count fingers at 1 m by the right eye, and acuity was 6/12 in the left eye. Color vision was normal in the left eye and was decreased appropriate to loss of acuity in the right eye. Fundus examination revealed focal anterior displacement of retina in right macula suggestive of a cystic lesion. Left eye fundus examination was normal and did not reveal any evidence of papilledema. Subsequently, full thickness retinal mapping was done which was suggestive of subretinal choroidal neurocysticercosis with greatly diminished visual field and retinal pigment epithelium/choroid disruption []. A brain magnetic resonance imaging (MRI) was done which revealed multiple intracerebral neurocysticercosis in both hemispheres without any significant mass effect or hydrocephalus [Figures and ] while MRI of the entire spinal cord was normal. The patient was advised surgical evacuation of the cyst followed by albendazole regime, but refused for surgery. AHD use in patients with ocular cysticercosis is associated with inflammatory response and retinal detachment leading to vision loss. He was thus started on treatment with only oral steroids given at 1 mg/kg dose and tapered off over 4 weeks. His visual acuity was static at 16 weeks of follow-up and is still not willing for surgical intervention. The patient does not report of any seizures till date and his electroencephalogram is repeatedly normal. |
A 63 years old lady carried out a complex re-laparotomy for a postoperative small bowel occlusion after a radical cystectomy because of urothelial carcinoma. The procedure lasted 3 h because of thick adhesions that needed to be cleared. At the end of the procedure, total blood loss was 2 litres, and two Units of Packed Red Blood Cells (PRBC) were infused. During the surgical procedure, a central venous catheter was placed in the internal jugular vein by ultrasound-guided puncture of the vessel, but an inadvertent puncture and cannulation of the right subclavian artery occurred before catheter placement. Because of the ultrasound-guided procedure, the anesthesiologist thought to have cannulated the carotid artery and applied local pressure for a few minutes. Two hours later, when the patient was in the Intensive Care Unit (ICU) around midnight, a chest X-ray to check the correct position of the central venous catheter revealed a massive hemothorax (), while the patient was hypotensive and responder to crystalloids and blood infusions. A chest drain was inserted without any substantial output but a small amount of clotted blood. The patient rapidly worsened, despite appropriate resuscitation with 10 U of PRBC, 8 U of Fresh Frozen Plasma (FFP), 3 U of cryoprecipitate and 1 U of platelets from apheresis. A second chest X-Ray to check tube position revealed a tension hemothorax (). The team in charge of the patient, comprising the anesthesiologist that did the general anaesthesia for the surgical procedure, made the diagnosis of suspected subclavian artery perforation and tension hemothorax with both hypovolemic and obstructive shock. The team decided to bring the patient in the hybrid room to control the likely bleeding for the right subclavian artery. While the patient has been positioning on the angiographic table, the ECG monitor showed severe bradycardia, with a heart rate of 30 and an impending cardiac arrest with a systolic blood pressure of 30 mmHg. An emergency thoracotomy to decompress the right chest was then performed via a V space incision, and five litres of blood under pressure were drained from the right pleural space, with a rapid improvement in the vital signs. During the endovascular procedure, the general surgeon left the thoracotomy open to allow a continuing suction in the pleural space to prevent the accumulation of clots. The endovascular procedure was conducted by the vascular surgeons and lasted 40 min, confirming the massive leak from a significant defect in the subclavian artery () and consisted in a 7 x 37 mm covered stent placement in the subclavian artery at the origin of the vertebral artery. The stent was expanded with a balloon taking care of not injuring the already damaged vessel (). The patient had a transient improvement, but in the next few hours, a hemodynamic instability again occurred, even if responsive to blood infusion. A CT scan revealed a leakage from the stent, because of retrograde revascularization of the vertebral artery (). A new endovascular procedure, with more pronounced balloon dilatation of the stent, definitely controlled the bleeding. ) The patient slightly improved after an open surgical debridement of the pleural space from clots and blood, given the absence of an output from the two large drains that were in place. In the next few days, the patient went back to the ward and made a gradual full recovery with no neurological or vascular defects (). |
A 43-year-old male patient was evaluated in psychiatry policlinic due to the complaints of bursts of anger. From his medical history, it was learnt that his complaints have begun 5 years ago and have gradually increased within the last years. It was learnt that burst of anger has caused disturbance in social and professional life and important legal and financial problems and thus he wanted to have psychiatric support. The patient told that bursts of anger generally develop suddenly, continue for approximately half an hour, and include verbal, physical attacks and attacks against objects. He mentioned that he completely loses his control during burst of anger and it is not possible to oppose him and he is in a condition just like seizure and the severity of anger might be more or less independent of the stress causing the burst.\nThere was no feature in his medical and family history. As hypocalcemia was detected in laboratory examinations, he was consulted with the internal medicine department. On physical examination, general condition of the patient was normal; he was conscious and cooperated. Vital signs were normal (blood pressure 120/85 mm Hg, pulse 75 beat/min, respiratory rate 15/min, and body temperature: 36.8) and Chvostek test was (+) in his systemic and neurological examination. There was no additional pathology and the laboratory findings of the patient are summarized in .\nOn posterior-anterior chest X-ray there was no pathological finding. ECG was in normal sinus rhythm. Computerized cranial tomography was performed for both differential diagnosis of hypocalcemia and differentiation of the burst of anger from an organic cause (). There were a great number of calcifications in both cerebellar hemispheres (), basal ganglions (), and subcortical white matter () in axial sections of cranial tomography. In the light of the present findings, the patient was diagnosed with idiopathic basal ganglia calcification.\nSome tests were performed to exclude other diagnoses and VDRL test was negative; TORCH group Ig M was negative and Ig G was positive. Anti-HIV antibody was negative. No pathology was observed in ultrasonography of thyroid and parathyroid glands. Thyroid function tests were normal and thus hyperthyroidism and hypothyroidism were excluded. Vitamin D level was normal. As there were no previous infection, previous thyroid surgery, drug use, and autoimmune disease in detailed medical history of the patient, the hypocalcemia was thought to be caused by an idiopathic etiology. On psychiatric evaluation which was performed according to DSM IV criteria, the patient was diagnosed with impulse control disorder. With the present findings, the patient was accepted as IBGC and impulse control disorder. Intravenous and oral calcium replacement therapy was administered and carbamazepine 200 mg/dy was started by the psychiatry department. After normalization of calcium values the patient was discharged to be followed up in the policlinic. |
The patient, a 19-year-old woman with sickle cell anaemia, was admitted due to acute onset of severe sensory-motor impairment of her left lower extremity. The patient was awakened during the early morning hours by severe pain in the waist, typical of a VOC, and realized that she had decreased sensation and mobility on her left leg (characteristically mentioned that she could not feel or move the affected leg). Mobility and sensation in the right lower and both upper extremities were intact. Her mental status was normal, her speech was unaffected, and there were no sphincter disturbances. Neurological examination at the time of admission revealed power 1-2 of all muscle groups of the affected limb. Tone was reduced and deep tendon reflexes were absent even after reenforcement, suggesting peripheral nerve pathology. Sensation was subjectively reported by the patient as being 80% decreased compared to normal and proprioception was lost. Gait could not be assessed as the patient could not stand. Save for lower spinal and left hip tenderness on palpation in keeping with VOC, the rest of the neurological and general physical examination was unremarkable. Results of baseline diagnostic tests are summarized in . Computer tomography (CT) of the brain, magnetic resonance imaging with angiography (MRI/MRA) of brain, and circle of Willis and MRI of the spine were performed. CT of the brain was unremarkable with no evidence of intracranial hemorrhage and subacute or any established territorial infarct. MRI of the brain showed no evidence of acute ischemia and there were no vascular abnormalities on MRA. MRI of the spine showed normal cord caliber and signal, with no evidence of intramedullary infarcts. There was no evidence of hemorrhage or compression.\nConservative therapy with fluids and parenteral opiate analgesia led to improvement of pain. In the absence of any anatomical abnormalities, it was felt that the most likely cause for her acute peripheral nerve injury was ischemia due to vasoocclusion and the patient underwent emergency automated red cell exchange transfusion (ARCET) 24 hours after her initial presentation. She received 12 units of red cells as per UK national standards for patients with SCD [] using the Spectra Optia Apheresis System. Pre- and posttransfusion haematological values are summarized in .\nARCET led to immediate clinical improvement with almost complete resolution of the neurological deficit by the end of the procedure and, shortly afterwards, the patient was able to walk independently. She was reviewed again by the neurologists who confirmed complete resolution of the deficit. Even though the patient was scheduled to have nerve conduction studies and a diagnostic lumbar puncture, these were now considered unnecessary and cancelled. She was discharged home, 48 hours after admission, without any neurological deficit. |
A 42-year-old female reported with the chief complaint of pain, restricted mouth opening, and swelling in the right lower jaw for 3 months. She had a history of a difficult extraction of her lower right mandibular third molar tooth, 3.5 months back. Her treating dentist had informed about her tooth. However, she developed persistent pain, restriction of mouth opening, and a firm swelling in her lower jaw and visited our institution thereafter. On examination, an interincisal opening of around 20 mm was observed. A firm swelling was present in her right submandibular area, which was tender on palpation. Intraorally, a slight bulge was present on the lingual aspect of the mandibular third molar area, near the mylohyoid ridge, which was hard and tender on palpation. We prescribed her with routine antibiotics and analgesics for 5 days and asked her to come for a follow-up after 7 days. On her second visit, the pain had completely subsided, and mouth opening had increased to 30 mm; however, the swelling in the submandibular area was persistent. To exclude the presence of any lesion, a computed tomography (CT) scan of her jaw was advised. The CT scan revealed an intact third molar tooth, displaced lingually and inferiorly in the sublingual pouch []. A fracture was also evident in the patient's lingual cortical plate near the third molar region. Surgical intraoral removal of the displaced tooth was planned under general anesthesia after the procedure, and potential complications were explained to the patient. Intraoperatively, the neck was extended, and bimanual palpation was done to locate the exact position of the tooth. Digital pressure was applied at and lingual to the lower border of the mandible to prevent further displacement of the tooth. Incision was placed directly over the lingual bulge, taking care to avoid injury to the lingual nerve. A substantial amount of fibrosis made dissection difficult. Minor blunt dissection of the mylohyoid muscle was done until the tooth was visible in the sublingual space with good illumination and support from extraoral digital pressure. With the help of a curette, the tooth was pushed outward and upward and retrieved from the oral cavity []. The wound was irrigated with normal saline and sutured with 3-0 Vicryl sutures []. The removed tooth is seen in . Antibiotics and analgesics were prescribed for 5 days. On the 7th postoperative day, the patient was called for suture removal and reported that she was not experiencing any troubling complications. Her healing appeared to be satisfactory. There was no incidence of lingual nerve paresthesia. After 1 month, the mouth opening significantly improved to 35 mm. |
The patient was a 66-year-old male with advanced malignant prostate cancer, bone metastases, and kidney failure requiring dialysis. While an inpatient at a cancer hospital, he was transported to the intensive care unit (ICU) for catheter placement and a hemodialysis session. The professional on duty chose a left subclavian vein access, using anatomic landmarks. The blood aspirate at puncture appeared to be venous and the guidewire was advanced without difficulties, but after dilation of the tract and insertion of the catheter, retrograde pulsating flow was observed. Inadvertent positioning in the left subclavian artery (LSA) was confirmed by blood gas analysis and Doppler ultrasound ( ). The examination ruled out the possibility of injuries to the carotid or vertebral vessels, which had normal morphology and blood flow. Physical examination found 4+ brachial and radial pulses. The device was left in place and the patient was transferred to a hospital with vascular and endovascular surgery services. Inherent problems within the Brazilian National Health Service (SUS - Sistema Único de Saúde) delayed the transfer by 18 days. Since there was a risk of fatal complications, the catheter was not removed from the LSA and the patient was not given anticoagulation because of a recent history of melena. After transfer, the catheter was removed, but endovascular repair was not possible because a thrombus was seen in the arterial lumen. There was no bleeding or formation of hematoma, and left upper limb perfusion was maintained, although the brachial pulse was rated 2+ and the distal pulses were absent at that time. The patient was transferred back to the cancer hospital. Doppler vascular echography was conducted again, showing a subacute thrombus in the LSA, where flow was monophasic ( \n ), constituting subocclusion. The arterial thrombosis was in topography distal of the emergence of the vertebral artery, in which flow was laminar, anterograde and with velocities within the limits of normality ( ). At the subclavian-axillary transition, an arterial branch was observed with reversed flow that, based on topography, may have been the dorsal scapular artery ( ). The axillary ( ) and brachial arteries were patent and exhibited slow, low resistance flow, as did the radial and ulnar arteries. The conduct adopted in this case was watching and waiting since, in addition to the contraindication to anticoagulation already mentioned, the patient’s level of morbidity was elevated for an attempt at open revascularization and predictive indicators of the success of a possible bypass were unfavorable: the time elapsed since thrombus formation (22 days), the poor prognosis of the patient’s cancer, and the presence of kidney failure. The patient was observed for a further 2 weeks and did not show any sign of cyanosis, pain at rest, or trophic lesions. He was discharged from hospital for palliative home care. |
A 73-year-old Caucasian woman presented for a total body skin check in November 2016. A squamous cell carcinoma on her chest had been diagnosed three months earlier; an excision of the site had been performed two months ago. There was no evidence of recurrence and no palpable axillary lymph nodes.\nHer past medical history was remarkable for right triple negative invasive ductal carcinoma of the breast, with metastases to three of 20 ipsilateral lymph nodes, diagnosed in 1991. She had a mastectomy with autologous latissimus dorsi flap reconstruction. She also received adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil.\nIn January 2009, she presented with a right axillary mass and lung nodules; excision of the mass showed invasive ductal carcinoma. From February 2009 to June 2009, she was treated with doxorubicin/cyclophosphamide followed by paclitaxel. The site was also treated with radiotherapy.\nFollow-up evaluation in February 2012 demonstrated metastases to bone. Biopsy demonstrated triple negative adenocarcinoma. Pathology review of the right axillary mass from 2009 established a revised diagnosis of invasive, intermediate to high grade, apocrine carcinoma; subsequent genomic analysis of the tissue in November 2012 revealed an AKT E17K mutation which suggested that the mTOR inhibitor everolimus might be effective.\nCapecitabine was started in April 2012 at a daily dose of 2000 mg each morning and 1500 mg each evening for one week on and one week off. Shortly after starting therapy, she developed mild hand-foot syndrome of grade 1 severity and noted that her fingertips had become smooth. She also observed that her new laptop computer would not recognize her index fingerprint to permit access. This inability of fingerprint access persisted not only for the duration of capecitabine treatment (which was stopped in October 2014) but also for more than two additional years (to her examination in November 2016).\nNew bone metastases were discovered in October 2014. Biopsy showed triple negative adenocarcinoma, and subsequent molecular profiling of the bone lesion in March 2015 showed AKT E17K and DNMT3A mutations; PDL-1 testing was negative. Capecitabine was discontinued and bicalutamide was started. Therapy was changed to exemestane and everolimus in March 2015.\nShe developed malignant pleural effusions. In August 2015, therapy was changed to eribulin. She developed new bone metastases in September 2016 that were treated with radiation therapy; eribulin was discontinued and fluoxymesterone was started.\nExamination of her hands in November 2016, more than two years after discontinuing capecitabine, showed that the palmar surface of her fingertips (Figures -) and thumbs (Figure ) was red and rough. A closer inspection of her erythematous fingertips showed partial to complete presence of the fingerprint ridges; several areas of pitting and desquamation with focal longitudinal creases were also present (Figures -). Although the loss of her fingerprints morphologically appears to have—in part or in total—reversed, she is still not able to confirm her identity by fingerprint scanning with her laptop computer. |
A 14-year-old boy with morbid obesity and no known prior psychiatric history underwent sleeve gastrectomy. Prior to the surgery, he weighed 167 kilograms with a body mass index (BMI) of 54.5. Within a few months postoperatively, he weighed 70 kilograms with a BMI of 22.8. The patient’s substance use disorder started at the age of 15, one year after the bariatric surgery. Of note, the patient's parents were separated and he lived with his mother and siblings. None of his family members or relatives had a history of substance use disorder. He initially started using fenethylline (marketed under the brand name Captagon), as it was a common substance used by his peers at school. He started with two tablets daily and increased his use gradually up to 15 tablets daily. He started smoking cannabis a year later, at the age of 16, starting with one cigarette per day and increasing his use gradually until reaching a peak of 20 cigarettes per day. The patient started drinking alcohol occasionally at the age of 16 as well, and it soon became an issue of excessive use on a daily basis. The patient drank different types of alcoholic beverages. He reported incidents of fainting in relation to alcohol use but had never experienced withdrawal. He mentioned that he started using alcohol as a way to reduce his use of other substances. Two years later, at the age of 18, the patient started using methamphetamine, which caused him to develop paranoid ideation, auditory hallucinations, severe insomnia, and aggressive behavior. The patient was admitted to an inpatient psychiatric unit for a few days and was started on haloperidol 3 mg orally twice daily, benztropine 2 mg orally twice daily, and quetiapine 50 mg orally as needed for insomnia. His psychotic disorder improved with the cessation of substance use and the treatments initiated on the inpatient side. After his discharge, he unfortunately relapsed and continued to use the aforementioned substances.\nAfter arranging for close follow-up, the patient voluntarily presented to the rehabilitation center, motivated to stop using all substances, as he was legally and financially burdened by this disorder. He was incarcerated twice for substance use-related criminal charges. He was also motivated to start a new life and to enroll again in higher education, as he dropped out of school previously due to his polysubstance use disorder. The patient has thereafter been involved in a rehabilitation and relapse prevention program, which included inpatient admissions as needed to the rehabilitation center, involvement in individual and group therapy, occupational therapy, and addiction counseling. |
A 32-year-old, previously healthy, African American man presented to an emergency department 45 minutes after the acute onset of left facial droop and right-sided weakness (Fig. ). A thorough history confirmed an episode 1-week prior, during which he developed sudden onset of dizziness associated with nausea and vomiting that resolved within hours. He denied any past medical or surgical history and was taking no medications. He has no family history of tumors. In the emergency room, his vital signs were within normal limits. His physical examination was significant for a left facial droop and right hemiparesis. Auscultation of his chest revealed a regular rate and rhythm with no appreciable murmur. No additional significant findings were noted. Stroke protocol was initiated. A chest X-ray was normal and an electrocardiogram showed normal sinus rhythm. A head computed tomography (CT) scan was negative for signs of intracranial hemorrhage. He was subsequently started on tissue plasminogen activator (tPA) therapy. Magnetic resonance imaging (MRI) of his brain demonstrated a right basal ganglia infarct and an old left cerebral infarct. A carotid ultrasound was negative. TTE demonstrated a 1 cm by 1 cm mass on the posterior leaflet of the mitral valve with a moderate mitral regurgitation In addition, TTE revealed a questionable mass on the left coronary cusp of the aortic valve. These findings were confirmed with TEE (Fig. ), which verified no sign of endocarditis and no atrial septal defect. A complete hypercoagulable workup was negative. Stroke protocol continued with the working diagnosis of cerebrovascular accident secondary to emboli from the mitral valve mass. Within 24 hours, he regained function of the right side of his body and had complete resolution of symptoms. He was diagnosed as having transient ischemic attack (TIA) and discussion was undertaken regarding surgical excision of his mitral valve mass.\nA median sternotomy was performed and cardiopulmonary bypass was employed via aortic and bicaval cannulation with full anticoagulation. His aorta was cross-clamped and his heart arrested with retrograde cardioplegia. The aortic valve was examined through an ascending aortotomy and all three valve leaflets appeared normal. A left atriotomy was made and the mass was easily identified on the posterior mitral valve leaflet adjacent to the mitral valve annulus (Fig. ). The mass was excised and a frozen section confirmed globular myxoma cells with abundant eosinophilic cytoplasm consistent with myxoma. The valve leaflet was reconstructed with an autologous pericardium patch and the annulus was supported using a running DeVega-type suture. The valve appeared normal and was tested; no regurgitation was noted. His left atrium and aorta were closed. His aorta was unclamped, after aggressive venting and de-airing maneuvers, and his heart returned to normal sinus rhythm with successful weaning from cardiopulmonary bypass. Anticoagulation was reversed with protamine and his chest was closed after placement of drains and pacing wires. At the conclusion of the operation, TEE confirmed appropriate mitral valve function and normal aortic valve with no evidence of a mass and no regurgitation at either location. |
A 24-year-old male reported to the Department of Periodontology, HPGDC, Shimla, HP with a chief complaint of extruded and badly positioned mobile upper left front tooth. On examination the upper left lateral incisor was found to be below the level of the occlusal plane of adjacent teeth, was buccally drifted and had Grade II mobility with a 10 mm deep periodontal pocket. Radiographic evaluation revealed vertical bone defect extending until the middle one-third of root, there was no bone defects or loss of attachment in the rest of the dentition []. Endodontic consultation was taken to rule out any pulpal pathology. There was no medical history associated. A primary diagnosis of severe localized chronic periodontitis resulting in extrusion and misalignment of the affected tooth was made based on the clinical findings. A two-pronged treatment plan was devised with the main aim to preserve the tooth by treating the periodontal disease and promoting the regeneration, followed by orthodontic treatment to align the tooth in the arch for long-term maintenance and esthetic reasons. Clinical pictures and cast (models) were made and decision was taken to start the Phase I periodontal therapy which included SRP and oral hygiene instructions. Once the Phase I periodontal therapy was completed, it was noticed that vertical bone defects and clinical attachment loss were still persistent, therefore the decision to initiate Phase II periodontal therapy was taken to reconstruct the lost periodontal support. Open flap debridement using Kirkland flap was done under local anesthesia and the bone defect was filled using bio-oss* (Bone graft material). The flap was re-approximated and sutured. The sutures were removed after a week, and the patient was placed on a maintenance and recall program, which included a recall visit every 2 weeks for first 1-month, followed by every 3 weeks for 6 months postoperatively. At the end of 6 months, there was a gain in clinical attachment gain by 7 mm, reduction in pocket depth by 2 mm, and there was no mobility. Intraoral periapical radiographs also showed evidence of bone formation. At this stage, the patient was referred to the Department of Orthodontics for alignment of the tooth to its original position.\nA full 0.22” preadjusted edgewise appliance was bonded to the maxillary arch and special attention was taken in using light force to achieve alignment and leveling with 0.14” NiTi archwire. Step by step ligation of 0.14” NiTi archwire was performed before inserting the archwire into the bracket slot that took 4 months. 0.16 × 0.22 NiTi archwire was ligated for 3 months for perfect slot leveling before space closure. After achieving the slot leveling, space closure was performed with 0.19 × 0.25 SS archwire and the wire was left passive for 3 months before debonding. A bonded retainer was given for 6 months after debonding the case. During the whole period of orthodontic treatment, the patient was put on supportive periodontal therapy [].\nAt the end of orthodontic treatment (i.e., 1-year after initiating the orthodontic treatment), the tooth was aligned properly, and a retention appliance was given to maintain its position in the arch. The patient was satisfied with the treatment outcome []. |
A 54-year-old woman was referred to our hospital for a recent identification of a left hepatic lobe mass on ultrasound which was performed for mildly elevated liver enzymes during a routine health care check. Her clinical history and physical examination were unremarkable. Liver function results obtained were as follows: aspartate aminotransferase 88 U/L and alanine aminotransferase 99 U/L, alkaline phosphatase 59 U/L, albumin 3.2 g/dl, bilirubin total 1.0 mg/dl, and bilirubin direct 0.2 mg/dl. A contrast enhanced computed tomography scan (CT) showed a hypoattenuating 7.8 cm lobulated mass in the left hepatic lobe (). The mass showed decreased enhancement in both the arterial phase and the delayed phase of the contrast CT and the findings were not specific for a particular liver lesion. No other masses were found in the abdomen and pelvis. The differential diagnosis at the time included a hepatocellular neoplasm, cholangiocarcinoma, or a metastatic tumor. Biochemical investigation for viral hepatitis and alpha fetoprotein was negative. A colonoscopy and a chest CT were negative for tumors. She was a nonalcoholic but she had a past history of taking birth control, and it was felt that this could also possibly be a hepatic adenoma. Based on the size of the mass, the patient decided that she wanted the mass to be removed instead of proceeding with a liver biopsy. The patient was scheduled for surgery, during which an intraoperative consultation with a liver biopsy was performed. The biopsy findings were positive for a spindle cell neoplasm with uncertain etiology and a differential diagnosis of a gastrointestinal stromal tumor or a sarcoma. The surgeon proceeded with a partial hepatectomy and the mass was sent to pathology for examination. Histologic sections of the mass showed sheets of spindle cells with mild cytologic atypia, arranged in fascicles and whorls with intervening bands of collagen (). A differential diagnosis of meningioma, sarcomatoid carcinoma, melanoma, or a mesenchymal tumor was considered. On immunohistochemistry, the tumor cells were positive for epithelial membrane antigen (EMA) (), vimentin, focally positive for progesterone receptor (20%), and negative for cytokeratin, HepPar 1, S-100, CD34, CD117, factor-VIII, CD31, human melanoma black 45 (HMB-45), inhibin, TTF-1, estrogen receptor, and smooth muscle actin. MIB-1 proliferative index was approximately 3% (). These results confirmed the diagnosis of metastatic meningioma. To identify the primary source of the meningioma, a magnetic resonance imaging of the CNS was performed, which revealed a 1.4 cm bifrontal parasagittal dural mass (). The patient underwent complete resection of the mass at an outside institution and histologic examination of the lesion confirmed the presence of a WHO grade 1 meningioma with bland spindle cells with minimal mitosis and a MIB-1 proliferative index of <3%. Yearly postsurgical imaging of the CNS and the liver did not reveal any residual disease. Six years later, the patient is currently disease-free, without any evidence of recurrence or metastasis. |
A 60 year-old right-handed man with a history of degenerative cervical disc disease presented with complaints of right hand and forearm weakness that started 6 months earlier following an acute traction injury sustained while moving a large mattress. The mattress fell and pulled his right arm, and he immediately felt pain in his shoulder and elbow. Two hours after the injury he noticed weakness in the first three digits of his right hand.\nOne month later the weakness persisted, but it had not worsened. His primary care physician was initially concerned about cervical root trauma given his history of degenerative disc disease and the nature of the injury, but an MRI and CT myelogram of the cervical spine showed no changes compared to his previous cervical spine images. It was then assumed that he had a brachial plexus injury, and the plan was to follow his course clinically.\nOver the next several months he developed progressive numbness over the palmar aspect of the first three digits, and progressive weakness in his hand and forearm. He also noted atrophy of the muscles in his volar forearm. Eight months after the initial injury he presented to our electromyography (EMG) laboratory. On examination he had profound weakness of the flexor pollicis longus and flexor digitorum profundus to the index and middle fingers, and mild weakness of the flexor digitorum superficialis, flexor carpi radialis, and abductor pollicis brevis. He also had decreased sensation over the palm in the distribution of the median nerve. Motor and sensory nerve conduction studies showed no response from the median nerve, and EMG localized the lesion as a focal neuropathy of the median nerve distal to the branch to the pronator teres muscle.\nHRUS using a Philips iU22 scanner (Philips Medical Systems, Bothell, WA) with a 12 MHz linear array transducer was performed to further explore this focal neuropathy. The median nerve was shown to be intact throughout the arm. At the presumed site of neuropathy the cross-sectional area of the nerve was enlarged, from 10.9 mm2 at the wrist to 17.2 mm2 at the site of maximal enlargement in the proximal forearm, but it maintained a normal echo-texture. The soft tissue deep to the median nerve at this site was hyperechoic and homogenous and appeared to engulf the nerve (Figure ). Ultrasound of the corresponding level of the contralateral forearm demonstrated normal appearing muscle in clear contrast to the symptomatic arm.\nApproximately one year had passed since the initial injury and based on the progressive weakness, new sensory findings, and ultrasonographic changes, median nerve exploration in the proximal forearm with planned neurolysis was pursued. A longitudinal incision was made in the anterior forearm just distal to the antecubital fossa. The median nerve was identified, surrounded by healthy pronator teres and flexor digitorum superficialis muscles. Initial intraoperative nerve conduction studies showed no response from the median nerve. Deep to the median nerve the flexor digitorum profundus to the index finger was found to be atrophic and fibrotic, and multiple rigid fibrous bands emanated from the muscle. Several of these bands crossed over and compressed the median nerve, both proximal and distal to the anterior interosseous nerve (Figure ). These bands were released and intraoperative nerve conduction studies were repeated, again with no response from the median nerve.\nTendon transfers were performed to improve function. AIN reconstruction was foregone due to the low probability of functional improvement given the extensive fibrosis observed in the FDP muscle tissue. The viable flexor digitorum profundus to the ring finger was attached to the flexor digitorum profundus to the index finger with side-to-side tenodesis, and the flexor carpi radialis was transferred to the distal flexor pollicis longus through an incision at the wrist. The post-operative course was uncomplicated, and two months after the procedure the patient had improved hand function, consisting of slow, partial return of his sensory recovery, improved motor function and grip strength. |
A 14-year-old Caucasian Spanish male, right hand dominant presented to the emergency department after falling on his left hand with elbow extension. On examination there was gross deformity and swelling on his elbow. There were no external wounds and no neurovascular involvement. No abnormalities were found in ipsilateral shoulder and wrist joints.\nPlain radiographs of the elbow revealed a posterolateral dislocation of the elbow (). Closed reduction with traction in prone position was performed immediately. After initial reduction, the patient was neurovascular intact, but referred no pain improvement. Examination revealed no possibility of passive flexion or extension through the elbow joint and valgus instability. Post-reduction radiographs showed incongruity of the joint with an entrapment fragment into the humero-cubital joint (). A CT scan was performed revealing the intraarticular fragment belonging to the medial epicondyle ().\nAfter written consent from the parents, surgery was performed. The patient was placed in supine position with the injured elbow on a hand table under general anaesthesia, with a tourniquet and prophylactic antibiotic administration. A medial approach to the elbow joint was performed, and the ulnar nerve was identified and protected. A tear of the origin of the wrist flexors on the medial epicondyle was observed. The epicondylar fragment was removed from the joint and fixed anatomically into its origin with a 3.0 mm diameter cannulated lag screw (Synthes, Solothurn, Switzerland), under fluoroscopy control (). Rigid fixation was achieved. The joint was inspected to be free of any small fragments of bone. Intraoperative testing revealed stability of the joint in the entire range of motion and varus and valgus stress. Postoperatively, a posterior above-elbow splint with the elbow joint in 90º of flexion and neutral rotation was applied for 7 days followed by early motion and a physiotherapy program to improve the muscle strength. At 3 months of follow up the patient had almost full range of motion with only a lack of 5 degrees of extension and slight atrophy of biceps and triceps muscles. At 6 months he restored full range of motion and muscle strength.\nAt final follow up at one year postoperatively there was full range of motion with no pain or instability, and no valgus or varus deformity was observed. |
A 5-year-old medically free female presented to us after falling down 10 days ago. She went to the Emergency Room immediately following her fall complaining of the left arm pain, she was discharged on a splint and paracetamol with the diagnosis of a greenstick fracture of her left ulna by the ER physician (, ). The pain has shown little improvement and she refused to move her arm completely. She had no other complaints on systemic review.\nThe child was generally well and she was holding her left elbow in a flexed position, the left forearm and elbow showed mild swelling, she was uncooperative with the range of motion examination, and she was guarding her left arm. Distal neurovascular examination was intact.\nOn reviewing her X-rays at the time of diagnosis, the lateral elbow X-ray has clearly shown a radial head dislocation with a proximal ulna fracture, the anteroposterior (AP) X-ray was poor quality and did not show any fracture (), on repeating the forearm X-ray, a complete fracture of the ulna shaft was noted ().\nThe patient was admitted for further treatment and consented for closed reduction under general anesthesia with the possibility of internal fixation versus open reduction and internal fixation. Intraoperatively, the patient was placed supine with the left arm on the arm board and was draped with strict aseptic technique due to the possibility of converting to open reduction. The traction-countertraction method was used to obtain reduction and slight pressure on the radial head to reduce it in place. The radial head was reduced and after a trial of range of motion and intraoperative fluoroscopy it was found to be stable, the patient was placed in an above elbow cast in slight hyperflexion to maintain reduction (, ).\nThe patient was kept for 24 h postoperatively to monitor the neurovascular status, she was discharged and given follow-ups at 2, 4, and 6 weeks. The cast was removed 6 weeks post-operative (, ) and the patient experienced slight elbow stiffness as expected. The patient was not given a formal physical therapy referral and the family was instructed with home exercises and where educated to advocate the patient to use his injured limb, at 12 weeks, the patient had full range of motion of the left arm and elbow and was discharged. |
A 77 year old Caucasian female was admitted to Basildon University Hospital with a one year history of poor appetite and weight loss of 2 stones accounting for a quarter of her body weight. She did not complain of any abdominal pain, nausea, vomiting, haematemesis or malaena. Apart from a history of clinical depression her past medical, family and social history was unremarkable.\nPhysical examination revealed a well looking elderly lady with normal vital signs. There was no peripheral lymphadenopathy and examination of the abdomen was unremarkable. The liver and spleen were not palpable and there was no ascites. Laboratory investigations showed FBC haematocrit of 39%, WBC of 4.9 × 109/L and Hb of 13.9 g/dL. Liver enzymes and other relevant biochemistry tests were normal.\nSubsequent multiple upper GI endoscopies revealed a large malignant ulcer of the greater curve of the stomach with multiple satellite lesions extending proximally. Histological examination of biopsies taken showed the ulcer to be benign. A CT scan of the chest, abdomen and pelvis demonstrated a tumour extending from the cardia into the body of the stomach with a large polypoid component. There was no evidence of lymphadenopathy in the vicinity of the tumour or in the para-aortic region. The liver, spleen and the pancreas were normal. Furthermore there was no evidence of mediastinal or hilar lymphadenopathy or pulmonary deposits.\nStaging laparoscopy did not reveal any intra abdominal seedlings, ascites or lymphadenopathy. At laparotomy intra-operative findings were of a large tumour involving the lesser curvature, the body and the greater curvature of the stomach with a 7 × 6 × 1 cm ulcer on the greater curvature infiltrating into the stomach wall. A radical gastrectomy was performed with en-bloc resection of 4 lymph nodes from the lesser curvature, 5 from the greater curvature and one from the greater omentum.\nInitial histopathological examination of the resected stomach from the ulcer site at the local hospital showed abundant lymphocytic infiltration composed of lymphocytes and eosinophils. Immunohistochemical staining showed numerous CD30 positive large cells (Figure ). A preliminary diagnosis of anaplastic large cell lymphoma was considered. Specimens were sent for a second opinion to University College London Hospital. A polymorphous lymphoid infiltrate was identified including scattered large cells showing Reed-Sternberg morphology (Figure ). A panel of immunohistochemical markers were stained for. A predominant expression of CD30, CD15 and EBV-LMP1 were seen in the cells while being weakly positive for CD20. Staining for CD79a, CD3, bcl-2 and bcl-6 were negative. A diagnosis of "Classical Hodgkin's disease of the stomach" was made.\nThe postoperative period was uneventful and follow-up with repeat CT scans at 3, 6 and 12 months revealed no evidence of residual disease or relapse. No chemotherapy was initiated; however a plan to administer a regime of chlorambucil and prednisolone was made should there be a relapse of disease on further follow-up. |
A 55-year-old woman was referred to our outpatient clinic with a one-month history of vague pelvic pain not associated with urinary symptoms or gross hematuria. The patient had a past history of a well-controlled hypertension and five uncomplicated vaginal deliveries. Physical examination was unreliable due to sever obesity. Abdomino-pelvic sonography and DMSA scan performed at another institution demonstrated a normal located left kidney with a proper cortical function and an ectopic right kidney in the bony pelvis with a 7.8 × 4.3 cm heterogeneous mass in its lower portion. The patient was admitted in our department for further evaluation. Metastatic work-up was negative. A Multi slice CT and 3D-CT angiography of abdomen and pelvis was obtained. No oral agent was administered. After performing an unenhanced CT, 150 ml of contrast material was injected intravenously. Arterial phase images were obtained after a 20-second delay with a collimation of 3 mm, table speed of 1 mm per revolution and an image reconstruction interval of 1 mm. The arterial phase was used to depict the renal arteries. Parenchymal-phase imaging was initiated 240 seconds after injection of contrast material with a collimation of 3 mm, a table speed of 2 mm per revolution, and an image reconstruction interval of 2 mm. Multi-slice parenchymal-phase CT scanning of the pelvis showed a heterogenous mass consisting of multiple solid and cystic areas arising from the lower portion of the ectopic pelvic kidney replacing most of the normal renal parenchyma []. In addition, 3D-CT angiography demonstrated the blood supply of the pelvic kidney to arise from a single renal artery originating from the right common iliac artery just below the aortic bifurcation []. In axial and coronal images there was an artery suspected to supply the renal mass but after 3D reconstructions was proved to cross just parallel to the kidney [].\nThe patient underwent radical nephrectomy without any peri-operative complication and was discharged on third post-operative day. On pathologic examination, the tumor was confirmed to be a renal cell carcinoma, clear type, and confined to the kidney. No evidence was found of renal vein involvement or lymph node metastasis. |
A 46-year-old, right-hand-dominant male presented with left ring and little fingers numbness and hand weakness that had been aggravated over the previous 4 months. He had chronic pain and progressive deformity of lateral elbow, and lost extension after one episode of elbow dislocation about 20 years ago. He was transferred to our office for further assessment with above symptoms. Tracing back his trauma history revealed that he noted a daily sensation of painful slip in and out on the lateral elbow joint after a dislocation underwent a closed reduction by a bonesetter. His elbow symptom didn't improve or got a diagnosis after visiting three orthopedic surgeons for the first 6 months. Although his elbow symptom was persisting but he was tolerable at eating, dressing, carrying or pulling of daily activity or working ability except lifting or push-up and he didn't visiting any physician for further help since then until this new symptom of hand numbness occurred.\nPhysical examination revealed the elbow with flexion arc from 20° to 120° and full forearm rotation compared with contra lateral side, and grip strength 105 lb (125 lb on the right side). Palpation revealed the deformed elbow with prominent radial head not lateral epicondyle on the lateral of the elbow. The result of neurologic examination was abnormal including paresthesias in the ulnar half of ring finger and little finger and dorsal ulnar wrist with positive Tinnel sign and nerve compression test of the ulnar nerve at elbow, little finger abduction weakness but without claw hand deformity. Plain radiographs showed arthrosis of the elbow joint with the radiohumeral joint more sever than ulnohumeral joint, radial head deformity including lost normal concave shape and hypertrophic marginal osteophyte with lateral subluxation and some chip bone or ectopic bone over lateral epicondyle (Fig. ). Patient was arranged to receive operation with the surgical plan to decompress the ulnar nerve by anterior transposition of the nerve and evaluate the elbow joint stability under anesthesia.\nAfter general anesthesia, the lateral pivot shift test by O'Driscoll's method [] with the patient's arm overhead was positive and the elbow stress test at fluoroscan revealed negative valgus and varus stress test and positive lateral stress test [], which the radiograph is taken with provocative stress applied during the lateral pivot shift test (Fig. ). The operation was performed with the patient positioned supinely and supported by a hand table. The elbow was approached with two separate lateral and medial incision. The traction neuropathy of ulnar nerve at cubital tunnel was noted and intact medial collateral ligament was identified after subcutaneously anterior transposition of the ulnar nerve. The lateral structure was exposure through the Kocher interval and an avulsed bone fragment of lateral collateral ligament complex including common extensor from lateral epicondyle was noted, the radial head was found to translate posterior by provocative test stress at 30° of flexion and the annular ligament was found to be intact. The lateral collateral ligament complex was repaired with a bone anchor with No.2 polyester braided non-absorbable suture, which in a running locked fashion at origin of tendon and ligament [] and augmented with a bone screw to fix the avulsed fragment. Postoperatively, the elbow was protected by a hinged brace with the forearm in a neutral position for 4 to 6 weeks and the flexion angle of the brace was allowed to step decreased 10° per week. Progressing loading and strengthening are permitted for the late of 2 to 6 months.\nAt 24 months after surgery, the patient was satisfied with the procedure; the symptom of ulnar nerve was recovering and he felt that his elbow was more comfortable and stable at daily activities except lifting. Examination revealed motion from 10° of extension to 130° of flexion, 75° of pronation and 80° supination, and no signs instability and grip strength increased to left 115 lb (126 lb on the right). Post-operative plain radiographs showed the deformed radial head still subluxation at anterior-posterior view but no progressing arthrosis of the elbow joint(Fig. ). |
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