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A four-year-old male was admitted to our hospital with left elbow swelling and pain. Plain radiography in anteroposterior and lateral view revealed a Gartland type 3 left supracondylar humerus fracture (Figure , ).\nThere was no neurological deficit. Under general anesthesia, using c arm control, closed reduction of the fracture was done by an orthopedic trainee under consultant supervision. After maintaining the reduction in hyperflexion and pronation of the elbow, a 1.6 mm diameter K-wire was inserted using the lateral entry point. After drilling the lateral column, it was felt that the wire was skiving proximally in the medullary canal, hence, further drilling was done to obtain purchase in the medial cortex. While the wire was being drilled it broke near the entry point and the broken end disappeared under the skin, leaving the remnant portion buried in the distal humerus (Figure ). Since the reduction was acceptable in anteroposterior and lateral views, three more 1.6mm K-wires were inserted from the lateral to the medial side (Figure ).\nFixation of fracture was confirmed under fluoroscopy. After fracture fixation, attempts were made to remove the broken K-wire but it was not possible to grab the tip, as the broken end was buried under the cartilaginous bone. At this point, intraoperatively we scrubbed out and discussed complications with the family and after taking their consent we proceeded further under the same anesthesia. A skin incision was made over the broken K-wire, surrounding tissue and bone were cleared off and the tip was exposed. Using a needle nose plier, the tip was held and the wire removed in a rotatory motion and confirmed under c-arm (Figure ). An above elbow slab was given for further stability. At one week postoperatively, the patient was found comfortable in the slab without any complaints. Follow-up at four weeks showed radiologic union and removal of K-wires was done in the clinic. The patient had a full range of motion of the elbow at three months. Further follow-ups were uneventful. |
A 70-year-old African American male was seen in the emergency department for acute anxiety and paranoia. He reported that his son gave him melatonin to help him sleep, but he felt the medication was poisonous. He also reported that he was struggling with the death of his partner of 40 years and was feeling anxious. The patient was prescribed risperidone and lorazepam and was discharged shortly thereafter. Twenty-four hours later, he was seen again in the emergency department for worsening anxiety, psychosis, suicidal ideation, and command hallucinations. The patient's son reported that his father “had not slept in weeks.” The son reported progressive agitation, paranoia, and bizarre behavior. Due to the worsening psychosis, he was admitted to the medical floor for further work-up. He reported feeling as though people were watching him and that someone was going to harm him. When questioned about his reported suicidal ideation, he blamed that thought on his post-traumatic stress disorder; but would not elaborate on the event. The patient was given a one-to-one sitter due to his suicidal ideation.\nThis patient lives with his family of seven children. He has a history of prolonged incarceration. His past medical history is significant for hypertension and negative for seizure disorders. The patient had never been hospitalized for psychiatric issues prior to this visit. He denied past suicidal behavior and any history of physically or sexually aggressive behavior. The patient reported a history of excessive alcohol abuse for more than a year following the death of his partner. He reported that he stopped drinking “cold turkey” five months prior to this visit. The patient's family history is significant for a son with an anxiety disorder. He denied a history of physical or sexual abuse in the past.\nThe patient's mental status exam was significant for an anxious affect with referential and paranoid ideations. He denied any thought broadcasting, insertion, or withdrawal. He had some paranoid and persecutory delusions. Insight, judgment, and impulse control were poor.\nThe patient's initial physical exam revealed an inability to ambulate and overall weakness. Further neurological examination revealed mental disorientation with bilateral muscle wasting, sensory deficit, and hyporeflexive ankles. Additionally, the patient exhibited stance and gait abnormalities. A later eye exam revealed bilateral light-near dissociation with accommodation but no reaction to light. Otherwise, all other neurological components were intact and within normal limits.\nInitial routine testing was positive for the Treponema pallidum antibody, suggesting prior infection, but the distinction between treated and untreated syphilis cannot be made as the Treponemal-specific immunoglobulin G (IgG) may remain elevated throughout life. An RPR was then ordered to help distinguish between acute or chronic infection and a Treponema pallidum particle agglutination test was ordered to distinguish between syphilis infection and a false positive screening test. The RPR returned nonreactive but the Treponema pallidum particle agglutination returned reactive, indicating a prior infection of Treponema pallidum. The initial differential diagnosis workup included testing to exclude thiamine, folate and B12 deficiency, insomnia, hypocalcemia, hypothyroidism/hyperthyroidism, HIV encephalopathy, dementia, stroke, drug or alcohol intoxication, and normal pressure hydrocephalus.\nFurther labs showed white blood cell count, sodium, potassium, calcium, anion gap, creatinine, glomerular filtration rate, glucose, mean corpuscular volume, and thyroid stimulating hormone within normal limits. Urinalysis, toxicology screening, alcohol levels, and HIV antibody were also negative. Imaging included a head computed tomography (CT), which showed no abnormalities, a brain magnetic resonance imaging (MRI) that showed cortical atrophy, and an electroencephalogram within normal limits. |
A 73-year-old man presented to our emergency department with lower right abdominal pain 3 days after a routine screening colonoscopy. His past medical history was significant for hypertension and gout. No significant abnormalities were found through the colonoscopy and no biopsy was performed. The procedure itself was uneventful, and intubation into the terminal ileum was easily performed. The bowel preparation was excellent and good visualization of the caecum, appendiceal orifice, and ileocaecal valve was obtained (Fig. ). There were no signs of inflammation in the caecum or around the appendiceal orifice. The patient initially felt mild lower right abdominal pain shortly after the procedure, but he did not pay enough attention to it at that time and left the hospital.\nThree days later his lower right abdominal pain gradually intensified and spread to the whole abdomen, accompanied by nausea, vomiting, and fever. The vomitus was stomach contents. On examination he was found to have a temperature of 38.3 °C, a pulse of 109 bpm, and a blood pressure of 158/84 mmHg. On physical examination the patient had signs of generalized peritonitis. His abdomen was diffusely tender, especially in the lower right quadrant, with rebound tenderness and guarding. The laboratory results revealed a white blood cell count of 13.1 × 109 cells/L, a neutrophil count of 11.8 × 109 cells/L (90.4%) and a C-reactive protein level of 188.9 mg/L. Abdominal and pelvic computed tomography (CT) (Fig. ) revealed the presence of multiple free gas in the right subphrenic space and abdominal cavity with exudate effusions in both sides of the paracolic sulci and the pelvic cavity, especially around the ascending colon and caecum. The CT scan also showed a dilated and inflamed appendix with fecaliths, and cholecystolithiasis.\nThe patient was arranged for exploratory laparotomy after initial diagnosis. A right middle-lower vertical rectus abdominis incision was made. Intraoperative findings were of a large amount of yellow purulent fluid in the abdomen, the greater omentum abnormal gathering in the right lower abdomen, and an inflamed gangrenous appendix with focal perforation in the midportion. The appendix was about 8.5 cm long and 1.5 cm wide with impacted fecaliths in the lumen of the appendix root. The colon showed no evidence of perforation or other areas of concern. An appendectomy was performed and the abdominal cavity was rinsed and drained thoroughly. Histopathological examination (Fig. ) subsequently confirmed the clinical diagnosis of acute gangrenous appendicitis with periappendicitis, perforation, and appendiceal fecaliths. The postoperative course was uneventful. |
A 78-year-old male patient presented in April 2015 with suspected lung cancer. Chest CT examination revealed a pulmonary space-occupying lesion in the left upper lobe of the lung (Fig. ). Following fine needle biopsy, pathology confirmed the patient had lung adenocarcinoma and EGFR (Fig. ), ALK and ROS1 were negative (Fig. ). Due to the advanced age of the patient (78) together with a diagnosis of atrial fibrillation, EGFR-TKIs was recommended as the treatment of choice. From 23 October 2015, the patient commenced gefitinib 250 mg orally once a day until the disease progressed in July 2016 when CT scan of the chest indicated metastasis in the lung. The gefitinib, everolimus combined therapy was subsequently recommended because of disease progression. However, after a few months of combined treatment, everolimus had to be withdrawn because the patient experienced severe breathlessness, cough and mouth ulcers. At that time, the patient had been taking gefitinib for 16 months until drug resistance developed on 16 February 2017 (Fig. (a)).\nThe patient had second gene mutation testing at this time which indicated EGFR T790M mutation. Osimertinib 80 mg/day orally was subsequently recommended from March 2017. After only one month of treatment, chest CT scan revealed the disease had almost completely resolved (Fig. (b)). However, severe interstitial lung disease was also confirmed (Fig. (b)). The patient was found to have severe cough and difficulty in breathing at this time and the symptoms did not resolve, even after anti-infection and anti-cough treatments were administered. The patient attended our hospital for further treatment. After reviewing his treatment history and chest xray, we considered that he was suffering from severe drug-induced interstitial lung disease and advised him to cease taking the osimertinib immediately. Unfortunately, he still continued to take the osimertinib as he considered the medicine to be effective for his tumor, and refused to tell the doctor the truth until it was found that he was suffering from further dyspnea. After anti-infection and high dosage methylprednisolone (240 mg/day) and mechanical ventilation, the patient finally died of multiple organ failure after 2 weeks treatment for severe interstitial lung disease and resultant complications. |
An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15–30 min after every meal. The full blood count, serum biochemistry values, and C-reactive protein level were within normal ranges. Additionally, arterial gas analysis was normal. Abdominal plain radiography showed free air between the liver and diaphragm, and PI (Fig. ). Abdominal computed tomography showed severe calcification of the SMA origin; SMA peripheral flow was reserved (Fig. ). Computed tomography (CT) revealed bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum (Fig. ).\nSince the patient did not have peritonitis, a conservative approach was performed. She was managed in the condition of intensive care unit, due to fears of the potential for acute mesenteric ischemia due to mesenteric artery occlusion or non-occlusive mesenteric ischemia. She was managed for bowel obstruction, which included fasting and intravenous fluid administration. She received heparin infusion to prevent SMA occlusion and maintain collateral flow. During admission, she reported abdominal pain relief. Seven days after admission, abdominal plain radiography showed improvement in PI and pneumoperitoneum; therefore, she was permitted to begin drinking fluids. There was no evidence of recurrent abdominal pain after the fluid consumption, so she was allowed to eat solid food.\nAngiography was planned to relieve the postprandial abdominal pain. The findings showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery (Fig. , ). ET, namely stenting to the SMA and common hepatic artery, was performed. The SMA trunk was engaged with a 6F Parent Plus 60 guiding catheter (Medikit, Tokyo, Japan) from the left brachial artery. Initially, 8000 units of heparin was infused, and additional heparin was added to keep the activated whole blood clotting time over 200 s. The SMA occlusion was traversed using a 0.014” NEO EVT Guide Wire Cruise (ASAHI INTECC J-sales, Tokyo, Japan). The SMA trunk to the hepatic artery was traversed using a 0.014” NEO EVT Guide Wire Cruise, which was engaged with a 6F SheathLess PV (Cardian Health, Ohio, USA) from the right brachial artery. Intravascular ultrasonography (IVUS) (Navifocus WR, TERUMO, Tokyo, Japan) revealed severe stenosis of the SMA trunk with calcification. Balloon dilation was performed with the kissing ballon technique using a 4-mm Coyote ES (Boston Scientific, Marlborough, MA, USA) to the SMA and 5-mm SHIDEN RX (KANEKA MEDICAL, Osaka, Japan) to the common hepatic artery. After dilation, two balloon-expandable stents (5-mm PALMAZ Genesis (Cardian Health, Ohio, USA) to the SMA and 6-mm PALMAZ Genesis to the common hepatic artery) were implanted with the kissing stent technique from the common ostium (Fig. ). The sizes of the stents were based on the IVUS measurements. IVUS showed good orifice expansion. Final angiography showed satisfactory circulation to the terminal organ from the orifice (Fig. ).\nEndovascular therapy relieved the patient’s symptoms. She required dual anti-platelet therapy (DAPT) with aspirin and clopidogrel post-intervention. Follow-up computed tomography showed patency of the orifice of the common hepatic artery and SMA, and there was no evidence of PI or pneumoperitoneum. No recurrent postprandial abdominal pain occurred for two years after the ET. |
A 66-year-old Caucasian male patient was first examined in January 2020 in our memory clinic (). The patient is married and father of a daughter. He achieved an educational level of 8 years and was employed as a factory worker until retiring in 2017. His wife described a marked loss of memory functions about 3 years ago. After a subacute onset of cognitive decline, his memory problems failed to resolve, and were accompanied by depressive symptoms with insomnia over time. Symptoms of cognitive impairment were initially attributed to the affective disorder, and he was given mirtazapine at a daily dosage of 15 mg by a psychiatric consultant. The patient underwent MRI imaging of the neurocranium in November 2019, which revealed asymmetrical atrophy of the mesiotemporal region suggesting Alzheimer´s disease (A,B). His wife also reported a progressive speech disorder, a beginning disorientation, and behavioral symptoms in the last few months. Behavioral symptoms comprised minor signs of frontal disinhibition and impulse-control dysregulation. She also reported that he had begun using swear words more often, and had developed delusional symptoms: he became convinced he was being addressed by the hosts of a certain afternoon television show and seemed to converse with them bidirectionally. The presence of hallucinations in the context of psychotic symptoms could not be confirmed. His treatment at the time of first contact in our memory clinic consisted of mirtazapine at a daily dosage of 15 mg, acetylsalicylic acid, magnesium and Vitamin D supplements. His mother grew very old (88 years), but suffered from dementia of unknown etiology. The cause of his father’s death was unknown. His medical history comprised a myocardial infarction in 2018 and intermittent muscle cramps. There were no signs of substance-related abuse, or consumption of illegal psychoactive substances.\nInitial physical and neurological examination revealed no pathologies, in particular, no signs of cerebellar disorders like ataxia or oculomotor abnormalities. Routine and extended laboratory tests excluded Vitamin B1, B6, and B12 deficiency. Ceruloplasmin and cupper values in serum were normal. Thyroidal hormone levels were also normal, and screening for autoantibodies against thyroidal gland tissue was negative. Any neurological manifestation of borreliosis and lues was excluded. IgM-antibodies against borrelia burgdorferi in serum were ascribed to a persistent antibody response with no clinical relevance, as no specific borreliosis-antibodies or elevated cell count were detected in CSF. Routine CSF diagnostics continued to reveal normal values (2 cells/µL, protein 401 mg/L, oligoclonal bands negative, MRZ-VZV-HSV-AI were not elevated). Biomarkers implied no neurodegenerative disease (normal were total tau, 181pTau, ß-Amyloid 1-42, ß-Amyloid-Ratio). An anti-neural antigen immunofluorescence test exposed Anti-KCNA2 (voltage-gated potassium channel ß-subunit Kv1.2) (1:100) antibodies in serum only. No LGI1 or CASPR2 reactivity was identified ().\nHis MRI dataset was reviewed in the Department of Neuroradiology, confirming an asymmetrical atrophy of the mesiotemporal and right temporopolar brain regions and progressive leukoencephalopathy in white matter (A,B). MRI data were initially compared to those obtained in 2014 that had shown no atrophy and fewer white matter lesions. The mesiotemporal atrophy was interpreted as being compatible with a limbic encephalitis at later stages, which was recently reported in courses of limbic encephalitis by Wagner et al. [].\nPreliminary cognitive screening detected a significant result in MMSE (Mini Mental State Examination) (23/30). The clock-drawing test was normal, but comprehensive neuropsychological assessments including the CERAD (Consortium to Establish a Registry for Alzheimer’s Disease) test-plus battery (covering these cognitive domains: attention, language, visuoconstruction, memory and executive functions) and ROCFT (Rey-Osterrieth-Complex-Figure test) revealed marked deficits in figural and verbal memory parameters associated with an impaired delayed recall. Moreover, language impairments (Boston Naming Test and Semantic fluency) were moderate. His working memory was also moderately affected, whereas visuoconstructual/visuo-spatial abilities were unaffected. As our patient is not a native German-speaker, his verbal memory and language functions must be interpreted very carefully (). Nevertheless, in light of his relevant deficits in daily-living abilities, we diagnosed a dementia.\nSubsequently, the patient was admitted to the Department of Neurology in February 2020. EEG recordings revealed no abnormalities—neither epileptic potentials nor any focal slowing. Thorough electrophysiological examinations (EMG, neurography) revealed no signs of peripheral nerve hyperexcitability, nor acute or chronic denervations. Thus, Morvan´s syndrome was unlikely. Daily intravenous corticosteroids were applied over 5 days and well tolerated. His wife reported improved speech fluency and attentiveness. We screened for any malignancy, including a conventional X-ray of the thorax and ultrasound diagnostics of the abdomen. An undefined tumorous structure in the bladder and additional hyperdense lesion in the lung were identified. We recommended a further computer tomography of the thorax and abdomen and PET (positron emission tomography)-tumor-screening, but the patient refused. |
Our report concerns a 51-year-old Caucasian man who was admitted to our clinic with severe abdominal pain. Two weeks prior, he had undergone an emergency operation in another hospital due to an IDSMA. Colleagues resected the dissection membrane and the SMA was reconstructed with a Dacron® patch. According to their medical history, the patient suffered from hypertension and non-insulin dependent diabetes mellitus (NIDDM). The patient was discharged free of symptoms two weeks prior to presentation in our department. Following admission to our emergency room, an immediate CT-scan and a blood test were performed, as the patient showed signs of an initiating peritonitis.The CT scan showed an isolated re-dissection in the proximal part of the SMA with embolization of a distal branch causing an almost complete decline of right hand side intestinal perfusion. Aggravating, the right hepatic artery originated from the proximal part of the SMA as an anatomical variant. The origin was located directly in the region of the dissection entry. Figure shows the major findings of the CT scan on admission. As endovascular therapy had a high risk of post interventional liver failure, the decision for open surgery was taken at an interdisciplinary level. Blood test results showed a normal serum lactate level, while C-reactive protein (CRP) and leukocytes (WBC) were raised. Thus, the patient had to be transferred urgently to the operating theatre.We resected the dissection membrane from the origin of the SMA and a selective embolectomy of the arcade arteries was performed. The SMA was re-constructed using a venous interponate. Thus, for the interposition the saphenous vein from the right upper leg was used. The patient was admitted to the intensive care unit (ICU) with an abdomen apertum. As hypercoagulability occurred during the operation and we suspected a heparin induced thrombopenia (HIT), anticoagulation was managed using Argatroban with an activated partial thromboplastin time (aPTT) of 50-70 seconds. This suspicion was later confirmed due to a Heparin-induced Thrombocytopenia Platelet Factor 4 Antibody Test. Figure demonstrates the representative findings of a CT-scan control five days after the operation. As a further course, negative wound pressure therapy was performed with wound dressing changes at intervals of two days and conducted within in the operating theatre (four times). In this context, the small intestinum was carefully inspected. We could not find any signs of hypoperfusion lesions. As the patient described persistent abdominal pain, performing a colonoscopy six days after the operation meant that ischemic colitis could be ruled out.\nA secondary closure of the abdomen apertum could eventually be performed using a mesh graft transplant as coverage. Anticoagulation was managed using Fondaparinux at a therapeutic dose. After closure of the abdomen, dual platelet inhibition with clopidogrel and acetylsalicylic acid was used as a long-term medication.\nFollowing the operation, the patient needed a bowel rest, nasogastric suction and intravenous fluid therapy. Diet was resumed after complete resolution of abdominal pain and nutritional support was required in the interval. The patient needed prokinetic medication at the outset, but during their hospital stay, a normal ingestion and defection frequency without any medical support was achieved. The patient could be mobilized and will undergo postdischarge rehabilitation. |
A 43-year-old male patient presented to our centre, with chief complaint of sudden onset, progressively worsening binocular diplopia in the right eye for the preceding 1 month. No history of any trauma or similar complaint was elicited in the past. The patient was found to be adequately built, with vital signs being normal and had no evidence of systemic abnormality. On ocular examination, best-corrected distance visual acuity and near vision in both the eyes were 6/6 and N6, respectively. Anterior and posterior ocular segment evaluation was unremarkable. Although the eyes were aligned in primary position, horizontal gaze palsy was noted with loss of saccades and pursuit movements in levoversion. On attempted dextroversion, the right eye was abducting with associated abduction nystagmus, in the absence of left eye adduction []. Both vertical gaze and convergence were normal. Based on ocular findings, the diagnosis of ipsilateral one-and-a-half syndrome was made.\nMagnetic resonance imaging (MRI) was advised following clinical evaluation, which revealed an irregular complex cystic enhancing space-occupying lesion measuring 42 mm × 39 mm × 35 mm, in the region of fourth ventricle closely abutting the brain stem posteriorly [Fig. and ]. Multiple small ring and disc enhancing lesions were also seen in the bilateral cerebellar hemispheres and right occipital lobe. Radiological findings suggested brain metastasis.\nFurther evaluation was supplemented with 18F-fludeoxyglucose positron emission tomography/computed tomography (CT) imaging to locate the primary pathology. Abdominal CT scans showed primary neoplastic lesion, arising from the upper pole of the right kidney and another exophytic mass in the lower pole of the left kidney. In addition, metastatic lesions in the right adrenal gland, pancreas, and brain were seen. Based on examination and investigations, diagnosis of Stage 4 RCC (inoperable) with brain metastasis with associated ipsilateral one-and-a-half syndrome was made. The patient was shifted to oncology department and started on palliative radiotherapy after sorting consultation for the same. |
We describe a 62-year-old Chinese female who was diagnosed with multiple EGCs with successful eradication of Helicobacter pylori in December 2017. The first lesion located in the greater curvature of the antrum was detected at the patient's first endoscopy in July 2010. It was classified as type IIa + IIc with dimensions of 1.5 × 1.0 cm. It had a nodular surface with a central depression and redness (Fig. ). The patient was diagnosed with H pylori infection based on a rapid urea enzyme test and eradication therapy was performed (esomeprazole, amoxicillin, clarithromycin, and bismuth quadruple therapy). Two synchronous early gastric lesions were also detected during the first endoscopy. One of these lesions was located on the lesser curvature of the antrum. It was classified as type IIa + IIc with dimensions of 1.0 × 1.0 cm. It also had a nodular surface with a central depression and redness (Fig. ). The other lesion was located at the lesser curvature of lower gastric corpus. It was classified as type IIb with dimensions of 2.0 × 1.0 cm. It had a nodular appearance and a faded mucosa (Fig. ). Over the next 7 years, she underwent endoscopy 4 times (August 2011, November 2012, March 2014, and July 2016). The 3 lesions did not show invasive features under white light endoscopy and the pathological diagnosis of endoscopic biopsies was LGD with moderate-to-severe atrophy and intestinal metaplasia (Figs. –).\nIn August 2017, at her sixth endoscopy, 2 new small emerging lesions were observed. Both lesions had a central depression, surface redness, or a nodular surface under white light endoscopy, which are risk factors for EGC. ME-NBI revealed irregular microvascular and microsurface patterns with a demarcation line and confirmed the presence of the 3 lesions previously detected. The lesions were highly suspected of being EGCs according to the VS classification system reported by Yao et al.[ The fourth lesion was located on the greater curvature of the antrum close to the corpus. It was classified as type IIc, with dimensions of 0.6 × 0.5 cm. It had a central depression and redness (Fig. ). The fifth lesion was located on the posterior wall of the gastric angulus. It was classified as type I with dimensions of 0.5 × 0.5 cm. It had an elevated, nodular surface (Fig. ).\nIn December 2017, she was admitted to our hospital for endoscopic resection of the lesions. Contrast-enhanced computed tomography did not show any lymphadenopathy before ESD. ESD with en bloc resection was performed for all 5 lesions. Resection margins were negative and there were no signs of lymphovascular invasion. Using the ESD tissue specimens, the first 4 lesions were pathologically diagnosed as adenocarcinoma confined to the mucosa whereas the fifth lesion was diagnosed as HGD according to the Japanese Classification of Gastric Carcinoma[ (Figs. –).\nAfter endoscopic treatment, she has been followed up with gastroscopic examination. She is alive in a good clinical condition. Endoscopic surveillance has revealed no further abnormalities, with no evidence of residual, recurrent, or synchronous lesions at 3, 6, and 12 months after ESD. |
A 40-year-old Caucasian female with a past medical history of hypertension presented to the outpatient clinic for evaluation of abnormal perception of motion which she described as constant rocking and swaying after a ship cruise which lasted for one week. It began few hours after returning from a week ship cruise four months ago. The symptoms are worse at bedtime when lying still and early in the morning upon awakening. Symptoms were alleviated by motion activities like driving and being in a moving car. She denied nausea and vomiting. She had no history of headaches, double vision, vertigo, ringing in the ears, or hearing deficits. In addition to her past medical history of hypertension for which she takes lisinopril, she had acid reflux and cholecystectomy. She denied tobacco dependence and alcohol or illicit drug abuse. Physical examination was unremarkable, with no signs of depression elicited. The patient had not responded to empirical treatment with various motion sickness therapies, which included meclizine, scopolamine, low dose steroid, and Medrol for possible labyrinthitis. Videonystagmography (VNG) and Vestibular Evoked Myogenic Potential (VEMP) to determine the functionality of the ears, vestibular deficits, and integrity of the inner ear were all normal. The ENT and neurology team evaluated her. All her laboratory studies were negative. Radiological studies such as CT scan and MRI were negative. In the setting of negative laboratory studies, imaging studies, and normal ENT and neurological evaluations, with symptoms unresponsive to conventional motion sickness therapy, a provisional diagnosis of MDS was made. The patient was started on low dose benzodiazepine (valium 2 mg at bedtime), which aided her nighttime symptoms. The patient received physical therapy for focused vestibular/balance rehabilitation, which offered partial relief. The patient joined the MDS online foundation support group, a forum to interact with other MDS patients and former patients who had recovered. She was carefully followed up in the outpatient until spontaneous resolution of symptoms after 8-9 months and she is completely back to baseline. |
We present the case of a 7-year-old girl who was referred to our hospital with severe symptoms of heart failure. An abnormal Q wave was noted during a school checkup, but the patient did not receive medical attention. She had severe fatigue and dyspnoea at the time of admission. Gallop rhythm was heard and coolness of extremities was prominent. She also had hyperkeratosis and a bullous skin lesion of unknown cause which appeared soon after birth (). Echocardiography revealed a dilated left ventricle and ejection fraction was <20% with Teichholz method (). Chest X-ray showed massive cardiomegaly and congestion. We diagnosed her with idiopathic dilated cardiomyopathy. We administered diuretics, dobutamine, milrinone, and human atrial natriuretic peptide, yet her heart function worsened soon after admission. She required extracorporeal membrane oxygenation support on Day 25 but did not recover thereafter. We decided to implant EXCOR® as a bridge-to-transplant therapy. We did not consider the skin lesions as a contraindication because they were located on the extremities. After implantation of EXCOR®, genetic testing detected a homozygous loss-of-function mutation of calpastatin (CAST). Both parents were found to be heterozygous for the mutation, and because other examinations, including skin biopsy and mitochondrial enzyme activity, did not reveal any abnormality, this was thought to be the cause of her skin lesions. Skin condition around the return flow cannula (RFC) worsened gradually, and granulomatous tissue formation occurred (). She occasionally experienced fever, which we treated as sepsis although a positive blood culture was never observed. At nearly 2 years after admission, she started to experience intermittent fever which required antibiotics. There was no vegetation on transthoracic echocardiography, and contrast-enhanced computed tomography (CECT) performed on Day 729 showed fluid retention along the RFC (). We continued debridement and antibiotic administration when required. On Day 767, she had another episode of high fever, with a positive blood culture of methicillin-resistant Staphylococcus aureus (MRSA). We administered vancomycin and daptomycin, and the subsequent blood culture was negative for MRSA. However, massive bleeding from the cannulation site of the RFC occurred on Days 768 and 775. Because the bleeding stopped by compression, cardiovascular surgeons considered that exploration of the cannulation site could be diagnostic and practical; yet we could not determine the origin of bleeding by the exploration, the bleeding was considered to be caused by neoplastic vessel along the RFC, and did not perform further images or exams. On Day 781, she had another episode of massive bleeding. At this time, we decided to perform surgical exploration with the intention of exchanging the whole system if needed. We did not perform CECT before moving to the operation room because the bleeding did not stop. When the sternum was opened, a tremendous amount of bleeding occurred instantly due to a ruptured pseudoaneurysm at the cannulation site of the ascending aorta. Despite all medical efforts, she collapsed into asystole and then to ventricular fibrillation. She passed away during surgical exploration. |
A 54-year-old Greek woman without a relevant medical history presented with a clinical diagnosis of breast cancer staged T4NxM0 by core needle biopsy. Histology revealed that it was an invasive ductal carcinoma. There were no palpable lymph nodes in the axilla and in the supraclavicular fossa.\nThe patient was initially administered neoadjuvant chemotherapy with 5-fluorouracil 500 mg/m2, adriamycin 50 mg/m2 and cyclophosphamide 500 mg/m2, showing very little tumor response after the third cycle. The chemotherapy regimen was then changed to gemcitabine 750 mg/m2 and cisplatine 30 mg/m2 and tumor progression was verified after the fourth cycle. We then opted for a third line of chemotherapy, using paclitaxel 175 mg/m2 concurrently with radiotherapy in order to achieve local control.\nThe patient was treated with a 6 MV linear accelerator. A three dimensional, conformal radiotherapy technique (3DCRT) was used. Patient was treated in the supine position with both arms raised above the shoulder and immobilized. The treatment volume was irradiated by two opposed tangential fields. The medial border was located at the midsternal line. The lateral border was at the midaxillary line to include the breast and to limit the amount of lung at the central plane to less than 2 cm. The superior border was matched at the horizontal line drawn through the supersternal notch, and the inferior border was located at a horizontal line 1.0 - 2.0 cm below the inframammary fold. Wedge compensation was used to ensure a uniform dose distribution throughout the target volume. The dose was prescribed at the isocenter which was placed at point midway along the central plane, two thirds of the distance from the skin to the base of the tangent fields. We kept the dose range between 95% and 107% of prescribed dose. Portal films were obtained in the treatment position with therapeutic beam to confirm patient positioning and adequate coverage.\nDaily irradiation dose was 2 Gy in 30 fractions; the total dose was 60 Gy. After finishing the radiotherapy treatment, at third cycle of paclitaxel, the patient developed grade III dermatitis, with intense local hyperchromia and hyperthermia (), followed by continuous dry desquamation throughout the breast. There was a partial response to the therapy and the tumor was reduced by more than 70%. For dermatitis, only topical treatment with corticoid was introduced, producing a gradual improvement of the actinic reaction. After three months of radiotherapy the patient dermatitis improved to grade II. Chronic cutaneous and subcutaneous changes have not been accessed. |
A 46-year-old Caucasian male presented with a 6-month history of a neglected rapidly growing lesion on the proximal left thigh. He had no relevant past medical history and took no medications, but admitted to binge drinking on weekends and a 10 pack-year history of smoking. He sought attention when the lesion became painful and malodorous. On examination there was a large approximately 30 x 30 cm geographic lesion centered in the left groin, with heaped edges lying 2 cm proud of the normal skin contour, and an ulcerated raised heterogeneous center. It extended superiorly to the lower abdomen, inferiorly 10 cm below the base of the buttock, laterally to the lateral aspect of the inguinal crease, and medially to involve the scrotum, penile base and contralateral perineum (). In addition there was 2 x 2 cm pigmented polypoid lesion at the dorsal penile base. He had stiffness within the proximal left thigh, had lost 25 kg over the last 6 months and had an ECOG performance status of one. CT of the abdomen and pelvis confirmed a large plate-like lesion lying superficial to the adductor muscle group and femoral vessels, as well as left inguinal and external iliac lymphadenopathy up to 5.2 cm in greatest dimension. A chest x-ray was normal. An incisional biopsy confirmed moderately differentiated squamous cell carcinoma, and he was staged as cT3 cN1 cM1. His disease was prohibitively large for either surgery or radiotherapy so he proceeded to palliative chemotherapy as follows: Cisplatin 75 mg/m2 and Docetaxel 75 mg/m2 every 3 weeks. He tolerated 7 cycles; the first 2 at full dose strength and the last 5 at 75% dose strength (55 mg/m2) due to myalgias, oral mucositis and 2 episodes of febrile neutropenia requiring hospitalization and G-CSF support. The visible lesion showed an early and sustained significant response to therapy (), however, after 7 cycles CT documented progressive inguinal lymphadenopathy so he went on to receive palliative radiotherapy as follows: 5000 cGy in 25 fractions via an anterior/posterior parallel pair of 6 and 10 MV photons to a 29 cm (superior-inferior) x 38 cm (medial-lateral) field. The lesion showed further improvement (), however, CT 4 months following radiotherapy noted new left common iliac lymphadenopathy and CT 3 months later confirmed progression of the primary lesion as well, with increased pelvic lymphadenopathy and a non-occlusive tumor thrombus invading the left common iliac vein and IVC to the level of the renal veins. At the time of manuscript preparation, however, 15 months following the time of initiation of chemotherapy he surprisingly maintained an ECOG performance status of zero and was working full-time. |
A 52-year-old man with a background of longstanding well-controlled epilepsy. He was not known to have a previous history of any mental illness. He tested positive for the novel SARS-COV-2 virus on a nasopharyngeal and throat swab after community exposure to a confirmed case. He was asymptomatic at the time of testing positive but was admitted to a governmental quarantine facility as per the country's guidelines (Table ). Eight days following his initial presentation, he was transferred from the quarantine facility to a designated COVID-19 hospital after developing fever, cough, and shortness of breath. Clinical imaging confirmed the diagnosis of severe covid-19 pneumonia; he was commenced on antibiotics (Oral azithromycin and intravenous cefuroxime), hydroxychloroquine, dexamethasone and oxygen therapy. Hemoglobin A1c was found to be high and he was diagnosed with diabetes mellitus and started on insulin. One week following hospitalization, he was noted to be confused and complained of severe headache and abdominal pain. He was transferred to the intensive care unit to be investigated and managed for an impression of an acute confusional state. The initial workup revealed hyponatremia for which he was started on hypertonic saline. Computed tomography of the brain did not show any abnormalities.\nDuring his stay in the intensive care unit, he was assessed by the consultation-liaison psychiatry team. The team's assessment was consistent with 5 days of an acute confusional state based on disorientation to time, impaired concentration and memory, visual and auditory hallucinations (seeing and hearing Jesus), persecutory beliefs against hospital staff, labile mood, and delinquent behavior requiring sedation with oral quetiapine and injectable haloperidol.\nThe patient responded well to treatment, he was transferred to a medical ward after spending four days in the intensive care unit and was discharged home two days later. Upon discharge, he was fully oriented, and his mental state examination did not show any abnormalities. He was discharged from the hospital on oral hypoglycemic agents, antiepileptic medications, and quetiapine 50 mg twice daily. His repeated Nasopharyngeal and throat swab was still Positive for SARS-COV2 but was declared to be noninfectious based on an RdRp-gene ct value of 32.3.\nTwo days after his discharge from the hospital, he presented to the emergency department following an episode of physical aggression in a hotel where he was residing, during the assessment, he justified his behavior by dereliction from the hotel staff. He was threatening to be physically aggressive if his demands were not immediately met. He was noted with a grandiose attitude and claimed to be a Master of Yoga. He demanded to be released from the hospital citing that he does not believe that he has any mental illness based on his medical, educational background. His family members and friends have reported that he was calling and messaging them repeatedly throughout the day.\nHis mental state examination was remarkable for psychomotor agitation, overfamiliar attitude, pressured speech, “very happy” mood, an expansive effect, persecutory and grandiose delusions and poor insight. Attention and orientation were found to be intact.\nPhysical and neurological examinations did not reveal any abnormalities.\nHis medical history is significant of epilepsy since childhood, he was well maintained on medications (levetiracetam 1000 mg and sodium valproate 1500 mg), his last seizure was 20 years prior to presentation. He was newly diagnosed with diabetes mellitus and was on two oral hypoglycemic agents. He denied any background of mental illness in himself or his family.\nHe had maintained a job as a financial consultant for the past 10 years. He is married for 25 years with 3 children. He was living alone, and his family resided in his home country. He is a nonsmoker and had no history of alcohol or illicit substance use. |
A 3-month-old female infant weighing 3050 g with Apgar score of 9 and 8 at 1 min and 5 min was referred to our centre to enter Home Parenteral Nutrition Program (HPN). The girl was born to a non-consanguineous Polish couple and delivered by spontaneous labour at 35 weeks of pregnancy. There were no records of genetic diseases in the family tree. During the ultrasound scan at 22 weeks, megacystis has been noticed in the fetal pelvis with bilateral pelvicalyceal dilatation. At 24 weeks gestation, fetal magnetic resonance imaging (MRI) was performed which revealed a large cystic mass with a maximum diameter of 8 cm and moderate bilateral hydronephrosis. Because of lower urinary tract obstruction, fetal vesico-amniotic shunt (VAS) was implanted at 31 weeks. At birth, there was abdomen distension and absence of intestinal sounds. A few hours after birth, the patient presented food intolerance and gradually developed respiratory distress. The infant has not passed stool for the first 24 hours. Because of these symptoms, intestinal obstruction was suspected. The nasogastric tube for decompression of gastrointestinal tract was inserted, and the central line was implanted to apply total parental nutrition (TPN). Abdominal radiography showed gastric distention and multiple dilated loops of small bowel (). Contrast study of upper gastrointestinal tract excluded the mechanical bowel obstruction. Microcolon was detected in the barium enema (). The infant underwent exploratory laparotomy on 2nd day of life, in which markedly enlarged intestinal loops extending to 20 cm from Bauhin's valve were discovered. A full-thickness biopsy was taken and ileostomy was performed.\nThe histological findings were nonspecific (smooth muscle cell vacuolization and insignificant disorders of cytoskeletal architecture). Alpha-smooth muscle actin (alpha-SMA) immunoreactivity was maintained. After surgery, the patient still presented oral feeding intolerance. Stoma has not passed intestinal content, and retention in the nasogastric tube was observed. The rectal biopsy was performed to exclude long-segment Hirschsprung's disease. The histological picture showed normal ganglion cells, and acetylcholinesterase (AChE) activity was normal. Because of persistent motility disorders and oral feeding intolerance, the patient was qualified to decompress gastrostomy tube, and the long-term central venous access (Broviac type) was implanted. Except for gastrointestinal disturbances, the patient was anuric and required protracted catheterization. Ultrasonography (USG) and abdomen MRI showed diminished corticomedullary differentiation, bilateral hydronephrosis, and tortuous ureters (). Urodynamics testing revealed hypotonic bladder and detrusor-sphincter dyssynergia. The patient required intermittent catheterization every 3 hours during daytime and night interruption. MMIHS was suspected. The diagnosis was confirmed in genetic tests. Heterozygous de novo missense mutation (c.533G>A/p.Arg178His) was identified in the 5th exon of ACTG2 gene. At present, the girl is one-year-old and has satisfying nutritional status.\nShe had repeated catheter-related bloodstream infections and one episode of urosepsis. |
A 57 year-old, right hand-dominant female sustained a right distal humerus fracture from a fall in mid-2009; her past medical history was significant for hypertension and depression. The patient underwent fracture fixation and collateral ligament repair at an outside institution. Due to persistent elbow pain and instability, revision collateral ligament repair was performed in late 2009. In early 2010, the patient underwent lateral collateral ligament reconstruction utilizing allograft tissue by her initial surgeon due to reported recurrent elbow instability.\nNine months after the ligament reconstruction procedure, the patient presented to our orthopaedic department with severe right elbow pain and instability (). She reported no specific history of recent trauma or infectious symptoms such as fever, chills, or other sites of infection. Given her age and functional status, the options of conservative management, interposition arthroplasty, or total elbow arthroplasty were discussed. Preoperative blood work consisting of a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) serum laboratory values was obtained and within a normal range. The patient proceeded with a long-stemmed cemented Coonrad-Morrey TEA (). Approximately 6 weeks later, in mid-2011, she developed a painless, persistent draining sinus from the posterior aspect of the elbow. The patient strongly desired to retain the elbow replacement and was agreeable to undergo a debridement procedure. Intraoperative cultures grew Candida parapsilosis, and she was subsequently placed on chronic fluconazole (). However, in late 2011, she required a resection arthroplasty after multiple debridements, a bushing exchange, and antimicrobial regimens failed to resolve the persistent draining sinus. At the time of resection, there was no evidence of implant loosening. The implant was replaced with an amphotericin, vancomycin, and tobramycin-impregnated cement spacer (Figures and ). She also underwent fixation of an ulnar fracture sustained from a fall prior to undergoing the resection arthroplasty procedure. Intraoperative cultures at this time grew Coagulase-negative staphylococcus and methicillin-sensitive staphylococcus aureus. She was treated as a mixed fungal and bacterial infection and treated with 6 months of fluconazole and 6 weeks of vancomycin. In the following 6 months, she reported no signs of infection such as erythema, soft tissue fluctuance, or drainage, and her neurovascular exam was unremarkable other than decreased ulnar nerve sensation. She was clinically ready for reimplantation in late 2012. Unfortunately, the patient died due to unrelated circumstances before reimplantation could be performed. |
A male infant, who was term appropriate for gestational age, was born via repeat caesarean section to a healthy 26-year-old woman. No family history of bleeding disorders was reported by the mother. Pregnancy was unremarkable, and Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. On initial physical examination, a localized hematoma to the left parietotemporal region was identified. A routine complete blood count (CBC) displayed normal counts. It was decided to repeat the CBC in 12 hours and, in the interim, to observe for dissemination of the blood collection. Prior to the next blood test, the physician was called to the bedside because the infant now had a change in his clinical examination: pale and tachycardic. His examination now revealed a large palpable fluid wave that extended behind the neck and left ear. Given the infant’s change in clinical status and concern for a subgaleal hematoma, the infant was transferred to the neonatal intensive care unit (NICU). The repeat CBC showed a hemoglobin level of 7.6 g/dL, with a hematocrit of 22% and platelets of 169 × 109/L. In the NICU, the patient received a transfusion of 20 cc/kg of O Rh-negative packed red cells. His coagulation profile disclosed a normal prothrombin time but an activated partial thromboplastin time (PTT) of 101 seconds (normal = 25-30 seconds).\nSubsequently, a FVIII level was ordered, which was very low at <0.01 U/mL. He was diagnosed with severe HA and was initially treated with 50 U/kg of recombinant FVIII. His repeat doses were adjusted to bring his FVIII level to 100%. A computed tomography (CT) scan of the head revealed a large subgaleal hematoma, beginning in the left parietal area, extending to the occiput and down the nape of the neck. The infant was discharged at 1 week of age following a repeat head imaging confirming complete resolution of the extracranial hemorrhage (ECH) without any evidence of intracranial bleeding. |
A 51-year-old man with no significant medical history was admitted to our hospital with sudden onset epigastric pain. He did not take any regular medications. He had smoked a packet of cigarettes a day for 30 years and was a social drinker. On admission, his vital signs were within normal limits: body temperature of 37.0 °C, blood pressure of 113/65 mmHg, heart rate of 54 beats per minute, and oxygen saturation of 100% in room air. He complained of slight epigastric pain but there was no rebound tenderness. His hemoglobin level was 12.0 g/dL. Computed tomography (CT) with contrast enhancement showed a massive hematoma in the lesser omentum (Fig. ). Moreover, the root of the celiac artery was severely stenosed (3.5 mm in diameter) and a RGA aneurysm was present (Fig. ). A RGA aneurysm and an anomaly of the artery; common hepatic artery branches from the superior mesenteric artery (SMA) were also detected (Fig. ). The dorsal pancreatic artery (DPA) was dilated and clearly connecting the SMA and the splenic artery (Fig. ). His diagnosis was determined as median arcuate ligament syndrome (MALS) with a ruptured RGA aneurysm.\nThere were two treatment options, including endovascular treatment and open surgery. Endovascular treatment is less invasive. However, there is a risk of recanalization in endovascular treatment. On the other hand, we thought there were also some merits in performing open surgery. A RGA aneurysm can be treated easily by resecting the lesser omentum, and in the same operation, the MAL could also be transected. This may prevent the recurrence of the aneurysm in the future, though evidence is lacking. We informed him of the two treatment options, endovascular exclusion and open resection of the ruptured aneurysm; he chose open surgery. During emergency laparotomy, the lesser omentum with the RGA aneurysm was resected together with transection of the MAL. The intraoperative aortogram before transection of the MAL depicted the blood flow of the splenic artery coming from the SMA via the DPA (Fig. ). After transection of the MAL, the blood flowed from the celiac artery to the splenic artery instead of the DPA (Fig. ). His postoperative course was uneventful and he was discharged on postoperative day 9. Eighteen months after the operation, 3D volume rendered CT showed further enlargement of the celiac artery (5.0 mm in diameter), an obscured DPA, and no de-novo aneurysm formations (Fig. ). Informed consent was obtained from the patient prior to publication of this case report. And the CARE guidelines have been followed in this case report. |
A 43-year-old male was admitted in July 2019 to the emergency department after being found unconscious in the street with anisocoria, severe right-sided hemiparesis with a Glasgow Coma Scale of 6 (E1V2M3). His initial clinical condition suggested head trauma due to alcohol intoxication. A head CT was performed at the local hospital (a), and the patient was sedated, intubated and transported to our hospital in order to perform a DC. The neurosurgeon on duty requested a preoperative CT angiography (CTA), which showed a suspect dissecting aneurysm of the M3 segment of the middle temporal branch of the left MCA (b,c). A DC was urgently performed in the evening and after consulting his superiors, the surgeon on duty did not immediately treat the aneurysm. However, he carefully preserved the STA within the supragaleal space of the skin flap. Early next morning, a postoperative CT was performed with acceptable results of midline shift regression (d).\nHowever, the patient was hemodynamically unstable, requiring continuous vasopressor support and it was impossible to obtain a valid neurological exam. Eight hours after the initial surgery, a second procedure was scheduled, aiming to treat the dissecting aneurysm. After skin flap eversion and durotomy, the neurosurgeon (first author) preferred dissection of the arterial donor from the skin flap and performed a protective bypass on the distal M4 segment of the middle temporal branch of the MCA (a). The reason for this was that performing dissection in the area of the aneurysm was very risky due to adhering coagula. Furthermore, it was uncertain that a direct reconstruction of the artery, which most likely supplied the superior temporal gyrus, would be possible. Patency of the bypass was verified via a transcranial Doppler (TCD), after which dissection of the proximal portion sylvian fissure was initiated, with necessary cutting a superficial sylvian vein branch followed by its suture (a). After placement of a temporary clip on the proximal M3 and evacuation of coagula surrounding the aneurysm, the surgeon verified a defect of the arterial wall without the presence of an aneurysmal sac—a true dissecting pseudoaneurysm (b). In this case, we considered trapping a short portion of the mother vessel to be safer than direct reconstruction of the arterial wall.\nCTA was performed the next day and demonstrated good patency of the bypass, successful trapping of the pseudoaneurysm and sufficient collateral flow (a,b). In the postoperative period, the patient required milrinone-mediated pharmacological angioplasty several times, due to moderate vasospasms. Surprisingly, the bypass itself was spared of vasospasms based on TCD measurements (insonation depth of 20–25 mm in the temporal region).\nAfter vasospasms receded, the patient was transferred to his local intensive care unit on the 17th day after the second surgical procedure. Clinically, the patient had a tracheostomy, a moderate right-sided hemiparesis (4/5) and was compliant to vocal commands. Two months later, he was readmitted to our neurosurgical department in order to perform a cranioplasty, which was technically challenging as careful dissection was required to identify and preserve the EC-IC bypass (c). A follow-up CT did not reveal any ischemic lesions in the patient’s left temporal lobe (d). The patient was then transferred to a rehabilitation department without a tracheostomy, without a hemiparesis and with residual moderate aphasia (modified Rankin scale, mRS3).\nAs this is a case report, approval of the ethics committee was not necessary for this paper. The participant has signed the written informed consent. |
A 28-year-old woman, gravida 3 para 1, had a medical termination of a miscarriage at seven weeks, with no dilation and curettage, in 2008. In 2015, a baby was delivered by caesarean section in the breech position, weighing 3900 g. She had no significant past medical history, and her antenatal care had been uneventful. On August 9, 2018, at 19:15, she was admitted to our hospital due to a pregnancy of 9+ months and irregular contractions for 4+ hours. Periodic uterine contractions occurred every 6–8 min. The patient was not accompanied by abdominal pain or vaginal bleeding and had intermittent term after contractions. Clinical examination showed that her body temperature was 36.7 °C, blood pressure was 102/65 mmHg, pulse rate was 100 bpm, and oxygen saturation was 100%. Blood tests showed mild leucocytosis (16.61 × 109/L), normal platelet count, normal coagulation test, and haemoglobin of 102 g/L. Vaginal examination showed the cervix was tightly closed; no vaginal bleeding or fluid was found. The ultrasonography indicated that the foetal head was located above the uterine cavity, the foetal size was consistent with the gestational age, the placental position was normal, and the scar thickness of the previous caesarean section was approximately 0.2 cm. Uterine contractions declined after admission. During admission, the patient was clinically and biochemically stable, and daily cardiotocograms showed a reassuring foetal heart rate pattern. Because of the patient’s progressive anaemia (blood tests revealed a slow decline in haemoglobin to 93 g/L, 87 g/L) and sudden increasing abdominal pain, ultrasound was used but did not show ruptured abdominal fluid. An urgent laparotomy was performed and revealed a massive haemoperitoneum caused by the rupture of the uterine posterior wall. A haemoperitoneum with approximately 1 liter of blood was recovered. The lower uterine segment was intact and not ruptured. A boy with a body weight of 2900 g was delivered. Apgar scores were 9 at 1 min and 10 at 5 min. The amniotic fluid was clear, the placental was completely delivered, and no placental abruption occurred. The patient’s uterus was closed in two layers. After removing the blood and clots, a 12 cm-long tear in the posterior wall and active bleeding from the uterine rupture were found. Uterine tissue adhered to the bowel (see Fig. ). After separation of the adhesions between the bowel and the uterine wall, two layer of uninterrupted stitches restored the uterine integrity, and interrupted stitches closed the mesentery defect (see Fig. ). It was suspected that future conceptions would be dangerous, so bilateral tubal ligation was performed at the same time, under the permission of the patient and the patient’s family member. Our patient’s uterine and pelvis showed no abnormalities and, particularly, no evidence of endometriosis. Inspection of her liver showed no rupture. The placenta was sent for pathological examination. Syntocinon (oxytocin) (Ma an Mountain Company, China, SFDA approval number: H34020474) was administered intravenously. The operation was uncomplicated, and the estimated total blood loss was 2500 ml. Ten units of blood and 400 ml of blood plasma were transfused. The patient’s postoperative course was regular, and she was discharged 6 days later. |
A 4-year-old boy was presented to our unit on referral with a three-week history of high-grade fever and a five-day history of generalized abdominal pain and abdominal distension. There was an associated history of headaches and body weakness. He had no history of jaundice. He had several episodes of vomiting which was initially none bilious, but later became bilious. There was an associated history of passage of diarrhea stools two days before presentation, although the patient had not passed stools on the day of presentation. He had no history of passage of melena or of hematochezia. His parents complained that he had been passing scanty urine for about five days before presentation. He had been receiving medications from the referring hospital for about two weeks before presentation.\nAt presentation, he was chronically ill looking with a toxic facie, febrile (temperature 38.5°C), pale, dehydrated, anicteric, and had no pedal edema. His respiratory rate was 28/minute; he had reduced air entry on both lung bases posteriorly. His pulse rate was 128/minute, which was regular but of small volume. Only first and second heart sounds were heard. Abdominal examination showed a distended abdomen which did not move with respiration. He had generalized tenderness with guarding. The bowel sounds were absent. A digital rectal examination showed an empty rectum with a full and tender rectovesical pouch. An initial assessment of a generalized peritonitis was made. The patient was placed on NPO with nasogastric tube for gastric decompression. He was commenced on IV fluid resuscitation and broad spectrum IV antibiotics (ceftriaxone and metronidazole) and was worked up for surgery. Initial laboratory investigations showed a hematocrit of 24% and hypokalemia (2.5 mmol/l) and a serum urea of 10 mmol/l. After an initial fluid resuscitation and correction of serum potassium, he had 300 ml of whole blood transfused. He had an exploratory laparotomy on the second day of admission. At surgery, about 600 ml of a feculent peritoneal fluid was drained, and a single perforation on the antimesenteric border of the terminal ileum was closed in two layers. An intraoperative diagnosis of perforated typhoid enteritis was made. Blood and tissue cultures were not done. He was continued on IV fluids and the same empiric antibiotics after the surgery.\nOn the third day of postoperation, the abdominal wound had a purulent discharge from the distal end. The wound was opened and stitches were removed from the site of drainage, with the institution of daily wound dressing. By the fifth day of postsurgery, a dark patch was noticed to have developed in the skin over the right iliac fossa and measured about 5 cm in its widest diameter. At about the 7th day of postoperation, the dark dry patch had extended to the right hypochondrium, and a similar patch had appeared along the edges of the abdominal incision and the left iliac fossa. A diagnosis of anterior abdominal wall gangrene was made. On the 8th day of postsurgery, the patient was noticed to have developed a complete wound dehiscence () and a fecal fistula. He had fluid resuscitation and was taken back to the theatre on the 10th day after the first surgery, for wound exploration and debridement of the anterior abdominal wall gangrene. A new intestinal perforation was seen at about 2 cm from the initial perforation. The intestinal perforation was exteriorized as an ileostomy, and the abdominal wound closed with tension sutures. Postoperatively, the patient's condition remained unstable, with intractable shock. He died six days after the reexploration of septic shock. |
A 62-year-old male patient presented to our emergency with the complaint of sudden onset giddiness from the past 2 h. This was followed by the loss of consciousness. The patient was a known case of T2DM for the past 1 year. No history of previous such episodes of giddiness or loss of consciousness was present. There was no history of chest pain, breathlessness, cough, oliguria, and palpitations. There was no history of hypertension or ischemic heart disease.\nTreatment history - patient has been taking metformin 1 g daily along with aspirin 75 mg and atorvastatin 10 mg. The patient had a good glycemic control which was reflected by the HBA1c levels of 7.2% (done 15 days back).\nFamily history - patient has two brothers who also have T2DM and both of them also developed CHB spontaneously. His elder brother, currently of 64 years of age, is a known case of T2DM since 56 years of age, and he developed CHB at the age of 59 years. His younger brother, who is 58 years old, is a known case of T2DM since 52 years of age, and he developed CHB at the age of 56 years. Both his brothers developed CHB spontaneously, similar to our patient and they too had no history of hypertension or ischemic heart disease. Both his brothers underwent Echocardiography when they developed CHB, and neither of the two had any evidence of ischemic heart disease on Echocardiography. Both his brothers underwent permanent pacemaker implantation and have been doing well since then.\nThe patient's mother also had T2DM and she also developed CHB at the age of 65 years and succumbed to death at the age of 75 years, due to cerebrovascular accident. His father was a nondiabetic.\nOur patient had two children and none of them had T2DM or CHB [].\nOn examination, his pulse rate was 36/min, regular, high volume; blood pressure of 140/60 mmHg; body mass index of 24.9 and waist-hip ratio of 0.85. Rest of the general examination was within normal limits. On examination of the cardiovascular system, a variable intensity of first heart sound was present. Rest of the cardiovascular examination and other system examination was within normal limits [].\nBased on the ECG [], a diagnosis of CHB was made, and temporary pacing was performed followed by permanent pacemaker implantation. Patient has been doing well since then. Arterial blood gas done at the time of admission revealed metabolic acidosis. A chest X-ray was performed later on and it showed no abnormality. Echocardiography was performed and there was no evidence of ischemic heart disease. |
A 64-year-old Chinese female patient admitted to a tertiary care cancer hospital was presented with abdominal unease due to increased stool frequency and bloody stools. Digital rectal examination revealed adenocarcinoma, computerized tomography (CT) imaging identified inguinal nodule shadow and enlarged lymph nodes, which implied the presence of rectal cancer. Further, a mediastinal aortic arch nodule shadow indicated metastasis. Subsequent histopathological examination of the biopsy confirmed the rectal adenocarcinoma. The patient got admitted to the general surgery department in January 2016 and underwent Miles’ resection to remove the distal portion of the pelvic colon, followed by intestinal adhesion release surgery that relieved the intestinal obstruction. Iliac vessel exploration facilitated containment of the hemorrhagic episodes. Post-operative histopathological results reported ulcerative and moderately differentiated adenocarcinoma (in the rectum and part of the sigmoid colon) with the invasion of adventitia. Based on the American Joint Committee on Cancer TNM classification system, the tumor stage was T3, N0, M0 (IIA). Genetic profiling of the tumor resections detected wild-type KRAS codon 12 and 13 mutations. Also, MSI analysis for detecting germline mutations of MMR genes showed microsatellite-stable (MSS) phenotype. The adjuvant chemotherapy regimen consisted of three cycles of oral capecitabine 1.5-g tablets (twice daily) and oxaliplatin 200 mg from February 2016, followed by four cycles of capecitabine tablets 1.5 g (twice daily). Additional file illustrates a detailed pictorial case presentation. The patient’s medical history included a cesarean section 30 years ago and no familial history of hematological disorders. The physical examination and vital signs were within normal limits. Blood biochemistry and renal and hepatic function tests showed no anomaly either. Additional file elaborates the detailed physical examination results.\nOn the 27th month (April 2018), a follow-up CT screening from the first surgery revealed vegetative tumor growth in the perineum requiring surgical management. In July 2018, the patient had transperineal pelvic tumor resection to stem the local recurrence of the tumor with the TNM staging of T3, N×, M1a (IVA). Histopathological examination showed a moderately differentiated adenocarcinoma and infiltration/metastasis associated with the invasion of the skin. All surgical margins were free of residual tumor. Immunohistochemical staining demonstrated positive expression of CDX-2, cytokeratin 20 (CK20) homeobox, and villin proteins, while cytokeratin 7 (CK7) protein demonstrated negative expression. First-line adjuvant chemotherapy consisting of irinotecan 240 mg/m2 + levoflofolate 150 mg + fluorouracil 0.6 g (intravenous) was initiated. Additionally, fluorouracil 0.9 g was administered to the patient as an infusion. The patient showed stable disease progression during the treatment, with an adverse reaction of Grade 3 gastrointestinal discomfort. However, during a follow-up CT screening in December 2018, a small inguinal nodule was found on the left side without any discomfort. By March 2019, the tubercle size increased gradually even with oral homeopathic treatment (cantharis capsule) by Heishi County Third People's Hospital (unknown specifics) with a poor prognosis. The further enlargement of the nodules called for another screening. CT scan indicated multiple metastatic tumors, rectal fistula, and enlargement of bilateral inguinal lymph nodes. Due to further enlargement of nodules with the formation of gall stones and enlarged inguinal lymph nodes, the patient received local bilateral inguinal radiography for bilateral inguinal lesions to a dose of 50 Gy in 25 fractions. Follow-up CT imaging showed recurrent metastasis, due to which following the subsequent modification of second-line chemotherapeutic regimen to bevacizumab 400 mg + oxaliplatin 200 mg + capecitabine 1.5 g (twice daily) was given for 14 days. However, due to adverse gastrointestinal reaction (Grade > 3) caused by due to oral capecitabine, the capecitabine dose was reduced to 1 g, this modified second-line chemotherapeutic regimen was led to an interruption in chemo regimen, following which bevacizumab 400 mg + oxaliplatin 200 mg + capecitabine 1 g (twice daily) was started and given for a single cycle in January 2020. The multiple rounds of chemotherapy showed partial response with recurrence of multiple nodules and masses. A follow-up CT imaging in March 2020 showed disease progression, additionally presented nodule formation in the left upper lobe and right lower lobe, with an iso-dense nodule. The TNM status at this instance was T3, N×, M1b (IVB).\nFurther, the patient tested positive for hepatic C virus, following which an oral administration of Jisandai (Bantongsha) that is sofosbuvir 400 mg and velpatasvir 100 mg as a composite tablet once a day was administered. Adverse effects included tooth pain caused by gingivitis, which was cured by oral administration of ornidazole 500 mg twice daily. Following recurrence of rectal adenocarcinoma, regorafenib was administered at 120 mg once daily combined with sintilimab 200 mg five times a day, and the patient's progress was followed up (as an out-patient once every week). Eventually, the sintilimab dosage was tapered to 100 mg four times a day due to economic reasons. CT scans of the chest and abdomen suggested that treatment achieved a complete response (CR). During the last follow-up in April 2020, re-examination by CT imaging (Fig. a–d) showed that the bilateral inguinal area had multiple nodules and masses, some of which were slightly smaller than the previous assessment. Follow-up CT imaging showed the absence of the frontal lobe iso-dense nodule that was present before. There were no severe adverse events, and the patient presented good overall performance status. The patient also received prophylactic treatment for hepatitis C. Additional file briefly outlines the reports of the medical imaging history. The clinical effect of regorafenib plus sintilimab was classified as CR according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 criteria, and the patient exhibited no tumor progression. CT imaging could not identify the presence of metastasis. The predictors of efficacy of regorafenib combined with sintilimab remain to be further analyzed. |
A 36-year-old man presented with a 2-year history of a cold left foot and left calf pain after exercise, and reported that these symptoms had worsened over the past month. Physical examination revealed mild amyotrophia and a 7 °C difference between the thigh and calf skin on the left leg. No pulse was palpated below the popliteal artery on the left side. Color Doppler ultrasound showed a multilobulated cystic mass, 40 mm × 11 mm in size, which was posterior to the popliteal artery and resulted in hemodynamically significant endoluminal stenosis. Only a thin linear arterial blood flow signal of 0.9–1.1 mm thickness was observed inside the affected popliteal artery, caused by compression from the cystic mass (Fig. a).\nAt surgery, a cystic protuberance, 6 cm long, was found at the junction of the femoral and popliteal artery (Fig. b). The translucent adventitia of the popliteal artery was opened longitudinally, and the intact arterial intima was found to have significant local thickening. A cystic collection of gelatinous material had accumulated within the adventitia of the popliteal artery, which resulted in significant endoluminal stenosis. The cystic lesion was removed completely using a conservative approach to maintain the medial and intimal layers; however, this did not improve the arterial stenosis remarkably. The patient had a severe form of bilateral varicose veins and assuming that the diseased vein was implanted into the arterial system, the thin vein wall would have been subjected to the high arterial shear pressure. As the resulting elevated vein pressure could lead to the formation of an aneurysm of the thin wall, we did not use the saphenous vein as the interposition graft. In situ vascular reconstruction was performed by a prosthetic ePTFE graft. Immediately after the operation, normal popliteal and distal pedal pulses were felt. The ankle brachial index increased from 0.46 to 0.97 after the successful vascular reconstruction. |
A 22-year-old female patient reported to the Department of Prosthodontics with a chief complaint of missing tooth in the upper left front tooth region. The patient was more concerned about her esthetics. There was no relevant medical history. Previous dental history revealed that the patient underwent extraction of the maxillary left lateral incisor 1 year back. There was no mobility in the remaining natural teeth. Clinical examination with bone caliper revealed 8.5 mm width (mesiodistally) and 9 mm (labiopalatally) at an occlusal third of the alveolar bone in the maxillary left lateral incisor region []. Radiographic examination showed that 17 mm of the bone height was present. Among the various treatment alternatives suggested to the patient was the conventional fixed partial denture taking support of the left central incisor and canine. Depending on the patient's expectation, cost consideration, and diagnostic information, the best treatment approach considered was implant placement in the maxillary left lateral incisor with a papilla-sparing technique to maintain hygiene and esthetics.\nThe area of interest was anesthetized with the local anesthetic agent (Lignospan Special, 2% lidocaine with 1:80,000 epinephrine, septodont, France). A horizontal incision was made along the palatocrestal aspect of the ridge which was terminated 1 mm from the adjacent teeth. The incision was given palatally to transpose the keratinized tissue to buccal side. From the horizontal incision, two bilateral buccal vertical releasing incisions were given which extended obliquely at a diverging angle.[] The mucosa was reflected and one root form implant (3.5mm diameter × 13mm length) was placed into the lateral incisor region of the maxillary alveolar bone []. The implant achieved an insertion torque of 35Ncm. Preserved papillae contain supracrestal fibers that subsequently help in maintaining the papillary height. The vertical extent of the incision depends on the type of procedure to be accomplished. At the end of the procedure, the soft-tissue segments were sutured using vicryl (absorbable, polyglactin 910) suture. A postoperative radiograph was taken to confirm the position of the implant placement []. Postoperative care instructions were given to the patient and medications were prescribed (amoxicillin 500 mg TDS, tinidazole 500 mg BD, and ibuprofen 200 mg TDS for 5 days). After a week from the surgery, the surgical site was evaluated for any infection and discharge and when it was found that the healing was appropriate, the sutures were removed. The implant was allowed to osseointegrate for 12 weeks []. demonstrates the complete implant protocol. |
Woman 52 year old with severe grade III APLD came in consultation. She was also aware of her familiar condition. Liver transplantation was offered to her in another center but she refused. Previous MRI from another center showed multiple giants cysts compromising the whole abdominal cavity. Cysts reached hypogastric area and both inferior quadrants. Higher segments of the liver seemed to be respected. Globulous deformation of the abdomen was clearly observed. Despite aesthetic and mild abdominal pain symptoms were not as significant as they were in her two sister so she did not want to underwent liver resection too. However she kept coming to consultation every six months.\nTwo years later she came back presenting jaundice with serum levels of FAL>1700 mg/dl. Bilirrubin 9,8/7,9 mg/dl. New MRI showed cyst compression of the hepatic pedicle including common bile duct and portal vein ( A and 3B)\nSurgery was soon programed and approach was discussed. We decided laparoscopic approach but being aware room will be very reduced even after pneumoperitoneum. We decided to start by performing aspiration and evacuation of the big lower and anterior cysts to intend reducing the mass and make new space for the laparoscopic procedure. By performing this gesture followed by several fenestration and partial cysts resections space was increased within the abdominal cavity so laparoscopic liver resection could be then performed. Once gallbladder was located, we then identified two cysts that seemed to be responsible for hepatic pedicle compression. Fenestration was done and, then, intra-operative cholangiogram showed no further compression of the common bile duct with adequate passage of contrast to duodenum. Standard cholecystectomy was completed and later laparoscopic left lateral sectionectomy was done in association with several more cyst fenestration. Post-operative course was un-eventful and patient was discharged at 6th day with decreasing levels of FAL and bilirubin. Late follow up imaging control are still to come. |
A 44-year-old Japanese man presented to the Maxillofacial Surgery Clinic at the Tokyo Medical and Dental University, Tokyo, Japan, with reports of a hard mass and dull pain in the left mandible. His medical history was generally unremarkable, though his mandible had been accidentally smashed against his young son’s head at the age of 40. No fracture was detected at the time, and no treatment was received.\nClinical examination revealed slight swelling in the left lower molar region and swelling of the left mandible. There was no disturbance of sensitivity in the left lower lip or chin, and he could move his lips normally. Radiographic examination showed large, irregular, multilocular radiolucency of the left area of mandible extending to the premolar and molar area, with no evidence of any impacted tooth (Fig. ). A computed tomography (CT) image revealed a 45 × 30 × 30 mm multilocular cystic mass in the mandible (Fig. ). An axial CT image showed thinning or partly resorption site of the buccal cortical plate. The coronal section images of the CT scan showed the mass lesion displacing the mandibular canal downward, near the inferior border. The roots of the adjacent teeth were resorbed, changing their shapes (Fig. ). The location of the teeth was not changed.\nThe initial clinical impression was an ameloblastoma, myxoma, keratocystic odontogenic tumor or another tumor type lesion.\nThe lesion was removed surgically with the buccal cortical bone and buccal mucosa in contact with the mass of the tumor. The mass fully excised intraorally under general anesthesia, and the inferior alveolar nerve in contact with the mass was preserved.\nThe resected specimen of the primary tumor was a soft, fragile, yellowish-white mass. Microscopically, tumor tissues were composed of plexiform or cord-like nests of tumor cells with round to oval nuclei and eosinophilic cytoplasm in a matrix with prominent myxoid change (Fig. ). On the other hand, the component of solid sheets of tumor cells was limited (Fig. ). In some areas, tumor cells surrounded small blood vessels (Fig. ). Moreover, tumor cells manifested a uniform cell morphology, poor dysplasia, and inconspicuous mitosis.\nImmunohistochemical staining was positive for vimentin (Fig. ), muscle-specific actin/HHF35 (Fig. ), and Calponin (Fig. ), a protein responsible for binding the actin-binding protein. A hairline-shaped area of positive staining for type IV collagen surrounding the tumor cells was also observed (Fig. ). VEGF and D2–40 was also focally positive in tumor cells. In contrast, staining for alpha-SMA, cytokeratin (AE1/AE3), cytokeratin (CAM5.2), CK19, CD34, CD68, p63, S-100, Factor VIII, and desmin, CD56, chromogranin A, synaptophysin was all negative in the tumor cells. Moreover, CD31 was also negative, but we observed many blood cells intervened between tumor nests. The Ki-67 labeling index was almost 1%. No necrosis or tumor invasion into the neurovascular channel was observed. The primary tumor was diagnosed as a glomus tumor based on these findings.\nThe patient remained symptom-free and manifested no signs of recurrence. However, a recurrent tumor was detected in a panoramic radiograph during an 8-year follow-up. The panoramic radiographs taken earlier, after excision of the primary tumor, showed normal healing process, bone regrowth, and increased radiopacity. The follow-up panoramic radiograph 8 years later depicted the recurrence as a radiolucent expansion in the lower area of the mandible. A CT exam showed an expanding lesion exiting the lower site of the mandible and a thinning buccal cortical bone in contact with the tumor (Fig. , ). In magnetic resonance imaging (MRI), the recurrent lesion showed a lower or compatible signal intensity compared to the muscle in T1-weighted images and a low-to-high inhomogeneous signal intensity in T2-weighted images. The apparent diffusion coefficient in the glomus tumor area was 2.0 × 10− 3 mm2/sec, suggesting a low cellular density (Fig. -).\nThe recurrent tumor mass and related teeth were removed under general anesthesia, and the bone surface was shaved. The recurrent tumor had the same microscopic, morphologic, and immunohistochemical features as the primary tumor (Fig. ). The tumor invaded the medullary cavity of the mandible, involving spongiosa and resorbing compressively the cortex bone around tumor.\nThe patient has no symptoms of recurrence as of this writing, 2 years after the second operation, and will be followed for the long term to promptly detect any signs of new tumor growth.\nThe patient is satisfied that the glomus tumor was regulated without resecting the mandibular region. He is pleased that there was no functional deterioration that he was worried about before treatment and there was no aesthetic damage.\nTimeline of patient diagnosis and treatment.\n1. 4 years before the first visit, the patient had been smashed against his young son’s head.\n2. At first visit, the symptom was slight swelling of the left mandible. There was no disturbance of sensitivity. The examinations were performed with X-lay and CT.\n3. First surgery was performed and started clinical follow-up after the surgery.\n4. 8 years later from first surgery, the recurrence was found by panoramic radiograph. The examinations were performed with CT and MR.\n5. Second surgery was performed, and it was passed 2 years with no recurrence from second surgery. |
A 50-year-old male patient with aortic dissection originating just above the aortic valve and extending down to the common iliac arteries (Stanford A, Figure ) underwent immediate surgery with repair of the ascending aorta in moderate hypothermia under cardiopulmonary bypass. The arterial line was inserted in the right axillary artery, the vent was placed in the right upper pulmonary vein, and two-stage venous line was inserted through the right auricula. The intact aortic valve was resuspended. Extracorporeal circulation was suspended after induction of moderate hypothermia (25°C) and the aortic cross-clamp from the ascending aorta was removed. The false lumen was then glued and an open distal anastomosis to a prosthetic graft was constructed. Then, extracorporeal circulation was resumed, systemic circulation was deaired and the patient was warmed.\nEarly on the first postoperative day, CT of the aorta was requested because of marked elevation of lactate-dehydrogenase (129 μkat/l) and signs of acute renal insufficiency (creatinine 292 μmol/l). CT showed good postoperative result in the ascending aorta, but large amount of air in the branches of the superior mesenteric artery up to the arcades was found (Figure ). There was absolutely no air in the portal-venous system including the liver. The bowel loops were not distended, and there were no signs of bowel paralysis.\nAt midnight on the first postoperative day, a biphasic CT scan of the abdomen was requested due to elevated intra-abdominal pressure (18 mmHg). The CT showed distribution of the intra-arterial gas more into the periphery and into the wall of the bowel loops that still did not display signs of ileus (Figure ). The next morning, surgical exploration was performed due to increasing intra-abdominal pressure as a sign of imminent abdominal compartment syndrome. An extensive bowel resection from oral ileum down to the splenic flexure had to be performed due to extensive necrosis of the bowel. Shortly after the operation, the patient became hypotensive with signs of overwhelming vasoparalysis and died on the third postoperative day of multiple organ dysfunction syndrome (MODS) with systemic inflammatory response syndrome (SIRS). |
We present a 57 year old gentleman with CKD 5 who had an autogenous brachiocephalic fistula 4 months prior to presentation to us. During their last surgical clinical visit, the fistula was noted to be poorly maturing and then referred to interventional radiology for fistulogram and possible endovascular intervention to assist with fistula maturation.\nThe patient had a fistulogram which demonstrated a high grade juxta-anastomotic stenosis which was successfully balloon dilated. After a 6 week follow up clinic visit the fistula was still immature and a duplex scan, a second fistulogram with possible intervention were requested.\nFistulogram was performed via an antegrade approach from an access just proximal to the swing point. There was an “apparent” stenosis (Fig. ) which was angioplastied then followed by severe spasm (Fig. ). which was perceived by the operator to be recalcitrant stenosis. In the light of this perceived recalcitrant stenosis, a decision to stent the area was taken. After measuring the vessel diameter based on the immediate post-plasty images a 6 mm diameter × 5 cm length Viabahn stent (Gore & Associates, Flagstaff, AZ) was selected and deployed in the standard fashion.\nFollowing stent deployment, the stent migrated and stopped at the confluence of the cephalic vein and the subclavian vein (Fig. ). At the time the operator thought the stent was stable and unlikely to cause harm to the patient in this position. However, after reviewing the images with colleagues including vascular surgeons a decision was made to attempt to retract the stent into the arm which would be easier for the surgeon to retrieve the stent surgically, if required. The patient was subsequently brought back 24 h later to the interventional radiology suite.\nInitial fluoroscopic image of the left shoulder region demonstrated the stent was absent from the final position documented the previous day indicating the stent had migrated further (Fig. ). Fluoroscopic scanning of the chest identified the stent to overlie the left lower lobe (Fig. ).\nSubsequent Pulmonary angiogram confirmed the stent to lie within a segmental pulmonary artery of the left lower lobe (Fig. ).\nAfter discussion of the options, risks and benefits with the patient and a multidisciplinary team, a decision to attempt stent retrieval was made versus leaving the stent in situ.\nAfter appropriate informed written consent, the right groin was prepped and in the standard fashion. Right common femoral vein access was then upsized to accept a 16 F sheath (Cook, Bloomington. IN USA). Main pulmonary access was then performed with an APC pulmonary catheter (Cook, Bloomington. IN USA). The APC catheter was then removed over a Storq wire (Cook, Bloomington. IN USA) wire and subsequently a 12 F 70 cm braided sheath was advanced into the main pulmonary artery and then left lower lobe pulmonary artery. Pulmonary angiograms performed identified the optimal projection to identify the vessel to access. After accessing the appropriate vessel the 12F sheath was advanced just to the origin of the branch above the stent. Subsequently a 15 mm Amplatz Gooseneck snare (ev3, Plymouth MN, USA) was manipulated until the stent was lassoed at about half way along the stent. Given the flexibility and potential collapsibility of the Viabahn stent it was over-sheathed carefully collapsing and gently retracting the captured stent to minimize potential vessel injury (Fig. , Additional file ). Once the stent had been totally ensheathed, the 12F sheath was retracted through the outer 16F sheath coaxially. The stent was retrieved intact (Fig. ).\nThe procedure was performed under moderate sedation using Fentanyl and midazolam with continuous monitoring of the patient’s vitals by a dedicated nurse. Throughout the procedure the patient remained hemodynamically stable with normal respiratory function. Post procedure the patient was observed for 6 h post procedure before being discharged home in a stable condition.\nThe patient has so far been followed up for 3.5 years and has not developed any adverse pulmonary or cardiac condition. Interval CTPA done at an outside facility showed normal pulmonary vasculature with no evidence of pulmonary vessel injury. |
A 79-year-old male with a medical history of cholelithiasis, for which he underwent cholecystectomy 11 years ago, hyperlipidemia, essential hypertension, and paroxysmal atrial fibrillation was admitted for mild acute pancreatitis. His presentation included severe epigastric pain radiating to the back, lipase of 1840 u/L, and no organ failure. He denied fever, chills, or body aches. The patient denied alcohol consumption and reported to have quit smoking 41 years ago. Liver chemistries, serum bilirubin, serum triglycerides, and immunoglobulin subclasses were within normal limits (). Abdominal CT scan demonstrated peripancreatic haziness consistent with noncomplicated acute pancreatitis (). Home medications included atorvastatin for several years and the addition of 160 mg fenofibrate six months prior to admission. These medications were held upon admission but resumed at discharge. Full medication lists on admission and at discharge are shown in (). The patient was managed with fluid resuscitation and pain control. The patient recovered well and was able to tolerate regular diet without any pain or nausea. The patient was discharged in a stable condition after three hospital admission days, and lipase level at the day of discharge was 307 u/l.\nThree days later, the patient returned with similar symptoms. Lipase levels were >30,000 u/l (), and magnetic resonance cholangiopancreatography showed acute interstitial edematous pancreatitis (). The patient was treated conservatively with intravenous fluid resuscitation, pain control, and nothing per mouth until his symptoms resolved. Four days after his second admission, the patient recovered well and was discharged home in a stable condition. Fenofibrate and atorvastatin were discontinued ().\nTwo months later, the patient remained asymptomatic and returned for further workup to rule out an alternative cause to fenofibrate-induced pancreatitis. Endoscopic ultrasound (EUS) was done, which showed a 12 mm x 20 mm pancreatic head mass without pancreatic duct stenosis, strictures, or dilation. There were no common bile duct abnormalities. Fine needle aspiration was performed, and cytology was negative for malignant cells. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to place a prophylactic pancreatic duct stent. Cholangiogram revealed a normal biliary system without dilation or strictures. The biliary tree was swept, and nothing was found. A prophylactic pancreatic duct stent was placed and a prophylactic sphincterotomy was performed. No recurrence of pancreatitis has occurred as of 6-month follow-up.\nGiven the course of the patient's illnesses in relation to fenofibrate usage, the timespan of drug initiation, and the fact that he had been taking atorvastatin for many years without previous signs or symptoms of acute pancreatitis, we hypothesize that his recurrent disease is probably due to the use of fenofibrate. |
A 67-year-old, Caucasian man presented with a 2-year history of numbness and burning pain on the anterolateral and lateral aspects of the left femur. His symptoms deteriorated within a period of 2 years, at the end of which they became present even at rest. The causalgia was not bearable with tight trousers or when wearing a belt.\nThe patient’s medical history, apart from medication for mild hypertension, was unremarkable. His Body Mass Index was within normal limits. On examination, there was diminished sensation on the anterolateral and lateral aspects of his thigh. The straight leg raise test was found to be negative; the range of hip motion was normal and painless, while no neurovascular findings were observed in the lower extremities. Tinel’s sign (2 cm distal and 2 cm medial to the anterior superior iliac spice; [ASIS]) was highly positive even on light palpation. The patient received a local injection with betamethasone and hydrochloric Lidocaine 2% w/v on two occasions, leading to temporal relief. No further investigation was performed and a diagnosis was made on clinical grounds as “compression of the LFCN at the level of the inguinal ligament.”\nThe condition was explained to the patient and he consented to carry on with surgical decompression of the LFCN. The operation was performed under general anesthesia with a 5 cm horizontal skin incision, 2 cm medial, and 2 cm distal to the ASIS. The nerve was identified and explored proximally. A spherical lump of 1.1 cm in diameter was found under the fascia at the level of the inguinal ligament. It was related to and in continuation with a fascicule of the anterior branch of the LFCN. The lump was detached from the nerve and removed together with the corresponding fascicule (, ). The fascia was loosely closed to avoid nerve compression. The pathology report described the tumor as a schwannoma (neurilemmoma), which was mostly composed of cellular (Antoni A) areas, while also displaying plexiform architecture and occasional nuclear palisading (, , ).\nFollowing removal of this benign tumor, the symptoms resolved progressively over a 3 month period, leaving a small area of hypesthesia anterolaterally. |
A 40-year-old Chinese female, 150 cm, 52 kg, American Society of Anesthesiologists physical status Grade I, underwent an elective surgery for the left-hand wound debridement. Pre-operative evaluation, physical examination, laboratory results, chest X-ray and electrocardiogram were all unremarkable. Patient opted for general anaesthesia over regional technique. Airway assessment showed a mouth opening of 5 cm, Mallampati class II and a full range of neck movements. No premedication was given. Anaesthesia was induced with intravenous propofol and fentanyl. After the loss of jaw tone, LMA Supreme™ size 3, lubricated with a lidocaine gel was inserted in a single attempt with ease. The LMA cuff was inflated with 20 ml of air, and cuff pressure was measured and kept below 60 cmH2O. Adequate care was taken so as to prevent trapping of the tongue between bite block and teeth. The head was maintained in a neutral position on a jelly ring. The correct placement of LMA was confirmed by smooth insertion of the gastric tube. Anaesthesia was maintained on sevoflurane 3% with 50% oxygen and 50% air. The lungs were ventilated with a tidal volume of 6–7 ml/kg and peak airway pressures of <20 cmH2O using a fresh gas flow of 2 L in a circle breathing system. The patient was kept in the supine position, and there were no adverse events noted during either maintenance or emergence of anaesthesia. The total duration of the surgery was 148 min. The LMA was removed with cuff partially inflated with no visible blood on the cuff. In the recovery, the patient complained of a patch of numbness over the right side of the hard palate. On local examination, the mucosa did not reveal any swelling, redness or erosion. She was managed conservatively and reassured about the recovery. She was offered neurology referral for the second opinion but declined. On regular follow-up, she showed significant improvement, but there was still residual numbness 6 months later. |
A two-year-old boy with a left mirror foot was referred to our orthopaedic department. He was born full-term by natural delivery and was the firstborn of the couple. There was no family history of similar skeletal abnormalities and there was no history of drug or radiation exposure during gestation. The clinical and radiological assessment did not reveal any other skeletal abnormalities. The child had eight toes of a central ray pattern with a medial toe syndactyly (Figures , ) with fully developed metatarsal, proximal, middle, and distal phalanges, except for the fourth toe from the medial side which appeared to be missing a middle phalanx and had a dysplastic metatarsal. This digit was similar to a great toe (Figure ).\nSurgery was performed under general anaesthesia, and a tourniquet was applied. There was a medial toe syndactyly and the fourth toe from the medial side was abnormal; therefore, we decided to remove the second, third, and fourth toe from the medial side. Simultaneous dorsal and plantar V-shaped incisions were made in the centre of the foot, and the extra skin and three central rays were removed. The extra tendons and digital nerves were resected, and the nerve stumps were cauterised by diathermy in order to prevent a neuroma. The middle cuneiform was not removed to avoid tarsal instability. There were no tarsal bone duplications, and therefore no tarsal bones were removed. The removal of the second toe from the medial side meant an inevitable disruption of the Lisfranc ligament. Therefore, the remaining adjacent metatarsals were approximated using a percutaneous K-wire, inserted through the first metatarsal. Furthermore for the restoration of stability, the intermetatarsal ligaments were sutured. A plantar skin flap from the excised second medial toe was used for covering the lateral surface of the first medial big toe (Hallux). The skin was sutured with an interrupted rapid suture (Figures , ). A below-knee cast was applied which was removed at four weeks. At that point, the K-wire was also removed.\nThe patient was followed up two years postoperatively and examined both clinically and radiologically (Figures , ). There was a mild widening of the left foot; however, there was no clinical instability. We would consider the possibility of removing the middle cuneiform at a later stage, were complications to arise. At the time of evaluation, the result was overall satisfactory. The patient had a plantigrade foot and was able to walk with normal shoes, without a limp. Additionally, he could actively dorsiflex his foot and extend his great toe. Also, he could walk on tiptoes. |
A 35 years old (height, 159 cm; weight, 85 kg; gravida 3, para 1) pregnant woman with SAS presented to our hospital and was scheduled to undergo elective CS under epidural anesthesia at 36 weeks of gestation. An echocardiographic examination at 34 weeks of gestation revealed that the diameter of the beginning portion of the aorta (under the aortic valve) was narrowed by about 17 mm. The diameter of the ascending aorta was normal, the average pressure gradient was 40 mmHg, and the ejection fraction was 67%.\nIn the operation room, her baseline vital signs were as follows: heart rate (HR), 82 bpm with normal sinus rhythm; noninvasive blood pressure (BP), 130/76 mmHg; and oxygen saturation (SpO2), 96%. Supplemental oxygen was administrated by a face mask at the rate of 3 L/min. Traditional epidural puncture was performed at the L1–2 and L3–4 interspaces in the left lateral position, and a catheter was inserted to a depth of 4 cm into the epidural space at the cranial and caudal ends of the surgical field. The patient was then placed supine in a left-tilt position; 3 mL of 2% lidocaine was injected as a test dose, and another 7 mL was injected 5 min later through the cranial catheter. Additionally, 3 mL of 1.5% lidocaine was injected through the caudal catheter. At 20 min after the lidocaine injection, the sensory block had reached T6. The patient had no discomfort, and her hemodynamic parameters were stable. The operating bed was adjusted from the left-tilt to horizontal position, and the operation was allowed. Two minutes later, the patient reported chest distress and difficulty breathing (HR, 110 bpm; BP, 80/69 mmHg; SpO2, 96%), and 3 mg of intravenous ephedrine was promptly administered. The patient immediately lost consciousness with no response (HR and BP were depressed to 40 bpm and 53/15 mmHg, respectively). The lowest BP at the time was not measured because the noninvasive BP measurement interval was set to 1 min. The obstetricians sped up the surgery, and in another 2 min, a 2750-g male newborn was delivered with an Apgar score of 10 at both 1 and 5 min. Spontaneous circulation of the patient was returned immediately after delivery, and stable vital signs returned with no other treatment. The postoperative course was uneventful. The mother and neonate recovered uneventfully and were discharged 4 days later. |
A 65-year-old male was admitted to the trauma service after a mechanical fall down from five cement stairs. The result was multiple left sided rib fractures and a small lung contusion without loss of consciousness. He was admitted for oxygen therapy and pain control with a patient-controlled-anesthesia unit, along with thiamine and Librium [Valeant Pharmaceuticals, Bridgewater, NJ] once it was evident he had a history of significant alcohol abuse. The patient had no primary care physician so there was no documented past medical history; however, he did not report angina symptoms. Without signs of alcohol withdrawal, he was scheduled for discharge 36 hours after admission. The night before his expected discharge he became tachycardic, hypertensive (systolic to 200 mmHg from baseline of 120 mmHg), and lethargic and was treated by beta-blocker, clonidine patch, nil per os (NPO) and upgraded to the intensive care unit. He was subsequently intubated for lethargy and was started on propofol, fentanyl, and tube feeds. He was stabilized and remained an 11 t on the Glascow Coma Scale and after a successful weaning trial he was extubated less than 24 hours later after intubation.\nOnce extubated he quickly became tachycardic and hypertensive but responded appropriately. It was decided that he would be treated symptomatically with intravenous BZ even though they proved ineffective previously. Hours later, he underwent rapid sequence intubation after prolonged hypoxia, respiratory distress, and tachycardia. Secondary to his hemodynamic instability, a 2D cardiac echocardiogram was performed which showed a left ventricle ejection fraction of 35%. He went into an episode of ventricular tachycardia as troponin of 22 ng/ml resulted along with electrocardiogram changes diagnosing a non-ST segment myocardial infarction (). This was presumed to be because of the increased myocardial oxygen demand associated with a prolonged interval of inadequate DTs treatment. Interventional cardiology took the patient to the catheterization laboratory where angioplasty and drug-eluting stents were placed in his left anterior descending (LAD) and left circumflex artery (LCA) for severe calcification and stenosis. Effient [Eli Lilly and Co., Indianapolis, IN], aspirin, a beta-blocker, and statin were started postprocedurally.\n72 hours later, he was persistently oliguric and hypotensive and troponins were elevating (stable at 4 ng/ml then elevating to 32 ng/ml over 12 hours). A repeat electrocardiogram was performed showing an ST segment elevation myocardial infarction in the inferior leads (). He was taken back to the catheterization laboratory where his distal right coronary artery underwent angioplasty and stenting for 90% stenosis. He was then transferred to the coronary care unit and started on vasoactive medication to maintain an adequate cardiac output. The dye load encountered during his cardiac procedures combined with periods of a low-flow state resulted in acute tubular necrosis and acute kidney insufficiency; the family refused hemodialysis as the made him do-not-resuscitate (DNR).\nOnce the patient was stabilized, over the course of a week, his sedation was weaned. It became evident that the patient was not responsive and his pupils were uneven with successful weaning of all sedation/narcotics. A computed tomography of the head was performed showing bilateral cerebral hemispheric infarcts as well as a 20 mm midline shift and partial effacement of the fourth ventricle. Neurosurgery recommended nonoperative care and started the patient on mannitol for cerebral edema, labeling him with a dismal prognosis. He developed Staphlyococcus pneumonia and was started on antibiotics appropriately. Twenty days after admission the patient went into asystole and expired. He never recovered from his myocardial ischemia induced by the catecholamine surge caused by delirium tremens. |
A 63-year-old Caucasian male with a past history of supraventricular tachycardia and recurrent deep vein thrombosis, who had been non-compliant with his daily Rivaroxaban® 20 mg, presented with pleuritic chest pain and was found to have a right lower lobe pulmonary embolus. The patient was subsequently restarted on Rivaroxaban® and discharged. He presented again 5 days later with left arm weakness and was found to have multiple areas of punctuate infarctions of both cerebral and cerebellar hemispheres, more confluent within the right frontal lobe on magnetic resonance imaging (MRI) of the brain ( and ). He has been compliant with his Rivaroxaban® since the previous hospital discharge 5 days prior. The patient was admitted and subsequently started on unfractionated heparin. On admission, his vital signs were blood pressure 138/93, heart rate 65 beats per minute, respiratory rate 16, and oxygen saturation 97% on room air. Cardiopulmonary examination revealed regular rate and rhythm, without murmurs, rubs, or gallops and clear lungs on auscultation. Neurologic examination revealed intact cranial nerves, preserved strength in all extremities with an exception of mild dysmetria in the left upper extremity and an NIH score of 1. Electrocardiogram revealed normal sinus rhythm, non-specific ST changes, and a premature ventricular contraction. Transthoracic echocardiogram was notable for normal left ventricular function with mild tricuspid regurgitation and stage 1 diastolic dysfunction. Transesophageal echocardiogram was negative for intracardiac thrombus. The echocardiography with agitated saline contrast revealed microbubbles of moderate opacity entering the left atrium from the left lower pulmonary vein indicative of a grade 2 intra-pulmonary arteriovenous shunt (). There was no atrial septal defect or patent foramen ovale. Unfractionated heparin was continued, and the patient was transferred to a tertiary care center for embolization of the shunt. There, he developed recurrent cerebral infarctions while anticoagulation was temporarily held. Computed tomography of the abdomen and pelvis was done for persistent abdominal pain, and noted an omental mass, and subsequent exploratory laparotomy revealed an adenocarcinoma within the omentum with nodular peritoneal implants. The patient was placed on weight-based Enoxaparin® and discharged home with scheduled outpatient chemotherapy. Embolotherapy of the intrapulmonary shunt was deferred given this new diagnosis of malignancy. |
Our case is an 11-year-old Sudanese girl, residing in Qatar, who presented to the pediatric outpatient department with an 18-month history of progressive abdominal distention. The parents had been attributing the abdominal distention to weight gain, especially as the child remained otherwise asymptomatic. They had in fact been encouraging the girl to lose weight. The parents sought medical advice at a local health center, due to flu-like symptoms. The examination at the health center was impressive for signs of massive abdominal distention and she was admitted to our tertiary care hospital promptly for further investigations with a preliminary diagnosis of ascites. Apart from the progressive abdominal distention, there was no other contributory history suggestive of any underlying malignancy, liver disease, heart failure, or undiagnosed renal problems. The girl did not complain of any abdominal pain, constipation, urinary retention, or respiratory distress secondary to her abdominal distention. Our patient had achieved menarche 1 year ago with infrequent menstrual cycles; her first day of the last menstrual period was two weeks prior to her admission. There was no history of menorrhagia or dysmenorrhea.\nUpon examination, the child was noted to be in good general condition with normal vital signs for age and in no apparent pain or distress. Her weight was 64.5 kg, which was above the 95th centile for her age. Apart from the massive abdominal distention, she was thin built. Her general examination did not reveal any clubbing, pallor, icterus, peripheral edema, or lymphadenopathy. There were no stigmata of chronic liver disease. Abdominal examination revealed a huge uniformly distended abdomen (maximum diameter was 105 cm), extending from the pelvis to the xiphisternum with full flanks. There were no visible dilated veins on the abdomen. Palpation did not reveal any tenderness or masses; fluid thrill was positive. She had normal female genitalia. Her respiratory, cardiovascular, and nervous system examinations were unremarkable. A bedside urine dipstick did not reveal any proteinuria.\nAs the physical findings detected a fluid thrill, her preliminary investigations were directed towards finding a likely explanation for what seemed like a massive ascites. Her preliminary laboratory work-up which included a complete blood count, peripheral smear, serum electrolytes, renal and liver functions tests were within normal. As our patient did not show any signs of chronic liver or renal disease, there was a strong concern among the treating physicians that the presumed ascites could be secondary to an underlying abdominal malignancy. At this stage, the pediatric oncology team was consulted and tumor markers which included Ca125 (6 U/mL), CEA 0.7 microgram/L, alpha-fetoprotein (<1.7 IU/mL) and beta-hCG (<5 IU/L) along with Uric acid 297 micromol/L, and LDH (174 U/L) were ordered, all of which were within normal limits.\nAn urgent transabdominal ultrasonogram of the abdomen confirmed the suspicion of massive ascites (). The possibility of requiring a diagnostic paracentesis was discussed with the family once the MRI of the abdomen and pelvis reasonably ruled out any underlying malignancy.\nThe MRI of the abdomen and the pelvis () revealed that what was visualized as massive ascites by the sonographer was in fact a large homogenous well defined unilocular huge cystic abdominopelvic mass which measured 39 × 29 × 18 cm in dimension, occupying the entire abdomen and pelvis and bulging into the anterior abdominal wall. No solid component could be noted within the mass lesion. No loculation or septation was seen given the likelihood of serous cyst adenoma of the right ovary.\nA lower abdominal midline incision was made revealing the peritoneum. An elliptical incision is carefully made through the ovarian cortex to the cyst wall.\nWhen the cyst wall was reached, blunt and sharp dissection using surgical scissors was used to separate the cyst wall from the surface of the ovary. Intraoperative visualization did not reveal any abnormality of the left adnexal structures. The cyst was aspirated prior to its delivery and gave 13000 milliliters of fluid. The patient underwent right ovarian cystectomy with complete preservation of both ovaries and fallopian tubes. It weighed 13 kg and contained 13 liters of fluid. () Histopathological examination of the cyst revealed simple tubal-type epithelium confirming the diagnosis of a serous cystadenoma of the right ovary, consistent with the preoperative MRI diagnosis.\nOur patient did well after surgery and was discharged on the fourth postoperative day. Her discharge weight was 48 kg. Upon follow-up a week after her surgery she showed an excellent recovery and will continue to have regular follow-up in our outpatient clinic with an ultrasound examination every three months for early detection of any recurrence. |
A 58-year-old Caucasian male presented to the emergency department with complaints of constipation and abdominal distension. He had experienced nausea and decreased bowel movements for a week, which were not alleviated by stool softeners or enemas. There was no history of diarrhea, fever, chills, weight changes, night sweats, hematochezia, or melena. A colonoscopy 4 years prior had only revealed a small benign polyp. The patient otherwise had no significant past medical history and was not taking any medications. No history of abdominal surgeries or significant family history of cancer was elicited. He denied the use of alcohol or smoking, but admitted to using smokeless tobacco. Vital signs and physical exam were essentially unremarkable. The abdomen was not visibly distended and normal bowel sounds were present. No hepatosplenomegaly or lymphadenopathy was appreciated. Laboratory results showed normal complete blood count, coagulation parameters, electrolytes, liver function tests, pancreatic enzymes, and kidney function. Alpha fetoprotein (AFP) and carcinoembryonic antigen (CEA) were within normal limits. An abdominal computed tomography scan (CT scan) was concerning for a neoplasm causing small bowel obstruction, showing mid to distal small bowel dilatation with abnormal wall thickening and significant retained debris. The patient underwent a laparotomy and resection of a distal segment of ileum was performed.\nOn gross examination, a 39 cm portion of distal ileum was received and the central portion contained an 8 cm length saccular dilatation that had a hemorrhagic and nodular mucosa (Fig. and ). The bowel wall measured up to 0.9 cm in thickness and demonstrated underlying, ill-defined pale yellow tissue extending into the mesentery. On microscopic examination, an extensive transmural atypical nodular and diffuse lymphoid infiltrate was present and consisted predominantly of small B-lymphocytes, few plasma cells and focal areas of monocytoid B-cells (Fig. and ). This lymphoid infiltrate extended into the subserosal adipose tissue. The majority of nodules did not contain germinal centers; however, few scattered small germinal centers were noted. Overlying the atypical lymphoid infiltrate, villous structures of the intestinal epithelium was flattened and focally denuded with sparse epithelial crypts and few lymphoepithelial lesions. No foci of necrosis were identified. No areas suspicious for large cell or high grade transformation were identified. The uninvolved mucosa was unremarkable with normal villi and crypt architecture. The atypical lymphoid cells were positive for CD20 (Fig. ) and BCL-2, while negative for CD5 (Fig. ), CD10 (Fig. ), CD43, and cyclin D1 by immunohistochemistry. The CD138 positive plasma cells (Fig. ) were most numerous and clustered beneath the mucosal surface and were kappa-restricted by light chain in situ hybridization studies (Fig. and ). The residual dendritic meshwork within lymphoid nodules was identified by CD23 staining (Fig. ). The proliferation rate of the lesion was low, with a Ki-67 percentage of approximately 10 % (Fig. ). The overall morphologic and immunophenotypic features are consistent with a diagnosis of marginal zone lymphoma. Few prominent lymph nodes were identified in the mesentery (measuring up to 1.5 cm in greatest diameter). Microscopic examination showed partial effacement of these mesenteric lymph nodes with germinal center infiltration by BCL-2 positive B-cells, consistent with partial nodal involvement by marginal zone lymphoma.\nThe large ileal mass in the setting of small mesenteric and hilar lymph nodes was clinically consistent with a diagnosis of extranodal marginal zone lymphoma arising from the ileum. A complete staging evaluation including PET and CT imaging studies revealed additional small hypermetabolic mesenteric and bilateral hilar lymph nodes. No other lesions were noted in the stomach, thyroid, liver, pancreas or other organs. A staging bone marrow biopsy was negative for involvement by lymphoma, by morphologic and flow cytometric analysis. The patient was clinically staged as 3E (lymphadenopathy above and below the diaphragm). Treatment was initiated with single agent rituximab (monoclonal antibody against CD20) every other month, and is planned to continue for 2 years. After six months of treatment, the patient was asymptomatic and radiologic studies demonstrated significant decrease in size of the mesenteric lymph nodes. |
A 78-year-old woman presented with a 2-week history of progressive lower limb weakness and bilateral numbness from her hips to her toes. Her primary care physician referred her for physical therapy, which did not improve her strength. Her symptoms continued to worsen until she became bed bound and presented to the hospital 2 months after the initial onset of symptoms. Her past medical history included stage IIIC ovarian adenocarcinoma 17 months prior to presentation. At that time, her Ca 125 level was 1612 units/mL. She received 6 cycles of neoadjuvant chemotherapy with carboplatin and Taxol, followed by exploratory laparotomy, bilateral salpingoopherectomy, splenectomy (due to concerning lesions in the spleen), and 3 cycles of chemotherapy. Two subsequent abdominal computed tomography (CT) scans showed no evidence of recurrence and Ca 125 levels had decreased to normal.\nOn exam she had left lower extremity weakness; 2/5 in both hip and knee flexion and extension, 4/5 in dorsiflexion and plantar flexion. Right lower extremity strength was 0/5 in both hip and knee flexion and extension, and 3/5 in dorsiflexion and plantar flexion. Ca 125 levels were normal. Cerebrospinal fluid analysis indicated nonspecific inflammatory changes and no sign of infection. Spinal magnetic resonance imaging (MRI) showed an intramedullary lesion at T11-T12 (). Positron emission tomography CT revealed focally increased FDG avidity at T11-T12. A laminectomy and biopsy of the lesion were performed; pathology indicated metastatic ovarian cancer ().\nThe patient received high-dose corticosteroid therapy for 1 week after her presentation. She was discharged to a rehabilitation facility and underwent outpatient radiation therapy with 30 Gy in 10 fractions of 300 cGy each, from T7 to L1. She tolerated the treatment well and gained slight improvement in sensation and weakness, but was unable to ambulate. She received a subsequent 6 cycles of chemotherapy with Taxol and carboplatin. On completion of this chemotherapy, her weakness improved with motor strength in the left lower extremity 4/5, and in the right lower extremity 3/5 in all muscle groups. MRI of the thoracic spine 4 weeks after the last cycle showed widespread bony metastases but no spinal cord compression. An MRI of the cervical spine showed no enhancing lesions. A CT of the abdomen and pelvis was without masses in the pelvis. Ultimately, patient gained improvement in her lower extremity strength, but she did not regain full function. |
A 19-year-old male of Caucasian origin was admitted to our center as a polytrauma after a road traffic accident. He was previously fit and well, a nonsmoker with an alcohol intake of approximately 10 units per month. The accident, in which his motorcycle collided with an oncoming vehicle, caused him to sustain multiple significant injuries including unstable pelvic fractures and femoral fractures. He had bilateral pneumothoraces, extensive pulmonary contusion, and a splenic hemorrhage. He presented in extremis with signs of hypovolemic shock. He was intubated and resuscitated using local major hemorrhage protocols to achieve a blood pressure of 159/93, receiving ten units of packed red cells and four units of fresh frozen plasma in the emergency department.\nHe underwent an emergency laparotomy and splenectomy and was subsequently transferred to the intensive care unit, where he became increasingly hypoxic with features of adult respiratory distress syndrome (ARDS). This culminated in him receiving veno-venous extracorporeal membrane oxygenation (ECMO) from day 15 of his admission for 21 days. He returned to theater on day 21 for a massive haemothorax which required an emergency thoracotomy. After being decannulated from the ECMO circuit, he was stepped down to the general intensive care unit on day 36 and was transferred to the ward on day 55 before being discharged after a 4-month admission including a prolonged rehabilitation and recovery period.\nAfter presentation and commencement of ECMO, there was a relatively modest change in liver function tests. Alkaline phosphatase (ALP) increased from 55 to 143 IU/L between day 1 and day 6 of hospital admission and no persistent alanine transaminase (ALT) rise until after decannulation. Proceeding decannulation, there was a sequential increase in ALP peaking at 2335 IU/L on day 113. ALT rose to a lesser extent, peaking at 781 IU/L on day 52. The bilirubin did not rise above 57 μmol/L. The pattern of liver function tests is summarized in Figure . Autoantibody screen, immunoglobulins, and viral hepatitis serology were negative.\nSerial ultrasound, computerized tomography (CT), and magnetic resonance imaging excluded biliary stones and sludge. The liver on CT at day 1 showed normal liver and biliary structure (Figure ), and it was not until 10 months after the admission, the repeat magnetic resonance cholangiopancreatography (MRCP) demonstrated a multistenotic pattern of disease within the intrahepatic ducts (Figure ).\nIn the absence of significant casts within the biliary tree and no evidence to suggest biliary sepsis, endoscopic retrograde cholangiopancreatography (ERCP) was felt not to be helpful. A conservative management approach was taken, and the patient was instigated on ursodeoxycholic acid to help improve cholestasis. With bilirubin improving, the patient was closely monitored as an outpatient upon discharge for progressive liver disease and dysfunction. Repeat imaging and noninvasive fibrosis assessments were undertaken. Despite having evidence of SSC, the synthetic liver function has remained excellent, cholestasis markers have improved, and there have been no episodes of cholangitis or biliary sepsis for over 1 year. |
A 66-year-old woman presented at a hospital with chest pain. Her history included diabetes, hypertension, and hyperlipidemia. On examination, the patient had a pulse of 100 beats/minute and blood pressure of 150/80 mmHg. Her electrocardiogram, echocardiogram, and blood test results were normal. Multislice computed tomography (CT) showed a saccular LMCA aneurysm and significant stenosis in the LAD artery (Fig. ). Coronary angiography revealed a saccular LMCA aneurysm measuring 9.8 × 7.5 mm with 75% stenosis in the proximal portion of the LAD artery. The operation was performed under general anesthesia. A median sternotomy was performed, and after a longitudinal pericardial opening was made, the heart was inspected. The LITA was removed from the inner chest wall in a skeletonized fashion using electric cautery. A distal segment of 1.5–2 cm was procured and reserved for use as a patch repair. Before aortic cannulation, the ascending aorta was dissected from the pulmonary artery. Under cardiopulmonary bypass, coronary artery bypasses of the left internal thoracic artery to the LAD artery were constructed in the beating heart. After aortic cross-clamping, the LMCA saccular aneurysm was exposed without main pulmonary artery transection. The saccular LMCA aneurysm was carefully dissected and completely excised. There was no thrombus in the lumen. Then, the LITA was longitudinally divided and trimmed to fit the incised LMCA. The small internal thoracic artery patch was sutured to the normal and firm lateral coronary arterial wall with a continuous 7–0 Polypropylene suture. Resection of the saccular aneurysm and closure using a small internal thoracic artery patch was then complete. The aortic cross-clamp time was 120 min, and the CPB time was 147 min. The patient had an uneventful hospitalization and was discharged on aspirin therapy. Follow-up multislice CT 10 days after the operation revealed the complete disappearance of the aneurysm and a successful repair with no luminal stenosis by the internal thoracic artery patch. The LITA graft was also found to be patent (Fig. ). The patient has been followed up yearly since 2009. Fortunately, at the 9-year follow-up, the patient was still asymptomatic, and there were no changes in the ECG and UCG. The patient included in the follow-up had preserved preoperative left ventricular function, and there was no coronary incompetence. Pathology of the aneurysm revealed that the aneurysm wall was very thin due to a lack of trilaminar arterial structure from the remarkable atherosclerotic changes (Fig. ). |
A 62-year-old man, who had known T3, N4, M0, Stage IVa squamous cell carcinoma of the middle esophagus, presented with dysphagia and was admitted to our institute. Regional radiotherapy extending from the supraclavicular fossa to the pericardial area, including the entire mediastinum, was planned. A total dose of 50.4 Gy of radiation therapy was delivered and systemic chemotherapy consisting of low-dose cisplatin and 5FU was concurrently performed. Eight months after the initial treatment, right supraclavicular lymph node enlargement was seen on follow-up computed tomography (CT). Although 20 Gy of additional irradiation were given to the right supraclavicular fossa, the metastatic lymph node enlarged and invaded the surrounding soft tissue. Left common carotid artery was confirmed to be intact on contrast enhanced CT.\nInspection of the neck confirmed the presence of a large mass in the right supraclavicular region with carotid sheath invasion. Necrotic skin caused by the irradiation was also observed within the tumor. As a result, direct pulsation of the common carotid artery was visualized in the cutaneous pocket on gross examination (Fig. ).\nIt was determined that the patient’s condition was critical, and the decision was made to proceed with a percutaneous interventional approach (Fig. ). It was decided that a covered nitinol stent graft could be placed to prevent rupture of the right carotid artery.\nAfter obtaining written, informed consent from the patient, an 8-French (8-Fr) angiographic sheath was placed via the right femoral artery. Radiopaque markers were placed on the right neck surface as markers of the appropriate position planned for placing the stent by adhesive tape before the procedure. A 4-Fr headhunter catheter was then inserted into the right common carotid artery, and angiographic examination was performed.\nAn angiogram showed a pathologic condition located at the midpoint between the origin of the right common carotid artery and the carotid bifurcation. The radiopaque markers were placed on the neck surface to mark the appropriate position where it was planned to place the stent (Fig. ).\nA covered stent graft (Niti-S stent, Taewoong Medical, Seoul, Korea), with a body diameter of 10 mm and a length of 60 mm, was advanced along the stiff guide wire to the right carotid artery in a similar way reported by previous studies (Chang et al. ; Chaloupka et al. ).\nThe stent was deployed to fully cover the artery that the adjacent tumor had invaded and threatened to cause impending rupture, with reference to the body markers. The distal end of the stent was placed below the carotid bifurcation, and the proximal end was placed at the origin of the common carotid artery.\nA carotid artery angiogram showed the full expansion and accurate positioning of the stent after stent placement (Fig. ). The patient was asymptomatic and had no neurological problems related to the procedure. Antiplatelet was not administrated because of his poor general condition.\nAfter 2 months, cervical contrast-enhanced CT revealed that the blood flow through the carotid artery was intact (Fig. ). Despite subsequent palliative treatment, the patient died 7 months after stent placement due to a respiratory infection. Rupture of the carotid artery did not occur while the patient was alive. |
A 14 year old girl who presented with history of acute pain, swelling, inability to bear weight on the right knee following a dance practice. Clinically she had a hemarthrosis and restricted movement of the knee. Radiograph revealed a loose body in the lateral gutter and MRI/CT confirmed that it was an osteochondral fragment measuring around 20 x 8mm from weight bearing area of lateral condyle femur ( & ).\nConsidering the age of the patient, size of the fragment and weight bearing area, it was decided to do an open reduction and internal fixation with bioabsorbable implants[,].\nArthroscopy was done 9th day after injury and the large defect on the femoral lateral condyle identified. The loose fragment was found in the lateral gutter. According to both Guhl’s classification[] and Ewing and Voto classification [] this was a stage IV lesion. It measured 20 x 8mm and consisted of smooth articular cartilage and subchondral bone (). The cartilage was mildly frayed at the edges on one side but the surface looked smooth but pale. This was fixed back to the defect through mini arthrotomy. The raw area was curetted and prepared to accept the osteochondral fragment. A K-wire was used for temporary fixation of fragment. C-arm was not used as the lesion was visible through the arthrotomy incision. 1.5mm bioabsorbable pin and a 2mm bioabsorbable cortical screw were used to securely fix the fragment. The child was kept non weight bearing for 6 weeks.\nStatic Quadriceps exercises were started immediately post-surgery in cylinder cast. The cast was removed after 6 weeks and gentle active and passive knee mobilization was initiated. With this physiotherapy, full range of pain free movements was achieved by 10 weeks post-op. CT scan at the end of 9 months showed good alignment and fixation of the fragment () and the child resumed dancing by 12 months post-surgery. |
A 56-year-old healthy Caucasian Brazilian woman presented with a six-month history of sternal pain and a two month history of increase in volume of the region, without phlogistic signs, fever, or urinary symptoms.\nThe patient was in good condition and her physical examination was normal, except for a painful palpable mass in the sternal region, without phlogistic signs, occupying almost the entire body of the sternum. Her hemogram, urea, creatinine, liver function tests, and urinalysis were unchanged. Technetium-99 m methylene diphosphonate (MDP) bone scanning showed uptake in the sternal body (). She was treated with anti-inflammatory drugs, and instructed to return ten days later, for new assessment. She did not return for the follow-up.\nSubsequently, the patient noticed increased local volume and worsening pain, and she again sought medical care. Computed tomography (CT) of the chest showed a soft-tissue mass with heterogeneous contrast enhancement, occupying almost all of the sternal body and extending to the subcutaneous tissue, but with no evidence of lung lesions or lymphadenopathy (). Because of the possibility that the sternal mass was a metastasis, a search for a primary tumor was undertaken with mammography and abdominal ultrasonography. Sonography showed an exophytic left-sided renal mass measuring about 5 cm in diameter, locally distorting the pyelocaliceal system, without venous thrombus. The result suggested RCC. Likewise, an abdominal CT scan following administration of contrast medium revealed a heterogeneous and avidly enhancing mass in the same location, with hypodense central areas indicative of cystic degeneration or necrosis. The CT scan also revealed local distortion of the pyelocaliceal system, without evidence of venous thrombus or lymphadenopathy ().\nPreoperative percutaneous biopsy guided by CT scan of both the renal and sternal lesions showed histopathologic diagnosis of clear-cell renal carcinoma. The patient was planned for nephrectomy and radiotherapy of the sternal lesion for palliation of the pain and reduction of the tumor volume. The patient returned for follow-up assessment six months later, complaining of left upper limb paresy/paresthesia. The cervical spine MRI showed lesions compatible with metastasis. She died six months later, with generalized metastasis. |
A 77-year-old man presented to a gastroenterology outpatient clinic with epigastric pain, dyspepsia, and early satiety lasting 10 days after the consumption of persimmons. He had undergone medical treatment for ulcers in the large duodenal bulb 13 years earlier. His medical history was unremarkable, except that he had recently consumed digestive medicine, purchased from a pharmacy, for intermittent indigestion. He had no known comorbidities, had not undergone previous gastrointestinal operation, and had no family history related to these symptoms. A physical examination revealed mild tenderness in the epigastric area. His heart rate, blood pressure, and respiratory rate were all within the normal ranges.\nBefore visiting our clinic, the patient had undergone esophagogastroduodenoscopy (EGD) at another clinic, which revealed duodenal ulcers and many bezoars in the distended duodenal bulb. As he did not show any signs of intestinal obstruction, he was instructed to drink sufficient amounts of water and Coca-Cola before endoscopic examination. EGD was performed again to obtain an accurate diagnosis and initiate appropriate treatment, and it showed a small amount of undigested food materials in the stomach. The endoscope was passed through the pyloric ring, and it showed multiple bezoars and two ulcers in the dilated duodenal bulb (). There were approximately 30 bezoars, each measuring <4 cm in diameter. We managed to successfully extract the bezoars from the duodenal bulb by using a retrieval net (). When the endoscope was turned to view the pylorus in the lumen of the distended duodenal bulb, it looked like the cardia of the stomach (). Because of the distention of the duodenal bulb, the endoscope could not be passed into the distal part of the distended duodenum, which formed a loop (). We suspected that the distended duodenal bulb was a herniated stomach. After pulling the endoscope out of the pyloric ring, we identified the true cardia of the stomach, which was normal in shape. Subsequently, the bezoars were removed endoscopically without any complications. The patient was instructed to stop consuming foods that included high concentrations of soluble tannins and to use proton pump inhibitors for treating the duodenal ulcers.\nA week after the endoscopic removal of the bezoars, the patient visited our clinic again and reported that his epigastric pain had improved considerably. He underwent radiological examination to assess the improvement in the distended duodenal bulb. Computed tomography (CT) gastrography showed that the proximal duodenal portion was distended and a mass of food material was present in the lumen (). There was no abnormal wall thickening or luminal obstruction at the distal part of the duodenum. Upper gastrointestinal (UGI) contrast study showed a movable mass-like lesion in the severely distended proximal duodenal portion and gastroesophageal reflux. Passage disturbance or loss of peristalsis was not observed (). The patient did not experience epigastric pain after the bezoars were removed and after he stopped consuming persimmons, although the follow-up radiological examination showed that the duodenal bulb remained distended. Follow-up endoscopy was not performed because of patient refusal. The patient stopped consuming dried persimmons and continued receiving treatment with proton pump inhibitors and prokinetics. |
A 66-year-old woman with a significant past medical history of well-controlled hypertension was admitted with complaints of microscopic hematuria and mild proteinuria for the past 3 years. Serum creatinine level was within normal range at that time and therefore the anti-GBM antibody was not tested. The first renal biopsy revealed mesangial proliferative glomerulonephritis with fibro-cellular crescents in one out of 18 glomeruli, excluding one global sclerotic glomerulus (Fig. ), and deposition of IgA and C3 in mesangial areas by immunofluorescence microscopy (Fig. ). Weak but significant IgG deposition was also observed in glomeruli in the distribution somewhat different from IgA or C3 (Fig. ). The electron-dense deposits were observed in mesangial areas by electron microscopy. Therefore, the diagnosis was IgA nephropathy. Antihypertensive therapy was initiated, mainly with an RAS inhibitor. Eight months later, the patient’s serum creatinine suddenly rose to 4.53 mg/dL (it was 1.04 mg/dL from the routine blood test 1 month before). Urinalysis showed 100 red blood cells per high power field and urinary protein excretion of 12.3 g/gCr (Fig. ). The serological tests that were performed to differentiate the cause of rapidly progressive glomerulonephritis revealed the presence of anti-GBM antibody at the titer of 116 IU/mL and the absence of anti-nuclear antibody and anti-neutrophil cytoplasmic antibody. Laboratory findings on admission are summarized in the Table .\nAfter admission, treatments with hemodialysis, plasma exchange, and intravenous methylprednisolone pulse therapy followed by oral prednisolone at the dose of 50 mg/day were initiated. The second renal biopsy was performed at 4 weeks after admission in order to assess the probability of renal recovery and to make the final diagnosis. It revealed cellular to fibrocellular crescents in 18 of 25 glomeruli, excluding six global sclerotic glomeruli by light microscopy. By immunofluorescence study, linear IgG deposition along the glomerular capillary walls and mesangial staining for IgA were observed. On the other hand, C3 deposition was observed in the mesangium as well as in the glomerular capillary walls (Fig. ). Electron-dense deposits were observed in mesangial areas, similarly as in the first biopsy, by electron microscopy (Fig. ). Based on the aforementioned findings, the diagnosis of anti-GBM glomerulonephritis and IgA nephropathy was confirmed. Plasmapheresis was performed eight times, anti-GBM antibody gradually decreased, and alveolar hemorrhage was prevented. However, her renal function could not be restored and she underwent maintenance hemodialysis (Fig. ).\nAdditional immunosuppressant was not given because the patient did not show any sign of pulmonary involvement and because the renal recovery was quite unlikely from clinical (continuous oliguria and hemodialysis dependence) as well as histological (crescent formation in most of non-sclerotic glomeruli) point of view.\nClinical and histological presentations from IgA nephropathy (at the time of first renal biopsy) and from anti-GBM disease (at the time of second renal biopsy) were summarized in the Table . |
A 63-year-old woman with metastatic breast carcinoma presented to the ophthalmology clinic with diplopia in right gaze and head turn to the right. Medical history revealed that she was diagnosed with estrogen receptor (ER)-positive and progesterone receptor (PR)-positive invasive ductal carcinoma 1 year earlier with mediastinal lymph node and bone metastasis at the time of diagnosis. She was treated with zoledronic acid 4 mg monthly and paclitaxel 80 mg/m2 weekly for 12 weeks, followed by endocrine therapy with letrozole.\nOn ophthalmological examination, best corrected visual acuity was 20/25 in both eyes. Slit-lamp examination of the anterior segment and fundus was unremarkable other than bilateral posterior chamber intraocular lenses. On motility exam, abduction was totally limited in the right eye with globe retraction and narrowing of the palpebral fissure on attempted abduction (). Abnormal head position towards the right side was noted. Magnetic resonance imaging (MRI) revealed isolated enlargement of the right medial rectus muscle (). Clinical evaluation and laboratory studies were carried out for differential diagnosis. There were no clinical findings suggestive of thyroid eye disease and thyroid function tests were normal. Rheumatologic assessment for inflammatory and vasculitic diseases was not contributory. Biopsy of the right medial rectus muscle was performed to establish a definite diagnosis and initiate appropriate treatment.\nHematoxylin and eosin staining of the biopsy specimen revealed large, round to polygonal epithelioid tumor cells arranged in loosely cohesive clusters and sheets infiltrating fibrocollagenous tissue and muscle fibers (). Immunohistochemical analyses using streptavidin-biotin peroxidase complex method revealed panCytokeratin and cytokeratin 7 positivity (). ER, PR and human epidermal growth factor receptor 2 (HER2/neu) were negative (triple-negative). Based on the patient’s clinical history and the morphological and immunohistochemical features of the tumor, she was diagnosed with breast carcinoma metastasis to the right medial rectus muscle. Pathological examination demonstrating a triple-negative breast carcinoma indicated discordance with the primary tumor, which was ER- and PR-positive at the time of diagnosis.\nThe patient was referred to the radiation oncology department for external beam radiation therapy. The orbital mass was irradiated with 45 Gy in 15 fractions. Following radiotherapy, chemotherapy with docetaxel 100 mg/m2 once every 21 days was initiated. After 15 months of follow-up, abduction of the right eye has partially recovered; the patient is stable and continuing to receive palliative chemotherapy. |
A 47-year-old female presented with a mass in the abdomen associated with diffuse abdominal pain, altered bowel habits, and significant weight loss of five months duration. On clinical evaluation, it was a large abdominal mass arising from the pelvic region, not moving with respiration. There were no ascites. There was a family history of carcinoma rectum (the patient’s sister).\nContrast-enhanced computer tomography (CECT) of the abdomen reported ovarian mass (28 cm × 21 cm × 27 cm) with multiple polypoidal lesions within the bowel and omental deposits. Colonoscopy showed rectal ulcer with multiple polyps until the sigmoid colon, and the endoscope could not be negotiated further. Biopsy of the rectal ulcer was reported as adenocarcinoma. The multi-disciplinary tumor board discussed the case. We determined a working diagnosis of primary rectal malignancy in the background of FAP with bilateral ovarian neoplasm. Immunohistochemistry (IHC) on the rectal ulcer specimen showed positive CK 20 (4+), CDX2 (4+), and carcinoembryonic antigen (CEA) (4+), and negative CK 7 (0), confirming the mass was originating from the large bowel and not an ovarian mass eroding into the rectum. The plan was that if IHC of the rectal ulcer showed an ovarian origin, the patient was to be started on anterior chemotherapy. Given rectal malignancy with possible FAP and synchronous bilateral ovarian masses with omental metastasis, the patient was given the option of exploratory laparotomy with a total abdominal hysterectomy and bilateral salpingo-oophorectomy, on table colonoscopy, and total colectomy with omentectomy. After obtaining informed consent, exploratory laparotomy was carried out. Frozen sections of both ovarian mass and omental deposits were suggestive of mucinous neoplasm; however, further characterization was not possible on the frozen section. On table colonoscopy showed > 200 polyps in the transverse and descending colon. Total proctocolectomy with end ileostomy was done. Ileal pouch-anal anastomosis was not done in view of the patient’s poor nutrition status.\nThe final histopathology report showed right and left ovarian lesions reported as mucinous ovarian neoplasm; colon showing adenocarcinoma in the rectum and sigmoid and multiple tubular adenomas (> 200) with omentum showing metastatic mucinous adenocarcinoma and uterus showing endometrioid carcinoma. She was started on adjuvant chemotherapy. A modified FOLFOX regimen with 750 mg 5-fluorouracil on days one, two, and three with 90 mg oxaliplatin at three weekly intervals was instituted. She underwent six cycles of chemotherapy. She was doing well at six months post-surgery. Evaluation showed increased CEA level. Repeat CECT abdomen showed metastatic deposits over the small bowel. She was advised a folinic acid, fluorouracil, and irinotecan regimen but was lost to follow-up after six months. She also had an incisional hernia. The ileostomy was functioning well, and she enjoyed a good quality of life.\nIn view of FAP on the colectomy specimen, she was advised mutation analysis for APC gene and polymerase chain reaction for microsatellite instability, IHC for mismatch repair gene, and screening of family members to rule out FAP or Lynch syndrome, and regular surveillance endoscopy. |
A 73-year-old man was evaluated at the neurosurgical outpatient clinic with an 18-month history of intermittent back pain and progressive gait disturbance due to diminished strength in both legs. Seven years before, the patient had similar neurogenic claudication as main symptom and a lumbar CT scan was done solely, which showed stenosis at the L4-L5 level as the key feature. He underwent lumbar decompressive laminectomy in another institution, with transient improvement at that time.\nDuring the following months, the symptoms slowly progressed and the patient became unable to walk without assistance. He also developed urinary sphincter disturbance with incontinence episodes. The neurological examination showed a bilateral lower extremity motor weakness with a motor strength grade 3/5 bilateral in hip flexion and extension, and a Grade 4/5 bilateral in knee extension, ankle dorsiflexion, knee flexion, great toe extension, and ankle plantar flexion. The patient also had hypoesthesia from L4 dermatome downward bilaterally, abnormally increased patellar and ankle reflexes bilaterally, and extensor plantar reflexes.\nA lumbar MRI was performed, demonstrating prominent vascular voids near conus medullaris but no significant high T2 signal involving the spinal cord [ and ]. Further evaluation was undertaken with CT angiogram and digital subtraction angiography (DSA). These examinations identified a FTAVF which was fed by the filum terminale artery that arose from the ASA and were supplied by the left D10 segmental artery [ and ]. The patient also had an electromyographic study done that reveals chronic neurogenic changes of L3, L4, L5, and S1 bilaterally.\nTherapeutic options were discussed with the patient, who decided to undergo surgery. Reopening and extension of the previous laminectomy down to S1 was performed, to expose the fistula. After durotomy, the direct connection between the artery of the filum terminale and the arterialized vein was evident, forming the arteriovenous fistula (AVF) at the level of L5-S1 []. With the aid of intraoperative neurophysiological monitoring, we confirm the filum terminale due to the absence of sensory-motor potentials on it [ and ]. An intraoperative angiography with indocyanine green (ICG) was performed to identify the exact shunt location []. After confirmation of the AVF, a clip was placed interrupting the fistulous path, followed by the observation that the draining vein was no longer arterialized []. This interruption was confirmed with the ICG video angiography [].\nSurgery and immediate postoperative period were uneventful. Over the following weeks, both sensory and motor deficits, progressively improved. Ten days after surgery, the patient recovered the voluntary control of the urinary sphincter and the urinary catheter was removed. He underwent physiotherapy and was able to walk unassisted 6 months after surgery. |
A 33-year-old previously healthy woman weighing 70 kg was brought to the emergency department (ED) by Emergency Medical Services (EMS) in cardiac arrest. The patient was undergoing liposuction of her thighs in a physician’s clinic with no intraoperative complications a few minutes before the event. The surgeon reported harvesting 1.5 L of fat from the patient’s thigh and mid-back during the procedure, which lasted 45 minutes.\nA few minutes following the procedure, the surgeon noticed that the patient was becoming more somnolent. Her vital signs were stable, including a blood pressure of 170/90 mmHg. The doctor suspected a possible clinical manifestation of hypoglycemia and subsequently administered oral dextrose solution without any improvement.\nTwo hours after the procedure, the patient started feeling dizzy with a rapid decline of her mental status leading to tonic-clonic seizure followed by a complete loss of consciousness. EMS arrived on the scene after five to 10 minutes. EMS personnel reported the patient was gasping, cyanotic, and drooling. During transport to the ED, she had a cardiopulmonary arrest, so the EMS team immediately initiated resuscitation using Basic Life Support guidelines.\nUpon arrival to the ED, the cardiac monitor showed asystole, so the patient was intubated and resuscitation resumed using the advanced cardiac life support algorithm. Return of spontaneous circulation was achieved after 12 minutes of resuscitation in the ED (22 minutes post-arrest).\nThe plastic surgeon who performed the procedure was asked for details about the procedure technique and the anesthesia modality. He reported using the power-assisted liposuction technique in his private clinic. As for anesthesia, he reported the use of five vials of 50 mL lidocaine 2% (20 mg/mL) subcutaneously during the operation; making the total dose of lidocaine equal to 5000 mg. He also pointed to prior use of the same procedure and anesthesia three months earlier while performing an uncomplicated abdominal liposuction on the same patient.\nFollowing the return of spontaneous circulation, electrocardiogram showed normal sinus rhythm, no QT prolongation with a corrected QT interval (QTc) of 466 ms and a normal QRS interval of
100 ms with no ST- or T-wave abnormalities [].\nNeurological examination revealed no response to verbal or painful stimuli (Glasgow Coma Scale of 3T), pupils equal in size bilaterally and reactive to light, preserved corneal and oculocephalic reflexes, and a downward Babinski reflex bilaterally.\nArterial blood gas analysis on mechanical ventilation on 100% fraction of inspired oxygen (FiO2) showed a pH of 7.34, a CO2 pressure of 39.9 mmHg, an O2 pressure of 131 mmHg, and a bicarbonate concentration of 20.8 mmol/L.\nLaboratory workup included a complete blood count, and measurement of serum electrolytes, lactate, cardiac and liver enzyme levels. The results were the following: white blood cell count 9.8 × 109/L with 41% polymorphonuclear cells; a hemoglobin level 10.4 g/dL; platelet count 336 × 106/L; troponin 0.003 ng/mL; sodium concentration 144 mmol/L; potassium 3.5 mmol/L; chloride 99 mmol/L; bicarbonate 16 mmol/L; glucose 346 mg/dL; blood urea nitrogen 13 mg/dL; creatinine 1.0 mg/dL; aspartate aminotransferase 225 IU/L; alanine aminotransferase 238 IU/L; γ-glutamyl transpeptidase 12 IU/L; alkaline phosphatase 55 IU/L; and lactate 17.55 mmol/L. Her serum lidocaine level upon presentation to the ED was 5.30 µg/mL (therapeutic range = 1.50–5.00 µg/mL).\nImaging included a computerized tomography (CT) scan of the brain without contrast material as well as CT angiography of the chest to rule out intracranial bleed and massive pulmonary embolism, respectively, which could be a reason for the patient’s arrest. Positive findings included bilateral consolidations consistent with aspiration pneumonitis without any signs of intracranial bleeding, pulmonary embolism, or aortic dissection. The patient was started on antibiotic therapy.\nThe patient developed generalized myoclonic jerks that were attributed to possible anoxic brain injury following her cardiac arrest so she was started on valproic acid.\nThe patient was admitted to the intensive care unit. Magnetic resonance imaging of the brain was done three days later and showed signs of severe hypoxic-ischemic brain injury, which was confirmed by electroencephalogram (EEG) (electrocerebral silence on EEG).\nThe patient’s hospital stay was complicated by an increase in brain edema and pressure, electrolytes disturbances, multiple nosocomial infections with end-organ damage leading to the patient’s death secondary to septic shock two months later. |
A 28-year-old man presented at a traumatic surgery unit in an outlying hospital, where an external rotation of the left leg and a patellar dislocation were detected. Examination also revealed clinical signs of a neurofibromatosis-1 (Figure ). The patient had stumbled doing his work as a cook and had fallen on his flexed left knee. Conventional radiography of the knee demonstrated an osteochondral flake near the medial patellar margin, whereas the femoral fracture remained unnoticed (Figure ). After reposition of the patellar dislocation, the joint was stabilized with an orthosis, and the patient was sent home.\nTwo days later, because of increasing pain and swelling of the left knee, his family doctor arranged further radiographic examinations with MRI and CT scans, revealing the Hoffa fracture. The patient was then referred to a medical center for traumatic surgery. Surgical treatment consisted of diagnostic arthroscopy, open reduction of the fracture, and internal fixation with three 40-mm headless compression screws (Figure ). The screws were placed in posterior to anterior and caudal to cranial directions. The anterior horn of the lateral meniscus was fixed to the joint capsule using FiberWire 2-0, and the ruptured retinaculum was fixed to the medial patellar margin with two Mitek anchors. A 3 × 3 cm tumor close to the articular capsule turned out to be a lipoma and not, as initially suspected, a neurofibroma.\nAfter surgery, the knee was stabilized with a knee orthosis, and partial weight-bearing was prescribed for 10 weeks. Fracture healing was regular. In <4 months after the accident, the patient returned to work without any orthopaedic therapeutic appliances. In this case, the occurrence of a femoral fracture after a low-velocity trauma was probably influenced by reduced bone quality because of an underlying NF1, but NF1 did not influence fracture healing. Two years after the operation, the range of motion of both knees was unlimited, and no osteoarthrotic changes were noticed. |
A 35-year-old male with a history of hyperlipidemia and seizure disorder presented to an outside hospital following a breakthrough seizure, where he was incidentally also found to have punctate areas of acute cerebral infarcts in multiple vascular territories. Additional workup revealed the presence of a left atrial thrombus and newly diagnosed atrial fibrillation. He was ultimately discharged to home on apixaban. The patient then re-presented a month later for evaluation of transient diplopia, expressive aphasia, daily right temporal headaches, and right facial and left leg weakness. MRI of the brain showed new areas of diffusion restriction in the left cerebellar hemisphere and left medial occipital lobe (Figure ). CTA showed no signs of carotid occlusion or stenosis. The etiology of his multifocal strokes was thought to be related to his newly diagnosed atrial fibrillation and left atrial thrombus.\nThe patient was then transferred to our hospital for further evaluation. His initial NIH stroke scale was 8 (primary deficits were including unilateral facial palsy, bilateral lower extremity pronator drift and ataxia). Stroke labs, including lipid panel and hemoglobin A1C, were unremarkable. MRI of the brain with contrast showed a new infarct in the splenium of the corpus callosum in addition to prominent generalized meningeal enhancement (Figure ). MRI of the spine with contrast showed possible meningeal enhancement as well as punctate areas of encephalomalacia in the C3-4, C7, and T3 spinal levels. A bedside LP revealed a mildly elevated opening pressure of 24 cm H20, lymphocytic pleocytosis (WBC 150 K/cumm, 61% lymphocytes), protein 170 mg/dl, hypoglycorrhachia of 15 mg/dl, and presence of cryptococcal antigen. Other notable CSF labs included the presence of 11 oligoclonal bands. He was diagnosed with cryptococcal meningoencephalitis and started on a four-week course of amphotericin B and flucytosine. A repeat LP after several days of treatment showed a normal opening pressure of 14 cm H20, mildly improved pleocytosis (WBC 130 K/cumm, 84% lymphocytes), protein 172 mg/dl, and glucose 14 mg/dl. He did not require any additional lumbar punctures, and his symptoms (including headaches and left lower extremity weakness) gradually improved. The patient was discharged to an inpatient rehabilitation facility prior to returning home.\nThough our patient in Case 1 had a history of an unknown autoimmune disease, our patient in Case 2 had no history of autoimmune disease or other existing immunodeficiency. Both patients developed multiple cerebral infarcts in multiple vascular territories in the setting of cryptococcal meningoencephalitis, though our patient in Case 2 also had recently diagnosed with atrial fibrillation which further confounds the underlying etiology of his strokes. |
A 54-year-old male patient with a height of 170 cm and weight of 77 kg visited a private hospital due to a headache and weakness in left muscle that started the day before his hospital visit. During the examination, the patient showed decreased consciousness, and internal hemorrhaging in the cerebral ventricle was observed in the CT scan, hence he was transferred to our hospital. When he arrived at the emergency room, the patient was semi-conscious and had difficulty in breathing, and his Glassgow coma scale (GCS) showed severe head trauma with a total score of 8 or lower. The head CT scan revealed worsened stage of hemorrhage in the cerebral ventricle, so he was immediately intubated and transferred to the ICU.\nA day after entering the ICU, the hemorrhaging in the patient was still worsened according to the CT scan and he was in a semi-comatose state; therefore, an extra ventricular drainage (EVD) was done to decrease the pressure in the brain and hematoma aspiration was also carried out. In addition, an emergency tracheostomy was done at the same time since long term mechanical ventilation was expected. There were no premedications given to the patient. Preoperative vitals were a blood pressure of 150/80 mmHg, a heart rate of 100/min, a respiration rate of 24/min, a body temperature of 38℃, and a SpO2 of 97%. After administering 0.2 mg of glycopyrrolate, anesthesia was induced with 125 mg of thiopental sodium. After complete loss of consciousness, muscle relaxation was achieved with 8 mg of vecuronium. Alfentanil at a concentration of 1.0 mg was administered to minimize hemodynamic changes when replacing the tube and at the same time anesthesia was maintained with O2 supply of 1 L/min, air supply of 2 L/min, and 2.0 vol% of sevoflurane. Considering the difficulty in maintaining airway characteristics in head surgery, the previously intubated polyvinylchloride (PVC) plain tube was replaced with a reinforced tube. The patient's vitals immediately after intubation were blood pressure of 130/70 mmHg, a heart rate of 95/min, and a SpO2 of 98%. Starting from the EVD, the operation proceeded smoothly and the tracheostomy was done in 2 hours and 30 minutes. Ten minutes after starting the tracheostomy, the FiO2 increased to 1.0. While adjusting for bleeding around the tracheal cartilage with monopolar coagulation before inserting the tracheostomy tube, a fire of about 15 cm in size suddenly started perpendicular to the direction of the trachea. The supply of sevoflurane and 100% O2 was immediately stopped after the initiation of fire and manual ventilation was done at a FiO2 of 0.2. Normal saline was used to extinguish the fire and soon the condition was brought under control. The endotracheal tube (reinforced tube) was taken out, tracheostomy tube was intubated to maintain manual ventilation, and SpO2 was again increased to 98%. Vitals before and after the tracheostomy were stable except for the temporary decrease in SpO2. The condition of the tube after extubation was as follows: the part directly above the cuff had holes due to melting from the heat; the coil inside the tube had melted, and there was overall charring (). The operation was completed without occurrence of any further incident, and since the patient was still in a semi-coma state, he was transferred to the ICU while maintaining bag ventilation through the tracheostomy tube. In the ABGA conducted directly after being transferred to the ICU, the pH was 7.406; the pCO2 was 33.6 mmHg; the pO2 was 121 mmHg; the HCO3 was 20.7 mmHg, and oxygen saturation was 97.8%. There were no observable changes in the chest x-rays both, before and after the operation () and no irregularities were observed in the bronchial endoscopy. The patient showed no improvement in consciousness during continuous mechanical ventilation; therefore, 5 days after the surgery, the patient was transferred to another hospital as per the wishes of the guardian. There were no irregularities in the chest x-ray images and clinical symptoms after being monitored for 4 months post-surgery (). |
A 67-year-old female with a medical history of congenital dislocation of the hip, which required six surgeries, suffered from an asymptomatic large aneurysm of the left paraclinoid ICA, with agenesis of the right ICA [ and ] and asymptomatic dilatation of ventricles. To prevent aneurysm rupture, endovascular coil embolization was performed. However, cerebral angiography performed 2 years after endovascular coiling showed coil compaction and persistent filling into the aneurysm [], and the patient underwent placement of a PED []. The distal end of the stent was positioned just proximal to the posterior communicating artery (PCoA). Cerebral angiography performed 1 year after insertion of the PED demonstrated reduced filling into the aneurysm, but not complete occlusion. Unfortunately, she suffered from severe osteoarthritis of the knee and her symptoms, persistent pain, and gait disturbance, rapidly worsened. She needed to undergo orthopedic surgery, but her treatment was complicated and was required to stop antiplatelet therapy. Time-of-flight magnetic resonance angiography and cerebral angiography performed 2 years after insertion of the PED revealed increased filling into the aneurysm [ and ], and we believed that it would be difficult to cease antiplatelet therapy under these conditions. The patient strongly desired to proceed with orthopedic surgery promptly, and we decided to perform ICA trapping with EC-IC high-flow bypass to withdraw antiplatelet therapy.\nIn the operation, the superficial temporal artery (STA) and radial artery (RA) were prepared. The cervical neck was exposed, and the common carotid artery, ICA, and external carotid artery (ECA) were preserved. The Sylvian fissure was opened widely, and the middle cerebral artery (MCA) was exposed. STA-MCA (M4) bypass was performed to ensure cerebral blood flow during occlusion of the MCA (M2), and subsequently, an ECA-RA-MCA (M2) bypass was performed. The PED was clearly confirmed using indocyanine green (ICG) angiography [ and ], and ICA trapping was completed from the cervical ICA to the proximal portion of the PCoA []. Final ICG angiography revealed that PCoA flow through EC-IC high-flow bypass was preserved and complete occlusion of the aneurysm was achieved [].\nA postoperative magnetic resonance imaging and angiography showed bypass patency without ischemic change [ and ]. During the postoperative course, she experienced mild worsening of her gait due to inactivity. She was transferred to a rehabilitation hospital 1 month after the surgery and discharged home after 2 months of rehabilitation. Antiplatelet therapy was completed 3 months after the surgery, and she underwent orthopedic surgery. |
A 51-year-old Bedouin Arabic man with a dominant right hand noticed a small nodule on the proximal dorsal side of his right forearm that had persisted for 18 months. He had not sought any medical advice. He is a known smoker and works as a security guard, has no prior history of alcohol consumption or radiation exposure, was previously diagnosed with depression and receiving oral risperidone 4 mg, and has a positive family history of ocular and breast cancer. When first noticed, the painless nodule was 1.0 × 1.0 cm, but it started to grow slowly over the course of 18 months. It was excised at an outside facility when it reached roughly 4.0 × 4.0 cm because it was thought to be a benign mass. It was removed in pieces using a transverse incision, and pathological examination showed a spindle-cell tumor with features suggestive of MPNST. The patient presented to King Hussein Cancer Center 4 months after the initial excision with an oval-shaped, large, exophytic, fungating, hemorrhagic, firm, and painful mass measuring 10.0 × 15.0 cm at the same site of the previously excised nodule (Fig. ). At presentation, his vital signs were unremarkable, with a temperature of 36.6 °C, pulse rate of 72 beats/minute, respiratory rate of 18 breaths/minute, blood pressure of 114/76 mmHg, oxygen saturation of 96%, and a pain score of 7/10. His physical checkup revealed power of 3+/5 in his fingers and wrist extension, an intact sensation at the dorsum of the hand with intact median and ulnar nerve function, full range of motion in the elbow and shoulder joints with an intact vascular examination, and no evidence of local lymph node enlargement. Magnetic resonance imaging (MRI) demonstrated a predominantly subcutaneous soft tissue mass at the proximal ulnar aspect of the right forearm with evidence of surrounding muscular fascial involvement and irregularity of the overlying skin, albeit without invasion of the surrounding bony structures (Fig. a–c). The mass measured 8.0 × 3.3 cm in the axial dimension and 9.8 cm in the craniocaudal dimension. Whole-body positron emission tomography/computed tomography scan showed multiple, bilateral, variably sized pulmonary nodules consistent with pulmonary metastasis, the largest of which measured 1.6 × 1.4 cm in transaxial dimension adjacent to the right oblique fissure (Fig. ). The result of a bone scan was negative. A multidisciplinary committee discussed with the patient and his family the treatment plan, stating that his cancer was in stage IV according to the American Joint Committee on Cancer guidelines [], including starting with chemotherapy followed by surgical excision, but he opted to proceed with the excision first because he could not tolerate the foul smell and severe pain and was concerned that he might develop an infection if he was left untreated. Also, it was discussed that pulmonary metastasectomy was impossible to achieve while maintaining functional lung capacity. On admission, the patient had a hemoglobin level of 13.7 g/dl, white blood cell count of 10.2 × 103/μl, platelet count of 234 × 103/μl, albumin of 4 g/dl, creatinine of 0.7 mg/dl, and normal values for the rest of the liver and kidney function tests.\nWith the aid of a bloodless field using a tourniquet without exsanguination, we outlined a wide local excision about 3 cm away from the tumor. An elliptical incision was made while carefully inspecting the soft tissue mass to avoid any iatrogenic dissection through the tumor. Multiple frozen sections were sent during the operation from the deep proximal and deep distal ends, and the result was negative for malignancy. The mass was taken en bloc with a safety margin from the extensor digitorum communis muscle (EDCM) (Fig. ). An approximation of the muscles was done to cover the exposed tendon, as well as undermining and approximation of skin (Fig. ). This was followed by vacuum pressure dressing and physiotherapy. After 10 days, the pathology report was issued with the final diagnosis of grade 3 MPNST with heterologous bony elements and negative resection margins (Fig. ). The patient was then staged for another procedure for both flexor carpi radialis tendon transfer to extensor digitorum communis tendon and soft tissue defect coverage with a split-thickness skin graft harvested from the ipsilateral thigh. The patient was splinted for 1 month, and he was seen every 2 weeks to check for the skin graft until it was completely healed (Fig. ). Two months after the procedure, and on a biweekly basis, physiotherapy and occupational therapy were resumed after the removal of the splint. The patient regained his full range of elbow motion as well as most of his finger extension.\nThe patient was then started on palliative intravenous chemotherapy (two cycles of 3600 mg ifosfamide and 200 mg etoposide daily for 5 consecutive days in each cycle) and radiotherapy to his lung metastasis (50 Gy/eight fractions), which all failed because of disease progression. The patient was planned for single-agent doxorubicin, but he developed respiratory failure type 2 and elected a “do not resuscitate” status, so he was referred for palliative care. The patient died at home 7 months after the operation, and an autopsy was not done, because it is only indicated in cases of homicide or upon family request in Jordan. |
The patient was a 69-year-old woman of Han nationality. She was admitted to the Hospital with coughing that had lasted for two months which had been aggravated by fever for three days. She had a previous history of right breast cancer resection 16 years ago, with no history of smoking. She had a history of modified radical thyroidectomy for left thyroid cancer with partial thyroidectomy for right thyroid lobe for five years, and continuous oral administration of Euthyrox. Choledochectomy, pancreatectomy, and subtotal gastrectomy had previously been performed 15 months ago. Postoperative pathology examination showed moderately differentiated adenocarcinoma in the lower segment of the common bile duct and the ampulla of the duodenum (Fig ). Immunohistochemistry analysis showed CK19 (+) and Villin (+) (Fig ). No cancer was discovered at the cutting edge of the stomach, duodenum, common bile duct, and the pancreas. Metastasis was found in the lymph nodes around the pancreas (1/2), but not in the lymph nodes at the side of the greater curvature (0/8). A lymph node with a size of 1.0 × 1.0 cm was detected above the left clavicle, which was tough in texture, with good mobility, and without tenderness. Chest and abdomen computed tomography (CT) scans showed multiple striped, patchy, nodular, and ground-glass high-density shadows in bilateral lungs with fuzzy edges and burr in some of the nodules; obvious enhancement was observed in some of the nodules and there were multiple cavity shadows in bilateral lungs (Fig ), whereas no enlarged lymph nodes were visible in the mediastinum (Fig ). The structure of the pancreatic head was disordered. The dilated pancreatic duct revealed changes after partial gastrectomy, absence of the gallbladder, and multiple enlarged lymph nodes in the small curved side of the stomach and retroperitoneum (Fig ). Transbronchoscopic lung biopsy (TBLB) of the lateral basal segment of the inferior lobe of the right lung and biopsy of the left supraclavicular lymph node were then performed. Pathological evaluation showed (lymph node) metastatic adenocarcinoma, which was considered to have originated from the digestive tract. Immunohistochemistry showed CK7 (+), CK19 (+), Villin (+), TIF-1 (−), and Napsin A (−) (Fig ); (right lung): metastatic adenocarcinoma, originated from the digestive tract, not excluding the bile duct (Fig ); immunohistochemistry: TIF-1 (−), Napsin A (−), CK19 (+), Villin (+). The final diagnosis was cholangiocarcinoma with bilateral lung metastasis, and lymph node metastasis. Unfortunately, the patient did not continue with treatment and died one month after discharge. |
A 40-year-old female patient presented with a 1 year history of developing multiple, itchy, pigmented lesions over both lower legs which gradually spread to involve the face, trunk and extremities over a period of 5 months. There was no history of remission of lesions during the past 1 year. She gave a history of exacerbation of lesions since the past 5 days with development of blisters on the existing lesions on the lower limbs and back. There was also a history of a fleshy lesion on her left buttock, which developed on a hyperpigmented plaque and was insidiously increasing in size since the past 3 months. No drugs were taken orally prior to the development of the eruption but there is a history of application of ayurvedic medicine. No similar illness was present in any of the family members. The patient was a known diabetic on irregular treatment. Cutaneous examination revealed erythroderma with hyperpigmented, violaceous, scaly, discrete and confluent plaques over extremities, trunk and back with relating sparing of the flexural areas []. There was also erythema and diffuse violaceous pigmentation of the face. A few tense bullae were seen on the extremities. A few of them had turbid fluid. Nicolski sign and bullae spread sign were negative. These bullae were present only on the existing violaceous lesions and not on the normal skin. An erythematous fleshy plaque measuring 5 × 4 was seen on the upper aspect of the left buttock []. It was not ulcerated or crusted and was non-tender on palpation. The palms and soles also had violaceous scaly plaques. The oral mucosa had diffuse pigmentation of inner aspect of both cheeks but had no whitish plaques. The genital mucosae, nails and hair were normal. Generalized non-tender lymphadenopathy was present. Systemic examination revealed no other abnormality. Routine blood and urine analysis revealed uncontrolled diabetes. A clinical differential diagnosis of erythroderma secondary to lichen planus, lichen planus pemphigoides or allergic contact dermatitis was considered.\nA skin biopsy from a plaque on the right forearm showed eczematous changes and was inconclusive. A skin biopsy of a bulla along with adjacent perilesional skin showed sub-epidermal bulla filled with a mixed inflammatory infiltrate. The adjacent epidermis showed parakeratosis, irregular acanthosis, and basal vacuolar degeneration with other features of lichen planus []. A differential diagnosis of bullous lichen planus and lichen planus pemphigoides was considered. Direct immunofluorescence revealed no immunoreactants along the basement membrane zone. Hence, a diagnosis of erythrodermic lichen planus with bullous lichen planus was made. A biopsy of the fleshy lesion of the left buttock revealed a moderately differentiated squamous cell carcinoma []. FNAC of adjacent lymph nodes ruled out malignant changes.\nThe patient could not be treated with corticosteroids due to her high blood sugar levels. She was treated with dapsone 100 mg, azathioprine 50 mg, antihistamines and topical steroids. The patient was started on insulin injections for diabetic control. She showed improvement of skin lesions on a 3-week follow up. A wide excision was advised for the squamous cell carcinoma, but the patient was unwilling for the procedure and was discharged against medical advice. She was then lost to follow up. |
A 43-year-old woman reported to our clinic with secondary infertility, a poor ovarian reserve and a bad obstetric history (BOH). Prior to visiting us, she had undergone four cycles of intrauterine insemination and four cycles of IVF (2 with self-eggs in Nigeria and 2 cycles of IVF with donor eggs in India) that had failed.\nShe was married for 16 years and had a normal menstrual cycle (4 days/26–27 days). Obstetric history revealed one full term birth and two early abortions with no living child. In 2002, the patient delivered a full term male baby after spontaneous conception. The baby expired at the age of one due to gastroenteritis. There was no history of pregnancy-induced hypertension, gestational diabetes or any other complication during that pregnancy.\nIn 2003 and 2013, she had missed abortions at 45 days after spontaneous conception. The last conception was after the first failed IVF-OD attempt. She had been investigated for BOH, and all investigations were normal. There was no evidence of congenital or acquired thrombophilia. The patient did not have any history of thrombosis, she was a nonsmoker. There was no family history of VT.\nShe had undergone laparotomy for an appendectomy in 1990 in Nigeria. In 1996, she had a diagnostic laparoscopy followed by diagnostic hysteroscopy done twice in 2009 and 2010 (all in Nigeria). The second hysteroscopy showed a false passage in the cervix at 11 O’clock position. No postoperative complications were reported in the patient.\nTwo IVF procedures with self-eggs in Nigeria, the last one in 2010 using long agonist protocol had failed. In November 2013, the patient had an IVF with embryo transfer (ET) using donor oocytes (IVF-OD) in India. The patient then underwent operative hysteroscopy with adhesiolysis in December 2013 followed by HRT for 2 months. The cavity was normal, but bilateral (B/L) ostia were not visualized. In February 2014, she again underwent another cycle of IVF-OD with the transfer of four embryos but this too did not result in pregnancy.\nThe patient presented at our facility in March 2014. At the time of presentation, the patient had a high body mass index (35.6 kg/m2; weight - 91.2 kg, height - 160 cm). Her blood pressure (130/80 mmHg), chest and cardiovascular examinations were normal. Pap's smear, breast ultrasound sonography (USG) and routine electrocardiography were normal. She had a deep vagina, the cervix was flush with the vagina. A false passage was identified at 11 O’ clock position, and the external ostium of the uterus was visualized with difficulty at 6 O’ clock position lying posteriorly. Her per vaginal examination showed that uterus was ante-verted, bulky, and mobility was restricted.\nAfter reviewing the patient's history and examination, and in view of multiple IVF failures and BOH, she was advised to go for IVF-OD after determining the exact window of endometrial receptivity. The patient had an endometrial receptivity array test done in March 2014. The dose of estradiol valerate (Zydus Cadila Healthcare Ltd.; German Remedies) had to be stepped up to 12 mg daily orally and 4 mg vaginally to build up the endometrial lining as her endometrial lining was consistent below 7 mm. She received a total of 2 cycles of HRT before the next IVF-OD attempt.\nIn April 2014, IVF-OD was done and 2 grade A blastocysts were transferred. ET procedure was traumatic as there was considerable difficulty in accessing the cervix. It was extremely difficult to identify the external cervical os due to the presence of a cystocoele, made worse because of the full bladder, depth of the vagina and the flush torn cervix. The bladder was half emptied by catheterization and ET catheter was negotiated after holding the cervix with an allis forceps. This attempt failed as expected.\nThe next frozen ET (FET) was planned in May–June 2014 cycle, and on patient's request three embryos were transferred. During this FET cycle, the patient again received estradiol valerate (OD, 12 mg) and progesterone (BD, 400 mg). Fourteen days after ET, her urine pregnancy test was positive and beta-human chorionic gonadotropin was reported to be 5013 mIU/ml.\nLow-dose asprin-loprin (OD, 75 mg; Unichem Laboratories) was given along with all cycles of HRT. A subcutaneous injection of lonopin (20 mg, Bharat Serums and Vaccines Ltd., Hyderabad, India) was administered on alternate days to improve implantation. In view of spotting during early pregnancy, both loprin and lonopin were stopped.\nA transvaginal ultrasound done on 5 July 2014 showed three I/U gestational sacs of 5 weeks and 3 days. Estradiol valerate dose was dropped from 12 mg to 6 mg after identification of gestation sacs on transvaginal sonography. Progesterone pessaries were continued. Ultrasound at 6 weeks revealed cardiac activity present in all the three embryos.\nThe patient reported with pain and swelling in left leg at around 7 weeks of the pregnancy. There was no antecedent history of trauma, fever, and varicose veins. On examination, the entire left leg showed edema, there was no discoloration or change in skin temperature. DVT was diagnosed clinically and was confirmed on Doppler test done on 14 July 2014. On Doppler, left common iliac, left external iliac and left common femoral in its upper one-third showed distension with soft tissue echogenicity of a thrombus, occupying the entire lumen of the vein. The diameter of the veins was approximately doubled. Right leg veins appeared normal. Other investigations done were normal including liver function test, serum blood urea (38 mg/dl), serum creatinine (1.35 mg), serum uric acid (3.5 mg), platelets (1.4 × 105/cc), prothrombin time (PT - 17.3 s at 1 min and 1.43 s at 2 min) and activated partial thromboplastin time (36 s). The patient was hospitalized and managed with enoxaparin (BD, 0.8 ml) subcutaneously in association with a hematologist. The thrombus started resolving within 3 weeks with the Doppler showing improved blood flow and was completely resolved on the scan done after 7 weeks of treatment. The patient was maintained on a daily dose of LMWH until 34 weeks of pregnancy and then in the postmartum phase. Thromboembolic deterrent stocking was given after the first 2 weeks of LMWH.\nAt 34 weeks, she had a premature rupture of membranes, and an emergency lower (uterine) segment cesarean section was done. She delivered one female 1.4 kg and two male babies 2.1 kg and 1.8 kg birth weight. The female baby died of necrotizing enterocolitis 1-week after the birth; the other two were discharged from the hospital after 2 weeks of delivery. |
A 10-year-old girl visited our affiliated hospital, complaining of pudendal deformity. The patient was born at 39 weeks of gestation by normal delivery as the second child, and the birth weight was 3,144 g. There was no disorder in the course of pregnancy in her mother. Intake of androgenic medicine or the disorders of ovaries and uterus was not observed by a periodic medical examination. No pudendal deformity was clearly observed at birth, but lateral asymmetry of the pudendal region was noticed at about 4 years old. A child care worker pointed out that she pressed her heel to the crotch while sitting on her folded legs. After 5 years old, her mother confirmed that her clitoral hood clearly hypertrophied. After entering primary school, a teacher in charge pointed out that she pressed her crotch to a chair or bar, and the mother told her to stop it, but she repeated this behavior every day. When she strongly wanted to be absent from an overnight school trip at 9 years old, the mother brought her to the Pediatric Department. Various tests were performed suspecting disorders of sex development (DSD). On the first visit, the height was 132 cm and the body weight was 26 kg. The clitoral hood was enlarged. The appearance was similar to the vulva in children with congenital adrenal hyperplasia, and the clitoris size was 8 x 5 mm. Labial fusion or adhesion was not detected, and the urinary tract and vagina were open at the normal positions. No masculinization, such as acne and polytrichosis, was noted (). Intake of androgenic medicine or the disorders of prepuce was not observed. In the blood test, the sex chromosome was 46, XX. The blood count, blood chemistry, and hormonal test were normal (). On abdominal ultrasonography, the uterus and ovaries were present. Abdominal CT and MRI examinations showed no tumorous lesion.\nBased on the above examination and test findings, DSD was considered negative. The patient was diagnosed with clitoral hood enlargement and referred to our department to undergo clitoral hood reduction. For surgery, a longitudinal incision was designed for the dorsal side in order to resect the clitoral hood by cut and try. In the clitoral region, the clitoral hood and corpus cavernosum were dissected through an inverted V-shape incision. The volume of the exposed corpus cavernosum clitoridis was reduced while conserving the neurovascular bundle, following the Marberger method []. The clitoral hood was resected into a triangle shape and used for labial formation. On histopathological examination, lymphedema and venous tasis in a grade consistent with the influence of foreskin excision were observed. No abnormality was noted in the corpus cavernosum. Her postoperative course was uneventful. As of 10 months after surgery, favorable improvement of the appearance was noted (). |
A 12-year-old boy was admitted with a 2-month history of progressively worsening fatigue. He had been noted to be anemic a month prior to his hospitalization, with hemoglobin of 7.9 g/dL and was started on oral iron by his primary care pediatrician. At his outpatient follow-up visit, because of persistence of his symptoms, repeat laboratory testing was performed and showed his hemoglobin had decreased to 7.3 g/dL. His serum potassium was 7 mEq/L, serum bicarbonate was low at 15 mEq/L, and serum creatinine was elevated at 8.7 mg/dL (estimated glomerular filtration rate [eGFR] 11 mL/min/1.73 m2). He was admitted to the pediatric intensive care unit via the emergency room where he received furosemide and sodium polystyrene. Studies to evaluate his renal disease included a renal ultrasound which revealed normal sized kidneys with bilateral grade 2 hydronephrosis without dilated ureters and with a distended, but thin-walled bladder; a voiding cystourethrogram showed no reflux and a normal urethra, but significant after void residual. Other studies included serum complements C3 and C4, both of which were normal, hepatitis B and hepatitis C and HIV serologies that were all negative, and an antinuclear antibody that was also negative. His urinalysis had a low specific gravity of 1.006 with no blood or protein. He was urgently started on hemodialysis because of hyperkalemia and was maintained on outpatient hemodialysis three times a week at discharge, with a presumptive diagnosis of advanced CKD likely from a urologic cause. His past medical history was uneventful with normal development and growth, and there were no documented urinary tract infections, unexplained febrile illnesses, or urinary complaints. For further evaluation of his renal disease and in preparation for a renal Tx, he underwent urodynamic studies which showed a normally compliant low-pressure bladder with complete bladder emptying. Even though he only had moderate hydronephrosis on ultrasound, due to the severity of his kidney disease, he underwent bilateral retrograde pyelograms which showed that both proximal ureters were somewhat medially deviated; the left proximal ureter had a 1 cm long narrow segment and the right proximal ureter had a 3 cm long narrowing. Double J ureteral stents were placed on both sides. Following stenting his urine output increased, and his renal function improved but only minimally, to a serum creatinine of 5 mg/dl (eGFR 19 mL/min/1.73 m2). Due to a concern that the narrowing was from extrinsic ureteric compression, abdominal and pelvic CT scans were performed. On these scans, performed about 2 months after his initial renal ultrasound, both kidneys were noted to be very large and almost entirely replaced with nonenhancing nodules throughout the parenchyma. Mild bilateral hydronephrosis was again noted. Also noted were multiple mixed sclerotic-lytic lesions in the L2 to L5 vertebral bodies; his serum calcium was normal. He was readmitted to the hospital for further management and underwent a percutaneous renal biopsy which established the diagnosis of diffuse large B-cell lymphoma. The biopsy tissue showed parenchyma infiltrated by large atypical pleomorphic lymphoid cells with prominent nucleoli and that stained positively with CD79A and CD 20. FISH probe for MYC rearrangement was negative. His bone marrow was normal. A whole body PET scan showed findings consistent with multifocal, infiltrative renal lymphoma associated with multifocal hypermetabolic lymphoma deposits in the axial and appendicular skeleton and retroperitoneal lymph nodes. With a diagnosis of PRL, he was started on chemotherapy with vincristine, cyclophosphamide, prednisone, and intrathecal methotrexate. Following a lack of response to therapy, he was transitioned to a more aggressive protocol, consisting of additional doses of vincristine, prednisone, methotrexate, doxorubicin, etoposide, and intrathecal methotrexate. Over time, his renal function progressively improved such that he was able to come off hemodialysis, and at discharge from the hospital, he had a serum creatinine of 1.7 mg/dl (eGFR 58 mL/min/1.73 m2). His subsequent clinical course was complicated by episodes of fever and neutropenia, typhlitis, and neurotoxicity from etoposide and vincristine needing extensive rehabilitation. At his last clinic visit, 5.5 years after diagnosis and 4 years after completing chemotherapy, his PET scan showed no hypermetabolic lesions to suggest active disease, his blood pressure was normal, and his serum creatinine was stable at 1.2 mg/dL (eGFR 94 mL/min/1.73 m2). On his most recent ultrasound, he had mild left hydronephrosis with a significant reduction in renomegaly; his ureteral stents had been removed in the interim. He was in school performing well academically and using a walker for ambulation due to his residual neurologic injury. |
A 27-year-old female was referred to our hospital on May 16, 1996 and admitted due to a suspected malignant bone tumor in the left distal femur. On May 20, biopsy was performed. Histopathological examination demonstrated osteosarcoma, and preoperative chemotherapy was immediately performed according the chemotherapy protocol of our department for osteosarcoma. On September 25, wide resection was performed, and the affected limb was reconstructed using a tumor prosthesis (Howmedica Modular Reconstruction System: HMRS). Subsequently, postoperative chemotherapy was performed for about 6 months. On May 2007, about 11 years after the operation, she noticed pain in the left thigh during walking. Due to gradual aggravation of the pain, she visited our department on September 6, 2007. X-ray examination revealed fracture at the base of the stem of the femoral component (Fig. ). We planned revision using a tumor prosthesis, and obtained a custom-made femoral component stem (diameter, 12 mm; length, 15 cm). Until the completion of the stem, a knee-ankle-foot orthosis was employed, and crutches were used for walking. The preoperative score of the Musculoskeletal Tumor Society was 60%. On November 7, 2007, revision surgery was performed. The wound was exposed using the previous skin incision. Bone formation at the stem base was good. Rectangular fenestration along the stem in the bone was performed in the proximal femur using a chisel, and the stem in the bone was removed. A new stem was inserted, and adequate grafting with Neobone and autogenous bone was performed around the stem. Only the bearing bush and femoral component were replaced with new ones, and the operation was completed (Fig. ). Two weeks after the operation, passive range-of-motion training was initiated. Until 6 weeks after surgery, no weight bearing was performed. Seven weeks after the operation, walking training was initiated using a knee orthosis with gradual weight bearing. The knee orthosis was used until 6 months after the operation. At present, about one year after surgery, good bone formation around the stem is observed on plain X-ray films. Evaluation using The Implant Evaluation System of the International Symposium on Limb Salvage showed excellent results for all items (Bone remodeling, Interface, Anchorage) after as well as before the operation (Fig. ). She can walk without using a cane or orthosis, and the score of the Musculoskeletal Tumor Society is 80%. |
An asymptomatic 42-year old woman presented to our sexual health clinic 1 month following unprotected sexual intercourse with a high risk male partner whom was later presumed to be the source of infection. She denied any other high risk sexual contacts at the time. A HIV Antigen/Antibody (Ag/Ab) test was reported as negative at that time, but she represented 5 months later for a repeat screen at which time a 4th generation Ag/Ab test was reactive. HIV line immunoassay testing was consistent with recent HIV-1 acquisition, and plasma HIV RNA at this time was detectable but below the level of quantification (< 200 copies/ml).The individual continued to follow up for routine clinical care, and plasma HIV RNA became undetectable 4 months following her initial positive test as shown in Table . Her CD4 count remained stable, but 2 years following diagnosis, she presented with groin and axillary furunculosis. She was treated with antibiotics however her skin condition did not improve to a satisfactory degree. A decision was made to commence abacavir/lamivudine/dolutegravir ART on clinical grounds. This subsequently improved with ART administration.\nSubsequent review of the sample taken at her initial STI screen revealed that the first-line 4th generation Ag/Ab (ARCHITECT® Abbott) screening assay result was at the threshold of positivity. However, this result was not confirmed on two other 4th generation tests. The clinical suspicion was low at the time, as her partner was not known to be high risk, and no further testing was performed. Retrospective HIV RNA testing of this sample, however, revealed a viral load of 71,550 copies/ml (Table ). Genotypic testing confirmed the presence of a Group M, subtype C virus. HLA typing demonstrated B27 positivity, which has been reported to be enriched in HIV controllers [].\nInformed consent was obtained and the patient provided blood for further analysis. Single copy viral load testing of a sample from September 2016 (acquired 27 months following infection and prior to initiation of ART) was performed using replicate Aptima viral load Target-Capture Transcription-Mediated-Amplification (TC-TMA) assay on the Panther system (Hologic), which detected 0.84 plasma copies/ml (3 positive replicates of 13 performed). Purified peripheral blood CD4+ T cells were tested from six samples obtained longitudinally between December 2015 and January 2017 (before and after ART initiation) for total cell-associated HIV-1 DNA and unspliced RNA testing using previously described quantitative PCR methods (10 to 20 million input cells per experiment) [, ]. Exogenous activation for 48 h using αCD3/αCD28 antibodies was incorporated to increase detection of HIV-1 RNA from cells. No cell-associated HIV-1 DNA or RNA was detected in any of these samples.\nFlow cytometry was performed to determine the frequency of markers of CD4+ and CD8+ T cell subset differentiation (CD45RA; CCR7), activation (CD69; HLA-DR/CD38), immune checkpoint (PD-1) and CCR5 expression prior to and following initiation of ART (September 2016 and November 2016). No major changes in surface marker expression were observed before and after ART initiation with the exception of modest increases in the frequency of CD8+ T cells expressing CD69, and decreases in CCR5 expression on both CD4+ and CD8+ T cells (Fig. a-f). In addition, HIV-specific CD8+ T cell responses were measured in samples obtained in June 2016 and following initiation of ART in January, 2017 by cell surface and intracellular staining as in supplementary materials following 6 h stimulations using HIV subtype C overlapping, pooled Gag peptides (obtained from the NIH AIDS Reagent Repository). The frequency of CD107a + (a toxic degranulation marker) and intracellular TNFα+ and IFNγ+ expressing CD8+ T cells increased following initiation of ART as shown in Fig. g, h. |
A 68-year-old female was admitted with fever and general weakness. The fever had developed 2 months prior, was persistent, over 38℃, and spiked 2-3 times per day with accompanying chills and headache. She thought she had caught a common cold and was observed for some time with prescription of antipyretics. The fever did not subside after 1 month and she was admitted to another hospital.\nThe patient had been generally well despite her fever and chills. Her blood pressure and pulse were normal. No bacteria were cultured from blood. Extended spectrum beta lactamase-negative Escherichia coli was isolated from the initial urine culture, but the fever did not subside after administration of appropriate antibiotics and conversion of urine culture status to negative. Computed tomography (CT) of the chest and abdomen revealed that the abdomen was normal, but diffuse thickening of the aortic wall, without significant narrowing or occlusion of vessels, was evident. Cerebrospinal fluid analysis and transesophageal echocardiography yielded normal results. No symptomatic improvement was evident and she was transferred to our hospital for further evaluation of the origin of fever.\nOn admission, she had a febrile sense, chills, and anorexia, but no change in body weight. She denied experiencing neck stiffness, tinnitus, dizziness, sweating, chest discomfort, dyspnea, symptoms of upper respiratory or urinary tract infection, claudication, arthralgia, or joint swelling. She had taken antihypertensive medication commencing 5 years prior and had no known drug or food allergies. She was a retired teacher and lived in a city. She consumed alcohol once or twice per month and did not smoke.\nOn examination, her temperature was 38.9℃, her blood pressure 136/66 mmHg, and her pulse 84 beats per minute. The respiratory rate was 20 breaths per minute, and the oxygen saturation 96% when ambient air was breathed. She appeared tired when the fever spiked, but otherwise did not appear to be ill. Her heart and breathing sounds were normal. Neither the liver nor spleen was palpable and no palpable lymph node could be found. The peripheral pulse was intact, palpable, and present bilaterally at the carotid, brachial, radial, popliteal, and dorsalis pedis artery. No skin rash, petechial development, joint swelling, or tenderness was evident. All other examination was normal.\nLaboratory examination indicated that anemia was present (hemoglobin 9.5 g/dL) in the absence of leukopenia or thrombocytopenia (white blood cell count 7,600/mm3, platelet count 498,000/mm3). The erythrocyte sedimentation rate was 82 mm/hr and the C-reactive protein level 7.08 mg/dL. Blood cultures and serologic markers for hepatitis B, hepatitis C, human immunodeficiency virus, and syphilis were all negative. The serum protein/albumin ratio was elevated (being 6.3/2.6), accompanied by rouloux formation when a peripheral blood smear was performed. Bone marrow examination revealed no specific abnormality.\nThe inflammatory focus was sought using FDG positron-emission tomography-computed tomography (PET-CT) imaging; significant radiolabel uptake was evident along the walls of the aorta () and the large vessels (). The fever subsided several days after commencement of systemic steroids. The elevated levels of inflammatory markers fell and the peripheral blood smear became normal. Our patient was discharged, and, after 1 year of outpatient follow-up, shows no evidence of disease progression. |
A 51-year-old male with a history of nonischemic cardiomyopathy with a left ventricular assist device was admitted for expedited heart transplant evaluation. The evaluation included an elective colonoscopy in light of a family history of colorectal cancer in his mother who died at age 61 from the disease. The patient had his first screening colonoscopy at age 45 and was diagnosed with benign polyps, which were removed, and left-sided diverticulosis. The procedure was uncomplicated and he was advised to repeat a colonoscopy in five years.\nThe patient was without GI symptoms at the time of his colonoscopy. He denied tobacco, alcohol, or illicit drug use. His medications included amiodarone, aspirin, famotidine, levothyroxine, lisinopril, metoprolol, sildenafil, and intravenous heparin as well as torsemide, acetaminophen, docusate sodium, and melatonin as needed. On examination, he had a left ventricular assist device port entering at the upper abdomen, but otherwise the abdomen was soft and nontender to palpation with normal bowel sounds and no appreciable masses or ascites.\nThe patient underwent a standard bowel preparation which included a clear liquid diet the day prior to the procedure and 20mg of Dulcolax with 4 liters of polyethylene glycol the night prior to the procedure. Monitored anesthesia care sedation was administered with propofol. The colonoscopy was performed at night without difficulty with good bowel preparation. Abdominal pressure was briefly required to maneuver around the splenic flexure. The colonoscope was advanced to the cecum with identification of the appendiceal orifice and ileocecal valve. Findings included multiple sigmoid and descending colon diverticula and two, small (<5mm) sessile polyps that were removed using cold forceps.\nThe night of the procedure the patient had no pain or nausea and ate dinner and breakfast the following morning without incident. He then developed epigastric abdominal pain in the midmorning approximately 12-14 hours after the procedure and had one episode of nonbloody, nonbilious emesis following lunch. On physical examination, he was afebrile with a blood pressure of 104/89mmHg, heart rate of 68 beats per minute, and oxygen saturation of 100% on room air. Abdominal examination was notable for mild distension and moderate tenderness to palpation in the epigastric region without guarding or rebound tenderness and decreased bowel sounds. Laboratory examination revealed an elevated lipase of 2275 U/L and amylase of 1141 U/L. Additional abnormal laboratory findings included an elevated aspartate aminotransferase of 105 U/L, alanine aminotransferase of 94 U/L, and total bilirubin of 1.4 μmol/L (normal prior to the procedure). An abdominal X-ray did not reveal an obstructive bowel gas pattern or evidence of free air. A computed tomography (CT) scan of the abdomen/pelvis revealed diffuse edematous changes of the pancreas with surrounding inflammatory stranding in the bilateral paracolic gutters, extending superiorly to the perihepatic region and inferiorly to the pelvis (). The constellation of symptoms, labs, and imaging were suggestive of an episode of acute pancreatitis.\nThe patient was treated conservatively with bowel rest, intravenous fluids, and analgesics as needed. Over the next three days his symptoms and abdominal examination improved and his diet was advanced to a regular diet. The lipase normalized to 15 U/L. |
A 35-year-old male with a history of hyperlipidemia and seizure disorder presented to an outside hospital following a breakthrough seizure, where he was incidentally also found to have punctate areas of acute cerebral infarcts in multiple vascular territories. Additional workup revealed the presence of a left atrial thrombus and newly diagnosed atrial fibrillation. He was ultimately discharged to home on apixaban. The patient then re-presented a month later for evaluation of transient diplopia, expressive aphasia, daily right temporal headaches, and right facial and left leg weakness. MRI of the brain showed new areas of diffusion restriction in the left cerebellar hemisphere and left medial occipital lobe (Figure ). CTA showed no signs of carotid occlusion or stenosis. The etiology of his multifocal strokes was thought to be related to his newly diagnosed atrial fibrillation and left atrial thrombus.\nThe patient was then transferred to our hospital for further evaluation. His initial NIH stroke scale was 8 (primary deficits were including unilateral facial palsy, bilateral lower extremity pronator drift and ataxia). Stroke labs, including lipid panel and hemoglobin A1C, were unremarkable. MRI of the brain with contrast showed a new infarct in the splenium of the corpus callosum in addition to prominent generalized meningeal enhancement (Figure ). MRI of the spine with contrast showed possible meningeal enhancement as well as punctate areas of encephalomalacia in the C3-4, C7, and T3 spinal levels. A bedside LP revealed a mildly elevated opening pressure of 24 cm H20, lymphocytic pleocytosis (WBC 150 K/cumm, 61% lymphocytes), protein 170 mg/dl, hypoglycorrhachia of 15 mg/dl, and presence of cryptococcal antigen. Other notable CSF labs included the presence of 11 oligoclonal bands. He was diagnosed with cryptococcal meningoencephalitis and started on a four-week course of amphotericin B and flucytosine. A repeat LP after several days of treatment showed a normal opening pressure of 14 cm H20, mildly improved pleocytosis (WBC 130 K/cumm, 84% lymphocytes), protein 172 mg/dl, and glucose 14 mg/dl. He did not require any additional lumbar punctures, and his symptoms (including headaches and left lower extremity weakness) gradually improved. The patient was discharged to an inpatient rehabilitation facility prior to returning home.\nThough our patient in Case 1 had a history of an unknown autoimmune disease, our patient in Case 2 had no history of autoimmune disease or other existing immunodeficiency. Both patients developed multiple cerebral infarcts in multiple vascular territories in the setting of cryptococcal meningoencephalitis, though our patient in Case 2 also had recently diagnosed with atrial fibrillation which further confounds the underlying etiology of his strokes. |
A 68-year-old male presented to the emergency department with headaches, right-sided weakness, and multiple falls for one-month duration. He was noted to have had 45 pounds of unintentional weight loss over the four months prior to presentation. Initial CT of the head showed a 3.2 cm right frontal mass with edema that was suspicious for meningioma, and the patient was admitted for further investigation and treatment. A metastatic workup was delayed by the urgent craniotomy due to mass effect at presentation. Preoperative workup showed anemia with hemoglobin of 9.7 g/dl, alkaline phosphatase of 144 IU/L, and elevated PSA of 66.7 ng/ml. Digital rectal exam revealed asymmetry of the prostate with an elevation of the left side of the gland but no discrete nodules. MRI of the brain showed a 2.8 cm right anterior frontal extra-axial mass with enhancing dural tail, likely representing meningioma. Additionally, MRI showed moderate vasogenic edema, raising suspicion for other histology such as oligodendroglioma (Figure ). Craniotomy was performed with an intraoperative frozen section initially reported as meningioma but subsequently diagnosed as metastatic adenocarcinoma of the prostate on permanent pathology. Bone scan postoperatively showed increased uptake in multiple thoracic and lumbar vertebral bodies, sacrum, left humerus, right femur, and several bilateral ribs, suspicious for metastatic disease (Figure ). There was also an increased uptake in the right anterior skull, suggestive of post-surgical change. The CT abdomen and pelvis showed patchy sclerosis throughout the thoracolumbar spine and bony pelvis, suspicious for osteoblastic metastasis. Three weeks later, the patient presented to the hospital due to lower extremity edema. At this time, repeat PSA was found to be 118.53 with total testosterone of 144 ng/dL. During the hospital stay, bicalutamide was initiated and then was followed by degarelix in the clinic one week later. Leuprorelin was subsequently planned for one-month post operatively and followed up with whole brain radiation therapy (WBRT). |
A 61-year-old female with hypertension and dyslipidaemia presented with the passage of altered blood of 4-day duration. This was the first episode, and her bowel habits had been normal to date. On admission, she was pale with a pulse rate of 118 per minute and a blood pressure of 86/66 mmHg. Her haemoglobin was 6.2 g/dl, and her coagulation profile, liver functions, and renal functions were normal.\nShe was resuscitated initially with crystalloids and then packed red cell transfusions. The next day, she underwent upper gastrointestinal endoscopy (UGIE) which revealed a protruding mass with active bleeding in the distal duodenum. Upper gastrointestinal assessment was repeated in the same setting using a paediatric colonoscope, and a profusely bleeding varix was observed in the proximal jejunum (). Haemostasis was achieved by glue injection. A colonoscopy was also performed in the same setting which was normal. Abdominal ultrasonography was unremarkable. On day 6 after admission, a contrast CT of the abdomen was performed. It showed a well-defined, exophytic, lobular lesion with mixed density in proximal jejunum measuring 3 × 4 × 4 cm (). The lesion displayed strong arterial phase enhancement, mainly at the periphery, and was supplied by a branch from the superior mesenteric artery and drained by a prominent tributary of the superior mesenteric vein just proximal to the portal venous confluence. Arterial phase enhancement of the draining vein, superior mesenteric (SMV), and portal vein (PV) was indicative of an AVM. The facility for magnetic resonance imaging (MRI) is very limited in our resource-limited setting, and therefore, we did not proceed with an MRI for further delineation of the lesion as the CT images were sufficiently conclusive.\nSurgery was carried out in the index hospitalization while the patient was stable, in order to avoid a risk of rebleeding. Laparotomy revealed a mass with two prominent feeder vessels at the antemesenteric border of the proximal jejunum, 10 cm distal to the duodenojejunal flexure (Figures –). A segmental jejunal resection including the mass was performed, and continuity was restored with a side to side anastomosis. Histology revealed a gastrointestinal stromal tumour (GIST) composed of short fascicles of spindle cells. There was no histological evidence of an AVM or angiodysplasia. Her postoperative recovery was uneventful. She was referred to the oncologist and received adjuvant oral imatinib therapy. |
In April 2007, a 40-year-old Caucasian woman admitted into our clinic for performing an orthopaedic operation. The chest x-ray, which is amongst the routine pro-operating exams preceding a surgery, revealed an asymptomatic left paramediastinal mass in the left hemithorax (Figure ). After a chest CT scan, there was revealed a large, 5.5 cm in diameter, multilobar mass attached to the upper lobe of the left lung, extending into the left lung, touching the cardiac wall and invading the pericardial fatty tissue, without infiltrating the parenchyma of neither the lung nor the heart (Figure ). The CT imaging of the abdomen showed no signs of lymph node enlargement or any metastatic disease. Subsequently, a biopsy of the tumour was conducted, through an FNA CT-scan. The histological results revealed a hyperplasia of the lymphoid tissue.\nFollowing these, the patient was scheduled for surgery. She was operated on through a posterolateral thoracotomy in the 5th left intercostal space. A 5 × 6 × 4.5 cm tumour was found with a pedicle stemming from the visceral pleura of the upper lobe of the left lung anteriorly. It was "touching" the wall of the left lung and heart, obscuring the pericardia fatty tissue. There were no signs of the tumour infiltrating the lung or any of the adjacent structures. Note that the only connection of the tumor with the lung was its pedicle and that there was no connection of the tumour with the mediastinum and the thymus. Consequently, the pedicle was sutureligated, divided and removed (Figure ).\nThe postoperative course was uneventful and the patient was released from the hospital on the 5th post-operative day. The anatomopathological examination of the sample using optical microscopy and immunohistochemical tests confirmed the diagnosis of an ectopic thymoma (Figure ). The resected specimen was a solid and elastic multi-lobulated, grey mass, with a thick fibrous capsule. The microscopy showed nodules of varying sizes comprising a mixture of polygonal, ovoid and spindle (epithelial) cells, associated with a dense lymphoplasmacytic infiltrate, vascular proliferation, nuclear pleomorphism, scanty mitoses, but no tumour giant or necrotic cells. These histopathologic findings were consistent with a type AB according to World Health Organization Classification System (1999) and the pathologic stage was stage I on the classification system of Masaoka (Table ) [,,]. |
The patient was a nonsmoking 53-year-old male with a history of obesity (body mass index 32 kg/m2), type 2 diabetes mellitus, and hypertension who developed fevers, diarrhea, and cough. After 6 days of worsening symptoms, he presented to an outside hospital for rapidly worsening dyspnea and confusion. Upon arrival, he was found to have profound hypoxemia with an oxygen saturation of 33% by pulse oximetry. He was emergently intubated and admitted to the intensive care unit (ICU). Initial chest X-ray demonstrated mild bilateral pulmonary infiltrates (). He was started on broad-spectrum antibiotics including vancomycin, piperacillin-tazobactam, and doxycycline. While in the ICU, his condition continued to worsen and he remained profoundly hypoxemic despite escalating ventilator support. Within five hours of hospital admission, he was on maximal ventilator settings, in the prone position, chemically paralyzed, and on inhaled epoprostenol. Despite these interventions, the patient remained severely hypoxic with oxygen saturation of 70% and PaO2 of 48 mmHg. Our institution was contacted to evaluate for initiation of VV ECMO. The patient was transferred to our surgical ICU still in a prone position and paralyzed.\nOn arrival to our surgical ICU, approximately 9 hours after his initial hospital presentation, his oxygen saturations were found to be between 40 and 60%, and he was increasingly hypotensive requiring norepinephrine and vasopressin to maintain an adequate blood pressure. His arterial blood gas identified a respiratory acidosis with a pH of 7.29 and elevated pCO2 to 59 mmHg. His PaO2 : FiO2 ratio was 36, consistent with severe ARDS. Initial management in our ICU included increasing PEEP to 24 cm while continuing 100% FiO2. Epinephrine was added as a third vasopressor for worsening hypotension. Despite these interventions, the PaO2 remained low at 44 mmHg and his oxygen saturation remained <70%. A bedside echocardiogram was obtained and identified globally diminished cardiac function with an estimated ejection fraction (EF) of 30%. His COVID-19 laboratory test returned positive soon after arrival to our institution.\nGiven the patient's ongoing profound hypoxemia and myocardial dysfunction with severely reduced EF, in collaboration with interventional cardiology, the decision was made to initiate venoarteriovenous (VAV) ECMO to provide oxygenation along with cardiac support for his stress cardiomyopathy. The patient was transferred to the interventional cardiology suite where coronary angiogram had no evidence of disease. A 17-French cannula was placed in the right femoral artery for arterial perfusion, a 29-French drainage cannula was placed in the right femoral vein, and an anterograde distal arterial perfusion 8-French catheter was inserted in the right superficial femoral artery to complete the VA circuit. A 31-French Avalon™ dual lumen venovenous cannula was then inserted in the right internal jugular vein, and the circuit was split with two “Y” connections to connect in parallel the VA and VV systems (). Oxygen saturation immediately rose to 100%, and rest ventilator settings were implemented to prevent ventilator-induced lung injury.\nAfter initiating ECMO therapy, his clinical condition gradually improved. His epoprostenol and chemically induced paralysis were discontinued, and all three vasopressors were quickly weaned off by HD 2 (ECMO day 1). His elevated troponin normalized after peaking at 1.953 mg/dL. A turndown study was completed and identified cardiac recovery with an EF of 40-45%. This was repeated on HD 3, and a normal EF was noted. During the turndown study, the femoral venous and arterial cannulas were clamped and the oxygen saturation was monitored. His oxygen saturation dropped from 100% to 82%, consistent with the decrease in total ECMO circuit flow from 5.5 liters per minute (LPM) to 4.6 LPM. With sustained hemodynamic stability and sustained oxygen saturation > 80% on VV ECMO (through the remaining right internal jugular dual lumen catheter), his femoral arterial and venous cannulas were removed through an open cut-down approach and vascular repair at the patient's bedside in the ICU (ECMO day 2). A heparin infusion was utilized for therapeutic anticoagulation while on ECMO targeting an activated clotting time of 160-180 seconds. While on VV ECMO, he was treated with piperacillin-tazobactam for empiric broad spectrum antibiotics for seven days.\nOn HD 7, the patient was treated with a single dose of sarilumab 400 mg (IL-6 inhibitor) for ongoing increase in inflammatory cytokines with fever concerning for cytokine release syndrome with subsequent improvement in inflammatory markers (.). Also on HD 7, he was noted to have worsening hypoxemia with oxygen saturation < 80% in a setting of high cardiac output of approximately 10 LPM. A transthoracic echocardiogram was also performed which revealed that the ECMO cannula had advanced to the IVC-RA junction with no flow towards the tricuspid valve. The cannula was therefore repositioned under echocardiographic guidance, and oxygen saturation slowly improved. He had dense consolidative opacities bilaterally on chest CT on the day of admission and worsening bilateral consolidative infiltrates on chest X-ray until HD 8, at which point, his oxygenation and chest imaging began to show improvement. His oxygenation gradually improved, and his ECMO sweep and flow rate was weaned until HD 12 (ECMO day 11) when he was decannulated after a 24-hour trial off sweep without ECMO support. After ECMO decannulation, he was maintained on rest ventilator settings until he was able to wean off the ventilator and was extubated on HD 14. He was able to gradually wean from the high-flow nasal cannula to room air. His COVID-19 RNA PCR test was repeated twice. After the return of a second negative COVID-19 RNA PCR test, airborne precautions were lifted, and he was able to ambulate in the hospital and was determined to be fit to discharge without the need for oxygen or support other than home physical therapy. |
A 58-year-old woman was newly diagnosed with advance (T3N1M0) moderately differentiated squamous cell carcinoma of distal esophagus involving gastroesophageal junction. She received her first cycle of neoadjuvant chemotherapy Carboplatin and Paclitaxel. The next day, she presented to the emergency room with two episodes of hematemesis containing fresh blood. In addition to that she had progressive dysphagia for solids. She remained hemodynamically stable. The Rockall et al. score was 2, owing to the disseminated esophageal malignancy. Her blood reports showed a hemoglobin drop of 2.6 g from 13.1 to 10.5 mg/dL. The platelet count and coagulation profile were within the normal range along with the liver and renal functions also being unremarkable. After initial resuscitation, patient was made nil by mouth and started on proton pump inhibitor (PPI) infusion. After taking informed written consent, an upper GI endoscopy was done. The findings revealed a stenosing non-traversable tumor, starting at 33 cm from the incisors, containing old clotted blood as well as mild oozing, as shown in . Initially, an attempt was made to maintain hemostasis using conventional methods including adrenaline injection and hemospray, but this was unsuccessful for this purpose. In view of the stenosing tumor and ongoing bleed despite using the aforementioned measures, it was decided there and then to place a temporary 20 mm × 130 mm FCSEMS (nitinol). This would not only help to achieve luminal patency but would also aid in bleeding control due to the tamponade effect. Using a catheter, a guidewire was passed through the stricture and its position confirmed fluoroscopically, as shown in . An FCSEMS was deployed over the guidewire under both direct vision and fluoroscopic guidance, which is shown in and , respectively. No further episodes of hematemesis or melena were observed along with no further hemoglobin drop. Patient stayed for 72 h in the hospital and was later discharged with a follow-up plan for stent removal at 2 weeks. Patient, however, was lost to follow-up with the GI team but continued to have chemotherapy and radiation therapy. She was sent back for esophageal stent removal after 5 months. Esophago-gastro-duodenoscopy (OGD) revealed no bleed from tumor, stent was removed, and scope was passed freely across the tumor, as shown in . Patient followed up notes of radiation oncology clinics confirmed no episodes of upper GI bleed between the time of stent insertion and removal. No stent-related early and late complications were seen. |
A 59-year-old male patient was admitted to the hospital because of having an irregular abdominal mass for >1 month that was detected by medical examination. No hematochezia, changes in bowel habits, abdominal pain, abdominal distension, or other symptoms were evident. No positive sign was observed during an abdominal examination. Thoracic and abdominopelvic enhanced computer tomography revealed irregular masses on the left side of abdominal cavity ∼3.7 × 2.8 cm in diameter with a lobulate edge and slightly uneven but with significant enhancement. Irregular calcification was observed inside the mass. The lesion was in close proximity to the wall of the small intestine, with a clear surrounding fat space. We considered that it could possibly be a stromal tumor. An abdominal ultrasound indicated a hypoechoic nodule in the upper abdomen 3.7 × 2.6 cm in diameter with a regular shape and clear boundary. A dot strong echo and rich blood flow were observed in the nodule, which moved with respiration. The mass was believed to have originated from the intestinal tract.\nThe patient's skin was disinfected with iodophor and covered with sterile towels, and a 12-mm Trocar was used as a viewing hole at the umbilicus. Pneumoperitoneum was established, 12-mm and 5-mm Trocars were placed as manipulation holes in the right lower abdomen and the right side of umbilicus, and a 5-mm Trocar was placed in the left lower abdomen as an auxiliary manipulation hole. There were no ascites in the abdominal cavity and no metastatic nodules were observed in the pelvis. No abnormalities were found in the hepatobiliary system, pancreas, or spleen. A dark-brown substantive spherical mass ∼5 × 5 cm in diameter with a smooth surface and intact capsule was observed in the small intestine.\nThe mesentery corresponding to the intestinal mass was separated both proximally and distally 5 cm from the lesion using an ultrasonically activated scalpel. The intestine was dissected with an Endo-GIA stapler and the cut ends were disinfected with alcohol gauze, after which the Endo-GIA stapler was used for side-to-side anastomosis. The site was sterilized again and a normal blood supply through the anastomosis site was ensured. The plasma muscle layer was strengthened.\nThe anus and rectum were disinfected and when anal opening was dilated using 4 fingers, an ∼2-cm transverse incision was made in the upper rectum ∼5 cm above the peritoneal reflex using an ultrasonic knife; the incision was disinfected with alcohol gauze. A 20-cm protective bag was inserted through the main Trocar hole in the right lower abdomen. Lubricated with iodophor, one end of the protective bag was pulled through the anus, into which the removed specimen was placed. When the entire specimen was inside the protective bag, the ligation strap at the opening of the proximal protective bag was tightened and the protective bag was pulled out with the sample, paying attention to maintaining the integrity of the tumor and avoiding any rupture of the tumor capsule. The distal rectum stump was lifted using a clamp and the endoluminal incision was closed using the Endo-GIA stapler. When no bleeding was ensured, the abdominal pelvis was flushed with distilled water and saline. A drainage tube was placed through the left lower abdomen and left within the pelvic cavity. Pneumoperitoneum was stopped and the Trocar hole was closed. |
A 56-year-old white female was brought into the emergency department presenting with severe abdominal pain and distension and reporting flatus expulsion and melenic stools in the previous two days. The patient had been experiencing nausea with cramping abdominal pain in the left flank, but with an absence of vomiting, for a period of two months. Although she had sought medical assistance on numerous occasions during this period, the symptoms had not improved.\nTen years earlier, the patient had presented with class III obesity (BMI 50.8 kg/m2) and had received laparoscopic RYGB with concomitant cholecystectomy. Postoperative recovery had been uneventful and the patient subsequently complied with nutritional guidelines. Her BMI diminished to 25 kg/m2 after one year and remained unchanged over the following years. The patient admitted smoking, but not alcoholism, during the last 30 years and had presented with vitamin D3 deficiency before and after the bariatric procedure.\nPhysical examination revealed peristalsis, intense pain on palpation, distended abdomen at the left costal border, and diffuse tympany on percussion. Abdominal computerized tomography (CT) revealed distension of the excluded stomach (Figures and ) and edema in the prepyloric wall. The patient was diagnosed with intestinal obstruction and referred for emergency laparoscopy.\nDuring the course of surgery, distension of the excluded stomach was observed together with a hard lesion in the antropyloric region. Gastrostomy was performed in order to improve the initial clinical conditions and to facilitate diagnosis. Three days later, a further CT scan with intravenous contrast was performed and, by gastrostomy, it was possible to confirm the presence of a mass in the antropyloric region, but with no distant metastasis.\nLaparoscopic intervention performed seven days later involved total gastrectomy, omentectomy, and D2 lymph node dissection while the primary Roux-en-Y (). Postoperative recovery was uneventful. Histopathological analysis confirmed the presence of a moderately differentiated gastric adenocarcinoma, with involvement of the submucosa, and lymphatic and venous tumor emboli. The adenocarcinoma was of the common subtype found in the antropyloric region. The patient was referred to adjuvant chemotherapy since all 26 resected lymph nodes presented metastasis.\nThe incidence of gastric cancer in the excluded stomach was 1 case (0.03%) in 3047 patients undergoing bariatric surgery between January 1999 and June 2014 at the Surgical Department of the São José do Avaí Hospital. |
A 28-year-old woman, gravida 3, para 1, was diagnosed with a missed miscarriage at 8 weeks’ gestation in a local hospital. A D&C with vacuum aspiration was performed and the presence of chorionic villi was confirmed by histology. She returned to the same hospital 4 weeks later, complaining of persistent vaginal bleeding. Transvaginal ultrasonography revealed placental remnants and a second suction-assisted D&C was performed together with diagnostic hysteroscopy. This showed the retained placental tissue to be located in the left lateral angle of the uterine cavity with mild adhesions. The evacuation failed because the metal D&C catheter could not reach the retained tissue. Two weeks later, she was referred to our hospital for further treatment. Another transvaginal ultrasound scan was done, which showed a 2.07 ’ 1.18 cm mass of mixed echogenic material suggestive of placental remnants extending to the left angle of the uterus. The left angular myometrial mantle was thinned to approximately 6 mm (Fig. A). Her serum beta-human chorionic gonadotropin (β-hCG) test was negative.\nThe hysteroscopic MyoSure morcellation device was introduced and the angular pregnancy was confirmed by a 2 cm area of yellowish-white placental remnants within the left cornual aspect of the uterus. Mild adhesions were found in the left angle (Fig. B, C). The retained placental tissue was found intraoperatively to adhere tightly to the uterine wall; nevertheless, it was completely excised stepwise under direct hysteroscopic visualization in 12 minutes (Fig. D). The entire procedure is shown in the supplementary video. The total blood loss during surgery was 5 ml with a total normal saline deficit of 100 ml (1800 ml of distension medium was used).\nHistology of the biopsied tissue after surgery confirmed the presence of chorionic villi and decidua tissue. The patient was discharged home the next day without any complications. Three months later, she was scheduled for a second-look hysteroscopy, which revealed a normal uterine cavity with mild membrane adhesion in the left angle (Fig. E, F). She was pregnant with a 15-week intrauterine gestation when we started to write this report. |
A 33-year-old woman, gravida 3, para 3, non-obese and with no chronic diseases, underwent TLmRH as curative treatment for clinical stage IA1 cervical cancer. Two months later, she presented to our department with abdominal pain and genital bleeding after her first sexual intercourse after surgery from the previous day.\nWe sutured the vaginal cuff with absorbable sutures during initial surgery. We performed colpotomy with ultrasonic device and monopolar device in both cases.\nBoth patients were immediately diagnosed with VCD (Figure ). The prolapsed organ was found to be the intestine and it remained within the vagina without evisceration out of the vagina. The color of the intestine was normal, indicating that there was no ischemia present. After washing of the prolapsed intestine, we pushed back the prolapsed intestine, with sterilized gauze to prevent herniation outside of the vagina until operation. Vaginal approach repair (repair from the vaginal cavity), open approach repair, or laparoscopic approach repair were treatment choices. Suturing from the vagina could shorten vaginal length. To prevent recurrence, we thought it would be better to suture the peritoneum. We already resected the vagina about 2 cm in the initial surgery in both cases; thus, we would like to avoid further shortening. We thought that the open approach should be avoided considering its invasiveness if we could safely avoid this complication laparoscopically. Thus, we initially employed total laparoscopic repair.\nThe ureter was separated from the paravaginal tissue during initial cancer surgery, losing its normal anatomical position. This may cause ureteral damage during repair (Figure ). Thus, in order to avoid ureteral injury and to create a tight suture, the vaginal wall was separated by 1.0 cm, to the extent that concrete vaginal cuff suture could be made (Figure ), and suturing was complete (Figure ). The peritoneum was sutured to prevent recurrence, hematoma, and infection. The postoperative course was good. The cuff remained intact at 1-, 2-, 3- and 6-month examination. We suggested that sexual intercourse is safe 6 months after surgery.\nInterviews conducted on these cases after the 6-month examination revealed that normal sexual intercourse was performed without troubles in both cases. |
This is the case of a 42-year-old woman originating from Iraq who had war experiences during the war in the 2000s. She sought asylum in Denmark together with her family, her husband and two children, in 2005. She stayed unemployed and was very isolated at home, with little interaction with people other than close family. After a year, she started complaining about intense pain in the stomach, head, shoulders, leg, and chest. Because of her intense chest pain and an accompanying rise in blood pressure, she was taken to the Emergency Department at the hospital and was put under intensive surveillance with ECG for 24 h several times per month. She also sought medical aid at her primary care center because of the pain in her feet, back, shoulders, and head. The general practitioner examined the patient finally and asked questions regarding traumatic experiences. The woman revealed that she had been imprisoned and tortured. She has been beaten on the soles of the feet (falanga), hung by her arms for several hours, and given electricity to her nipples in order to give information to the military regarding her brother, who was a political dissident against the Saddam Hussein regime. She was referred to Dignity, a former RCT in Copenhagen (a Center for Rehabilitation of Traumatized and Tortured Patients) and assessed by a multi-professional team with knowledge of trauma and torture. She went through a 9-month rehabilitation period with a bio-psycho-social focus, not with the aim of pain reduction, but to increase functioning and activity in daily life and reduce disability. After this period, the patient's pain reduced to some extent. Interestingly, she did not report any stomach or headache pain. As a major positive outcome, the woman decreased her visits to the general practitioner, the number of episodes of chest pain decreased, and she did not seek emergency care for them.\nThe IRB ethics committee of Dignity—Danish Institute Against Torture waived the need for written informed consent and approved the use of verbal informed consent for the publication of this case report.\nThe two female patient cases above not only illustrate the importance of taking the experience of trauma in general and torture more specifically into consideration when meeting refugee women with pain. The cases also illustrate the lack of knowledge within the healthcare systems and the immediate need for action regarding specialized units for this patient group. This will not only help patients but will also save money and resources that today are becoming more and more scarce.\nPatients have given their verbal consent to publish their cases in a scientific peer review paper; written informed consent has not been obtained. The patient cases have previously only been used in lectures for students, and ethical approval has not been required. |
A 4-year-old girl child, Hindu by religion, was brought to the psychiatry OPD by her mother. She was the elder of the two siblings, second also being a girl aged 2½ years. She was a full-term normal vaginal delivery, with no antenatal or postnatal complications in the pregnancy. Cried immediately after birth, all milestones were achieved at appropriate ages till date. She was exclusively breast fed till 6 months of age and then gradually weaned off. When she was around 1½ years old, the mother became pregnant again. This second pregnancy was unplanned, and her mother could not manage taking care of herself and the toddler. Feeling overburdened, mother shifted to her own parents place which was in a different village altogether. The primary care taking responsibility of this child was hence shifted abruptly from the mother to the grandmother when the child was almost 2 years of age. Grandmother remembered that initially she noticed that this girl became very irritable and would cry often, especially demanding for her mother to come back. The family would try to arrange meetings with the mother, but they were not very frequent. Gradually, she adjusted with the mother's absence, but her temperament changed altogether to being very stubborn and throwing temper tantrums, which made it extremely difficult for the family members to manage. This was the time the family first noticed that she would be seen pulling out her hair from the head, especially by her left hand. Most of the time, she threw away the hair immediately after plucking it; however, sometimes, she was seen smelling it before throwing. There was never a history of eating the hair or putting it in the mouth. There was no particular situation or time when she would do it. If asked or pointed out the same, the child would immediately deny doing it. This girl was often yelled at or shouted at by her family members for this behavior; she would cry aloud for a little while when that happened but soon went back to her normal self. The hair plucking behavior continued even after the mother came back to stay with them and even she could not keep it in check. It soon progressed to such an extent that the whole left half of the head had very little hair and there was a distinct demarcation between the right and the left side []. Her parents also said that she would not be welcome to play with the kids in her neighborhood as they would find her weird looking. Hence, overtime, she had reduced going out to play as well. This, the parents felt, often made her mood irritable and would sometimes burst out crying on minimal provocation. On examination, she had significant hair loss on the left side of the scalp. No other abnormalities were detected. All her vitals were within normal limits. On mental status examination, she did not reveal any features suggestive of anxiety, depression, or psychosis. Her intelligence seemed average with no insight into her illness. She denied pulling out her hair even though she did acknowledge the fact that her family members often keep yelling at her for the same. The child was very shy and it was difficult to establish rapport. The child was started on syrup fluoxetine 10 mg and sent for a Children's Apperception Test (CAT) test to look for any depressive or anxiety features. Unfortunately, the parents did not get the child for follow-up. |
A 79-year-old female on a ventilator was transferred to our ICU from another hospital due to biliary sepsis. Previously, the patient had been treated for about 1 week with combined antibiotics and another supportive treatment. The patient looked severely ill and jaundiced. The patient also has comorbidities such as heart problems, hypothyroidism, and diabetes mellitus. The total and direct bilirubin levels were high (10.94 and 9.67 mg/dL), with a very high CRP level (269.48 mg/L). The abdominal ultrasound (US) and MRI evaluation from the previous hospital showed a large cyst 14.7 × 6.2 cm in size suspected from the left liver lobe which caused gastric compression, and there was also evidence of bile duct obstruction with a large stone in the distal common bile duct (CBD) area (Fig. ).\nThe main treatment given during admission was as follows: a combination of the antibiotics piperacillin-tazobactam with amikacin, levothyroxine, insulin therapy, and other supportive treatments. Then an abdominal MRI was blindly reviewed by our senior radiologist, and it was concluded that there was a large cyst possibly arising from the pancreas (possible pancreatic pseudocyst [PPC]). After discussion with the family, it was decided to do biliary drainage. The bedside biliary drainage procedure was performed in the ICU without any fluoroscopy guidance, only transabdominal US guidance. After the dilated bile duct was seen on the US image, an 18-G Chiba needle was used to puncture the dilated bile duct, followed by bile fluid aspiration and guide wire insertion. The distance between the tip of the needle inside the bile duct and the area of the US probe was measured for length guidance marked on the PTBD pigtail catheter (DIALL abdominal drainage catheter, China). Then, slowly, the needle was pulled out with maintenance of the guide wire inside the bile duct. The final step was PTBD pigtail catheter insertion into the bile duct, after which, by following the marker, the needle inside the catheter was pulled out and the catheter was pushed further inside. When there was evidence of bile fluid from the drain catheter, the catheter was fixed and locked to prevent migration. The cyst was evaluated further for percutaneous aspiration.\nThe dark-brown cyst fluid during aspiration showed evidence of an infected cyst. The cyst fluid analysis showed an infected cyst with amylase at 42 U/L, lipase at 125 U/L, and CEA at 476.55 ng/mL. After several days, the bilirubin level was decreased (3.38 mg/dL), and the CRP level had gone down (180.93 mg/L). There was evidence of breathing improvement after cyst aspiration, which was shown by the change of ventilator mode (continuous mechanical ventilation/CMV mode to synchronization mode and until continuous positive airway pressure mode).\nOn the 6th day, the pigtail catheter was accidentally dislodged and pulled out. So, it was decided to do the endoscopic procedure with the portable ventilator in the fluoroscopy room. An ERCP procedure was performed, and the cholangiogram showed a large stone. Due to the patient's clinical condition, a 7-Fr double-pigtail stent was placed inside the CBD for salvage biliary drainage (Fig. ). After having placed the stent, EUS was performed for cyst evaluation (Fig. ). A first evaluation of the location for puncture was difficult as it was very close to the left liver lobe. After the second evaluation, using a 19-G FNA needle, the cyst was punctured slowly, and the liver lobe was spontaneously pushed away during needle insertion, followed by guide wire insertion through the cyst cavity. A 6-Fr cystotome was used to make a sufficient fistula track; then, a 7-Fr double-pigtail stent was inserted into the cyst cavity (Fig. ).\nThe patient's condition was getting better day by day until the patient could breathe spontaneously and be discharged from the ICU. After several days in the common ward, the patient was discharged from our hospital in good clinical condition. Three months later, the patient underwent a repeat ERCP procedure for CBD stone crushing using a SpyGlass Cholangioscopy DS Direct Visualization System (Boston Scientific, USA), and the pancreatic cyst showed a reduction in size on EUS examination. The pancreatic cyst stent has been maintained for the next 3 months. |
A 71-year-old man with progressive angina was found to have severe stenosis in the circumflex artery and complex CTO of the left anterior descending artery (, Supplementary ). Coronary artery bypass surgery was offered to the patient but declined. He underwent uncomplicated stenting of the circumflex artery, followed by staged CTO recanalization of the LAD. A guidewire was passed relatively easily across the occlusion into the true lumen of the distal LAD beyond the bifurcation. Antegrade wiring of the diagonal artery was difficult. An epicardial collateral from the distal right coronary artery was used to access the diagonal branch retrograde, and this wire was steered into the antegrade guide catheter and externalized (). Both the LAD and diagonal were dilated with 3.0 mm noncompliant balloons. The diagonal was stented into the proximal LAD, and the distal LAD was rewired. The distal LAD was dilated through the stent struts to allow passage of stents into the distal LAD (Culotte technique). The distal LAD was stented using four everolimus drug-eluting stents. The stents were postdilated with 3.0 mm noncompliant balloons in the diagonal and distal LAD and 4.0 mm noncompliant balloon in the proximal LAD. Within the distal-most stent in the distal LAD, the balloon had a persistent waist until an inflation pressure of 12 ATM. At that point, the balloon suddenly expanded. Angiography revealed contrast filling of the right ventricle (RV), with the appearance of one or two focal jets of contrast extravasation at the location of the rigid lesion in the distal LAD, consistent with iatrogenic LAD-RV fistula (, Supplementary ). Of note, the flow beyond the stents in the distal LAD was not seen, likely due to shunt flow and “coronary steal.” The patient remained hemodynamically stable and was asymptomatic, and it was elected to manage the fistula conservatively. Serial echocardiograms revealed only trace pericardial effusion. He was discharged in stable condition.\nApproximately three weeks after the CTO procedure, the patient was presented to the emergency department with chest pain and dyspnea. He described several episodes of “tearing” sensation in the chest. Blood pressure and heart rate were 123/69 mmHg and 64 beats per minute, respectively. A 12-lead ECG revealed inferior T wave inversion. Troponin I was elevated to 0.06 ng/mL. Urgent coronary angiography was performed, which revealed patent stents in the proximal LAD and diagonal branch. LAD-RV fistula appeared relatively unchanged compared to during the CTO procedure (). The right coronary artery was normal and provided a very faint collateral to the apical LAD. Left ventriculography in the left anterior oblique projection revealed no evidence of a ventricular septal defect. The patient developed profound hypotension of unclear etiology during angiography. A right heart catheterization revealed normal filling pressures, normal cardiac output and ratio of pulmonic to systemic flow (Qp:Qs) 1.7. A transthoracic echocardiogram revealed preserved ejection fraction and normal left ventricular wall motion with turbulent flow signals at the LV and RV apex throughout the cardiac cycle (Supplementary ). There was no pericardial effusion. The patient was transferred to the cardiac intensive care unit in stable condition.\nHeart team evaluation was undertaken, and it was decided to perform coil embolization of the distal LAD. A standard 6 French left coronary guide catheter was used to advance a ProGreat (Terumo Medical Corp., Somerset, New Jersey) guidewire and 2.8 French catheter into the distal LAD. This was used to deploy two Ruby (Penumbra, Inc., Alameda, California) coils at the distal end of the stent.\nThere was still persistent shunt flow, so two Tornado (Cook Medical, Bloomington, Indiana) coils were subsequently deployed. Angiogram of the LAD confirmed complete cessation of flow into the distal LAD and absence of shunt flow (, Supplementary ). Hemodynamics postprocedure demonstrated a 20 mmHg increase in systolic blood pressure and normalization of Qp:Qs. A follow-up echocardiogram revealed the obliteration of apical shunt flow, normal left ventricular ejection fraction, and no left ventricular wall motion abnormalities. Creatine kinase eight-hour postprocedure was normal. The patient was discharged home in stable condition. At follow-up, one month later, the patient remained asymptomatic. |
A 74-year-old female patient presented with a locally advanced tumor of the proximal pancreatic body. The patient showed no signs of obstructive jaundice and did not require biliary stenting. Initially, her tumor was noted to involve the major visceral vessels, including the celiac artery, portal vein, and splenic artery and vein (). The tumor was deemed unresectable and the patient underwent extensive chemotherapy with multiple cycles of gemcitabine, Abraxane, 5-fluorouracil, Alloxantin, Avastin, and Xeloda. After showing a favorable response, she was referred for surgical re-evaluation. The post neoadjuvant chemotherapy CT scan () showed a poorly defined infiltrative pancreatic neck and body mass measuring ∼25 × 15 mm with ill-defined soft tissue encasing the proximal splenic artery, common hepatic artery (CHA), distal celiac axis, and superior mesenteric artery (SMA). The mass also partially encased the portal vein and superior mesenteric vein (SMV). There was no radiologic evidence of hepatic metastasis and there was mild pancreatic duct dilatation. Pre-treatment and post-treatment serum CA 19–9 levels were 46 and 9, respectively. The patient did not receive any additional studies to assess GDA flow or the need for preoperative coiling/embolization. The absolute need for resection of the celiac axis was not determined until the time of the operation. The patient's functional status, perioperative risk, and likelihood of response were weighed and she was determined to be a candidate for an attempt at a modified Appleby procedure. After being properly informed of her various treatment options, she elected to undergo the operation.\nExploration of the duodenum and pancreas revealed a firm mass in the body of the pancreas with a soft pancreatic neck. No gross evidence of metastatic disease was present. There was a benign appearing lesion in the superior aspect of liver segment II, which was excised in its entirety and confirmed to be benign. Cholecystectomy was performed, followed by Kocherization of the duodenum and dissection of the pancreas and major vessels. We were fastidious in preserving the GDA. The splenic artery was controlled distal to the tumor, leaving a normal CHA pulse. The spleen and pancreatic body and tail were then serially elevated out of the retroperitoneum. The aorta was exposed, taking down the diaphragmatic crura. The celiac artery was identified at its origin, tied, divided, and oversewn with 5–0 polypropylene suture. Abnormal soft tissue was palpated along the proximal CHA. In light of this vessel involvement, we divided the distal CHA near the GDA. We then dissected the specimen off the SMA successfully and divided the pancreatic neck.\nThe inferior mesenteric vein was then clamped and tied. The inflamed pancreatic neck and proximal body were then dissected free from the right lateral aspect of the SMV and portal vein. The splenic vein was taken flush with the SMV, and its stump was oversewn, leaving good forward flow of the SMV to the portal vein. The proper hepatic artery (PHA) and the GDA were preserved throughout the resection. A Doppler ultrasound probe was used to test the GDA and PHA. Both arteries had adequate signal and in fact, the PHA had a faint palpable pulse. The liver parenchyma was also found to have a strong arterial signal. The specimen had two short stitches and purple dye placed at the neck margin and the rest of the specimen was inked per our Jefferson protocol.\nPathology of the resected specimen showed ductal adenocarcinoma with marked treatment effects with invasion of tumor into the peripancreatic soft tissue. The excision margins were free of neoplasia and the specimen had no regional lymph node metastasis (0/26). The tumor was within 2.0 cm from the pancreatic resection margin and within 0.1 cm of the circumferential margin in the posterior peripancreatic tissue. The maximum diameter of the tumor was 3.0 cm in size.\nIn the initial postoperative period, the patient had a transient transaminitis. A postoperative hepatic vascular ultrasound showed good hepatic arterial flow through the PHA and the transaminases normalized. The patient was discharged on postoperative day 9. She remains well without evidence of disease 7 months postoperatively, and has elected to receive no further chemotherapy. |
The second patient is a 72-year-old woman with a past medical history including hypertension, type II diabetes, and obesity, who presented with weight loss and steatorrhea. As her symptoms were suggestive of pancreatic exocrine insufficiency, and with the associated weight loss, she underwent a CT scan for additional evaluation. This demonstrated a suspicious 2.5-cm complex cystic pancreatic head mass with associated pancreatic gland atrophy and a dilated pancreatic duct. She was also noted to have fatty infiltration of the liver (although not overt cirrhosis) and ascites.\nShe was then referred for further evaluation. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography demonstrated diffuse dilation of the pancreatic duct up to 7.5 mm with an associated cystic mass in the head of the pancreas, suggestive of main duct IPMN (). EUS was attempted, but was unable to be completed due to severe tortuosity of her esophagus. Positron emission tomography (PET) demonstrated heterogeneous metabolic activity within the pancreatic uncinate process and to a lesser degree within the body and tail. Additional workup included a paracentesis to evaluate the ascites, which was unremarkable and ultimately deemed secondary to poor nutritional status from her exocrine insufficiency. Laboratory results were within normal limits with the exception of tumor markers and a mildly low albumin (3.4 gm/dL). Carcinoembryonic antigen was elevated at 6.0 ng/mL, and CA 19-9 was elevated at 46.7 U/mL. She was placed on pancrelipase, which resolved her symptoms of exocrine insufficiency and helped improve her nutrition.\nDue to the concern for main duct IPMN, she was referred for surgical resection. Again, it was unclear if the diffuse dilation of the pancreatic duct was secondary to involvement by main duct IPMN or due to proximal pancreatic duct obstruction. The patient was planned for a Whipple procedure with possible total pancreatectomy if high-grade dysplasia was noted intraoperatively at the resection margin. Upon transection of the pancreatic neck, IPMN with focal high-grade dysplasia was indeed noted at the margin. Due to the abnormal preoperative PET scan, in addition to the high-grade dysplasia at the margin, a completion pancreatectomy was performed. Due to her poor nutritional status preoperatively, a gastrojejunal feeding tube was placed at the time of the operation. She had an unremarkable postoperative course and was discharged with feeding tube supplementation.\nHer final pathology demonstrated a 1.1 cm well-differentiated mucinous colloid carcinoma arising in a background of IPMN (intestinal type) with foci of high-grade dysplasia and intermediate grade dysplasia throughout the remaining pancreatic duct (). Staining of the tumor was positive for MUC1, MUC2, and MUC5. All margins were negative. Zero of 24 lymph nodes was involved with tumor. Her final pathologic staging was pT2N0Mx. She was referred to medical oncology for discussion of adjuvant therapy and will be initiating gemcitabine adjuvant chemotherapy in the near future. |
In May 2016, a 67-year-old woman came primarily to our hospital for a consultation about painless mass of the left lower gingiva. Intra-oral examination showed a 46 × 25-mm tumor with induration on the left lower gingiva (Fig. ). A submucosal mass, independent of the gingival tumor, was palpable in the left buccal region. Several cervical lymph nodes on the left side were also palpable. Pathological examination of a biopsy sample taken from the gingival tumor revealed a well-differentiated squamous cell carcinoma.\nA computed tomography (CT) scan with contrast showed a large gingival tumor, with destruction of the adjacent mandibular bone, and four metastatic left-cervical lymph nodes that were markedly enlarged, non-homogeneously enhanced, and partially necrotic. These lymph nodes included two left submandibular and two left upper jugular nodes. CT imaging showed no metastases to the lungs. Magnetic resonance imaging (MRI) showed a large primary tumor on the left side, with its epicenter located in the lower gingiva. The tumor appeared to extend into the sublingual space medially and into the buccinator muscle laterally. A non-homogeneously enhanced mass was identified in the buccinator space along the facial vessels, anterior to the anterior edge of the masseter muscle, and lateral to the buccinator muscle (Fig. ). This mass lay on the cranial side of the primary tumor. The mandibular ramus and pterygoid region that are on the cranial side of BN were not invaded by primary tumor (Fig. ). Moreover, T1-weighted MRI showed a thin layer with high signal, indicative of fatty tissue, between this mass and the primary tumor, indicating that the mass was independent of the primary tumor. Based on its anatomic location, the mass appeared to be metastatic disease to BN. Greyscale sonogram showed some metastatic cervical lymph nodes on the left, and metastatic BN. These cervical lymph nodes were markedly enlarged, round in shape, heterogenous hypoechoic, and without an echogenic hilus. Metastatic BN was round in shape, hypoechoic, with well-defined borders, and without an echogenic hilus.\nThe tumor was diagnosed as a cT4aN2bM0 squamous cell carcinoma of the lower gingiva. The patient received neoadjuvant chemotherapy, consisting of docetaxel 60–70 mg/m2 and cisplatin 70 mg/m2 on day 1, and 5-fluorouracil 700 mg/m2/day 96 h continuous infusion. Gross examination after two cycles of chemotherapy showed marked shrinkage of the primary tumor. A slight reduction in BN size was observed. According to the Response Evaluation Criteria in Solid Tumors (RECIST) guidelines, version 1.1 [], this patient showed a partial response to treatment.\nThree weeks after the end of neoadjuvant chemotherapy, the patient underwent surgery, consisting of suprahyoid neck dissection (levels I–II) on the right side, classical radical neck dissection (levels I–V) on the left side, segmental mandibulectomy, and oromandibular reconstruction with a scapular osteocutaneous flap. The primary tumor and buccinator space including BN were dissected in continuity with neck dissection. Histopathological examination of the segmental mandibulectomy specimens showed that the alveolar bone and part of the bone trabeculae of the mandible had been resorbed and replaced by fibrous connective tissue. This tissue contained a few nests of squamous cell carcinoma, composed mainly of necrotic tissue with a small number of viable cancer cells and remnants of keratin pearls. The surgical margins were free from tumor. Metastatic disease was detected in five cervical lymph nodes, including one left submandibular aggregated-node, three left upper jugular nodes, and one left middle jugular node. No metastatic nodes revealed extra-nodal extension. Metastasis to BN was also present (Fig. ). These metastatic regions contained few viable cancer cells and consisted primarily of necrotic tissue.\nFollowing surgery, the patient was treated with adjuvant radiotherapy (50 Gy/25 fractions) with concurrent oral chemotherapy (S-1, 100 mg/day for 5 days per week for 5 weeks) []. Two years later, there has been no evidence of tumor recurrence or metastasis. |
A 71-year-old man with symptoms including a productive cough and fever was transferred to our emergency room. He underwent endoscopic removal of a fish bone and 1 week later was admitted to a local clinic for symptoms suggestive of mediastinitis. However, no mucosal defect was found during an esophageal endoscopic examination, and he was conservatively managed with nothing by mouth and antibiotics. After the productive cough and fever progressed, chest computed tomography (CT) was performed at the clinic, and the CT scan showed a wide esophageal perforation, mediastinal abscess, and right pleural empyema. Upon arrival at our institution, his blood pressure was steady, but he was tachypneic. A gastrografin esophagogram showed a perforation in the middle thoracic esophagus ().\nUrgent intervention was necessary, but the aspiration pneumonia progressed while the patient was in the intensive care unit. Moreover, he had a history of traumatic hemothorax and pleural drainage for empyema in the right chest, and there were some calcified pleural lesions visible in the CT scan. We thought that a right-side approach in the chest, which is the conventional option, would be time-consuming and present a high risk. Considering the patient’s septic condition and perioperative risk, we decided to avoid intervention with a thoracic incision, and therefore chose to perform neither a conventional thoracotomy nor video-assisted thoracoscopic surgery. Instead, we performed posterior mediastinal drainage with the Barovac PS400L (Sewoon Medical Co. Ltd., Cheonan, Korea) by making an incision on the left side of the neck on the second hospital day. However, the drainage seemed insufficient. On the following day, an esophageal endoscopy was performed, and results showed multiple sites of wall injuries; one perforation site was 26–30 cm from the incisor, another 3-mm perforation was 32 cm from the incisor, and a 2.5-cm-deep laceration was 35 cm from the incisor. We then inserted 2 Levin tubes via esophageal endoscopy: one 12-Fr tube was inserted into the mediastinum through the larger perforation site for internal mediastinal drainage and another 12-Fr tube was inserted into the stomach for gastric drainage (). After Stenotrophomonas maltophilia was identified during the initial microbiological culture of the sputum, the antibiotic regimen was adjusted.\nWe started continuous suction of 60–80 mm Hg both for the internal mediastinal drainage and for the gastric drainage. After beginning the aggressive mediastinal and gastric drainage, the patient’s condition improved. On the ninth hospital day, we performed a jejunostomy to provide sufficient nutritional support and a gastrostomy for gastric drainage and to allow one Levin tube to be removed. We maintained continuous suction for the internal mediastinal drainage, but we started natural drainage during the jejunostomy and gastrostomy. The patient was extubated on the 11th hospital day, and then he was moved to the general ward on the 18th hospital day. The next day, we turned off the suction for the mediastinal drainage and started to drain naturally, because the amount of drainage was sufficiently reduced. The microbiologic culture obtained on the 13th hospital day showed no pathologic microorganism other than normal flora, and the results of multiple consecutive microbiologic cultures were the same.\nThe remaining Levin tube for the internal drainage was removed on the 25th hospital day. At the follow-up endoscopic examination on the 26th hospital day, the previous injury sites were nearly healed, and there was only a 0.5-cm defect 28 cm from the incisor (). According to the follow-up chest CT scan obtained on the 29th hospital day, there was a notable decrease in the extent of the mediastinal abscess. The follow-up esophagogram on the 39th hospital day showed no evidence of leakage, so the patient was started on an oral diet. Finally, the patient was discharged on the 46th hospital day. There were no abnormal findings on the last follow-up esophagogram and endoscopic examination 6 months after the initial presentation. |
The patient is a 69-year-old woman. She was infected with pneumonia at the age of three and had a high fever for a long period. After the fever abated, she became aware of hearing loss. Because she lived in a mountain village, she rarely visited medical facilities. Since then, she had never worn a hearing aid, had gone to a school for the deaf from elementary school to high school, and communicated with people in sign language. Her husband also used sign language, so she had not used oral communication from elementary school to the present. In 2011, family stress triggered the onset of tinnitus. Because around the same time, she began suffering from sleep onset disorder (it took about one hour until sleep onset), nocturnal awakening, and palpitations, she went to a nearby psychosomatic medicine clinic. She received medication at the clinic but her tinnitus did not improve, so she was referred to our department in 2014.\nVarious questionnaires were given at her consultation. The result of THI (Tinnitus Handicap Inventory) [], which is used to evaluate the severity of tinnitus, was a high of 94, which indicates the most severe form of tinnitus. Also, an SDS (Self-rating Depression Scale) [] score, which is used to measure depression tendency, was as high as 61, showing that she had a tendency toward depression. The STAI (State-Trait Anxiety Inventory) [], which is used to measure anxiety tendency, returned a State Anxiety (STAIs) score of 69 and a Trait Anxiety (STAIt) score of 67, indicating that she had an extremely high anxiety tendency. As one of the personal features of her tinnitus, she had no concept of the “loudness of tinnitus” because she had been deaf since childhood.\nIn imaging tests, there were no abnormal findings except for a slight enlargement of the inner ear canals observed by temporal bone CT scan. Head MRI showed no abnormal findings within the skull or in the internal auditory canals.\nFor treatment, we started oral administration of a serotonin reuptake inhibitor (SSRI) (paroxetine hydrochloride, Paxil®, 12.5 mg, started as one tablet a day, increased to three tablets a day) and a sleep-inducing agent (suvorexant, Belsomra®, 15 mg, one tablet a day). One and a half months later, the sleep onset disorder and nocturnal awakening improved, but early morning arousal persisted. Then, a benzodiazepine anxiolytic was added (etizolam, Depas®, 0.5 mg, one tablet a day). At four months after the initial visit, THI was 84, SDS 43, STAIs 50, and STAIt 48, which showed that her psychological condition had improved, although the tinnitus distress level did not change.\nAt this time, there was no improvement in perceived palpitations, and “pulsatile tinnitus” that seemed to synchronize with the heartbeat became the chief complaint concerning tinnitus, which led us to suspect that she had autonomic disorders. Six months after the initial visit, she started to receive psychotherapy (autogenic training). After the start of the treatment, we treated the patient with psychotherapy once a month, which continued until the 7th therapy session was completed. At the end of psychotherapy, our test results showed THI at 60, SDS 45, STAIs 32, and STAIt 43, showing a further improvement trend. The THI score was still high at 60, but the subjective tinnitus distress became “not so annoying,” and the “echoing tinnitus” that was the cause of the patient’s discomfort at the time of the initial visit disappeared. Only the pulsatile tinnitus, which seemed to be related to palpitations, remained.\nOne year and seven months after the initial visit, palpitations and pulsatile tinnitus, as well as anxiety and insomnia, were aggravated due to work stress. She restarted psychotherapy. At the same time, SSRIs were replaced by noradrenergic and specific serotonergic antidepressants (NaSSAs) (mirtazapine, Reflex®, 15 mg, started as one tablet a day, increased to two tablets a day). As a result, improvement of the palpitations and insomnia gradually occurred, and two years and one month after the initial visit, our test results showed THI at 40, SDS 47, STAIs 40, and STAIt 46.\nBy three years after the initial visit, the symptoms had stabilized and the anxiolytic drug was discontinued, but oral administration of the NaSSA and sleep induction drugs continued. The subjective tinnitus and palpitations at the time of sleep almost disappeared, and the sleep onset disorder and nocturnal awakening rarely occurred.\nNow 4.5 years have passed and she is taking only a low dose NaSSA (mirtazapine, Reflex®, 15 mg, 0.5 Tablets a day). The latest test results were THI 0, SDS 43, STAIt 47, and STAIs 50, indicating that the tinnitus distress had disappeared completely. |
An 11-year-old female was referred by her dentist in Community Medical Center to the Orthodontic Section, Department of Dentistry, Hamad Medical Corporation, Doha, Qatar, with the chief complaint of a swelling on the left side of her lower jaw since three months earlier. The swelling had been growing slowly over the period and was associated with no pain or discharge. The overall general physical health of the patient was good with nonspecific general medical history, without any contraindication to dental treatment.\nThe extraoral examination revealed a symmetrical orthognathic facial profile with no signs of neurological deficit in the lower half of the face. There was no sign of any regional lymphadenopathy. Intraoral examination revealed a mixed stage of dentition, bilateral Class I molar relationships and Class I incisors. A hard, non-tender, non-fluctuant swelling of 2.5 × 2 cm was evident in the lower left vestibule, extending from the distal surface of the left permanent canine to the distal surface of ipsilateral first permanent molar. The swelling was associated with expansion of buccal and lingual cortical plates and covered by healthy-appearing and freely-moving mucosa. The teeth adjacent to the swelling were quite firm and not associated with any decay. A panoramic radiographic examination (OPG) revealed the presence of all the permanent teeth without any decayed or supernumerary teeth. There was a well-circumscribed unilocular radiolucent lesion in the body of the mandible on the left side, which was associated with the crown of a vertically impacted second premolar. The root of the impacted second bicuspid was developed approximately up to half of its usual length and the apex was quite wide open. The cystic structure appeared to have originated from the second bicuspid with inferior and distal displacement of the same tooth. The corresponding deciduous tooth (second molar) was still present with normal crown and roots\n().\nA clinical diagnosis of a dentigerous cyst involving the crown of the impacted left mandibular second bicuspid was made with the differential diagnosis of an inflammatory cyst, a keratocyst and a unilocular ameloblastoma.\nAims and objectives\nConsidering the age of the patient, her occlusal status, size of the cyst, position, and developmental stage of the root of the involved tooth a conservative treatment modality was decided upon. The main objectives of the treatment were clinical and radiographic elimination of the pathologic entity and to bring the involved permanent tooth into its proper position.\nTreatment plan\nExtraction of the left mandibular second deciduous molar and decompression of the cyst through the extraction socket.\nHistopathologic examination of the cystic lining.\nTrans-lingual arch to hold the permanent first molars bilaterally in their current position and to maintain the space for unerupted left bicuspids.\nFollow-up of the progress of eruption of the impacted second bicuspid with periodic radiographs.\nFitting of a fixed orthodontic appliance for final alignment of teeth in due course if needed.\nTreatment progress\nThe left second deciduous molar was extracted under local anesthesia (2% Lidocaine with 1:100,000 Epinephrine) and the socket was used to establish a communication between the cyst cavity and the oral cavity. An incisional biopsy was obtained from the cyst wall for histopathologic examination, which confirmed the initial diagnosis of a dentigerous cyst without evidence of any dysplastic changes. A BIPP (bismuth iodoform paraffin paste) gauze pack was inserted into the cyst cavity and secured with a suture. One week after surgery, the pack was removed and repacking was done with another BIPP gauze pack, which was kept in place for another week. Two weeks after surgery, the patient was sent back to an orthodontist for the fabrication of trans-lingual arch and for further follow-up\n().\nHowever, the patient could not return for further follow-up and treatment as she was out of the country. She reported eight months after the initial surgery and at this stage the clinical examination revealed inadequate space for the unerupted second premolar. The panoramic view (OPG) showed a favorable change in the position of the impacted premolar with increased\nradiopacity of cystic lesion, suggesting osteogenesis\n(). A fixed orthodontic appliance was fitted in the lower arch without further delay with the aim of reopening the lost space for the impacted premolar and preventing mesial migration of the permanent first molar. The space was opened with the help of an open coil spring and the permanent first molar was held in position by a mesial stop in the archwire. The impacted premolar was monitored for its eruption by periodic panoramic radiographs\n(). After twenty-four months, the impacted premolar erupted spontaneously. The tooth was bonded and engaged into the archwire when it erupted up to bondable crown height. After a few weeks it was aligned to its normal occlusal position (in relation to its adjacent, contralateral and opposing teeth)\n(). It took a total of 37 months to finish the treatment. The final panoramic view which was taken just after debonding shows complete radiologic healing of the cystic lesion with normal trabecular bone and normal alignment of the impacted left mandibular second premolar\n(). |
A 48-year-old man with a 6-month history of anorexia, lasting mild fever, and general fatigue one month after having his teeth extracted noticed slight impairment of his visual acuity over a month. He had no previous history of immunological disorder including HIV infection. He visited an ophthalmologist and was immediately referred to our hospital because of rapid aggravation of his vision in the preceding few days. The radiological study showed an intrasellar mass with ring-enhancement compressing the optic chiasm on MRI (). His visual acuity continued to aggravate very rapidly. He finally became almost blind and comatose on the second day of the admission. He underwent urgent transsphenoidal surgery to diagnose and remove the mass. During surgery, he was diagnosed with a pituitary abscess based on the findings of the white-green pus from the intrasellar cystic mass. The sella was irrigated with copious normal saline after the pus was evacuated. Cerebrospinal fluid (CSF) leakage was not seen intraoperatively. Because there was concern about the recurrence of the abscess, we hesitated using devascularized tissue such as abdominal fat for the intrasellar packing. Therefore, nothing was placed in the sella. The anterior wall of the sella was reconstructed using the vomer bone. Immediately after surgery, the patient's consciousness and visual impairment showed a remarkable improvement. He received intravenous administration of 2 g of cefotiam twice a day for a week. Postoperative MRI showed total drainage of the abscess. No causative agents were identified by Gram-staining or postoperative culture. Nineteen days after the surgery, however, he suddenly presented with CSF rhinorrhea, high fever, and severe headache. The emergency computerized tomography revealed the presence of air in the lateral ventricles (). MRI revealed no findings of recurrent abscess (). Lumber puncture showed an elevation of cell count to as many as 4250/mm3 (99% neutrophils). CSF culture failed to show any bacterial growth. Because these findings indicated severe bacterial meningitis, intravenous antibiotic therapy was immediately initiated using 2 g of penicillin and cefpirome twice a day. His symptoms subsided and the laboratory findings including CSF cell count became normal over a week. He was discharged and has had no recurrence of abscess and meningitis in six months. |
A 22-year-old female patient was admitted to our clinic with swelling at the site of the vaccination. She had received her Td vaccination for internship 3 weeks ago, and the swelling had started at the injection site 4 days following this immunization. The vaccine was a toxoid vaccine containing aluminum adjuvant (Tedatif; Turk Drug and Serum Industry Inc). On physical examination, this mass was about 6 × 6 cm in size and fluctuating, but had no pain, and no redness (Fig. ). Oral amoxicillin/clavulanic acid (daily 2 × 1 gram) and local antibiotic (2% cream, Fusidic acid 2 × 1) were applied for 10 days. She had no immunosuppressive disease and no history of recurrent infection. On her medical history, she had received all of her childhood vaccinations and had not experienced any serious side effects. During admission, the patient had no history of trauma, and no fever, and no lymphadenopathy on examination. The laboratory values showed a total white blood cells count of 6500 cells/ McL, with 70% neutrophils, while C3, C4, immunoglobulin (Ig) A, IgM, IgG, IgE, sedimentation rate, and C-reactive protein were within normal ranges. Serology for human immunodeficiency virus was negative. On ultrasound, two interconnected abscesses were seen in the subcutaneous area, and did not involve the muscle tissue (Fig. ). She was not pregnant and did not receive any other vaccines simultaneously. Despite the administration of antibiotics, the swelling did not regress, and on the contrary, continued to increase in size. Later, the abscesses were completely drained, and the samples were cultured. The current antibiotics were continued. The gram staining of the samples revealed abundant leukocytes but no microorganisms. The solid and liquid cultures of the materials remained negative, although they were repeated more than once. Under the current antibiotic treatments, the swelling appeared again at the same site 6 days after the first draining. Then the mass was re-drained. The cultures of samples remained negative and no specific etiology was reached. However, seven days after the second draining, the mass re-appeared. Following the drainage, the abscesses were cultured. The abscess aspirate was not cultured for tuberculous bacilli. The Ehrlich-Ziehl-Neelsen of the sample was negative and other results including cultures and gram staining of the specimens remained negative. After a course of 23 days of treatment, the causal etiology was not identified. Finally, the patient was regarded as having a sterile abscess due to the Td immunization. The antimicrobials were stopped and oral prednisolone (daily 40 mg) and mometasone furoate (0.1% cream, 2 × 1) were initiated. The swelling regressed significantly, and the treatments continued for seven days. The patient has been doing well and no recurrence has been observed for over a year. |
A 67-year-old female, with a typical presentation of carpal tunnel syndrome in the right hand, presented initially with numbness in digit IV and V a year later. A few months later, she developed numbness in all five fingers on the left side. Furthermore, the patient mentioned that she had had a burning sensation in both feet for a few years. Another few months later she complained of weakness in all four limbs and was sent for a neurological consultation with electromyography. Clinical examination revealed a Hoffmann-Trömner reflex on the left side, mild loss of strength in both hands, loss of vibratory sense and hypoesthesia in the distal end of all four limbs and loss of proprioception in both legs. The electromyography showed disturbed sensorimotor signals in the left hand and mildly disturbed sensorimotor signals in the right hand. The disturbed electromyography was attributed to carpal tunnel syndrome, which was presumably less severe on the right side due to treatment with long acting corticosteroid injections. The paresthesia in digit IV, digit V and both feet, however, could not be explained with the diagnosis of carpal tunnel syndrome. Therefore, magnetic resonance imaging (MRI) of the cervical spine was performed. Imaging showed an extra-dural soft tissue mass posterior to the odontoid process of the axis. The mass extruded through the transverse ligament of the atlas with severe compression of the myelum and myelomalacia at the level of C1 (Figures , and ).\nA plain radiograph of the cervical spine was performed to check for atlanto-axial instability. The radiograph during flexion shows a slightly widened atlantodental interval, measuring 4 mm (normal value: <3 mm) (Figure and ).\nPre-operative imaging of the cervical spine also revealed an anatomical variant of the craniocervical junction, atlanto-occipital assimilation of the massa lateralis bilaterally (Figure ).\nThe patient was treated with laminectomy of C1 to decompress the spinal canal followed by posterior fixation of C1-C2 for stability. |
A 71-year-old female patient was presented to the emergency department after falling from her own height with a direct contusion on both hands, with the wrist and elbows in extension. She had a past medical history which was positive for arterial hypertension (treated with Captopril) and rheumatoid arthritis (treated with Leflunomide).\nHer fall resulted in localized pain in both shoulders, and limited range of motion leading to an inability to perform activities with her arms raised above the head. X-rays were taken on an anteroposterior (AP) bilateral view (Figure ), and she was diagnosed with a Neer III bilateral displaced proximal humerus fracture.\nSimple X-rays are the most commonly used diagnostic method for a proximal humerus fracture, and often two different views are necessary to analyze the pattern of a fracture. AP and lateral views should be taken. In cases of complex fractures or uncertainty based on the x-rays, a computed tomography (CT) scan can be used.\nAfter a clinical evaluation of the patient, though there was no contraindication for surgical treatment, conservative treatment was chosen to address the pathology. Two hanging casts were placed using two slings on both arms. A week later, a control x-ray was taken showing a reduction of some of the fragments (Figure ).\nAt week three of treatment, a new x-ray was taken showing even more bone fragment reduction when compared to week one (Figure ). Clinically, the patient showed consolidation with partial radiographic consolidation, so the casts were removed. She continued to use the bilateral slings and initiated pendulum movements for the following three weeks at home. She initiated active movements at week six.\nAt the week seven follow-up consultation, she arrived with only mild pain during any activity behind the back during active internal rotation on both arms. The bilateral ranges of motion were as follows: flexion, 100°; extension, 15°; internal rotation, 100°; external rotation, 90°; abduction, 100°; adduction, 30°; muscle strength, 5/5; with no alteration of the distal neurovascular status (Figure ). We obtained the Disabilities of the Arm, Shoulder and Hand (DASH) Score of 16/100 (100 representing the worst-case scenario). |
A 68-year-old Chinese female was admitted to our department for an incidental discovery of a nodule in her left breast. She was diagnosed with grade 2 clear cell RCC 10 years earlier, and she underwent a nephrectomy for an incidental kidney mass found during a routine imaging examination. No abnormal findings were revealed during the physical examination or laboratory tests. Diagnostic mammography showed an asymmetric, dense shadow in the inner, upper quadrant of the left breast, and no obvious nodules were identified in the oblique view. Breast ultrasonography (US) of the left breast (Fig. ) revealed a solid hypo-echoic nodule of approximately 10 mm × 6 mm in size with an oval shape, smooth edges and a well-defined boundary. Color Doppler flow imaging showed abnormal blood flow. The resistive index (RI) was 0.62–0.67. Elastography showed a completely soft lesion, which was classified as E2. We paid close attention to the extensive vascularity accompanying the nodule. Subsequent breast magnetic resonance imaging (MRI) (Fig. ) revealed a nodule with marked homogenous contrast enhancement in the left breast adjacent to the chest wall. The nodule was given a score of IV B based on the Breast Imaging Reporting and Data System (BI-RADS) [].\nDue to the limited volume, deep location, and abundant vascularity of the lesion, as well as the risk of bleeding, percutaneous US-guided core needle biopsy was not performed. Surgical excision of the nodule was performed. Macroscopically, a suspicious nodule was found at the site of the specimen, but unfortunately, no pictures were taken during the surgery. Microscopically (Fig. –d), the nodule was similar in appearance to the RCC in the primary renal site. Nests, sheets, and cords of polygonal cells were present in the nodule and were associated with a rich sinusoidal vascular network (Fig. –d). Immunohistochemistry staining revealed strong positive labeling for the cluster of differentiation 10 (CD10) and vimentin, and an absence of labeling for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (Her-2). This staining pattern further suggested metastatic RCC to the breast (Fig. –f). Currently, there are no clinical or radiological findings regarding the recurrence of metastasis after 2 months of follow-up. The patient has undergone no further therapy since the surgery. |
A 22-year-old young female presented in outpatient department (OPD) for uncontrolled hypertension from past 3 years, she has a past history of subarachnoid hemorrhage in 2016 for which she underwent craniotomy with right middle cerebral artery aneurysm clipping. On clinical evaluation, she had a blood pressure (BP) of 180/110 mm Hg in both the upper limbs, with no palpable pulses in both the lower limbs, prominent suprasternal pulsations with a systolic murmur in the left side precordium and a soft bruit over the back on both the sides. Her routine blood investigations were within normal limits\nHaving a possibility of coarctation of aorta, she was subjected for detailed cardiac evaluation. Electrocardiogram (ECG) revealed normal sinus rhythm. 2-D echocardiogram (ECHO) had evidence of coarctation of the aorta (post ductal) with high gradients (94 mm Hg), normal left ventricular function. Chest X-ray showed signs of bilateral posterior rib notching in the inferior aspect and no evidence of aortic dilatation (). The patient was subjected for computed tomography (CT) aortography for localizing the site and extent of coarctation of aorta which revealed coarctation of aorta 22 mm caudal to the origin of the left subclavian artery, measuring 4 mm in length and about 2.3 mm in caliber. Bilateral extensive collaterals were seen in the scapular, paravertebral and posterior thoracic wall with hypertrophied right internal mammary artery (RIMA), left internal mammary artery (LIMA) and intercoastal arteries. B/L renal arteries were normal (). The diagnosis of coarctation of the aorta with secondary hypertension was made, and the patient was planned for coarctoplasty. The patient underwent successful coarctoplasty through right femoral artery approach using a Tyshak balloon measuring 15 × 30 mm (). The stent was not placed as the results were very good with gradients across the coarctation of aorta reducing from 95mm Hg to 10 mm Hg post balloon dilatation. The patient tolerated the procedure well and her BP of both the upper limbs dropped to 130/80 mm Hg and lower limb systolic BP measured 120 mm Hg with easily palpable pulses (). |
A 47-year-old male presented with dizziness for 10 days, and he also complained that he once had a sudden loss of consciousness accompanied by convulsion of his limbs which lasted for 3 min at the this duration. Syndromes of headache, vomiting, and hypoplasia were not described. Mild cognitive impairment and weakness of the right side were detected at admission.\nComputed tomography (CT) of the brain were performed, which manifested multiple intracranial lesions synchronously. Positron emission tomography-computed tomography (PET-CT) revealed no abnormal neoplasms in the other tissues of the body. The magnetic resonance imaging (MRI) revealed 4 occupying lesions with surrounding edema in the left frontal and parietal lobes. Deep-seated lesions invaded to the parenchyma adjacent to the left ventricle, contributing to the mass effect and middle line shift. The whole masses presented with a heterogeneously ring-enhanced character with necrosis and cystic changes after gadolinium (Gd) administration (Fig. a–i).\nThe patient underwent a left frontoparietal craniotomy of 3 lesions with the guidance of intraoperative navigation and sodium fluorescence-guided technique. Lesions were seen with grey appearance, obscure boundary, and rich blood supply and removed for decompression of the intracranial pressure. We successfully resected the masses micro-surgically for additional biopsy. Then, the gross total resection of these masses around their approximate boundary was achieved. We used the same way to resect the last lesion in occipital lobe under prone position.\nHistopathological examination revealed that these tumor cells possessed increased necrosis, and significant heterogeneity of nucleus (Fig. j, k). Immunohistochemical staining demonstrated that these lesions shared the similar characters of intensity of the biomarkers such as glial fibrillary acidic protein (GFAP) and Olig-2. The abnormal expression of Ki-67 (20%) revealed the potential proliferation activity of the tumor cells which indicated poor prognosis and high incidence of recurrence. Both the lesions showed the amplification of epidermal growth factor receptor (EGFR), which indicated the high aggressiveness. Pathological results were compatible with a diagnosis of multifocal glioblastoma. We also performed the whole genome sequencing (WGS) of the four lesions. The WGS results revealed that four samples had TERT promoter mutation C228T (chr5:1,295,228:C>T), but none of IDH1/2 mutation, ATRX mutation, and EGFRvIII were detected.\nThe patient presented with no other abnormal neurological signs and his right limb’s strength had improved gradually after operation. There was no recurrence of his epilepsy at this duration. After 5 weeks, a follow-up MRI was performed before radiotherapy and revealed that local tumor control was achieved and the initial resection cavities were seen; however, two new lesions occurred adjacent to the primary lesion areas and exhibited intense enhancement; nevertheless, remarkable mass effect and middle line shift were not observed either (Fig. a–i). Concurrent radiotherapy and chemotherapy were then administered to the patient.\nIntensity-modulated radiotherapy (IMRT) targeted these lesions and areas of enhancement. A dosage of 60.0 Gy in 30 fractions were performed and constantly orally administered temozolomide (TMZ), with a dosage of 120 mg (75 mg/m2/day) per day for 46 days were also performed to achieve the concurrent radio-chemotherapy. Side-effects and toxicity such as liver and hematopoietic dysfunction did not occur.\nThe following adjuvant chemotherapy of temozolomide with 240 mg (150 mg/m2/day) for 5 days every 28 days was then administered to the patient. Hematologic and gastrointestinal toxicity was examined every cycle and no significant abnormality was detected. We also monitored the functions of liver and kidney constantly. Dysfunctions of the organs and anaphylaxis were also not seen. After 2 cycles, the repeat MRI revealed that the former two new lesions enlarged distinctly, manifesting ring-enhanced character, and two more new lesions had emerged again, infiltrating the white matter tract of ventricles and parenchyma (Fig. a–i). Eventually, the patient abandoned the chemotherapy after the 2 cycles due to his low quality of life. The patient died 1 year later. |
A 45-year-old male walked into our center with a history of pain in the left submandibular region for the past 6 months. The pain was dull, intermittent, and associated with meals, and the swelling enlarged in that area during and after meals.\nOn extraoral examination, there was a localized swelling in the left submandibular region measuring approximately 4 cm × 3 cm. The swelling was soft and tender on palpation with normal overlying skin. Intraoral examination revealed an edematous floor of the mouth on the left side. Intraorally, on bimanual palpation on the floor of mouth, a hard mass measuring approximately 3 cm × 2 cm was felt in the premolar-molar region. Milking of the left submandibular gland yielded very less saliva but pus discharge.\nOrthopantomogram (OPG) [] and lateral oblique view of the mandible [] revealed a calcified mass, exactly mimicking an impacted canine tooth in the premolar-molar region. In the occlusal view x-ray of the mandible [], this calcified structure was seen bearing a close resemblance to a canine tooth but the radiopacity was homogenous. On the basis of clinical and radiological findings, a diagnosis of the sialolith of the left submandibular salivary gland duct was done.\nConsidering the large size of the sialolith (giant), transoral sialolithotomy was done under local anesthesia after giving a proper antibiotic cover. Upward and medial pressure was applied at the submandibular area for stabilizing the floor of the mouth and for proper localization of the sialolith. Intraoral mucosal incision was placed directly over the sialolith. After careful mucosal dissection, the submandibular duct was identified and incised over the sialolith. The giant sialolith was mobilized and gently picked with tissue forceps and the wound was closed only at the mucosal layer. In the subsequent follow-up at 6 months, there was complete remission of the symptoms with effective salivary drainage and normal function of the submandibular gland. The sialolith removed [] measured 31 mm in length and 16 mm in circumference, weighing 1.250 g.\nOn the basis of clinical, radiological and histopathological findings, the diagnosis of a giant sialolith of the submandibular salivary gland duct was confirmed. Stone analysis report revealed 100% carbonate apatite, as done by the fourier transform infrared spectroscopy (FTIR) technique. |
A 63-year-old Japanese woman was referred to our department because of an abnormal shadow at the left side of her chest wall on computed tomography. She had undergone total hysterectomy and radiotherapy for cervical carcinoma 4 years prior. One year after the first surgery, three metastatic lung nodules appeared at the upper lobe of her right lung, the lower lobe of her right lung, and the lower lobe of her left lung. Wedge resection for upper and lower lobe of her right lung was initially performed via three-port thoracoscopic surgery. Then, wedge resection for the lower lobe of her left lung was performed via eighth intercostal single incisional thoracoscopic surgery. After the surgery, an intrathoracic chest wall mass developed which increased in size gradually. Her gynecologist introduced her to our department for surgical resection of the mass. Her family, including her parents and two sisters, had been healthy and had no inheritable diseases. She had no symptom, drug history, tobacco smoking history, or psychosocial history, and she was a social drinker. She had not received any medications since the mass developed and until admission to our hospital. She had undergone an operation three times as mentioned above and had been a carrier of type B hepatitis.\nAfter her admission to our department, her general condition was good, and there were three operative scars at both sides of her chest and lower abdomen. Her chest sounds were clear and there was no neurological abnormality. She was 151.1 centimeters tall and weighed 49.8 kilograms. Her heart rate was 77/minute, blood pressure was 135/87 mmHg, and body temperature was 36.1 °C. The laboratory findings were white blood cells 5.25 × 103/μL, hemoglobin 12.7 g/dL, and platelets 156 × 103/μL. A liver function test revealed: albumin 4.6 g/dL, aspartate aminotransferase 15 U/L, alanine aminotransferase 13 U/L, and total bilirubin 0.3 mg/dL. A renal function test revealed blood urea nitrogen 13.6 mg/dL and creatinine 0.79 mg/dL. An electrolyte test revealed sodium 143 mEq/L, potassium 3.8 mEq/L, and chlorine 106 mEq/L. A tumor marker test revealed carcinoembryonic antigen 3.4 ng/mL and squamous cell carcinoma antigen 0.80 ng/mL. Another test revealed positive reaction to type B hepatitis surface antigen and C-reactive protein < 0.1 mg/dL. Computed tomography demonstrated a gradually increasing low-density mass measuring 2.0 × 1.8 cm in diameter (Fig. ). Magnetic resonance imaging demonstrated a low-intensity mass in T1-weighted imaging and a high-intensity mass in T2-weighted imaging (Fig. ). The mass was thought to be a singular cyst; however, this type of cyst was rare and the mass was increasing. Therefore, dissemination of cervical carcinoma could not be excluded, and surgical removal of a part or tissue of the mass was performed.\nIn the right lateral position, thoracoscopic excision of the mass was done with two ports (3 mm and 2 cm access ports) by two general thoracic surgeons (Fig. ). First the 3 mm port was set at the sixth intercostal space on the inframammary line. Most of her left lung was attached to her chest wall; therefore, the second port was set above the cyst and lysis of adhesions was done. After the lysis, the cystic mass was found adhering to the upper lobe of her left lung. The adhesion of the mass to her lung was not strong and could be separated without injury to the visceral pleura. Therefore, the mass was thought to derive from the chest wall pleura and was resected by adhesiolysis.\nThe mass was a unilocular cyst containing mucinous fluid. On microscopic examination, the cyst was lined with a single layer of cuboidal epithelium (Fig. ); immunohistochemistry showed positive staining of calretinin and D2-40 (Fig. ). Thus, the cyst was diagnosed as mesothelial cyst derived from the chest wall pleura. Five years after the surgery, our patient had no evidence of cyst or cervical carcinoma on computed tomography. |
A 62-year-old woman presented with a one-month history of sudden painless visual loss in the right eye. On examination, best corrected visual acuity (BCVA) was 20/20 in both eyes. Intraocular pressure was 21 mmHg in both eyes. Dilated funduscopic examination in the right eye revealed retinal emboli inferior to the optic disc obstructing a small arteriole associated with retinal ischemia (Figures and ). The left eye was unremarkable. There was no prior past ocular history. The patient had hypertension and hypercholesterolemia and had an extensive smoking history.\nFluorescein angiography revealed delayed retinal perfusion along the inferior arcade in the right eye (Figures and ). Optical coherence tomography showed normal foveal contour with inner retinal ischemia and thickening, consistent with an acute inferotemporal branch retinal artery occlusion (). The patient was started on Latanoprost at nighttime in the right eye to lower the intraocular pressure in hopes to increase reperfusion of the retina. An extensive cardiovascular workup was done, and significant carotid artery stenosis of less than 70% was found. She was started on plavix and aspirin by her cardiologist. The patient continued with BCVA 20/20 OU vision and persistent highly refractile peripapillary emboli; retinal ischemia resolved. Her OCT showed inner retinal atrophy (Figures and ).\nUnexpectedly, the patient presented with a three-day history of sudden painless visual loss OD a year and a half after her initial presentation. BCVA was counting fingers (CF) in the right eye. Fundus exam revealed new superotemporal retinal ischemia associated with two new emboli. OCT demonstrated thickening and hyperreflectivity of the inner retinal layers consistent with an acute BRAO OD (). The patient refused fluorescein angiography at that time. Urgent workup revealed worsening stenosis to 80% in her right common carotid artery. The vascular surgery referral prompted a right carotid endarterectomy with a carotid stent placement approximately two months following her presentation with acute vision loss.\nAfter endarterectomy, vision in the right eye improved from counting fingers to 20/200 and 20/250 at 2 months and 6 months, respectively. Postoperatively, retinal whitening resolved and reduced intraretinal edema was noticed (). One year after endarterectomy, visual acuity was 20/30. The retinal swelling had resolved (). |
This is a case of a 30 year-old gentleman with a history of Crohn's disease. He was on a regimen of infliximab, infused every 8 weeks and oral methotrexate daily. He had no other significant medical history. He was in his usual state of health until he developed a sore throat and fevers on day 0. His symptoms began while he was traveling in Europe. During his trip, he took a 10-day course of amoxicillin and felt some improvement.\nAfter returning to the US he felt well but on day 14 he developed fevers and sore throat again. He was evaluated at an urgent care clinic and sent home with a diagnosis of a viral syndrome and instructed to treat this with non-steroidal anti-inflammatory agents. He felt some improvement initially but presented again on the day of admission with concern that he may not be well enough for his infusion of infliximab. He was found to have a temperature of 38.3 C and on day 30 was sent to the emergency department for further evaluation.\nIn the emergency department, he reported a non-productive cough, fevers, and sore throat. He had elevated liver enzymes: aspartate aminotransferase (AST) 340, alanine aminotransferase (ALT) 540, alkaline phosphatase 145. Additional testing was sent including a Monospot test, cytomegalovirus (CMV) and Epstein's Barr virus (EBV) serum viral levels, respiratory viral panel by PCR, adenovirus serum viral level, HIV antibody/antigen as well as HIV viral level, viral hepatitis serologic panel, human herpesvirus type 6 (HHV6) serum viral level, Varicella zoster virus (VZV) serum viral level, and syphilis IgG. He was admitted to the inpatient medicine service for fevers and hepatitis of unknown origin. His social history was remarkable for frequent trips to the Midwest for work. He did not pursue outdoors activity while traveling. He did not smoke, drink alcohol or use illicit drugs.\nOn day 31 he developed daily fevers to 40 C and subsequently progressed to hypoxemic respiratory failure that required high-flow supplemental oxygen and transfer to the intensive care unit. He had a chest CT showing ground-glass opacities at the lung bases and a left upper lobe nodular opacity (, ). His CT also demonstrated tonsillar enlargement and splenomegaly. He had a laryngoscopy performed that revealed an exudative pharyngitis. He was noted to have atypical lymphocytosis that peaked to 12,000 cells/uL on day 33. He was started on broad-spectrum antibiotics for presumed hospital-acquired pneumonia; including coverage of atypical organisms. He underwent a bronchoscopy on day 33. Bronchoalveolar lavage (BAL) fluid was negative for Legionella culture, AFB stain and culture, pneumocystis stain, and bacterial culture. Mycoplasma, zygomycetes and Mycobacterium tuberculosis were not detected by PCR. A respiratory viral panel by PCR from the lavage fluid was positive for Bocavirus and one of 2 samples for aspergillus galactomannan was moderately elevated but later determined to be negative on repeat testing.\nOn day 33 his AST peaked at 351 and his ALT at 662. His viral studies sent earlier returned negative. He had further serologic testing for atypical organisms including Blastomyces, Coccidioides, Q fever, Bordetella pertussis, as well as urine Legionella antigen that all returned negative. He was started on methylprednisolone and his fevers improved. His antibiotics were discontinued when his bacterial cultures were negative at 48 h. On day 37 the fungal PCR from BAL returned positive for Histoplasma capsulatum and cultures from that fluid later grew the organism. Urine Histoplasma antigen testing, sent earlier during his hospitalization, ultimately returned with a titer of 2.16 ng/mL (normal high 0.1 ng/mL). His Coccidioides antibody was also positive, but this was felt to be due to cross-reactivity from his Histoplasma infection.\nOn day 37 he was started on liposomal amphotericin B and 6 h later he had his highest fever to 42 C along with hypotension, tachycardia and worsening hypoxemia despite having received a dose of methylprednisolone earlier that day. He was felt to have a paradoxical worsening with treatment and exacerbation of immune reconstitution inflammatory state rather than an infusion reaction due to amphotericin given this time course . His infliximab was restarted the following day with subsequent resolution of his fever, hemodynamic instability and improvement in his respiratory status within hours of this infusion. He continued amphotericin B for one week before transitioning to oral itraconazole. His ALT/AST improved significantly. He was discharged on oral itraconazole with continued clinical improvement and recovery as an outpatient. |
A fifty-six-year-old female resident from a remote village in Nepal presented to our emergency six hours after a fall from a tree which she had climbed to collect food for her livestock. She was taken to a district hospital. The X-ray of cervical spine showed cervical spondyloptosis and she was referred to our tertiary care centre. At the time of presentation in the ER room, her Glasgow coma scale was 15/15 and she was neurologically intact. General systemic examination was normal. She was complaining of neck pain so a rigid cervical collar was placed. Her single breath count (SBC) was >20 and there was no evidence of Horner's syndrome. As the previous X-ray showed some doubt in the lower region of her subaxial spine, we investigated with the CT scan her cervical spine which confirmed cervical spondyloptosis at C7-T1 region (). She was started on methylprednisolone as per the national acute spinal cord injury study (NASCIS III) protocol. Gradual traction with continued neurological examination was applied to her and X-ray was checked to prevent overdistraction. Despite the application of recommended weight there was no evidence of reduction which probably was because of bilateral locked facet joints ().\nThe decision was taken for manual reduction under anesthesia followed by global fixation with a view of providing rigid stable construct to a mobile cervical segment (cervicothoracic junction). An anterior cervical discectomy was done; then the posterior approach was taken. Fractures of the spinous process and lamina of C7 were confirmed. Reduction of the locked facets with alignment of the anterior and posterior spinal lines was confirmed by C-arm. Lateral mass screws were placed at C6; crossed laminar screws were placed at T1 and were interconnected with rods (Figures and ). Then the patient was placed supine with placement of cage at C7-T1 followed by C7-T1 plating and screw fixation ().\nPostoperatively patient had no deficits and no Horner's syndrome. Checked CT of cervical spine showed good reduction of the spondyloptotic segment (Figures and ). Patient was advised bed rest for 4 weeks and then gradually mobilized on cervical collar. Patient made an uneventful full recovery. |
We present the case of a 44-year-old, otherwise healthy, Caucasian German woman who had been experiencing paresthesia in both forearms and hands for 3 months. Occasionally, she had pain and paresthesia in her face when moving her head. Physical examination showed normal muscle strength in both upper limbs and a discrete sensory loss. Movement of the cervical spine was almost free but painful at the end of the motion range. X-ray showed osteolysis of C7. Magnetic resonance images (MRI) indicated increased signal intensity on T2-weightened images. The osteolysis was diagnosed as a metastatic osteolysis of C7 (Figure ). The CT scan showed that the stability of the vertebra was compromised. "Hemangioma-typical" radiological findings could not be observed either on MRI or CT scans. Angiography did not show an arteriovenous malformation around the lesion and no accumulation of contrast medium was found in the vertebra. The laboratory investigations, including blood count, electrolytes, renal and liver values and infection parameters, were normal.\nA complete staging including thoracic and abdominal CT scans, skeleton scintigraphy and MRI of the whole spine revealed no further lesions. The osteolysis was regarded as an unstable metastasis from an unknown primary tumour. Therefore we decided to perform corporectomy of the seventh cervical vertebra and implantation of a customary titanium cage via a lateral approach. A biopsy was ruled out because the lesion was already seen as unstable. We did not want to risk a pathologic fracture with further complications for the patient.\nDuring corporectomy, an intra-operative consultation was performed. The frozen sections showed a cellular lesion displaying spindle-shaped cells with predominantly small, partly elongated nuclei with moderate chromatin density interspersed with immature, partly calcified osteoid. Thus, the intra-operative diagnosis was a mesenchymal tumor.\nThe postoperative recovery was uneventful and the patient's complaint of neck pain and paresthesia in the forearms disappeared soon. Ten days after surgery she was discharged.\nFurther microscopic examination of the paraffin-embedded tissue revealed vessel-like structures adjacent to and within the dense mesenchymal cells as well as osteoid (Figure ). Typical linings of osteoblasts or osteoclastic giant cells were not observed. Thus, our working diagnosis was that of a mesenchymal lesion consistent with an aneurysmal bone cyst, in particular with a solid variant because of the solid areas containing capillaries and osteoid.\nThis atypical presentation represented a severe diagnostic challenge prompting consultation with a specialist pathologist. Intensive immunohistochemical work-up by the pathologist revealed a distinct vascularization of the lesion with partly collapsed sinusoidal and slit-like blood vessels (Table ). Criteria of malignancy such as cytologic atypia or an increased mitotic rate were not fulfilled; the lesion was classified asa hemangioma with reactive osteoid formation.\nSince the final histopathological diagnosis rendered was "hemangioma with reactive osteoid formation", we recommended postoperative radiotherapy, which was refused by the patient. Six months later movement of the cervical spine was painless with a loss of rotation of 20 degrees. There was no sensorimotor loss in the upper limbs. X-ray examination affirmed a good and maintained position of the cage and a normal alignment of the cervical spine (Figure ). |
We present the case of a large concealed paravaginal haematoma as a cause of severe postpartum haemorrhage.\nA 30-year-old primiparous woman presented at 40 weeks and 1 day of gestation in early labour. Her pregnancy was complicated by the diagnosis of a small for gestational age baby (abdominal circumference 5th percentile, estimated fetal weight 3260 g [26th centile]) on ultrasound at 39 weeks and 5 days. Otherwise she had an uncomplicated antenatal course.\nThe patient received an epidural block and augmentation of labour with oxytocin and progressed well in labour with a 1st stage of 5 h and 45 min and 2nd stage of 35 min.\nA fetal bradycardia was noted on cardiotocography at full cervical dilatation and a live male infant weighing 2740 g was delivered by Neville Barnes forceps in one pull, positioned directly occipito-anterior from the level of the ischial spines. The baby had Apgar scores of 8 at one minute and 9 at five minutes. A right mediolateral episiotomy was made and repaired without complication. Estimated blood loss was 400mLs immediately postpartum and mother and baby were well.\n3.5 h postpartum the patient was hypotensive, with a BP of 80/40 mmHg, and heart rate of 94 bpm despite 1 L of intravenous fluid resuscitation and minimal vaginal bleeding postpartum. She complained of worsening rectal pain despite being given oxycodone 5 mg and morphine 10 mg subcutaneously. On examination the uterine fundus was deviated to the right and palpable well above the umbilicus. On vaginal examination there was a large palpable mass extending up the right vaginal wall. Repeat haemoglobin was 7.1 g/dL, down from 13.2 g/dL intrapartum, with normal platelets and coagulation studies.\nAn urgent computerised tomography (CT) examination of the abdomen and pelvis with intravenous contrast demonstrated two extraperitoneal haematomas without active extravasation. The largest measured 7 cm × 8 cm × 12 cm, lying paravaginally and extending superiorly into the supralevator and extraperitoneal space, displacing the bladder, rectum and uterus []. The second haematoma was located in the extraperitoneal space, underlying the right broad ligament and measuring 12 cm × 2.8 cm × 6 cm on axial CT [].\nAn initial plan was made to proceed to theatre for examination under anaesthetic and consideration of incision and drainage of the haematoma but the patient's blood pressure improved to 100/50 mmHg and heart rate to 60 bpm. Given the location of the haematoma and the patient's haemodynamic stability, a decision was made for conservative management with ongoing fluid resuscitation, transfusion of one unit of packed red blood cells, analgesia and commencement of intravenous antibiotics to prevent secondary infection of the haematomas.\nThe patient's pelvic and rectal pain improved significantly day one postpartum and resolved by discharge on day three postpartum. She completed a two-week course of oral cephalexin and metronidazole and remained well postpartum. Repeat CT of the abdomen and pelvis demonstrated partial resolution of the two haematomas, the largest measuring 6.3 cm × 4.6 cm × 4.5 cm on repeat imaging (). The patient was reviewed on day 20 postpartum and was well, with no perineal bruising or palpable vaginal wall haematoma and a haemoglobin level of 10.2 g/dL, up from 9.4 g/dL at the time of discharge. |
A 30-year-old male patient referred to our clinic with right-side pain, dysuria, and incontinence complaints. It was learned that the patient had endoscopic stone surgery due to right ureteral stone and kidney stone 11 years before the presentation. In the direct urinary system graphy [] and uncontrasted computed tomography of the patient, it was observed that the forgotten DJ stent was separated into three pieces, and the first piece was in the renal pelvis [], the second piece was between the renal pelvis and the medium ureter [], and the last piece was between the bladder and the urethra []; there were stones in the right kidney and ureter. One of the stones was nearly 19 mm × 18 mm attached to the end of the stent in the right kidney upper pole [] and the other was 7 mm × 6 mm in the right kidney lower pole, and there were two sequential calculi attached to the second torn piece of the stent lying between the renal pelvis and the right medium ureter, and the larger of these calculi had a dimension of nearly 29 mm × 11 mm []. The patient stated that he did not know about DJ catheter. No pathological examination finding for urogenital organs was detected in the physical examination.\nAccording to the biochemical tests, blood urea nitrogen was 70, creatinine: 2, Na (sodium): 143, and K (potassium): 3.7 and hemogram parameters such as hemoglobin: 11.4 and leukocyte: 13,100. There was no reproduction in urinary culture.\nProviding visualization, urethra was entered with 19-F cystoscope in lithotomy position under general anesthesia. Following the torn end of DJ stent in distal urethra, it was extracted with foreign object forceps. Then, it was entered with 8/9.8-F semi-rigid ureterorenoscope (URS). It was observed that DJ catheter was calculized in the right ureter middle section. The calculi were fragmented with pneumolithotriptor, and DJ catheter segment lying between the ureter and the right renal pelvis was extracted. Then, the last piece of the DJ stent in the right kidney upper pole and a stone in the calculized end were noticed. The patient was placed in prone position after catheter insertion, and using an 18-gauge needle and guidewire, the lower posterior calyx was accessed percutaneously under C-arm fluoroscopy guidance. For tract dilatation up to 12–30 F, amplatz dilators were used. The last piece torn from DJ stent and fragmented stones were removed with pneumatic lithotripter (Lithoclast; EMS, Nyon, Switzerland) and retrieval graspers through a rigid nephroscope (26 F, Karl Storz®). With an antegrade approach and under fluoroscopic guidance through the percutaneous nephrostomy tract, the stent was gently removed.\nIn dwelling, an 18-Fr re-entry nephrostomy tube was kept for 48 h. To confirm stone-free and stent-free status after the operation, kidney-ureter-bladder radiography was performed. A severe regression was observed in urea (38) and creatinine (1) values of the patient in postoperative biochemical tests, and the patient did not have kidney failure. The next day, the patient was discharged. |
A 62-year-old lady, a known case of diabetes mellitus, hypertension, dyslipidemia, and chronic kidney disease (CKD), was admitted with abdominal pain, vomiting and loose stools of 7 days duration. For the last 6 years, she has been on CAPD, and her dialysis has been largely uneventful.\nShe had similar symptoms about 4 weeks ago which was diagnosed as peritonitis and was treated with IP cephalosporin, aminoglycoside, and vancomycin. Her cultures were negative. She showed gradual improvement and her antibiotics were stopped after 14 days of therapy. After 48 hours, she started having abdominal pain, vomiting, and diarrhea. She was restarted on intravenous (IV) antibiotics (meropenem and amikacin). As she did not show any improvement, she was referred to us, and she was subsequently admitted in our hospital.\nAt admission, she was afebrile and her vitals were stable. Her systemic examination revealed a soft abdomen with no evidence of exit site or tunnel infection. Her laboratory investigations are shown in . The peritoneal fluid count came as 3233 cells/mm3 with 85% neutrophilic predominance. The peritoneal fluid culture was negative. Acid fast bacilli (AFB) were not seen on ZN stain, and a mycobacterial culture was asked for. A relapse of CAPD-associated peritonitis was diagnosed, and IV Vancomycin was added. Tenckhoff catheter removal was planned for the next day.\nEarly next day, she showed hemodynamic deterioration and her peritoneal dialysis catheter was removed on the same day. Her postoperative course was satisfactory, and she was switched to hemodialysis. However, on fourth postoperative day, she deteriorated again. A computed tomography (CT) scan of the abdomen was done which revealed dilated, thin and fuzzy appearing wall of a segment of the jejunal loop with air in the parietal wall. The adjacent mesentery showed fat stranding suggestive of mesenteric ischemia.\nAn exploratory laparotomy revealed extensive infarction of the gut extending from jejunum to transverse colon []. No vascular occlusive lesion was found and arterial pulsations were appreciated by the operating surgeon. No resection was attempted because of extensive gut involvement. |
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