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A 32-year-old man arrived at the Oral and Maxillofacial Surgery Department with a history of having been shot 15 years ago. During those years, the patient could not be treated because of the lack of financial support and social conditions. External examination revealed a depression in the projection of the left mandibular body,l shortening of the mandibular length () and mobility of the mandibular body, which was adequately covered by soft tissue ().\nNo spontaneous occlusion was observed due to the lack of some superior and inferior teeth. A craniofacial computed tomography (CT) was performed and prototypes of mandible and face were manipulated, which demonstrated a segmental defect of the left mandibular body. The prototype was manipulated and adjusted following some craniometric points, aligning together the midline of the face and the mandible. The condyles were set in their best fossae position. A 5 cm defect could be determined, which was filled with auto-cure resin to maintain the structural positions ().\nA long and heavy mandibular plate extending from the mandibular ramus to the symphysis was prebent preoperatively and an occlusal guide was fabricated to stabilize the mandible position to the maxilla ().\nThe surgery was undertaken under general anesthesia with nasal intubation, permitting free manipulation of the patient to set an ideal occlusal relationship before fastening the plate, which was step aided by the occlusal guide. A submandibular approach with anterior extension was sufficient to show the segmental defect. The fragments were repositioned, stabilized, and fixed with the prebent mandibular reconstruction plate that was perfectly adapted without any complementary adjustments. An autogenous corticocancellous free and non-vascularized graft measuring 9 cm was harvested from the left iliac crest, which was adapted to increase the contact surface with the lingual aspect of the proximal stump, improving the graft’s stability and blood supply. The graft was fixed in an interfragmentary manner with two long screws of 2.4 system and the plate was further fixed to the mandible. Additional graft stability was gained with a four holes 2.0 system plate fixed to the graft ().\nThe postoperative period was uneventful, local or systemic infection was not detected during the 6-month follow up was and bone graft maintained viability. The control CT demonstrated adequate bone tissue for the further insertion of implants. At the sixth month, the patient was referred for oral rehabilitation. Physiotherapy began with the objective of improving his maximal open mouth until 40 mm was reached and muscular function was re-established (). shows the long-term postoperative aesthetics vision and the amplitude of mouth opening.
A 17-year-old Chinese female presented to our obstetric clinic with pain in the perineal and perianal area and positional abnormality in the 34th week of gestation. A cord-like neoplasm about 1 cm × 1 cm in size was found on her perianal region in week 14 of gestation in a private clinic of the remote area where she lived. The patient refused treatment despite explanation of the prognosis by the local doctors back then and administered some topical traditional Chinese medicine herself. However, the patient recounted that the mass kept growing rapidly. Unfortunately, the details of that care encounter were not available. Since she noticed her genital lesion, her husband had presented the same type of neoplasm multiple times, and he cut the cauliflower-like growth on the penis by himself at home without any further physician visits or follow-up.\nWhen she presented to our obstetric clinic in week 34 of gestation with perineal pain, she was not able to stand upright as a result of compression from the two large masses. On physical examination, large, irregular, ulcerative, and verrucous vegetations were identified, which covered both the perineal and perianal region with malodorous discharge on the surface (Figure ). The anterior vegetation measured 5 cm × 3.8 cm and the posterior one 13 cm × 6 cm. We presented the case to the board of multidisciplinary teamwork to discuss the plans for her delivery and the proper sequence of the two procedures, namely the mass removal and the infant delivery. Given the giant vegetation had occupied the vaginal birth canal and that prolonged general anesthesia might increase the neurological risk to the infant, we decided to perform a C-section before the neoplasm resection. Risks and benefits of infant delivery and resection procedure were discussed with the patient. The infant was delivered successfully via C-section at full term. Two weeks later, the perineal and perianal giant tumors were excised en bloc at the pedicles by electric scalpel until healthy tissue was reached in gynecologic position under general anesthesia. As the resection did not leave large wound or tissue defect, reconstruction was not indicated for this patient (Figure ).\nThe resected masses were sent to pathology for staining and sectioning of paraffin-embedded tissue. The pathological report revealed squamous mucosa with dysplasia and viral cytopathic effect, consistent with koilocytosis in HPV infection (Figure ). Cytological study on the cervical specimen revealed HPV-11 positivity, one of the two serotypes associated with GCA from the literature (Dianzani et al., ; Gissmann et al., ).\nAfter the procedure, the patient was informed of possible recurrence, which is common and presumably related to the infection in the surrounding healthy tissue. Her husband received treatment as well and would be followed up in the local health organization.
A 10-year-old male fell while riding a bicycle on the road. On the day of the fall, he had no definite symptoms; however, he complained of a mild, intermittent headache and nausea five days after the incident and visited the hospital. His neurological state was normal and there were no blood stains in the ear, nose, or throat. The brain computed tomography (CT) revealed a linear fracture, small amounts of epidural hematomas and pneumocephalus in the right occipital area. When compared to the left side, a higher density lesion within the right sigmoid sinus was found (). The brain magnetic resonance image (MRI) showed the effusion and hemorrhage in the right mastoid air cell and a signal intensity, which was suspected to be thrombus, in the right sigmoid sinus (). The brain magnetic resonance venography (MRV) revealed an absence of a flow signal between the right sigmoid sinus and the jugular bulb, which was confirmed to be sigmoid sinus thrombosis (). During the physical examination, he showed no papilledema, intracranial hypertension, or otogenic infections such as otitis media. His blood tests, including complete blood count, prothrombin time, partial thromboplastin time, antithrombin III, protein C activity, and protein S activity, were in the normal ranges. The patient was treated conservatively because the patient's symptoms were mild and gradually improved. He was discharged with a full recovery on the 4th day in the hospital. On the 10th day after discharge, the patient complained of vomiting and visited the department of pediatrics. The laboratory tests, including a prothrombotic evaluation and a physical examination, were performed. The results of the laboratory tests were normal. Due to concern regarding the progression of the previous sinus thrombosis, the brain MRV was re-checked, and it showed the recovery of the flow signal in the right sigmoid sinus (). The spontaneous recanalization of sigmoid sinus thrombosis occurred within about three weeks of the trauma. His vomiting may have been caused by gastrointestinal problems, and it ceased the following day.
A 27-years old male was involved in a devastating motor vehicle accident in June 2015 and had sustained closed fracture left neck of femur, open comminuted fracture (Gustilo – grade 3B) of the midshaft of the tibia and fibula and closed fracture distal third of the right tibia. He was treated surgically with screw fixation of the left neck of femur and wound debridement with Illizarov external fixator of left tibia after the accident (). The right tibia fracture was treated with cast. However, his surgical wounds broke down infested with multidrug resistant organisms. Multiple wound debridement and intravenous antibiotics were administered for six weeks before the patient was transferred to our hospital for further management. The diagnosis on admission was infected implant of left hip with septic arthritis.\nCT scan and bone scan of left hip confirmed destruction of the femoral head. Hence wound debridement, removal of screws of left femoral head with temporary antibiotic cement rod insertion was performed. Intra-operatively, about 50 cc pus was found extending up to hip joint with biofilm surrounding all three screws and osteomyelitis with femoral head collapse (). This was followed by debridement of the femoral head and antibiotic-loaded arthroplasty insertion after a week (). Appropriate intravenous antibiotics were given for six weeks’ duration and the patient was discharged well with wheelchair ambulation, and range of motion (ROM) physiotherapy for the hip, with a plan for second stage surgery later.\nOn follow up after a year, patient could walk with crutches, partial weight bearing over his left lower limb. He achieved adequate ROM of left hip: flexion 0-110 degree, internal and external rotations of 60 degree. His infective markers (ESR, CRP, white cell count) were within normal range. In view of his young age, he was given the surgical option of hip fusion or replacement later in life when there was unbearable hip pain affecting the quality of life. He was content with the functionality provided by the antibiotic cement arthroplasty for now and wished to delay the operation.
A 45-year-old man presented to his general practitioner complaining of 2 months of progressive left hip pain. Over the preceding 2 weeks he had been struggling to mobilize. His general practitioner (GP) investigated with a non-contrast computed tomography (CT) of the pelvis. This found a cystic lesion within the left psoas muscle with areas containing coarse calcification. The findings, overall, were suspicious of tumour, likely a teratoma. A CT chest, abdomen and pelvis with intravenous contrast was arranged. The pathology in the left psoas was found to represent a pancreatic pseudocyst extending from a heavily calcified pancreas, over the anterior aspects of the aorta and inferior vena cava (IVC) before reaching the left psoas muscle body ( and ). There were multiple other cystic regions noted within the pancreatic parenchyma and peripancreatic tissue. The patient was referred to the emergency department for surgical review.\nOn examination of the patient in the emergency department the patient was lying in a supine position with his left hip in external rotation and left knee moderately flexed for comfort. He had an antalgic gait, with discomfort that was most evident weight bearing on his left leg. He also had pain elicited upon active movement of the left hip and in particular resisted hip flexion. He had no abdominal tenderness. Blood tests, including inflammatory markers and lipase, were within normal limits, with no evidence of acute pancreatitis.\nThe patient had a past medical history significant for a single episode of alcohol induced acute pancreatitis 10 years earlier. He had no diagnosed repeat episodes of pancreatitis in the intervening years. On further questioning he did mention occasional episodes of mild post-prandial epigastric pain. At the time of presentation, he had ongoing issues with alcohol misuse, consuming between 6 and 8 standard drinks per day.\nOn review of the CT scans, the dominant cyst was deemed not to be amenable to transgastric drainage. The psoas component of the cyst was however deemed appropriate for percutaneous drainage under CT guidance. Twenty millilitres of serous fluid was aspirated from the drain at the time of insertion, with minimal further output over the following 24 h. A repeat scan on Day 1 post drain tube insertion showed reduction in the size of left psoas collection. The drain tube was removed on Day 1.\nFour weeks after his initial presentation the patient underwent endoscopic ultrasound and insertion of an AXIOS™ (Boston Scientific, Marlborough, Massachusetts, USA) stent. A 6-cm pseudocyst was identified in the pancreatic head, which was accessible from the second part of the duodenum and a 10-mm AXIOS™ stent was delivered into the pseudocyst. The stent remained in place for a total of 2 weeks and was then removed endoscopically.\nAt the time of writing, the patients’ symptoms had significantly improved following drainage of the dominant cysts. He does, however, have smaller pseudocysts remaining in the pancreas and peripancreatic tissues.
A six-month-old previously healthy female presented to our tertiary care pediatric ED with fever and vomiting. Her parents noted that she had recently had mild cough and congestion but otherwise no significant preceding symptoms. Over the prior 48 hours, however, she had developed persistent fever with a maximum temperature of 39º Celsius and had been vomiting for the preceding 24 hours. The patient was up to date on vaccines, the product of an uncomplicated full-term pregnancy, and had no significant past medical or family history. Her initial vital signs were remarkable for a heart rate of 185 beats per minute, temperature of 38.7ºC, and normal oxygen saturation. She was evaluated by a board-certified pediatric emergency physician. The exam was notable only for minimal oropharyngeal erythema and a very mild diaper rash without skin desquamation. Due to the constellation of symptoms, physical exam and duration of high fever, a straight catheter urine sample was ordered to evaluate for pyelonephritis.\nThe attending physician was later called to the room by the ED nurse due to difficulty removing the catheter from the urethra following urine sample collection with a 5F straight catheter. The experienced nurse reported no resistance or difficulty with insertion and immediate drainage of urine. The physician evaluated the patient and noted the catheter to be appropriately exiting the urethral orifice. There was no external evidence of trauma or genitourinary abnormality. Using sterile technique, the catheter was easily advanced forward but, with gentle traction, could not be withdrawn from the urethra.\nA single view abdominal radiograph was then obtained that demonstrated a urinary catheter with the distal tip knotted on itself (). Pediatric urology consult recommended repeat gentle traction to remove the catheter; this was re-attempted and again was unsuccessful. Pediatric urology subsequently evaluated the patient in the pediatric ED. Their team was also unsuccessful in removing the catheter with traction only. A range of guidewires was available at the bedside for the urology team to attempt to relieve the knot. They inserted a 0.025-inch diameter guidewire into the catheter and advanced it with minimal resistance. This simple procedure was done without any imaging guidance. The guidewire and catheter were then easily removed without a persistent knot. The patient tolerated the procedure well and was able to feed comfortably within 10 minutes. The urine studies returned and were negative for any sign of infection. After tolerating oral feeds and returning to her baseline level of comfort, the patient was discharged with a short course of cephalexin due to the straight catheter manipulation of the sterile GU system. To our knowledge the patient did well and did not require further interventions following discharge.
The patient is a 25-year-old Sri Lankan female who developed fear of swallowing. This was following an incident where she choked a mouthful of rice during an episode of gastritis. She found the incident painful due to acidic regurgitation that followed. The initial episode lasted for over one year during which she was totally dependent on fluids and semisolids which lead to significant weight loss. During this period, she was extensively investigated for dysphagia which included several invasive methods. She recovered temporarily but with waxing and waning of symptoms. She was on several psychotropic medications including antipsychotics.\nAt the time of presentation, she had not eaten for one week and was only on liquid and semisolid diet. She had intensive craving for food and inability to swallow solid food and pills. She avoided food and had intrusive images of the first choking episode whenever she brought food close to her mouth. She also had anticipatory anxiety prior to meal times.\nThe patient had several behaviours like, consuming fluids and semisolids, monitoring every step of swallowing, monitoring anxiety symptoms like palpitations and tachypnea, eating solids in small mouthfuls, swallowing one mouthful in several attempts, frequent drinking of water to facilitate swallowing and avoiding eating in social situations.\nAdditionally it was identified that the patient had misconceptions about swallowing, food and gastritis. For example she thought that foods she did not like to eat caused gastritis and that food should be eaten warm.\nHer condition worsened with stress and the symptoms recurred whenever she experienced strong emotions like anger or sadness. The high expressed emotion of family members and the stigma of being thin as she had lost a considerable amount of weight contributed to her anxiety and maintained the symptoms. She did not have features suggestive of panic disorder, generalized anxiety disorder or psychosis.\nThe management of her condition was multifaceted. First she was educated about the mechanism of swallowing, food with high calorie and low calorie intake and gastritis. The subsequent steps in therapy were relaxation training particularly of the head and neck muscles, strengthening of the coughing mechanism in case of an actual event of choking, distraction from self-monitoring of stages of swallowing and replacing the image of the initial choking episode with a pleasurable image.\nShe was gradually exposed to different eating situations. The situations in order were eating with the therapist, family members, friends, social gatherings and strangers. She was also exposed to food that she was preoccupied with and to swallowing of pills. Graded exposure was done for the amount of food eaten, gradually increasing the size of mouthfuls and reducing the number of times she swallowed each mouthful. Cognitive therapy was done to restructure her cognitive errors and maladaptive thinking along with coping skills training.\nThe patient improved steadily with the above methods. She gradually regained the ability to swallow small food boluses aided by water by the end of first week. She was seen daily during this period. She was later able to swallow much larger boluses in front of others as well. With improved confidence in swallowing, cognitive therapy for the correction of faulty assumptions, and education of family members to carry out therapy, her anxiety subsided. The stress management techniques and better coping strategies helped prevent relapse at stressful times. Her session frequency was decreased to twice weekly by the second week and later to weekly. She recovered in three months which consisted of 20 sessions of therapy. Currently, she has been asymptomatic for more than one year and did not relapse even after several stressful life events.
The patient is a 74-year-old male with comorbidities of coronary artery disease, congestive heart failure, hypertension, and renal insufficiency who presented to an outside hospital with back pain and left upper extremity weakness associated with high fevers and urinary incontinence. Outside spinal imaging showed a large spinal abscess; therefore, he was transferred to our institution for a higher level of care. On presentation, the patient was in septic shock requiring fluid boluses and inotropic agents to stabilize him. Further history was obtained from the family as follows:On November 2016, he underwent an elective right TKA complicated by an early MRSA PJI associated with bacteremia On May 0f 2017, he underwent resection of the hardware in the knee, incision and drainage, followed by 12 weeks of daptomycin therapy Five months later, on October of 2017, due to relapse, he had a second debridement of the right knee for source control as well as left ankle incision and debridement followed by another 8 weeks of daptomycin for this relapse of infection A daptomycin-susceptible, vancomycin-susceptible MRSA was isolated from blood and both surgical sites, knee and ankle, on both occasions He had ongoing thoracic back pain since 2016 which was monitored radiographically by his local providers, until the development of spinal epidural abscess with upper extremity weakness, which prompted his current hospitalization in January of 2018\nReview of systems on presenting to our institution was significant for general weakness and malaise, right shoulder and thoracic back pain, and constipation from narcotics. He was hemodynamically unstable requiring inotropic support. He was awake and oriented, following commands with intact speech. There were no cranial nerve deficits. On motor testing, he had normal muscle bulk with generalized hypotonia. There was no movement of his left upper extremity. He had 2/5 strength on his right upper extremity and 2/5 strength on his bilateral lower extremity. There was decreased sensation to light touch on his left side. Reflexes were globally decreased with negative Hoffman and Babinski signs. The white blood cell count was 30,000/L, and procalcitonin was 4.88 ng/ml. Blood cultures grew MRSA rapidly. Repeat imaging of the brain and spine at our institution showed extensive epidural phlegmon throughout the cervical, thoracic, and lumbar spine with intracranial expansion into the posterior fossa beneath the cerebellum with pockets of possible early organizing abscess within the phlegmon (). Brain imaging identified no discrete abscess or leptomeningeal enhancement.\nNeurosurgery immediately evaluated the patient and promptly performed a cervical spine decompression of C1–C7 and thoracic spine decompression of T5–T7. Operatively, a large epidural abscess was found, drained, and washed out. He was started on vancomycin every 12 hours with trough vancomycin levels being therapeutic. The patient subsequently underwent irrigation and debridement of the right knee, left ankle, and left great toe as well at our institution; all surgical sites grew MRSA with vancomycin MIC of 1 mcg/ml. Despite attempts at source control and optimal pharmacokinetic dosing of vancomycin with a trough level of 20.5 mcg/ml on day 5, he had refractory MRSA bacteremia. Infectious disease deemed he had failed daptomycin therapy; therefore, ceftaroline 600 mg every 8 hours (MIC of 0.38 mcg/ml) was added to vancomycin. Repeat blood cultures showed clearance of bacteremia after 48 hours of initiation of the combination therapy. His left ankle and right knee continued to yield MRSA. Due to his multiple comorbidities and need for more aggressive source control of his infection, i.e., amputation of the leg, palliative care was sought by the family, and he died a few days later.
A 35-year-old nulliparous woman was referred to our hospital from an in vitro fertilization center for pelvic mass and adenocarcinoma on Pap test. The review of her past medical history revealed that she had been diagnosed to have stage 1B1 cervical adenocarcinoma 6 years ago when she had presented with complaints of postcoital bleeding and bloody vaginal discharge. On her examination, she had been found to have an exophytic lesion involving the central part of the cervix and protruding into the vagina. The outer parts of the exocervix and vaginal fornices had looked normal. A punch biopsy of the lesion had shown invasive adenocarcinoma and the patient had been subjected to a radical abdominal trachelectomy with pelvic and para-aortic lymphadenectomy without any further diagnostic evaluation. On her permanent pathology, the disease was a grade 2 adenocarcinoma which was 1.5 cm in diameter with no vaginal or parametrial involvement. Excised vagina was 2.5 cm in length while the excised parametria was 3.0 and 2.8 cm in width at the left and right sides, respectively. Also, 29 lymph nodes were negative for metastasis and all surgical margins were free of disease. However, there was diffuse lymphovascular space invasion and the disease invaded the cervical stroma deeply with 75% of stromal invasion detected in some areas. The patient and her husband had rejected adjuvant pelvic radiation treatment which had been recommended due to those two intermediate pathological risk factors. Despite strict follow-up recommendations, she had been lost to follow-up thereafter. During the subsequent period, she failed spontaneous conception for the first postoperative year. Then, 6 cycles of controlled ovarian hyperstimulation with intrauterine insemination (COH + IUI) were done but failed. Lastly, four in vitro fertilization cycles were performed without any success. Her conception attempts lasted for 5 years in total and during that period the patient was not subjected to any investigations for her cervical cancer and she did not meet with any gynecologic oncologist.\nOn her admission, the patient had abnormal vaginal bleeding lasting for more than 1 year with severe pelvic pain, gross hematuria, right lower extremity pain, and swelling. On pelvic examination, the residual cervix was completely infiltrated with tumor. In addition, the upper anterior vagina and lateral fornices were involved. The right parametrium was infiltrated with tumor extending to the pelvic sidewall and a right adnexal mass was palpated. Under general anesthesia, a cervical biopsy was done which revealed recurrent adenocarcinoma. Cystoscopy was done for gross hematuria during the same operative session which showed neoplastic invasion causing a mass within the bladder. Cystoscopic biopsy from the bladder mass confirmed adenocarcinoma infiltration. After assuring that cervical adenocarcinoma has recurred, imaging studies were performed to document the extent of recurrence. Computerized tomography of abdomen and thorax and magnetic resonance imaging of pelvis showed recurrent cervical mass invading upper vagina and bladder with right parametrial infiltration up to pelvic sidewall (). A right adnexal heterogeneous mass measuring 11 × 9 cm was seen (). Severe hydronephrosis on the right side () and multiple hepatic metastases () were detected. Thorax was free of metastatic involvement. Due to multiple distant metastases and unresectable locoregional recurrence, surgery was not considered. Combination chemotherapy consisting of paclitaxel and carboplatin was initiated following the placement of right percutaneous nephrostomy. After 6th cycle of chemotherapy, the patient had significant symptomatic improvement. Her last visit was five months after the completion of chemotherapy when she was alive with disease.
A 45-year-old man presented to the emergency department of our hospital with a chief complaint of epigastric pain with radiation to the back.\nThe patient experienced persistent abdominal pain for two weeks, starting from UGI panendoscopic and colonoscopic procedures performed at our facility. The pain had persisted for 2 wk before he returned to our hospital for further examination.\nThe patient had a history of untreated hypertension and hyperlipidemia. He experienced immediate abdominal pain after endoscopic procedures performed during a voluntary health checkup and brought this to our attention while resting in the recovery room. Four hours later, plain abdominal standing X-ray was taken and an apparently normal small bowel ileus pattern without subphrenic free air was found (Figure ). Consequently, the patient was treated conservatively using menthol packing of his abdomen and allowed to go home in Tai Tung, which was in the eastern part of Taiwan, about 5 h drive from our facility. During the following 2 wk, he experienced persistent abdominal symptoms and sought help from several local clinics/hospitals, where he received conservative treatments mainly for gastritis or enteritis. As the discomfort did not improve, the patient contacted us for help 14 d after the initial endoscopic procedures and was transferred to our emergency room (ER) for further management.\nAt the ER, the patient complained of persistent epigastric pain radiating to the back with abdominal distension for the past 2 wk, but appeared otherwise easy-looking. There was no fever or chillness, and his vital signs were normal. Physical examination of the abdomen revealed mild epigastric tenderness without any signs suggestive of peritonitis. Soft and mild distended abdomen was found while no muscle guarding or board-like abdomen was observed. Since mechanical hollow organ perforation and peritonitis were both ruled out after thorough examination of the patient, acute abdominal aortic dissection was suspected.\nLaboratory examination performed at the ER included complete blood count and biochemistry examinations. All data were within normal limits.\nAfter thorough physical and laboratory examinations upon returning to ER, the patient was subjected to contrast-enhanced computed tomography (CT) of the abdomen. Isolated spontaneous SMAD was revealed (Figure ). The dissection began from just below the orifice of the superior mesenteric artery with intra-mural hematoma and without stenosis. Although the intra-mural hematoma compressed the true lumen, there was no suggestive signs of bowel ischemia, bowel thickening, or ascites.
The patient is a 74-year-old male with comorbidities of coronary artery disease, congestive heart failure, hypertension, and renal insufficiency who presented to an outside hospital with back pain and left upper extremity weakness associated with high fevers and urinary incontinence. Outside spinal imaging showed a large spinal abscess; therefore, he was transferred to our institution for a higher level of care. On presentation, the patient was in septic shock requiring fluid boluses and inotropic agents to stabilize him. Further history was obtained from the family as follows:On November 2016, he underwent an elective right TKA complicated by an early MRSA PJI associated with bacteremia On May 0f 2017, he underwent resection of the hardware in the knee, incision and drainage, followed by 12 weeks of daptomycin therapy Five months later, on October of 2017, due to relapse, he had a second debridement of the right knee for source control as well as left ankle incision and debridement followed by another 8 weeks of daptomycin for this relapse of infection A daptomycin-susceptible, vancomycin-susceptible MRSA was isolated from blood and both surgical sites, knee and ankle, on both occasions He had ongoing thoracic back pain since 2016 which was monitored radiographically by his local providers, until the development of spinal epidural abscess with upper extremity weakness, which prompted his current hospitalization in January of 2018\nReview of systems on presenting to our institution was significant for general weakness and malaise, right shoulder and thoracic back pain, and constipation from narcotics. He was hemodynamically unstable requiring inotropic support. He was awake and oriented, following commands with intact speech. There were no cranial nerve deficits. On motor testing, he had normal muscle bulk with generalized hypotonia. There was no movement of his left upper extremity. He had 2/5 strength on his right upper extremity and 2/5 strength on his bilateral lower extremity. There was decreased sensation to light touch on his left side. Reflexes were globally decreased with negative Hoffman and Babinski signs. The white blood cell count was 30,000/L, and procalcitonin was 4.88 ng/ml. Blood cultures grew MRSA rapidly. Repeat imaging of the brain and spine at our institution showed extensive epidural phlegmon throughout the cervical, thoracic, and lumbar spine with intracranial expansion into the posterior fossa beneath the cerebellum with pockets of possible early organizing abscess within the phlegmon (). Brain imaging identified no discrete abscess or leptomeningeal enhancement.\nNeurosurgery immediately evaluated the patient and promptly performed a cervical spine decompression of C1–C7 and thoracic spine decompression of T5–T7. Operatively, a large epidural abscess was found, drained, and washed out. He was started on vancomycin every 12 hours with trough vancomycin levels being therapeutic. The patient subsequently underwent irrigation and debridement of the right knee, left ankle, and left great toe as well at our institution; all surgical sites grew MRSA with vancomycin MIC of 1 mcg/ml. Despite attempts at source control and optimal pharmacokinetic dosing of vancomycin with a trough level of 20.5 mcg/ml on day 5, he had refractory MRSA bacteremia. Infectious disease deemed he had failed daptomycin therapy; therefore, ceftaroline 600 mg every 8 hours (MIC of 0.38 mcg/ml) was added to vancomycin. Repeat blood cultures showed clearance of bacteremia after 48 hours of initiation of the combination therapy. His left ankle and right knee continued to yield MRSA. Due to his multiple comorbidities and need for more aggressive source control of his infection, i.e., amputation of the leg, palliative care was sought by the family, and he died a few days later.
Case 2 was a 75-year-old Japanese man who presented at our hospital with acute abdominal pain, nausea, and cold sweat. His CT scan showed retroperitoneal bleeding (around the pancreas and the dorsal side of the ascending colon). His general condition was stable, but he was admitted to our hospital as a conservative measure. His angiography (6 days after admission) showed an aneurysm of the pancreaticoduodenal artery without active bleeding.\nOur experience treating MAL syndrome in case 1 enabled us to diagnose the disease accurately in case 2. MAL syndrome was the cause of the aneurysm in this patient too (). We selected laparoscopic surgery based on the MAL syndrome and the benefits of this surgery. The patient's posture for the surgery was the lithotomy position. Intra-abdominal pressure of 12 mmHg was maintained. The points of the trocars were as follows: a 12 mm trocar at the navel for the camera, two 12 mm trocars at the right upper abdomen, and a 12 mm trocar and a 5 mm trocar at the left upper abdomen ().\nFirst, we lifted the liver umbilical ligament by surgical sutures and put in an organ retractor to the crus of the diaphragm in order to improve the field of vision. After opening the omental bursa, we lifted the stomach with a snake retractor and observed the dorsal side of the stomach. We confirmed the left gastric artery and tied it with tape. The tape was taken out from the right outside trocar, and an assistant pulled it to provide traction of the surgical field. Following the celiac artery to the root, the artery was fastened by the MAL. We cut the MAL away little by little with a vessel-sealing system until the running direction of the celiac artery was clearly confirmed. Using a blood flow meter, we confirmed the improvement of blood flow of the left gastric artery (from 5 mm/min to 69 mm/min). A drainage tube was placed in the left subphrenic area, and the wound of the abdominal incision was closed. The operation time was 3 hours 35 minutes, and the blood loss was minimal at 15 ml. The patient's CT scans have shown no recurrence of the aneurysm for 2 years.
A 25-year-old man presented with swelling and pain in left ankle joint without any history of acute trauma. He had experienced another episode of severe swelling and pain in left ankle area without any preceding trauma about 2 years before arrival. After definite diagnosis of ABC by another surgeon in another hospital, He had undergone curettage and autologous bone grafting via medial ankle approach and detachment of deltoid ligament.\nEight months after previous surgery, pain and swelling had begun again and continued till the time of second operation. On examination, swelling and tenderness on medial side was clearly evident. The neurovascular status of left ankle and foot was intact. Range of motion of ankle was limited to 25 degrees in plantar flexion and 10 degrees in dorsiflexion in comparison to the right ankle. Moreover it was painful particularly in full plantar flexion. Left ankle plain radiograph showed a cystic lesion in posteromedial of left talus with invasion to the articular surface of tibiotalar and subtalar joints (Figure ). As ankle CT scan clearly approved the size and intra-articular invasion of the lesion (Figure ), magnetic resonance imaging was not requested.\nSurgery was performed under general anesthesia in the lateral position after inflation of a thigh tourniquet using sterile conditions. Through direct lateral approach to the lateral malleolus, fibular osteotomy from 10 cm above tip of fibula was done and completely resected. The articular surfaces of tibiotalar and subtalar joints were removed. The ABC was carefully resected because of adhesions to the posteromedial structure of the ankle joint. The pathologic report confirmed recurrent ABC. After curettage, the bone graft from the excised distal fibula bone was impacted in the arthrodesis site. The correct position of tibiotalar and subtalar joints for fusion was prepared and fixed by a Steinmann wire temporarily. Finally, the fixation was achieved utilizing a compression screw and a PHILOS plate on lateral side from calcaneus to the distal of tibia. Short leg cast was applied till complete union at 3 mo postoperatively.\nFollow-up imaging at 18 mo after the operation showed no apparent sign of recurrence (Figure ). The patient has a little claudication due to triceps surae weakness. He also suffers from occasional pain after long-distance walking.
The patient is a 74-year-old male with comorbidities of coronary artery disease, congestive heart failure, hypertension, and renal insufficiency who presented to an outside hospital with back pain and left upper extremity weakness associated with high fevers and urinary incontinence. Outside spinal imaging showed a large spinal abscess; therefore, he was transferred to our institution for a higher level of care. On presentation, the patient was in septic shock requiring fluid boluses and inotropic agents to stabilize him. Further history was obtained from the family as follows:On November 2016, he underwent an elective right TKA complicated by an early MRSA PJI associated with bacteremia On May 0f 2017, he underwent resection of the hardware in the knee, incision and drainage, followed by 12 weeks of daptomycin therapy Five months later, on October of 2017, due to relapse, he had a second debridement of the right knee for source control as well as left ankle incision and debridement followed by another 8 weeks of daptomycin for this relapse of infection A daptomycin-susceptible, vancomycin-susceptible MRSA was isolated from blood and both surgical sites, knee and ankle, on both occasions He had ongoing thoracic back pain since 2016 which was monitored radiographically by his local providers, until the development of spinal epidural abscess with upper extremity weakness, which prompted his current hospitalization in January of 2018\nReview of systems on presenting to our institution was significant for general weakness and malaise, right shoulder and thoracic back pain, and constipation from narcotics. He was hemodynamically unstable requiring inotropic support. He was awake and oriented, following commands with intact speech. There were no cranial nerve deficits. On motor testing, he had normal muscle bulk with generalized hypotonia. There was no movement of his left upper extremity. He had 2/5 strength on his right upper extremity and 2/5 strength on his bilateral lower extremity. There was decreased sensation to light touch on his left side. Reflexes were globally decreased with negative Hoffman and Babinski signs. The white blood cell count was 30,000/L, and procalcitonin was 4.88 ng/ml. Blood cultures grew MRSA rapidly. Repeat imaging of the brain and spine at our institution showed extensive epidural phlegmon throughout the cervical, thoracic, and lumbar spine with intracranial expansion into the posterior fossa beneath the cerebellum with pockets of possible early organizing abscess within the phlegmon (). Brain imaging identified no discrete abscess or leptomeningeal enhancement.\nNeurosurgery immediately evaluated the patient and promptly performed a cervical spine decompression of C1–C7 and thoracic spine decompression of T5–T7. Operatively, a large epidural abscess was found, drained, and washed out. He was started on vancomycin every 12 hours with trough vancomycin levels being therapeutic. The patient subsequently underwent irrigation and debridement of the right knee, left ankle, and left great toe as well at our institution; all surgical sites grew MRSA with vancomycin MIC of 1 mcg/ml. Despite attempts at source control and optimal pharmacokinetic dosing of vancomycin with a trough level of 20.5 mcg/ml on day 5, he had refractory MRSA bacteremia. Infectious disease deemed he had failed daptomycin therapy; therefore, ceftaroline 600 mg every 8 hours (MIC of 0.38 mcg/ml) was added to vancomycin. Repeat blood cultures showed clearance of bacteremia after 48 hours of initiation of the combination therapy. His left ankle and right knee continued to yield MRSA. Due to his multiple comorbidities and need for more aggressive source control of his infection, i.e., amputation of the leg, palliative care was sought by the family, and he died a few days later.
A 76-year-old woman complained of left inferior limb pain and intermittent claudication. She was diagnosed with ASO in another clinic about 10 years ago. While the prolonged conservative medical treatment was undergone, the condition got worse. Then, she consulted a vascular surgeon in another hospital and the angiographic examination was undergone. The complete obstruction of left femoral artery was observed. Percutaneous transluminal angiography (PTA) was performed and stent was detained at the left femoral artery (). Revascularization was achieved and she could walk about 300 meters postoperatively. However, the left inferior limb pain still remained. Since the limb pain got worse, she was not able to walk five months after detaining stent. She was diagnosed with rapidly destructive coxarthrosis by plain radiography in an orthopaedic clinic and admitted to our hospital for the purpose of total hip arthroplasty (THA). She had no history of a large quantity of alcohol or steroid drug intake.\nPlain radiography showed the stent which is detained in left femoral artery, collapse of left femoral head, and disappearance of joint space (). MRI T1WI showed bone marrow edema, collapse of left femoral head with appearance of low band, and pooling of joint fluid (). Terminal stage of coxarthrosis was diagnosed from these findings. Angiography before PTA showed complete obstruction of left femoral artery; however bloodstream for left femoral head could be identified (). Angiography taken just before THA at our hospital showed increasing of blood vessel around left hip joint (). These findings suggested compensation of the ischemia. Six months after detaining stent, THA was performed with noncemented cup and cemented stem. Macroscopic findings of the resected femoral head showed severe osteoarthritic change, such as flattening of the upper part of femoral head and osteophyte formation. From microscopic findings in high magnification field (×100), empty lacuna and addition of newly formed bones adjacent to those necrotic bone areas were observed (). These histological findings indicated that bone necrosis occurred firstly and osteoarthritic change progressed secondarily.
A 52-year-old rural male farmer reported to the Department of Orbital Surgery complaining of a huge tumor in the right eyelid. Patient medical history revealed that the mass was initially the size of a soybean and gradually grew over 3 years to the size of a fist. Vision in the right eye diminished as the tumor became bigger and was completely gone approximately 1 year prior to examination. The patient had delayed proper medical treatment due to financial difficulties.\nUpon physical examination, the basal part of the tumor was found to be derived from right lower eyelid and was growing eccentrically. The tumor invaded the right inner canthus and lacrimal system medially, reached the right side of maxillary buttress laterally and extended from supraorbital ridge to the horizontal level of nasal alar superoinferiorly. The tumor surface was approximately 7 × 7 × 8 cm3, ulcerative, nodular, exophytic, and had purulent blood exudate. The skin of the upper eyelid appeared to be intact. The vision in the left eye was normal, ocular movements in all directions were intact and all other parameters were within normal range. The axial and coronal sections of the orbital CT showed that the eyeball was squeezed superiorly and laterally, that the lesion occupied most of the orbital cavity space and that the orbital cavity was extruded and increased; however, no obvious erosive damage was observed in the bony structures (Fig. ). Based on the clinical history, examination, and radiological findings, a provisional diagnosis of carcinoma of right lower eyelid was suggested and sebaceous gland carcinoma (SGC) was highly suspected considering it was a solitary nodule with an eccentric growth pattern.\nA safe surgical excision (5 mm skin around the tumor base including the lacrimal system and lateral canthus) was performed and skin margin control was inspected with rapid frozen sections. The orbital contents were completely enucleated and a canal connecting the orbital cavity to the ethmoid sinus was made in order to drain the cavity exudatives. The normal skin and subcutaneous muscle layer of the upper eyelid was preserved (Fig. A). Finally, a pedicle myocutaneous flap from the upper eyelid was transposed inferiorly to cover the orbital cavity and sutured with a skin incision margin. Histopathological examination revealed SGC with necrosis in the center of the tumor. The tumor contained large anaplastic cells that exhibited sebaceous differentiation, hyperchromatic nuclei, and characteristic features of vacuolated foamy-frothy cytoplasm (Fig. ).\nAt the 3-week follow up, the flap had healed satisfactorily and the patient had good compliance (Fig. B–D). The patient was advised to undergo further adjunctive radiotherapy and to undergo follow-up orbital examinations and general physical checkups every 3 months to reduce the risk of recurrence.
A 34-year-old Caucasian female, who had originally undergone an uneventful laparoscopic adjustable gastric band 4 years ago, presented to the bariatric surgery clinic with inability to tolerate solids. A work-up revealed that the laparoscopic band remained in good position but the patient had oesophagitis and gastritis, causing swelling of the mucosa at the band site. The fluid was removed from the reservoir, and the patient was treated conservatively with anti-reflux medication and a full liquid diet. After 2 weeks of treatment the patient’s symptoms improved. After careful consideration, she wished to undergo revisional surgery converting the laparoscopic adjustable gastric band to a laparoscopic vertical sleeve gastrectomy. The patient moved through the appropriate multidisciplinary team approach and was found to be an appropriate candidate for surgery. She underwent laparoscopic removal of the adjustable gastric band and conversion to a laparoscopic vertical sleeve gastrectomy without complications. Her post-operative course was uncomplicated and she was discharged on post-operative day 3.\nOn post-operative day 12, the patient was readmitted to an outside tertiary care hospital for lightheadedness and shortness of breath and was found to have leukocytosis, with white blood cell count of 18,000 cells μl–1. The work-up included a CT scan with intravenous contrast of the chest, abdomen and pelvis, and the patient was diagnosed with a pulmonary embolism. The patient was immediately transferred to our centre for definitive care. When the patient arrived at our centre, the CT films from the outside hospital were reviewed by our radiologists and there was concern that there was air and a faint suggestion of oral contrast outside of the suture line (). Given this finding, an UGI evaluation was ordered. During the early phase, no leak was observed, owing, in part, to the slow passage of 30 ml oral non-ionic contrast (). Some residual contrast from the outside hospital CT was present in the transverse and descending colon. Only after delayed imaging and with administration of additional non-ionic contrast for a total of about 65 ml (approximately 2 h after the start of the fluoroscopic examination) was there a faint suggestion of extravasated contrast, best seen below the left hemidiaphragm (). Follow-up CT scan with oral contrast confirmed the obvious leak ().\nThe patient was treated definitively with endoscopic stent placement and clipping using an Ovesco clip (Ovesco Endoscopy AG, Tubingen, Germany) to close the leak. After an extended hospital course, she was discharged and is presently doing well.
A 38-year-old woman presented with a degloving injury in her right hand due to an industrial accident. Clinical and radiological examinations of her right hand showed PIP joint dislocation of the patient’s index and middle fingers. The radial digital artery of her index finger was avulsed from the proximal phalanx, and the distal part of her index finger had no blood flow and was not revascularizable (Fig. ).\nAfter debridement and reduction of the dislocated PIP and MP joints, a long vein graft was taken from the palmar side of her forearm to reconstruct an outflow course for her thumb and index finger. The degloving skin of her thumb and the dorsal surface of her hand were sutured in situ (Fig. a). The ulnar digital artery and nerve of her thumb were repaired to restore blood flow and sensation, respectively.\nTo restore blood supply to the patient’s index finger, a mid-lateral skin incision was made from the distal interphalangeal joint (DIP joint) to the MP joint. The radial digital artery of the patient’s index finger was severely injured and the proximal part could not be explored. The ulnar digital artery of her index finger was twisted. The incision was extended to the middle of her hand, as the first arteria digitalis communis was also injured. Therefore, a second incision was made at the midportion of the middle phalanx to the MP joint of the middle finger, and the radial digital artery was incised at the PIP joint. The blood flow at the proximal stump of the radial digital artery was not ideal, which confirmed that the first arteria digitalis communis was damaged in the degloving injury. Since the blood flow from the distal radial digital artery of the middle finger was good, the distal radial digital artery of the middle finger was anastomosed to the distal stump of the ulnar digital artery of the index finger. A skin pedicle was made by suturing the dorsal skin of the middle finger to the palmar skin of the index finger. No circulatory problems occurred postoperatively (Fig. b, c).\nDetachment of the index and middle fingers was performed 4 weeks after and both fingers showed signs of good blood supplies. The K-wires were also removed during the detachment. The appearance and function of the index and middle fingers were satisfactory 16 months postoperatively (Fig. ).
A 59-year-old male underwent uneventful DDLT for decompensated hepatitis B-related liver cirrhosis with a MELD score of 19. The transplant surgery and postoperative course were uneventful. He was discharged on the 11th posttransplantation day with stable liver function. Immunosuppressive protocol was as per standard institution protocol. The patient was admitted after 6 weeks in an emergency department with hypotension, vomiting, and altered sensorium associated with oliguria. Liver functions were grossly elevated, and he had a systolic hypotension of 70 mmHg. Emergency abdominal ultrasound scan showed mild hepatomegaly and an echogenic thrombus in the retrohepatic IVC near the suprahepatic anastomosis () which was confirmed by computed tomography (CT) angiography that also revealed renal vein and iliac vein thrombosis as an incidental finding.\nThe patient was admitted in ICU and started on anticoagulation therapy, and a digital subtraction inferior venacavogram was done. This showed a focal severe stenosis approximately 70% in the inferior vena cava at the level of the T12 vertebra. There was an associated thrombus 6 × 3 cm within the retrohepatic and suprahepatic inferior vena cava with complete cut-off of the inferior vena cava 3 cm proximal to its junction with the right atrium. Intravascular thrombolysis using urokinase 50,000 IU was immediately instituted, and the patient was maintained on 100,000 IU/hour of urokinase infusion in the IVC with repeated mechanical thromboaspiration. The patient remained stable during the thrombolysis, and there was reestablishment of blood flow across the previously occluded part of the IVC. Post procedure abdominal ultrasound and Doppler ultrasound were done after 48 hrs, and both still showed the presence of a thrombus. Abdominal CT scans also showed severe stenosis in the suprahepatic inferior vena cava just proximal to the right atrial junction with mild to moderate ascites and splenomegaly. The patient had another angiography done which confirmed a 2 cm short segment severe stenosis of about 95% in the IVC at its junction with the right atrium (). The IVC was twisted along its long axis in this region.\nHe then underwent inferior vena cava venoplasty, and an endovascular stent was inserted whereby a balloon-mounted stent was deployed across the stenosis site to a size of 18 × 32 mmm (). Post stenting, there was improvement in the calibre of the IVC and it was untwisted (). There was no pressure gradient proximal and distal to the stenosis.\nFollowing the procedure, the patient was given low molecular weight heparin 2500 IU subcutaneously for 3 weeks. The patient made uneventful recovery and was discharged 2 weeks post stenting on warfarin with a target international normalized ratio between 2 and 2.5. The liver functions were normal at the time of discharge.\nFollowing the procedure, the patient was given low molecular weight heparin 2500 IU subcutaneously for 3 weeks. The patient made uneventful recovery and was discharged 2 days post stenting on warfarin with a target international normalized ratio between 2 and 2.5. The liver functions were normal at the time of discharge.\nSix weeks after discharge, he was reviewed and had no complaints. An abdominal ultrasound done showed no thrombus in the inferior vena cava and the rest of the abdominal organs were normal as well as his liver and renal function tests.
A 13-month-old girl with the manifestation of diarrhea was admitted to a local hospital, and the symptoms of diarrhea were relieved after taking some medications, which are unknown. Two days later, she suffered from diarrhea again and was prescribed some traditional Chinese medicine (TCM), the components of which were also unknown. However, the child went into convulsions 12 hours after intake of the TCM, and the convulsions lasted for approximately 2 minutes. Four hours later, the patient developed fever, accompanied with a nonprojectile vomiting. Emergency examination revealed elevated serum myocardial enzymes and bradycardia. Vitamin C, cephalosporins, mannitol, and cimetidine were prescribed for treatment. Although bradycardia was relieved, the rest of the above symptoms remained after a week of treatment. A productive cough also appeared subsequently. The child was then transferred to our institution for further management.\nOn examination, her vital signs were stable. Results of routine blood and urine analyses as well as serum cardiac enzymes were normal. The respiratory sound of the patient was rough, and there were rales as well as expiratory wheeze during lung auscultation. A routine chest X-ray and cranial computed tomography (CT) were performed because the symptoms were persistent. We incidentally found a linear metallic mediastinal foreign body (FB) located within the cardiac shadow (). No abnormality was detected by CT scan of the head (data not shown). Echocardiogram showed that the metallic FB was located below the aortic valve, passing through the ventricular septum and aortic root, with the eye point reaching the right ventricle and left atrium (). Mild pericardial effusion was also presented. Some scattered floccus could also be seen near the posterior wall of the left ventricle on ultrasound as a hyperechoic area.\nBased on the above findings, the surgical removal of the FB was performed with the heart beating. Under extracorporeal circulation, we approached the FB with a median sternotomy. A small amount of blood (approximately 100 mL) was seen in the cardiac sac and was drained. The surface of the heart was found to be covered with a layer of cellulose-like substance, especially at the area of right ventricular outflow tract (RVOT), and one puncture site was also observed in the RVOT. With the beating of the heart, a small amount of blood was discharged intermittently from the pinhole. Because neither end of the needle was denuded, an incision was made into the right atrium, which was nearby the arterial septum. The needle appeared to have migrated through the right ventricle and ventricular septum and almost pierced through the posterior wall of the left atrium. A sewing needle of 5 cm in length and 1 mm in thickness was successfully removed by catching it with a clamp from the left atrium (). Remarkable fibrous deposits could be seen in the heart around this needle and were removed during the surgery. The pericardium was irrigated with antibiotic solution. The operation was completed without any complication. Recovery was uneventful, and she was discharged 8 days after the surgery.
A 72-year-old man with Parkinson disease was found to have experienced a presumed intracranial hemorrhage approximately 4 months after an uneventful placement of a unilateral deep brain stimulation (DBS) lead into the subthalamic nucleus for treatment of Parkinson disease. He presented for evaluation of short-term memory difficulties and expressive aphasia. Imaging studies () revealed a cystic cavity midway along the DBS lead most consistent with an intracranial hemorrhage that was resolving. Immediate postoperative imaging at the time of lead placement had not suggested any hemorrhage or infarction (), and the patient's early postoperative course was otherwise unremarkable, with improvement of contralateral motor fluctuations and tremor and reduction of bradykinesia and rigidity. The patient did not experience an acute decline in function associated with this imaging finding but rather experienced a gradual worsening of memory and speech. It is presumed that a small hemorrhage occurred and that edema associated with the development of a hemorrhage capsule led to his delayed presentation.\nConservative treatments including speech therapy were initiated, and his memory difficulties began to slowly improve. While recovering from the aphasia, he presented approximately one month later with the acute onset of profound dysarthria, confusion, right facial weakness, and diplopia. A noncontrast computed tomography scan showed a 1.9 × 1.5 cm acute hemorrhage in the left cerebral peduncle just distal to the tip of the DBS electrode (). On examination, the patient was oriented to name only and was dysarthric but able to follow commands in all four extremities. All laboratory values were within normal limits, and no platelet products or clotting factors were administered.\nOnly during admission for this second intracranial hemorrhage it was established that the patient had continued in a randomized clinical trial of a new direct factor-Xa inhibitor, edoxaban, for atrial fibrillation. Previously, the patient had reported that he would be finished with the clinical trial one week before DBS placement. In fact, he restarted this medication only 5 days after lead placement. Unfortunately, the study participation was not revealed despite multiple medication reviews at the time of the initial memory difficulties.\nThe patient was admitted to the neurocritical care unit for frequent neurological examinations. A repeat non-contrast CT ~24 hours after admission showed mild decrease in the size of the hemorrhage (). Over the next few days, the results of the patient's neurologic examinations slowly improved, although he remained intermittently confused. He was discharged to the inpatient rehabilitation unit on hospital day 7 with a plan to remain off all anticoagulation therapies. The patient was withdrawn from the edoxaban trial and was started on antiplatelet therapy after three months. He recovered well, with mild expressive aphasia and weakness; however, his contralateral bradykinesia and rigidity did again worsen as the hemorrhage resolved.
An 86-year-old female patient presented to the Head and Neck Service at Memorial Sloan Kettering Cancer Center for management of a locally advanced squamous cell carcinoma of the left nose (Figure A,B). The patient was recommended to have a total rhinectomy with bilateral modified neck dissection with reconstruction of the nasal defect with a nasal prosthesis. The oncological resection was carried out by the head and neck surgical team. Subsequent pathology showed an advanced primary cancer with clear surgical margins and with no pathological involved lymph nodes. As such, no postoperative radiation was recommended. After a discussion of the risks and benefits of treatment, including the course of treatment for surgical and/or prosthetic reconstruction, the patient elected to have her planned nasal defect prosthetically reconstructed. The patient was preoperatively evaluated by the Dental Service, and a nasal moulage was made. The patient was then planned for craniofacial implants to facilitate retention of the nasal prosthesis.\nTotal rhinectomy with bilateral modified neck dissection was performed by the head and neck team. A provisional nasal prosthesis was delivered postoperatively which replicated the patient's nasal contours. The prosthesis was secured with three pieces of medical grade adhesive tape and was removed daily by the patient.\nA postoperative CBCT was completed for craniofacial implant planning. A nasal surgical stent was fabricated to assist in the accurate placement of the craniofacial implants based on the surgical plan. The patient was then brought back to the operating room 2 weeks following rhinectomy for placement of the craniofacial implants. The surgical stent was utilized to identify the planned implant locations intraoperatively. An incision was made on the nasal floor exposing the premaxilla and vertically along the glabellar skin to expose the bone in the glabellar region. Three osteotomies were created, two in the premaxilla region and one in the glabellar region, and three 4 mm craniofacial implants (Vistafix VXI300; Cochlear) were then placed to the proper depth with adequate primary stability. Three sterile cover screws were placed on the implants and were hand-tightened (Figure ). Primary closure was achieved with 3-0 vicryl sutures on the nasal floor and 5-0 nylon sutures in the glabellar region. Xeroform packing was placed within the nasal cavity. The patient was counseled to return for follow-up in 2-3 months to begin fabrication of a definitive nasal prosthesis.\nThe patient returned to the Dental Service 3 months status postsurgery for uncovery of the craniofacial implants. Topical betadine was administered to the skin surrounding the nasal defect, and local anesthesia (68 mg 2% lidocaine with 1:100 000 epinephrine) was directly administered to the skin surrounding the implant sites. The implant in the glabellar region did not require tissue excision as the implant platform was exposed. The cover screw of the superior implant was removed, and a 7.5 mm sterile healing abutment was placed and hand-tightened. Then, two soft tissue punches were completed using a 4 mm-tissue punch, exposing the two implants in the premaxilla area and two sterile 7.5 mm healing abutments were placed and hand-tightened. Xeroform gauze was used around the abutments in the premaxilla to compress the adjacent skin, and the patient was counseled to use bacitracin for postoperative wound care.\nAfter 1 month, the patient returned to begin fabrication of the nasal prosthesis. A nasal moulage was completed using irreversible hydrocolloid impression material (Jeltrate Plus; Dentsply Sirona) and fast setting plaster (Type V, Diekeen green; Kulzer Dental). Then, the healing abutments were removed and replaced with 7.5 mm final abutments (Vistafix VXA300; Cochlear) and were torqued to 25 Ncm. Three prosthesis magnets were placed: one on the abutment in the glabellar region (Maxilip magnet; Factor II Inc) and 2 on the abutments in the premaxilla region (Minilip magnet; Factor II Inc) (Figure ). Magnetic impression copings (S-range, Factor II Inc) that had been luted together with acrylic resin (Jet, Lang Dental Manufacturing Co., Inc) were used to complete another facial moulage with irreversible hydrocolloid (Jeltrate Plus; Dentsply Sirona) and fast setting plaster (Type V, Diekeen green; Kulzer Dental) to transfer the implant locations onto a model of the patient.\nUsing the patient's model, a wax sculpture of the nasal prosthesis was then made and was subsequently tried on the patient. A custom magnetic keeper (S-range, Factor II Inc) was tried on the magnetic abutments and was properly adapted. A base shade for the nasal prosthesis was selected followed by processing of the prosthesis into silicone (RTV 40, Factor II Inc) which was extrinsically tinted to match the patient's adjacent skin colors. The completed nasal prosthesis was then delivered (total treatment time 8 months following surgery) (Figure A,B), and home care instructions were reviewed. The patient and family were very satisfied with the esthetics, fit, and function of the nasal prosthesis.
A 42-year-old man complained of severe pain in the left knee, which had started several months ago. He had no preceding trauma, regular sport activity or previous relevant medical history. Knee movements were associated with severe pain. Localized swelling and numbness of the lateral aspect of the knee was observed.\nThe patient first consulted a local orthopedic clinic, due to pain and swelling in the knee. Loss of range of motion (ROM) was also seen due to the pain. A radiograph was taken and revealed a high attenuation area located near the lateral femoral condyle, which continued to the lateral side of the proximal tibia along the course of LCL (). Myositis ossificans, ruptured calcified tendinitis, infected bursitis, or extra-skeletal osteosarcoma was suspected. Three days later MRI was performed to delineate in detail the region surrounding the calcified structures to differentiate these entities. T2-weighted image showed a low signal area located mainly in the proximal portion of LCL. A part of the low signal area continued to the space adjacent to the iliotibial tract. There was edema in the surrounding tissue (). Considering the imaging findings and clinical condition, ruptured calcified tendinitis of the LCL was suspected.\nTen days after the MRI at the local clinic, local steroid injection was performed due to the pain that had persisted for two weeks, but no improvement was obtained, and the patient was referred to our hospital. Although calcifying tendinitis or myositis ossificans was suspected based on the initial radiograph and MRI findings, the intense pain continued unexpectedly with increasing numbness of the lateral aspect of the thigh, associated with loss of the ROM. Physical examination showed a mass at the lateral aspect of the fibular head with redness and spontaneous pain. A radiograph was taken and showed a large high attenuation area downward around the lateral side of the head of the fibula. A second radiograph was taken which showed slit-like calcification with changes in its shape and moving downward compared to the first radiograph (). A second MRI was performed one week after the second radiograph to confirm the diagnosis of ruptured calcifying tendinitis and evaluate where the primary lesion existed. Another aim was to rule out any co-existent conditions or infective complications. There was a low signal in the LCL area with edematous change of the surrounding soft tissue corresponding to the high attenuation area noted on the radiograph (). A follow-up radiograph was taken six weeks after the second MRI. By this time, the pain and loss of ROM had subsided. The high attenuation area almost vanished beside the calcified nodules at the insertion point of the lateral femoral condyle of the LCL ().\nThe most probable hypothesis is that some calcified matter developed a liquid-like feature (so-called “milk of calcium”) induced by inflammation and ruptured causing severe pain. This could have happened in a bursa nearby since the LCL itself usually does not and cannot contain such a space. After rupture, the calcified matter likely moved downward due to gravity and into a potential space such as an acquired bursa, and then gradually dissolved, which is consistent with the timing of the decrease in pain. Puncture was not performed for this patient, and our hypothesis is not proved pathologically. At one-year follow-up, no recurrence was evident on MRI (not shown). The patient gained a full ROM with no pain and he was able to comfortably perform his routine activities.
A 23-year-old female presented to the clinic with a history of focal impaired awareness seizure. She is a known case of tuberous sclerosis (confirmed by genetic testing and evident on MRI brain) and BRBNS, which the patient was diagnosed with early in childhood. Her BRBNS presents with hemangiomas involving multiple organs in the body including the brain, GI system, and skin.\nEarlier in her diagnosis, she was managed with various modalities, such as chemotherapy and interventional radiology, which failed to control her disease and specifically her active GI bleeding. To treat her subsequent iron-deficiency anemia, she was transfused on a weekly basis. Owing to her progressive uncontrolled disease, she traveled to seek further treatment at medical centers in the United States, where her disease was controlled by surgical resection and interventional sclerotherapy. The patient returned to Saudi Arabia and was later commenced on sirolimus, which she showed some response to. In 2016, the patient started developing multiple new lesions on her neck and trunk. Later, she started presenting complaints that are consistent with focal aware seizures. These attacks are characterized by loss of memory over a couple of minutes that is slowly regained in the proceeding 30 min. The patient reports feeling fear that lasts seconds to minutes preceding the seizure. It has been reported that her first attack happened when she was 2 years old. It occurred daily at any time during the day or night. After 9 years of age, it became less frequent and occurred once per week in the form of staring and behavioral arrest with mouth automatism lasting less than 10 seconds. At that time, she had been started initially on ethosuximide and valproic acid. After her 20th birthday, the semiology changed to focal impaired awareness seizure presenting in the form of palpitations and fear followed by behavioral arrest lasting less than 30 seconds. Carbamazepine was effective at that time in controlling her seizures as a mono-therapy. Alas, at the age of 23 years, the seizure recurred. At that time, the immunosuppressant for her dermatological case, sirolimus, was commenced and had interacted with the carbamazepine she was on. Therefore, levetiracetam (LEV) was added and was later reported to have aggravated her anxiety symptoms. Our patient was then shifted to lamotrigine (LTG) due to the psychiatric side effects she developed from LEV including anxiety and depression, which has successfully kept her seizure free during her 6-months follow up.\nUpon examining the patient, she had small, dark blue, round or ellipsoid, soft compressible nevi (20-mm diameter) on her face, abdomen, and back. Her physical exam and vital signs were otherwise within normal limits. Upon further investigation, a 30-min EEG study performed was found to be normal with rhythmic mid-temporal theta bursts of drowsiness (RMTD), a benign variant also known as the psychomotor variant. Video-EEG or continuous EEG to ensure the absence of seizures is yet to be performed. Multisequential multiplanar nonenhanced and enhanced MRIs of the head and neck were performed showing extensive scalp, neck, chest wall as well as para-spinal soft tissue mass lesions involving also deep regions like the deep neck and chest, posterior deep cervical, oral, around the thyroid and para-tracheal regions. Additionally, the radiological findings showed a similar soft tissue lesion in the right oropharynx causing narrowing. The overall appearance was described as suggestive of extensive multiple vascular malformations in keeping with the known diagnosis of Blue Rubber Bleb Nevus Syndrome. Other MRI findings have shown to be consistent with Tuberous Sclerosis of multiple bilateral cortical/subcortical tubers involving bilateral frontal, parietal as well as left temporal lobes with ill-defined gray-white matter junction and cortical thickening.
A 14-year-old boy complained of short of breath for 10 months was admitted to our hospital. Computed tomography (CT) revealed a giant multilocular mass of approximate 20 × 20 × 25 cm in size with right pleural effusion. It compressed the heart, superior vena cava, and diaphragm with the total right lung atelectasis. The tumor contained multiple cysts with calcifications and fat. Tumor cells were not found in the pleural effusion (Figure ). The teratoma was considered unresectable and malignant, which contained immature components by CT guided fine-needle biopsy 8 month ago in a foreign hospital. The boy took 4-cycle BEP chemotherapy. But the tumor didn’t shrink evaluated by CT scan. Then the patient received an exploratory thoracotomy 3 month ago by another hospital. But the huge size, widespread adhesions and abundant new vascularization of the tumor resulted in massive bleeding allowed only a small part of the mass excised for pathologic diagnosis. Pathologic findings revealed a mature teratoma. Cranial MRI, upper abdomen CT scan and bone nuclear scan revealed no further lesions in our hospital. The right-sided posterolateral thoracotomy was performed on July 18, 2013. Venous conduit bypass between the right jugular vein and right femoral vein was established immediately before operation in case of SVC replacement. Because of the widespread and severe adhesions among the tumor with surrounding chest wall, diagram, lung, pulmonary vessels, SVC, and pericardium, great care was taken for the dissection. Reducing the tumor volume to facilitate the dissection, the fluid contents of the mass were aspirated via a small incision of the wall. With partial resection of the dense adhesions of the pericardium, and wedge resections of the severe adhesions of the right upper, middle, and lower lobes of the lung, en bloc resection of the huge tumor was completed (Figure ). The tumor weighed 4320 g and its largest diameter was 25 cm. Considering the weight of the tumor, continued traction via the sutures placed on the tumor maintained during dissection to prevent from compressing of the heart. The right lung was re-expanded. We used ventilation with peep 6 cm on the first postoperative day, 3-day corticosteroids, and diuretics to prevent re-expansion pulmonary edema. The postoperative course was uneventful, and the boy was discharged from the hospital on the 16th postoperative day (Figure ). Final pathological diagnosis was a benign mature teratoma. At 6-month follow-up, the patient is well without recurrence.
A 68-year-old woman with a history of colon cancer was referred for thoracoscopic resection of a metastatic lesion in the right inferior pulmonary lobe (). Preoperative coronary angiography revealed total occlusion of the left anterior descending artery (LAD) after the origin of the first diagonal branch (). Percutaneous coronary intervention was not performed because of its technical difficulty and contraindication for perioperative anticoagulation. To minimize the operative trauma, we performed simultaneous MIDCAB via a small left thoracotomy and thoracoscopic wedge resection of the lung lesion.\nThe patient was anesthetized and intubated with a double-lumen endotracheal tube. Single-lung ventilation was used to facilitate exposure for harvesting of the left internal thoracic artery. The patient was positioned supine with 30° rotation toward the right decubitus position by means of a rolled towel. External pads for emergency defibrillation were placed on the right anterior and left posterior sides of the chest wall. A 5-cm left anterior thoracotomy incision was then created along the inframammary line and tunneled into the fourth intercostal space according to the preoperative chest X-ray and coronary angiography images. After harvesting of the left internal thoracic artery, a pericardial incision was made to expose and stabilize the LAD with a specially designed minimally invasive stabilizer. The coronary anastomosis was performed using a continuous running suture technique (8-0 suture) and intracoronary shunting.\nAfter heparin neutralization and switching of the single-lung ventilation to the other side, the patient was positioned supine with 30° rotation toward the left decubitus position. A 4-cm incision in the fifth intercostal space was made along the right anterior axillary line for wedge resection of the dorsal segment of the right inferior pulmonary lobe using a thoracoscopic linear stapler with a blue reload. After the surgery, the patient was transferred to the intensive care unit and recovered well. She was discharged on postoperative day 8. A perioperative red blood cell transfusion was not necessary. The patient’s postoperative mechanical ventilation time was 12 h. Postoperative transthoracic echocardiography showed a normal ejection fraction and heart chamber. Pathologic examination of the lung lesion showed a moderately differentiated metastatic colonic adenocarcinoma. The lesion was positive for cytokeratin (CK), CK20, Ki-67, CDX2, and carcinoembryonic antigen as determined by immunohistochemistry.\nThe patient was clinically well at the 1-year follow-up visit. She was in NYHA I without symptoms of myocardial ischemia. Chest computed tomography showed no indication of a lung mass at the 1-year follow-up.
An 81-year-old male patient was referred to our department with dysphonia. There was no history of smoking. A status past multiple myeloma was known in his medical history that was in complete remission at the time of presentation. The patient denied dyspnea, dysphagia, pharyngalgia, and fever. Laryngoscopy revealed a diminished mobility of the right vocal cord and a thickening of the right vestibular fold so that a microlaryngoscopy with tissue sampling was performed. The histological examination of specimens obtained from this region revealed fibrosis. Computed tomography (CT) scans of the neck and the thorax were without any pathologic findings. The patient was discharged to outpatient care.\nThree months later, the patient was admitted with progressive dyspnea along with inspiratory stridor. The clinical examination revealed now a complete paralysis of the right vocal cord and a remaining glottic cleft of only 1 mm due to a supraglottic protrusion of the right vestibular fold. The CT scan () showed now a tumor of the right vocal cord extending to the right piriform sinus.\nAfter tumor debulking in order to expand and secure the airway, the excised material that consisted of several red brown elastic tissue fragments measuring together 24 × 12 × 10 mm was sent for pathological examination. Histologically, one could see tight lymphoid infiltrates. The cells had large nuclei and were irregularly shaped, and the proliferation was strongly enhanced in the staining for Ki67 (50%). The immunohistochemical analyses showed a negative result for CD20 and CD3, and a positive staining for CD138. BCL2 and CD10 were coexpressed (). The clonal light chain restriction for lambda chains substantiated the diagnosis of a multiple myeloma. These results were consistent with laryngeal involvement from the patient's previously diagnosed multiple myeloma.\nThe patient was referred to the Department of Hematology and a systemic therapy with the proteasome inhibitor Bortezomib was discussed. Ultimately, instead of that, a local radiation therapy with 60 Gy was performed. In a control laryngoscopy with tissue sample taken after the radiotherapy, the myeloma could not be verified anymore. The patient is in continuous otorhinolaryngological and oncologic follow-up. To date, almost two years later, no recurrence of the myeloma has occurred so far.
A 39-year-old male patient was evaluated at another center for dysphagia to solids and weight loss for 6 months. Upper gastrointestinal (GI) endoscopy showed an ulceroproliferative growth starting at 33 cm and extending up to 42 cm involving the gastroesophageal junction. Biopsy was positive for adenocarcinoma. Contrast-enhanced computed tomography (CECT) abdomen done at the same center was suggestive of asymmetrical mural wall thickening involving the lower one-third of the esophagus, gastroesophageal junction. and extending onto the proximal stomach . He was initiated on neoadjuvant chemotherapy with docetaxel, cisplatin, and 5 fluorouracil and received three of those cycles. He subsequently came to us for further management after having done a repeat imaging which showed marked response to treatment with a diffuse thickening of the distal esophagus remaining. General and systemic examination revealed no abnormalities except for a low body mass index (BMI). Repeat upper GI endoscopy showed the growth starting at 33 cm and extending along the lesser curvature up to 2 cm below the gastroesophageal junction.\nIn view of the marked response to chemotherapy demonstrated on two successive imaging, we planned for a radical thoracoscopic esophagectomy. Cardiopulmonary and anesthetic fitness was ascertained. We initiated Incentive spirometer for respiratory fitness and high-protein supplements in view of low BMI. Patient was counselled, informed consent was obtained, and scheduled for a thoracoscopic esophagectomy followed by gastric/colonic pull up.\nInitial staging laparoscopy in supine position did not reveal any distant metastases. Subsequently, we thoracoscopically completed esophagectomy in the prone position according to our standard technique.\nAs expected from the imaging, the ulceroproliferative growth was involving the lower esophagus, gastroesophageal junction, and initial 2 cm of cardia and lesser curvature. The tumor was not adherent to the surrounding pericardium, aorta, or diaphragm and could be removed with a safe margin along with an adequate extended two-field lymphadenectomy. The thoracic duct was excised in its course along the tumor in the thorax and the proximal and distal ends were doubly clipped securely in the thorax in order to prevent a chyle leak. We at our center, preferably ligate and excise the thoracic duct during esophagectomy whenever possible (unless it is technically not feasible and patient is unstable). The reason for this strategy is supported by evidence and is two fold: (1) it significantly reduces the incidence of postoperative chylothorax,\n(2) it significantly increases the lymph node yield, especially around the region of the thoracic duct.\nA standard gastric pullup and cervical esophagogastric anastomosis was subsequently performed.\nPostoperatively patient had a high output from the right intercostal drainage tube from postoperative day 2 which turned chylous once jejunostomy feeds were started. Drain fluid triglyceride levels were high confirming a chylous leak. We initiated conservative management with total parenteral nutrition, nil by mouth, and octreotide injections thrice a day. However, the right intercostal drainage output was persistently high in the range of 1.5 to 2 L/day. We refrained from reexploring immediately in view of the fact that we had already identified and clipped the thoracic duct intraoperatively.\nOn postoperative day 9, we attempted radiological identification and embolization of the thoracic duct leak by injecting lipiodol in and around the bilateral superficial inguinal lymph nodes using ultrasound guidance (\n) and subsequent c-arm visualization of the site of leak from the thoracic duct.\nTo our surprise, we found that the thoracic duct was opacifying well up to the site of the clip in the thorax, but without any leak from it. The only leak that could be demonstrated was a minor one in the left subdiapghramatic location from an adjacent lymphatic tributary (\n). A subsequent computed tomography (CT) thorax and abdomen on the same day confirmed the same findings. As there was no significant free fluid in the abdomen on imaging and the right subhepatic abdominal drain was nil, we decided on further conservative management by adding intravenous octride infusion and oral midodrine as some evidence has suggested for refractory chylothorax. However, there was no respite from the high output chylothorax (more than 1 L) though initially it came down to 500 to 750 mL per day (\n).\nOn postoperative day 18, after several sessions of thorough preoperative counselling with the patient and relatives, we decided to reexplore the patient. Anticipating dense adhesions during the unfriendly third postoperative week, we decided to explore the abdomen rather than the thorax first. The transverse colon had densely sealed off the supracolic compartment form the rest of the abdomen. As soon as we released it, there was a gush of chyle of about 2 L, and we could slowly identify after a lot of suction and irrigation that the source of leak was from robust lymphatic vessels in the retroperitoneum in the left subdiaphgrmatic area where the splenic artery lymph nodes were dissected out as a part of the standard d2 lymphadenectomy.\nOnce these vessels were secured with repeated ligatures of 2–0 prolene, there was no more active chyle leak in sight. There was no active chyle draining from the thorax into the abdomen through the hiatus or into the right chest tube.\nPatient was extubated after the operation and the right ICD output reduced significantly in the next few days; so it was subsequently removed 6 days after the reexploration. Patient was discharged on a normal diet and is doing well. Histopathology was reported as t3n1 adenocarcinoma with partial response to chemotherapy.
A 3-year-old boy presented to our hospital with a big abdominal circumference (Fig. ) since he was born. He had no history of urinary tract infection or flank pain. The abdominal examination showed a defined cystic abdominal mass with a smooth surface measuring 15 × 10 cm. The abdominal ultrasound revealed a separated acoustic dark area on the left abdomen and bilateral hydronephrosis with upper ureter dilatation on the right abdomen. Similarly, abdominal computed tomography (CT) scan demonstrated a giant ureter on the left side and right hydronephrosis with the whole dilatation of right ureter (Fig. ). Contrast-enhanced CT scan further showed renal dysplasia with a giant ureter (Fig. ). In addition, a dynamic diethylene triamine pentaacetic acid (DPTA) radionuclide renogram showed no function in the left glomeruli and compensatory increase in the right glomeruli. On cystoscopy, the left ureteric orifice could not be found. Based on these examinations, a diagnosis of left CGM causing a malfunction of the left kidney and bilateral hydronephrosis was made.\nAt one-stage of the operation, the giant left ureter and the right ureter dilated about 5 cm from the entrance of the bladder (the submucosal segment of the ureter) were found in the deep right bladder. So we considered that the right ureter was compressed by the giant left ureter, and then a left nephrostomy with a right ureterolysis were performed. After the first operation, the liquid outflowing from the single J tube was about 10 mL per day. After the first operation for 19 days, a dynamic DPTA radionuclide renogram was performed again and revealed a serious decline in the function of left kidney. In addition, an intravenous pyelography showed no images of the left kidney and ureter (Fig. ). These results indicated a poor left kidney function and we considered that the left kidney could not be kept any more. As a result, a second-stage operation was performed thirty days after the first operation. During the operation, we could see a dysplastic left kidney and an almost entirely dilated left ureter with only 1 cm stricture at the entrance of the bladder, then nephroureterectomy was performed through cutting off the left kidney and ureter close to the bladder (Fig. ). The postoperative pathologic examination showed that the left kidney and ureter were similar to multicystic dysplastic kidney (Fig. ). The patient recovered well and remarkably reduced right hydronephrosis was found by the follow-up abdominal ultrasound (Fig. ). The patient was observed to be asymptomatic after 2 years of follow-up.
An 8-year-old boy visited the outpatient clinic for evaluation of facial asymmetry and narrowing of the right external auditory canal. Upon physical examination, the patient showed right side facial enlargement, cranial protrusion, gingival hypertrophy, and soft tissue thickening of the external auditory canal. There was no evidence of asymmetry of the body trunk and limbs or any subcutaneous/cutaneous lesions noted. The patient denied any prior history of medical, surgical problems, or any family history of hemihyperplasia. A chest posteroanterior film identified a large mediastinal mass draping over the right cardiac shadow (). A chest lateral image indicated a mass filling the anterior mediastinal space (). For further evaluation, contrast-enhanced chest CT was performed. Chest CT revealed a large mass occupying the anterior mediastinum showing no mass effect or displacement of adjacent structures. It had a bilobular configuration with asymmetric mass-like enlargement of the right lobe which contained curvilinear or nodular areas of fatty component. The left lobe was slightly enlarged and showed relatively homogeneous attenuation. Concomitant diffuse fat attenuation filling the pericardial space suggestive of pericardial lipomatosis was also noted. No evidence of associated mediastinal lymphadenopathy or focal lung lesion was noted (). A fat containing benign mediastinal mass including thymolipoma or lipoblastoma was suspected. A malignant mass such as liposarcoma or malignant germ cell tumor was also included in the differential diagnoses. As it was difficult to determine whether the more predominantly enlarged right lobe was the only portion involved or both the right and left lobes were pathologic, mediastinal MRI was performed to further determine the precise extent of the lesion. The MRI results revealed a large anterior mediastinal mass that showed heterogeneous iso-signal intensity to the chest wall muscles on T1- and T2-weighted images and heterogeneous enhancement on fat saturated T1-weighted images. There were whorls or nodular areas of high signal intensity within the thymus on both T1- and T2-weighted images which showed suppression on fat saturated contrast enhanced T1-weighted sequence. The pericardial space was also filled with high signal intensity on both T1- and T2-weighted images and showed fat suppression on fat saturated contrast enhanced T1-wieghted images (). For evaluation of facial asymmetry and narrowing of the right external auditory canal, contrast-enhanced CT of the paranasal sinuses was also performed. Paranasal sinus CT showed hypertrophy of the right side parotid gland, adenoid tissue, temporalis muscle, and sternocleidomastoid muscle. The right inferior nasal turbinate was also prominent. Moreover, mild narrowing of the right external auditory canal was noted due to soft tissue thickening along the posterior wall of the canal ().\nThe patient underwent surgery consisting of a total thymectomy with mediastinal lymph node dissection. The operative findings revealed a large anterior mediastinal mass showing no invasion into the mediastinal structures and the parietal pleura. On gross specimen, the mass was yellowish with a lobulating contour confined within a thin fibrous capsule. The mass was about 17 × 13 × 3 cm in size and weighed 280 g (). The cut surface showed multifocal areas of light-yellow spots of fatty tissue scattered within the thymic mass. There was no evidence of hemorrhage or areas of cystic, necrotic changes (). Microscopically, the tumor showed normal distribution of the cortex, medulla and Hassall's corpuscles. It had fibrous and myxoid stroma with focal areas of adipose tissue admixed in various proportions (). The histologic diagnosis was a true thymic hyperplasia. The postoperative course was uneventful and the patient was discharged to follow-up on an outpatient basis for further management of right facial hemihypertrophy. The patient was followed up for about a year and a half and has not shown any evidence of progressive course or cutaneous/subcutaneous lesions thus far.
A 62-year-old man presented at the Neurology consultation with a six-week history of a severe, strictly left orbitotemporal headache, with a frequency of three attacks per week, occasionally more than one at the same day. Most of them occurred in the first half of the night, waking him up, and lasted between thirty minutes and one hour. He used to take ibuprofen as acute treatment, with unsatisfactory response, since he did not notice a significant difference between treated and untreated attacks in terms of duration and pain intensity. To relief the pain, he used to open the window to get some fresh air. The headache was always associated with ipsilateral conjunctival injection and lacrimation. Pain triggers were not identified by the patient. He had no personal or familial history of headaches. His medical history was remarkable for hypertension and asthma, with a past surgical history including septoplasty and bilateral middle turbinectomy and uncinectomy due to nasal respiratory insufficiency. By the time of medical evaluation he was asymptomatic and neurological exploration was unremarkable. The clinical picture was suggestive of a CH and the patient was medicated with verapamil 120 mg daily. A MRI scan was performed, which revealed a sphenoid sinus mucocele, without secure expansion of the sinus. Two weeks later the patient came to the Emergency Department with complaints of horizontal diplopia that he noted when he woke up in that morning. He maintained the headache attacks, with similar characteristics, despite prophylactic therapy. Neurological examination revealed left eye adduction palsy and ptosis. A brain CT scan was performed and excluded lesions other than the mucocele. Paranasal sinus MRI revealed molding of the medial wall of left cavernous sinus by the sphenoid mass (). A paranasal sinus CT scan was also performed to allow for a better characterization of the lesion, showing sclerosis and interruption of the roof and posterior wall of the left sphenoid hemisinus (). The patient was submitted to surgical drainage of the mucocele by transnasal-transphenoidal approach, with complete resolution of the adduction impairment, persisting a mild left eye ptosis. After the surgery the attacks stopped, and in the six-month follow-up he reported no further attacks.
A 26-year-old male patient with a history of spastic cerebral palsy, shunted hydrocephalus, and epilepsy was referred for his baclofen pump refill as well as increasing discomfort from spasticity. He was being treated with baclofen administered via an intrathecal baclofen pump that had been originally placed in subfascial position more than 20 years ago. His pump had been replaced twice previously. Specifically, he had undergone one previous end-of-service pump replacement and one revision to replace a fractured catheter, and the patient had not experienced any complications with any of his prior pump refills.\nBecause the patient’s baclofen pump could not be palpated in the created pocket and he continued to have signs of spasticity, an X-ray was performed, during his referral appointment at the clinic. The X-ray demonstrated a subcostal location of his baclofen pump, but it wasn’t clear from the X-ray whether the pump had migrated into the peritoneal cavity or not ().\nThe patient was subsequently admitted and taken to the operating room for revision of his baclofen pump. Upon opening the subfascial pump pocket, we saw the pump catheter, but unexpectedly noticed that the pump had migrated. The dissection was extended along the catheter until the peritoneal cavity was entered where the 40-mL baclofen pump was found ().\nWe removed his pump and inspected the bowel to ensure that no perforation had occurred. On further examination, we identified a fascial tear through which the baclofen pump had migrated. This defect in the fascia was in the right lower abdominal quadrant, on the posterior aspect of the subfascial pump pocket. For this reason, a smaller (20 mL) baclofen pump was filled and inserted instead subcutaneously.\nFollowing the removal of his migrated baclofen pump and its replacement with a subcutaneous one, the patient was discharged home on postoperative day 7 only to return on postoperative day 9 with constipation and abdominal pain. Subsequently, he was readmitted and placed on a strict bowel regimen with milk of molasses enema treatments. As his diet was slowly advanced, he was monitored for any evidence of bowel distension. Once the patient was able to have normal bowel movements and tolerate oral food intake, he was discharged home on postoperative day 12. Additionally, on discharge it was noted that the patient would later need a proximal and distal revision of the ventriculoperitoneal shunt for his worsening hydrocephalus.\nDue to progression of his hydrocephalus, the patient was then readmitted for a scheduled proximal and distal revision of his ventriculoperitoneal shunt. Although patient had significant adhesions, ventriculoperitoneal shunt revision was successfully performed. The patient was observed until postoperative day 7 to exclude the possibility of his ventriculoperitoneal shunt failure and sent home in good condition following this second procedure. However, on postoperative day 22, the patient began to develop evidence of shunt failure, including headaches and increasing ventriculomegaly. The patient was subsequently readmitted and returned to the operating room for a second revision of his ventriculoperitoneal shunt. Unfortunately, approximately one month later the patient passed away suddenly from what was believed to be sudden unexpected death in epilepsy. Of note, he was being managed with anti-epileptic drugs and intrathecal baclofen has no known effects on seizure exacerbation.
A 58-year-old male presented to the emergency room (ER) of our institution with sharp neck pain of three weeks' duration. The pain was acute in onset, radiating to right shoulder and right lateral aspect of the head. He reported that the pain was associated with numbness in right hand, blurring of vision in the right eye, tinnitus, and dizziness. Patient denied recent trauma to the head and neck. There was no history of weight loss or decreased appetite or change in bladder or bowel habits. Patient also denied headache, vomiting, chest pain, or shortness of breath.\nHis medical history is significant for cirrhosis of liver secondary to chronic hepatitis C infection and alcohol. His other medical conditions include essential hypertension and chronic obstructive pulmonary disease. Patient denies undergoing any prior surgical procedures. His mother was diagnosed with breast cancer. He reported smoking one pack of cigarettes for the past 40 years. He has been dependent on alcohol but denied recreational drug use.\nOn initial evaluation, he was afebrile and hemodynamically stable. Physical examination revealed a tender point in the posterior aspect of neck without any visible anatomical abnormalities. On neurological examination, his mental status was intact and cranial nerve examination was normal. He had increased deep tendon reflexes on right side compared to left. There was decreased sensation to touch on the right side and Romberg sign was positive. There were no signs of meningeal irritation. Cardiopulmonary and abdominal examinations were within normal limits.\nHis laboratory results revealed normal blood counts including platelets. His electrolytes and renal and liver function tests were within normal limits. His hepatitis C antibody was positive. He was immune to hepatitis A but not immune to hepatitis B.\nComputerized tomography (CT) of the cervical spine () revealed a mass at level of C3 with marked osseous destruction and encasement of right vertebral artery. Subsequent magnetic resonance imaging (MRI) of cervical spine () revealed destructive enhancing mass at level of C2-C3 with evidence of spinal cord compression. CT and MRI of the brain revealed no acute intracranial hemorrhage or evidence of intracranial neoplasm. CT imaging of abdomen () was significant for a right hemiliver mass. His laboratory results showed elevated alfa-fetoprotein (AFP) of 1167 ng/mL.\nHe developed spontaneous intraperitoneal bleeding from tumor leading to drop in hematocrit. He was transferred to critical care unit for close monitoring. He was evaluated by interventional radiologist and underwent imaging guided selective arterial embolization. Subsequently upon stabilization he underwent occipital cervical stabilization and fusion () with excisional biopsy. Histology of the cervical mass confirmed the diagnosis of metastatic hepatocellular carcinoma (Figures and ). His hospital course was complicated by the development of pneumonia leading to septic shock and death.
A 31 years old right hand dominant gentleman presented to our orthopedic specialty clinic with fracture distal end radius on left side. On further evaluation, there was deformity in ipsilateral shoulder joint and asymmetry was present as compared to opposite side. There was an anterior globular bony swelling palpable with well defined margins. Transmitted movements from humerus were present confirming it to be bony humeral mass. There was wasting of deltoid muscle as compared to opposite side. Range of motion were flexion upto 170 degrees (), extension up to 10 degree (), internal rotation up to L3 (), and external rotation up to 30 degree () and abduction up to 120 () in both active and passive movements, further movements were restricted and mildly painful. Patient did not have any history of significant trauma to shoulder in past. However he gave a history of seizure attacks three years back following which he had shoulder pathology. He had taken antiepileptic treatment; however no treatment was taken for the shoulder. There were no further epileptic episodes and he was taking antiepileptic treatment. Radiographs of shoulder joint were taken which confirmed anteriorly dislocated humeral head (). Further views of shoulder joint were taken to check for any bony changes. They didn’t show any significant abnormality. CT scan showed anteroinferior dislocation with neocavity with pseudojoint formation (,,). Chronic hillsachs lesion was also seen. MRI Scan showed anteroinferior shoulder dislocation with intact rotator cuff muscles (,) Since the patient had good functional range of movement we explained him the treatment options. He opted for non surgical line of management. Hence was given shoulder mobilization exercises. Presently patient is being followed up with no fresh complaints and maintained join movements.\nAnterior dislocation of shoulder unlike posterior dislocation is most commonly traumatic in nature. The mechanism of anterior dislocation following trauma is that greater tuberosity abuts against acromion when arm is abducted and extended, causing leverage forces leading head to come out of glenoidcavity []. Posterior dislocation secondary to seizure attack is caused due to imbalance between strong internal rotators and weak external rotators and deltoid. The cause of anterior dislocation following seizure is postulated to be direct trauma due to collapse of patient hitting the floor []. Anterior dislocation of shoulder is commonly missed after seizure because of its unusual occurrence, post seizure drowsiness and subsequent medical management[].\nThe term chronic dislocation of shoulder is applied to condition where there is loss of recognition of injury for at least 3 weeks [] or 4weeks []. Many authors have described chronic dislocation with varying amount of duration at presentation. Rowe and Zarin presented eight patients with anterior dislocation with seven patients presenting at 3 week to 2 year interval and one patient at 10 year duration []. Goga presented 31 patients with chronic anterior dislocation with longest duration of failed recognition at 2 years []. Postacchini and Facchini presented five patients with 6 weeks as longest duration of failure of diagnosis[].\nMansat et al showed five patients with 6 weeks to 3 years as the duration of missed diagnosis[]. Mancini et al presented a case with 24 years of missed anterior shoulder dislocation []. Our case presented 10 years after the dislocation.\nTreatment options for neglected shoulder dislocation include observation, manipulation, open reduction with or without allograft reconstruction, bankarts repair, capsulolabial repair and arthroplasty [, ]. Surgical treatment for chronic dislocations is usually advocated for better functional outcome, however the results can be poor and unsatisfactory[].\nVery few cases describe chronic dislocation of shoulder with good functional range of motion which were treated nonsurgically. Table shows epidemiological details of patients reported with asymptomatic neglected anterior shoulder dislocation. Essi et al showed a case with 15 years old neglected anterior shoulder dislocation in a 35 year old lady with good functional range of movement and neocavity formation leading to preserved movements []. Similar neocavity formation seen in a case described by Mancinni et al with 24 years of neglected dislocation ion a 74 year old lady with low functional demand []. Jerosch et al [] presented a case of a young male with preserved movements 4 years after missed diagnosis. This case didn’t show neocavity formation, but had a large Hill Sachs lesion which locked the head in dislocated position. In our case we found neocavity formation with large hill Sachs lesion.
A 79-year-old female patient with a past medical history of hypertension, previous stroke and Schatzki rings treated with dilation 7 years ago presented with progressive dysphagia to solid food. The patient reported the sensation of food getting stuck in her throat with associated coughing and choking spells. Seven years ago, she had similar symptoms and was treated with endoscopy and esophageal balloon dilation, which was complicated by a stroke resulting in left-sided weakness. No clear cause of the stroke was found at that time. Eventually her weakness improved with physical and occupational therapy.\nDuring this admission, a conventional video-endoscopy was performed with propofol injection for sedation throughout the procedure. At the onset of the procedure, the patient had a brief episode of hypoxia with a drop in her oxygen saturation to 70%. The scope was removed, and she was ventilated with Ambu bag resulting in an increase in oxygenation to 100%. The procedure was then resumed. The patient was monitored during the procedure with pulse oximetry, blood pressure monitoring and continuous telemetry electrocardiogram (ECG) tracing. Endoscopy showed an esophageal ring in the proximal esophagus, 15 cm from the incisors (). The ring was traversed with moderate resistance. Further down the esophagus, many linear esophageal ulcers with oozing blood and small diverticula were appreciated. A through the scope (TTS) dilator was passed through the scope and a dilation with a 10 mm balloon was performed at the site of the ring. The dilation showed mild improvement with a small mucosal tear. The scope was able to be passed to the stomach and duodenum which were found to be normal mucosa with unremarkable findings.\nAfter the procedure, the patient failed to regain conscious and was intubated for airway protection and kept on mechanical ventilation in the intensive care unit. An urgent head computed tomography (CT) showed multiple foci of intraparenchymal air suggestive of air emboli as well as visualization of small infarcts in the left frontal lobe (). Transthoracic echocardiogram was performed, which showed no evidence of patent foramen ovale or atrial septal defect on bubble study. The patient’s condition worsened over the next 12 h. She became hypotensive, her hypoxia worsened, and brainstem reflexes were absent. Repeat head CT showed diffuse cerebral edema and mass effect along with obliteration of the basilar cisterns as well as uncal, trans-tentorial and developing tonsillar herniation. CT angiogram of the head and neck showed occlusion of the intracranial carotid arteries, mid and distal cervical internal carotid arteries, anterior and middle cerebral arteries, and distal posterior cerebral artery branches (). Although mechanical ventilation and other supportive measures were continued, the patient passed away a few hours later in the intensive care unit.\nA systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in order to identify all studies of patients with cerebral air embolism. Literature search was conducted in databases such as PubMed/MEDLINE, Google Scholar, Ovid and Web of Science from 1998 to 2020. Search item included the keywords of “air embolism AND (EGD or ERCP)”, “cerebral air embolism AND (EGD or ERCP)”, “gas embolism AND (EGD or ERCP)” and “cerebral gas embolism AND (EGD or ERCP)”. All study designs included case reports and case series were eligible for final analysis. We excluded guidelines that 1) were not published in English, and 2) were published before the year 1998.\nTwo reviewers independently assessed the titles and abstracts retrieved from the search. Full text papers of relevant titles and abstracts were then obtained, which were then assessed for eligibility based on the inclusion criteria. Any discrepancies were resolved through discussion to reach a consensus in the presence of the third and fourth reviewers. A PRISMA flow chart of study selection is shown in .\nFor each eligible study, demographic data were extracted including number of patients, age, sex and clinical characteristics (medical history, surgical history, social history, medications, presenting symptoms and type of procedures used). We also included the CT, echocardiogram and magnetic resonance imaging (MRI) findings. Statistical analysis was performed with GraphPad Prism statistical software. The data were tabulated, and outcomes were cumulatively analyzed. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies or percentages.
A 22-year-old female is on chronic remission treatment for ulcerative colitis, initially presented acutely after experiencing a sudden loss of vision in the right eye. This was found to be secondary to an acute occlusion of the retinal artery. During her hospitalization, she experienced a sudden weakness in the left side of her body. The weakness gradually resolved over 72 h of onset. The patient was evaluated by the attending medical services and was diagnosed to have a cryptogenic stroke with recurrent embolization. She was initiated on low dose aspirin and the novel oral anticoagulant rivaroxaban.\nAs part of the screening of the embolization source, the patient had a magnetic resonance angiography of the brain which revealed nonspecific bilateral periventricular and subcortical white matter hyperintense foci. Ultrasound Doppler of both carotid arteries was negative. The screening for hematologic hypercoagulable conditions, autoimmune disease, and heparin induced thrombocytopenia was also negative. The holter ECG surveillance showed no evidence of arrhythmia. The tras-thoracic echocardiography revealed a small PFO with a restricted shunt from the left to the right side. Further cardiac evaluation by trans-esophageal echocardiography yielded a small fenestrated secondum ASD (0.8 cm × 1.2 cm) associated with mild right ventricular volume overload. The rest of the cardiac imaging was non-significant. Both the mitral and aortic valves were normal in structure and function with no evident clots in the left atrial appendage.\nAfter addressing the patient’s condition in the combined interventional cardiology and cardiac surgery meeting, it was decided that the patient would be better served by a surgical closure of the ASD as opposed to a device closure. The fenestrated ASD and the inability to conclusively exclude a possible embolization source within the heart by imaging were strong points for the surgical closure. The heart was approached via a median sternotomy. Cardio-pulmonary bypass was initiated through direct aortic and bi-caval cannulation. The heart was arrested with blood cardioplegia and the right atrium was opened. The fenestrated ASD and the floppy rims were conglomerated in one clean defect. Further inspection of the left heart through the defect was seemingly insignificant except when the cooptation margins of the P2/A2 scallops of the mitral valve leaflets were pulled in view from the left ventricular cavity. This unexpectedly revealed two discrete masses (0.3 cm × 0.2 cm × 0.2 cm) which were adherent to the margins of the P2/A2 scallops. They were easily picked-out using a tissue forceps (see ). The site of the extracted mass from the margins of the mitral leaflets left a central mitral regurgitation jet which was negated by placing an annuoplasty band.\nPost-operatively, the patient made a quick recovery. Her post-operative echocardiographic study showed no residual shunting and a normally functioning mitral valve. She was discharged home on aspirin and rivaroxabam for 3 months, then to continue treatment with low dose aspirin indefinitely. Both the histopathology and culture of the specimens were negative for any organisms or growth. The findings were consistent with a mature clot formation. The patient continues to do well on all subsequent clinic visits.
A 14-year-old male presented to the emergency department with complaint of left lower extremity pain for 5 days. The pain was localized to the left thigh, worsening over time despite analgesic intake. Patient also complained of swelling of the thigh, difficulty in ambulation for 2 days, and numbness for 1 day. There was no history of trauma, recent surgery, medication use, or prolonged immobilization. There was no family history of clotting or bleeding disorder or venous thromboembolism. He denies any history of smoking or illicit drug use.\nPatient is a known case of type 1 diabetes mellitus diagnosed at age of 10 years, currently on insulin pump. He was diagnosed with hypertension at age 9 and is on enalapril. He was born in Jamaica, via normal spontaneous vaginal delivery at term and had shoulder dystocia at birth for which he stayed in the hospital for 10 days. A sling was applied and no other intervention was done. Patient's mother denied any other complications at birth.\nOn examination he was noted to have marked asymmetry between the two lower extremities. There was tense swelling of the left posterior thigh and the left calf, which was tender to palpation. No erythema, warmth, varicose veins, or ulcers were present. Peripheral pulses were palpable and equal bilaterally with normal neurological exam.\nHis initial laboratory results in the emergency room showed normal complete blood count, basic metabolic panel, prothrombin time, and activated partial thromboplastin time. A lower extremity ultrasound showed the left common femoral, left superficial femoral, and left popliteal vein were noncompressible and demonstrated no vascular flow, with intraluminal echogenic thrombus suggestive of deep vein thrombosis of the left lower extremity ().\nHe was admitted to the pediatric floor and started on low molecular weight (LMW) heparin and warfarin after hematology consultation. His chest X-ray was normal. A thrombophilia workup was done which showed no prothrombin gene mutation, normal levels of Factor V Leiden, antithrombin III, and protein S. Protein C was low 51.9 (normal 55–123 units IU/dL). Low protein C in the setting of a large DVT was attributed to consumption of coagulation factors. LDH, uric acid, and homocysteine level were normal. Anticardiolipin and lupus anticoagulant were normal.\nA CT of the abdomen and pelvis was done to determine the extent of the thrombosis in the pelvis. The CT showed the suprarenal IVC and the hepatic segments of the IVC were patent. There was absence of infrarenal IVC (). There was an anomalous course of the external iliac veins communicating with lumbar veins. There was heterogeneous material within the left common femoral vein and left external iliac vein and hypodensity within the left lumbar vein consistent with thrombus (). There were prominent azygous and hemiazygous veins. The left kidney was small in size and there was compensatory hypertrophy of the right kidney (). The renal veins were not thrombosed and the origin of the left renal vein was normal in caliber. There was calcification of the right adrenal gland noted consistent with prior adrenal hemorrhage, the etiology of which could not be ascertained.\nOn review of patients past medical records it was noted that as a workup of hypertension he had a CT angiogram done which demonstrated atrophic left kidney supplied by two hypoplastic renal arteries arising from the abdominal aorta. The origin of the more inferior renal artery had a short segment of stenosis (). The right kidney was normal. A DMSA renal scan done subsequently demonstrated left renal uptake of approximately 13% and right renal uptake of approximately 87%.\nThe patient was continued on low molecular weight (LMW) heparin until his international normalized ratio (INR) reached more than 2. His pain and stiffness improved and he was discharged on oral warfarin therapy. Patient and mother were made aware that he may need lifelong anticoagulation therapy. In view of the fact that the patient had venous and arterial anomalies, prior to discharge the patient received a brain MRA/MRV to look for any other vascular anomalies, which were normal. A genetic evaluation was also normal. The patient is being followed by hematology team for venous thrombosis as an outpatient and is on oral warfarin therapy with therapeutic INR.
An 80-year-old male had an elective admission for an anterior resection for adenocarcinoma of the rectum. Initially, he had a laparoscopic approach but because of the poor bowel preparation (despite preoperative enemas) and the tumour being unable to be seen with either on-table rigid sigmoidoscopy or with the laparoscope, the operation was converted to an open procedure. During dissection, both ureters were clearly seen and reflected. The patient had a small pelvis with relatively bulky contents. An anastomosis was formed with a covering loop ileostomy. During both laparoscopic and open phases, LigaSure was used for dissection and to secure haemostasis. Postoperatively, he initially progressed well; however, his urinary catheter output gradually dropped, and his peritoneal drainage output increased over the first three days.\nA sample of the peritoneal drain output had a high level of urea and the assumption was made that there has been a ureteric injury. A CT KUB was done which was inconclusive but raised the suspicion of ureteric injury by showing fluid in pelvis with density similar to that of the fluid in urinary bladder.\nThe patient was taken back to theatre where cystoscopy, bilateral retrograde ureterograms and insertion of JJ stent on the right side were done. He was found to have an injury to the right ureter with a defect in the medial portion of its lower third just below the pelvic brim. He was returned to HDU and had problems with fluid overload, type II NSTEMI, CHF, and fast atrial fibrillation over the next few days. Following all of this, he recovered well and was discharged home.\nIt is likely that he sustained a thermal injury to the right ureter from the use of LigaSure with later necrosis and perforation. This could be a result of direct damage to the ureter by holding it between the jaws of LigaSure during dissection but as both ureters were clearly identified and moved away, it is unlikely to be the cause of ureteric damage. More likely, it was the result of the conduction of thermal energy from tissues within the jaws of LigaSure during dissection close to the right ureter on its medial side.
We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. As part of our ongoing study “Vaginal delivery after caesarean section”, she underwent saline contrast sonohysterography 6 months after the caesarean section. The caesarean scar had a small indentation and the remaining myometrium over the defect was 7.5 mm (Fig. ).\nIn the current pregnancy, she had a dating scan at around 11 weeks with no remarks. She came for a transvaginal ultrasound examination at around 13 weeks as part of our study. This scan revealed a duplex pregnancy with one viable intrauterine fetus with normal anatomy and placenta located high on the anterior wall and a small gestational sac (8 mm) with a yolk sac without embryo was located in the caesarean scar (Fig. ). There was no extensive vascularity surrounding the sac. One corpus luteum was found in each of the two ovaries. She was asymptomatic.\nShe was informed that not enough evidence existed to advise a specific management of this condition. After discussion with her and her husband, expectant management was chosen with a new ultrasound examination after 5 weeks.\nShe came to our ultrasound department at 18 weeks, 22 weeks, and 30 weeks of gestation. She remained asymptomatic. The ectopic gestational sac was not visualized with transvaginal or transabdominal scans at the 18 weeks examination (Fig. ). The niche in the scar and the thickness of the thinnest part of the remaining myometrium appeared unchanged at all visits. The intrauterine pregnancy developed normally with no signs of abnormal placentation. At 30 weeks of gestation the ultrasound appearance of the scar area did not indicate any contraindications for vaginal delivery. The thickness of the lower uterine segment (LUS) was 4.9 mm (Fig. ). In agreement with our patient, vaginal delivery was planned. The staff of the labor ward was fully informed.\nShe was admitted to the labor ward with irregular contractions in week 37 + 0. Her cervix dilated to 3 cm with no further progress. Due to that oxytocin augmentation was administered for 3 hours. The duration of active labor was 6.5 hours. A healthy male neonate weighing 2985 g was delivered, with Apgar scores 9–10 at 1 and 5 minutes and umbilical cord pH 7.27. The placenta delivered spontaneously and total blood loss was 250 ml. The postpartum period was without any complications, and she was discharged home the next day.\nAt a follow-up visit 6 months postpartum, saline contrast sonohysterography showed no signs of the previous CSP, and the remaining myometrium over the hysterotomy scar defect was 5.7 mm (Fig. ).\nEthical approval for the ongoing study was obtained by the Ethics Committee of the Medical Faculty of Lund University, Sweden, reference number 2013/176. Our patient has given permission for publication of this case report in a scientific journal.
The patient is a 32-year-old G4P2012 admitted at 23 6/7 weeks of gestation for fetal tachycardia. The fetal heart rate was noted to be persistently between 180 and 190 beats per minute, which is shown in . Fetal ECHO revealed a structurally normal heart, with an isolated pericardial effusion which is demonstrated in . The patient's past medical history was significant for Graves' disease for which she underwent radioactive iodine ablation 2 years earlier. She became hypothyroid soon thereafter and has been maintained on thyroid replacement. Her current dose is 150 mcg daily. She had two prior full term vaginal deliveries without complication and one first trimester elective abortion. Her past surgical history was significant for a laparoscopic appendectomy. She denied tobacco, alcohol, or illicit drug use. On arrival to labor and delivery, the fetal tachycardia was again noted. Laboratory studies revealed a normal metabolic and thyroid profile. Stimulating thyroid antibodies were drawn but not yet available. The patient had a normal EKG. Because of the persistence of the fetal tachycardia and the pericardial effusion, the decision was made to treat the fetal tachycardia with maternally administered digoxin. Although there was suspicion that the tachycardia may be secondary to thyroid stimulating immunoglobulins (TSIs), the decision was made to start with our usual first-line drug for SVT in the absence of confirmatory results. The patient was loaded with IV digoxin and subsequently placed on an oral maintenance dose of 0.375 mg daily. She was discharged home with close follow-up.\nDespite having a maternal digoxin level as high as 2.5 ng/mL, the tachycardia persisted. Over the following week, she complained of increasing nausea. A maternal EKG showed nonspecific changes. The thyroid stimulating antibodies returned significantly elevated at 195% of basal activity. The digoxin was discontinued, and Sotalol 80 mg PO bid was begun. There was no significant improvement over the following few days with the fetal heart rate between 170 and 190 bpm. The Sotalol was increased to 120 mg bid. A few days later the patient complained of decreased fetal movement. A maternal EKG showed a HR of 62. The decision was then made to begin maternal PTU 100 mg three times a day for presumed fetal hyperthyroidism secondary to the transplacental crossing of maternal thyroid stimulating immunoglobulins. Within 48 hours, the fetus had a normal sinus rhythm of 150 bpm. The Sotalol was decreased to 80 mg bid and discontinued the following visit when the FHR was noted to be 140 bpm.\nThe pericardial effusion resolved over the next few weeks, and the fetal heart rate remained normal for the remainder of the pregnancy. She was maintained on the same dose of PTU, and her thyroid function testing remained normal.\nAn induction of labor was undertaken at 37 weeks of gestation for presumed fetal hyperthyroidism, which resulted in a vaginal delivery of a live born female infant, with Apgar scores of 9 and 9 after 1 and 5 minutes. The neonate appeared well and in sinus rhythm of 164 bpm. Initial thyroid labs revealed a suppressed TSH of 0.013, a normal free T4 of 1.4 ng/dL, and an elevated free T3 of 5.1 pg/mL. Although the neonate appeared clinically stable, thyroid function tests redrawn at 2 days of age were markedly abnormal, with a TSH of 0.008, free T4 > 8, free T3 > 20, and thyroid stimulating IG 372. By days 4-5 of life she was noted to be tachycardic, jittery, and with loose stools. Methimazole was started at 0.35 mcg every 8 hours. Propranolol 0.5 mg/kg/dose three times a day while being in the hospital for a HR of 180–200, which improved to a baseline of 150 bpm. The neonate was discharged home in stable condition at 1 week of age, with close follow-up. The methimazole was gradually lowered over the following few weeks based on thyroid function testing every 7–10 days. The medication was discontinued at 6 weeks of age.
A 59-year-old male with a past medical history of hypertension, hyperlipidemia, chronic pain taking opioids, chronic obstructive pulmonary disease, gastroesophageal disease, and recently diagnosed coronary artery disease status post stent placement in the setting of acute coronary syndrome, presented for a follow-up cardiology appointment after a recent visit to the emergency department for coughing spells and right-sided flank pain. Of note, eight months prior, the patient was found to have critical stenosis of the distal right coronary artery when he was admitted to the hospital with acute coronary syndrome and was treated with percutaneous coronary intervention and medical management. His medical therapy included guideline therapy of atorvastatin, lisinopril, metoprolol succinate, and dual antiplatelet therapy consisting of aspirin and ticagrelor initially and changed to clopidogrel during outpatient follow-up due to cost. The patient had multiple coughing spells secondary to chronic obstructive pulmonary disease exacerbations before his presentation of flank pain. He had computed tomography (CT) imaging of the abdomen that revealed a 12 × 4.5 × 12 cm hematoma within the rectus sheath musculature (Figure ) and was discharged with advice to follow up on conservative management.\nHis aspirin was stopped, and he continued clopidogrel only on his medication review after the ED visit. He also met with his primary care physician during which ultrasound imaging revealed a decreasing hematoma of 7 × 2 × 5 cm (Figure ).\nDuring his primary care visit, his COPD treatment was optimized, and he was continued on conservative management for the resolving hematoma. During follow-up with his cardiologist, there was minimal ecchymosis, as compared with the ecchymosis that prompted his initial presentation to the emergency department. His lisinopril was also changed to losartan, and he was advised on the benefits of vaping cessation. The hematoma completely resolved, and he is solely treated with aspirin therapy. He is closely followed by his primary care physician and cardiologist and has not had any recurrence or bleeding for almost 18 months since the development of a rectus sheath hematoma.
We present a case of 40-year-old building and construction male worker who slipped and fell from a height of three (3) meters and sustained a deep penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He was apparently working from the above height when he slipped and fell on a sharp piece of iron rod which penetrated deep into the right anterior neck. He quickly pulled the sharp iron rod out when he got up from the floor. According to him, the bleeding was not profuse and stopped when he arrived at the local hospital to search for remedy (). He did not have hemiplegia, paraplegia, or quadriplegia when we saw him. He is not known to be hypertensive. He did not take alcohol prior to the fall although he takes alcohol occasionally. He had a left femoral fracture at the age of 24 and a right femoral fracture at the age of 32; both incidences were operated on successfully. On examination at our facility we saw a middle aged man who was conscious and alert but however acutely ill with his neck fixed in cervical collar. General as well as systemic examination did not yield much. All the systems where grossly normal. Neurological examination revealed normal pupils which reacted normally to light. Cranial nerves examination was unremarkable. Power on four limbs as well as reflexes was normal. Digital rectal examination revealed a normal spinster tone. Routine laboratory as well as other ancillary (ECG, CXR, etc.) investigations were normal.\nNeck CT-scan done at the local hospital revealed C2-C4 transverse process fractures on the right side, fracture at the right lamina of C3, and right common carotid artery dissection. CT-scan of the head showed no abnormalities (Figures and ). Explorative three-dimensional reconstruction plain and enhanced scan imaging of the cervical spine, chest, and abdomen done at our facility revealed two segmental stenoses of the right common carotid artery with very pale V1 and V3 segment of the right vertebral artery as well as blockage at V2 segment (Figures –) as well as fracture at the right lamina of C3 and C2-C4 transverse processes with free bone fragments and peripheral soft tissue swelling (Figures –). The skin at the right anterior cervical region is discontinuous, with adjacent soft tissue swellings and gas accumulation. The bilateral carotid artery sheath lymph nodes slightly enlarged. At the upper lobe of the right lung there were multiple calcifications, some of which were adjacent to the pleura. There was also slight thickening of the left pleura. The heart was not enlarged but we observed slight accumulation of gas in the anterior mediastinum. Multiple low-density lesions were seen in the liver which we think are constant cysts. A working diagnosis of right common carotid artery dissection with C1-C4 fractures was made.\nAfter preoperative education and counselling of the patient as well as the relatives, surgery was scheduled the next day. Intraoperative cerebral angiography showed right carotid artery dissection and right vertebral artery occlusion. There was some reparation at the distal end of the right vertebral artery. The left vertebral artery was however normal. We introduced the guiding catheter guide wire to the proximal end of the right common carotid artery with continued infusion of heparinized saline, after which we introduced a guide wire with a Cordis stent (10 ∗ 60mm) to completely cover the right common carotid artery dissection site with stenosis and released the stent gradually until it completely filled the stenosis area (Figures –)). We delivered contrast agent into right common carotid artery to make sure it was patent before removing the guiding catheter followed by withdrawal of the femoral arterial sheath. Control contrasted angiograph done revealed stenting was successful (Figures and ). The patient recovered markedly and was discharged home a week after. Scheduled outpatient visit every 6 months for 2 years revealed no neurological complications.
The patient, a 69-year-old Caucasian woman, was admitted to our department for a spreading hematoma in her neck. She complained of throat and neck pain as well as progressive dysphagia which had started 3 days prior to her admission. She has denied dyspnea or shortness of breath. She has reported that a day earlier a small hematoma appeared in her neck, which has rapidly spread. She had sought medical consultation on the day that her throat pain began and had received oral antibiotics.\nHer medical history were significant for two ICA aneurysms which have been diagnosed in 2002 following a head CT that has been performed due to headaches. Following the scan, the patient underwent a cerebral angiography and coiling of an aneurysm located in the paraophthalmic segment of the right ICA (see ). A 6 × 7 mm aneurysm in her left ICA was managed conservatively. Typical FMD changes have been noted in the left ICA. In 2009, following headache complaints, the patient returned for medical followup, and an increased diameter of the left ICA aneurysm (up to 12 mm) was diagnosed on MRA, with dissecting features. The patient underwent stent insertion in the left ICA. Follow-up imaging revealed normal blood flow in both ICAs with no new aneurysms diagnosed.\nThe patient's medications included 100 mg aspirin and 100 mg amiodarone per day prescribed for atrial fibrillation.\nOn admission, the patient had normal vital signs and was afebrile. The oral cavity and oropharynx were normal in appearance. There was a large subcutaneous hematoma extending from the thyroid gland and to the right third rib inferiorly. Marked sensitivity was noted while palpating the right lateral neck, superior to the cricoid cartilage. A slight tracheal deviation to the left has been noted. The patient did not demonstrate any signs of airway compromise such as stridor or dyspnea. Fiber-optic laryngoscopy demonstrated normal glottis and clear pyriform sinuses, without signs of hematoma or laryngeal compression.\nStandard laboratory tests, including a coagulation profile, were within the normal range. Blood calcium level has been obtained in order to rule out a parathyroid adenoma and was 8.2 mg/dL (normal range 8.4–10.2).\nUrgent neck ultrasound (US) has been performed, revealing a large hematoma displacing the right lobe of the thyroid anteriorly.\nAfter consulting with vascular surgeons, a contrast CT angiography was performed (), demonstrating a large right neck hematoma that has caused anterior displacement of the right thyroid lobe and tracheal deviation to the left. No active bleeding was demonstrated. The aortic arch and the right and left ICA were intact.\nBased on the stable clinical presentation and vital signs, lack of any sign of possible airway compromise, and lack of active bleeding on imaging, a decision to manage the patient conservatively was made. IV antibiotics were administrated as prophylaxis. During the night, a progression in the hematoma has been noticed, yet vital signs have remained stable throughout the night, with no complaints regarding airway distress or neck pain.\nNext morning, hoarseness has been noted, as well as an expansion of the hematoma to midchest and to the right areola (). Fiber-optic laryngoscopy revealed small hematomas on the right true and false vocal cord, as well as on the right arytenoid. A bed side US demonstrated heterogenic area without clear borders between the thyroid gland and the hematoma. In contrast to the signs mentioned above, the patient remained without any respiratory distress and without even a slight sign of airway compromise. Nevertheless, the patient was transferred to the intensive care unit (ICU), and conventional angiography was performed () in an attempt to localize and control the source of the bleeding.\nAngiography revealed normal arteries of the right cervico-cephalo region: both the internal and the external carotid were intact as well as the aorta and the left common carotid. The lack of active bleeding in the major arteries has raised a dilemma whether to attempt entry into the small branches of the right external carotid. Since FMD is known to increase the risks of dissection, following an invasive vascular procedure [], the small arteries have not been visualized.\nThe patient remained in a stable condition in the ICU and later returned to the ENT department. She was discharged on the fifth day of hospitalization, with stable signs and marked improvement of hoarseness, swelling, and size of the hematoma.\nAdditional clinical improvement was noted 10 days after her discharge, by the attending doctor in the outpatient clinic.
A 35-year-old male patient was diagnosed with a local metastatic neck carcinoma during regular follow-up after the resection of a T1N0M0 (stage I) squamous cell carcinoma of the right lateral border of the tongue. The primary surgical procedure was performed in the Oral and Maxillofacial Surgery department of our institution, 12 months prior to the detection of the metastatic carcinoma.\nThe initial surgical procedure comprised a transoral resection of the carcinoma and an extended supraomohyoid neck dissection. The surgical defect was covered by means of mucosal suturing and healed by primary intention. Histopathological examination revealed a tongue specimen with clear resection margins and a neck specimen with 40 lymph nodes that were negative for metastatic infiltration. However, on account of depth of invasion of 10 mm and perineural infiltrations, the patient received postoperative adjuvant radiotherapy of 63 cGys.\nOne year after the primary surgical procedure, a metastatic neck mass of dimensions 22×20×15 mm was detected on a routine follow-up magnetic resonance imaging (MRI). The lesion involved the carotid bifurcation and the radiographic images gave the impression that the ICA was affected up to its distal part at the level of the C1 vertebra. However, the extension of the lesion could not be ascertained from the MRI images, owing to the lack of clarity (). In addition, computed tomography (CT) angiography was performed, which did not clarify the level of ICA involvement. Further radiographic investigation using a positron emission tomography scan revealed negative results pertaining to other metastatic foci.\nThe patient underwent neck exploration, which was performed by a multidisciplinary surgical team involving oral and maxillofacial and vascular surgeons. The lesion was approached through the previous incision. The CCA, external carotid artery (ECA), and ICA were encircled. During the surgical procedure, it became evident that the ICA was involved up to its distal part. The division of the posterior belly of the digastric muscle did not provide sufficient access to the uninvolved part of the ICA, distal to the neoplastic tissue (). The retrojugular approach to the ICA has been suggested to offer easier dissection, especially in cases that warrant greater exposure. However, the aforementioned approach did not give the impression of being adequate in our case, which warranted control of the ICA up to the level of the C1 vertebra. Consequently, a vertical ramus mandibulotomy followed by anterior and cephalad retraction of the distal mandibular part facilitated access to the ICA at the level of the C1 vertebra. Prior to the osteotomy, preplating was performed using three miniplates. The osteotomy was placed posterior to the lateral mandibular foramen, in order to preserve the inferior alveolar nerve (). In the current patient, all the internal jugular veins were ligated, on account of the adherence to the tumor mass. Regarding the manipulation of cranial nerves, the hypoglossal, vagus, and accessory spinal nerves were identified during the surgical procedure. Unfortunately, the hypoglossal nerve could not be preserved and was sacrificed, in order to achieve complete excision of the tumor, whereas the vagus and accessory spinal nerves were recognized and protected.\nClamping of the ICA did not have any significant effect on the cerebral oximetry, owing to normal collateralization through the circle of Willis. Consequently, it was decided that a shunt was not required. The ECA was ligated and an interposition graft was placed from the CCA to the distal ICA in a standard fashion, using a segment of the great saphenous vein (GSV) as a conduit. Prior to the tumor resection, revascularization was performed to ensure quick cerebral reperfusion, which provided sufficient time for the complete dissection and resection of the tumor. Subsequently, en bloc excision of the tumor with the ICA and ECA was performed (). The mandible was reconstructed by way of the fixation of the three miniplates in the corresponding preplating positions ().\nThe patient had an uneventful recovery with normal neurological functions and was discharged on the fifth postoperative day. Postoperatively, the patient underwent adjuvant radiotherapy. No signs of recurrence were observed during the course of the six-month follow-up. A follow-up CT angiography showed sufficient tumor excision and adequate graft patency ().
A 30-year-old nulliparous woman of Nigerian origin was admitted in the Obstetrical Department of the University Hospital of Verona with pPROM and active uterine contractions at 23 weeks' gestation. Previous medical history was unremarkable except for an illegal abortion induced by means of an instrumental traditional method in the country of origin some years before. A liveborn male fetus of 560 g was delivered but died in the Intensive Care Neonatal Unit in the early postnatal period. A transvaginal examination in the delivery room showed a 4 cm wide uterovaginal fistula: the supracervical lesion in close proximity of the internal cervical os and connecting the uterine cavity with the posterior fornix was repaired right after the 3rd stage of labor. A few months later the same patient came again under our observation with the clinical presentation of a late miscarriage at 18 weeks due to recurrence of the fistula. The former suture had failed to hold and the intact gestational sac was bulging through the uterovaginal opening () with spontaneous expulsion occurring shortly after. In order to increase chances of a successful repair it was decided to differ a new hysteroplasty to a later time. The patient went through a 3-month course of continuous combined low-dose hormonal treatment and was then scheduled for surgery: the procedure consisted of a transvaginal fistula repair associated with laparoscopic cerclage. The placement of the cerclage was performed under general anesthesia. After dissecting the uterovesical space, a 5 mm nonabsorbable polyester ligature with double blunt needles was introduced into the abdominal cavity. The fiber suture was placed by passing each needle from posterior to anterior, medial to the uterine vessels, just over the internal cervical os bilaterally. Needles were then cut and removed and the tape was tied tightly around the cervix with intracorporeal knots (). The uterovesical peritoneum was then reapproximated to cover the knot. One year later the patient started a new pregnancy which proceeded uncomplicated until a caesarean section was performed at 37 weeks' gestation and a healthy 3,000 g boy was delivered. Intraoperative examination of the lower segment found no sign of dehiscence of the posterior uterine wall. The cerclage was left in situ in view of the patient's desire for other children. The posterior vaginal fornix was intact as well, except for a slight mucosal retraction, the result of the previous repair.
A 22-year-old woman, gravida 3 para 2, was admitted to our labour ward as a referral from Magu District hospital at 32 weeks with a one week history of generalized abdominal pain, reduced fetal movements and dysuria. She had been seen initially for antenatal care at a gestational age of 16 weeks, and had a total of two antenatal visits. Her pregnancy was thought to be uncomplicated during these visits. On admission to the labour ward, her vital signs were: blood pressure of 120/80 mmHg, pulse 110 beats/minutes and respiratory rate of 18 breaths/minute. Her abdomen was distended with a fundal height corresponding to 32 weeks with hypogastric tenderness. Fetal heart rate could not be established by fetoscope. Her laboratory results showed hemoglobin of 6 g/dl and urinalysis with 20 leukocytes per high power field. An ultrasound examination revealed a live intrauterine pregnancy at 31 weeks of gestation but the lie of the fetus and location of the placenta were not established. The impression of the admitting doctor was of an intrauterine pregnancy complicated by anemia and urinary tract infection (UTI). The patient received iron supplements, oral nitrofurantoin 500 mg every 8 hours for 5 days and paracetamol; her pain subsided, and she was admitted to the ward for follow-up and further investigation. Two days later, the case was reviewed by senior doctors on the ward, at that time, the patient continued to have generalized abdominal pain, and on examination she was found to have generalized abdominal tenderness with rebound tenderness and easily palpable fetal parts. A provisional diagnosis of abdominal pregnancy was made and an urgent repeat abdomino-pelvic ultrasound examination was performed. The ultrasound revealed an empty bulky uterus, a viable fetus in the abdominal cavity at 31 weeks, and a placenta attached anterior to the uterus. The decision was made to do an emergency laparotomy based on clinical features of peritonitis. Under general anesthesia and through sub-umbilical midline incision, the uterus was found to be empty and small. A fetus was found floating in the abdominal cavity without an amniotic sac. There was hemoperitoneum of about 1 litre. A baby girl weighing 1.7 kg was extracted with Apgar scores of 8 and 10 at the first and fifth minutes respectively. The placenta was adherent to the omentum and to the right cornual area extending to the fundus superiorly. Both ovaries and the right fallopian tube were healthy. The left fallopian tube had adhesive bands and fimbrial phimosis. Suctioning of the hemoperitoneum was performed, omental adhesions were released, and cornual resection was done at the site where the placenta had implanted. Intraoperatively one unit of blood was given as the patient was severely anemic prior to surgery, and a tourniquet was applied to minimize uterine vessel bleeding prior to resection. The placenta was completely removed and hemostasis was achieved after the removal of the tourniquet 20 minutes later. By day 3 post-laparotomy, the mother could mobilize fully, eat, drink and had normal bowel movements and micturition habits. The baby was breast feeding and eliminating well.\nThe patient was discharged on day 7 after suture removal with iron and folate tablets. During her stay in the hospital, she was counseled on the possibility of recurrence of abdominal pregnancy. She was told to come back for follow-up after 2 weeks, but the patient was lost to follow-up.\nAlthough ultrasound can be useful in diagnosing abdominal pregnancy, it is easier to appreciate the abdominal pregnancy during the end of the first trimester or early in the second trimester, when the pelvic organs are best visualized. In advanced abdominal pregnancy visualization of pelvic organs becomes limited. Other diagnostic tools include plain abdominal radiography and magnetic resonance imaging (MRI) [,]. In our patient, initially a diagnosis of advanced abdominal pregnancy was missed by both clinical findings and imaging studies. Thus the diagnosis requires clinical suspicion, as ultrasound will miss almost 50% of abdominal pregnancies in the absence of clinical suspicion [,].\nThere are several risk factors for abdominal pregnancy which include previous history of tubal pregnancies, pelvic inflammatory disease, tubal sterilization, tubal infertility, tubal reconstructive surgery and conceiving with intrauterine contraceptive device (IUCD) in situ []. In our case, the possible risk factor could be pelvic inflammatory disease, suspected due to the presence of adhesion bands and fimbrial phimosis on her left fallopian tube.\nEarly diagnosis of abdominal pregnancy depends on a high index of suspicion from the antenatal care providers [,]. Several symptoms have been established to suggest the presence of abdominal pregnancy. These symptoms include recurrent abdominal pain, painful fetal movements, and easily palpable fetal parts. Difficulty in establishing fetal lie and presenting part is another sign which should raise suspicion for abdominal pregnancy. Signs and symptoms of peritoneal irritation can be an additional indicator, as this can suggest hemoperitoneum as in our patient [,,,].\nIt is vital for the diagnosis of abdominal pregnancy to be made early in pregnancy. Morbidity and mortality are largely due to massive hemorrhage that may arise from complete or partial placental separation [,]. The placenta can implant at different sites including but not limited to the uterine wall, adnexal, bowel, omentum, liver, spleen and pouch of Douglas, and the placenta may separate anytime during pregnancy leading to hemorrhage and anemia as illustrated our case. In our case, we found a live fetus floating in the peritoneal cavity due to a ruptured amniotic sac. The survival of this fetus could be in part due to a timely decision for laparotomy, as well as to a placenta that was partially adherent to the fundus and left cornual end which provided enough blood supply and oxygenation to the fetus. In most cases of advanced abdominal pregnancy, fetal outcome tends to be good if the fetus is covered by the amniotic sac [].\nOur patient required emergency laparotomy due to the suspicion of hemoperitoneum, as unstable maternal hemodynamic status is among the criteria for surgery. Other criteria for surgery include fetal congenital malformations, fetal viability, gestational age at presentation and availability of facilities for neonatal care. If the fetus is alive, surgery may be performed regardless of gestational age or fetal status due to difficulties in predicting placental separation leading to massive hemorrhage. If the fetus is dead, surgery is necessary due to the risk of disseminated intravascular coagulopathy (DIC) or sepsis, although a period of 4–8 weeks may be allowed for observation to allow atrophy of placental vessels [,].\nIn our patient, the placenta was easily removed by performing wedge resection at the right cornual end and uterine fundus. Otherwise, the placenta should be left in situ to minimize the risk of massive hemorrhage. Attempts to remove the placenta should only be done when the surgeon is able to ligate all the placental vessels [,].
A 32-year old female patient came to the emergency room with the chief complaints of right side LBP, buttock pain, and lower leg pain, which began two days before the visit and became worsened on the day of the visit. The patient was without any particular trauma history and mentioned that the symptom started after she had walked a long distance the previous day. The patient expressed the symptom as a "twinge". The pain was weak when in the supine position, but it was aggravated when rising up or moving, so that the patient could not carry out the movements and activities of daily living. A pertinent part of the patient's history was that she had received conservative treatments in another hospital for right LBP and right radicular leg pain, six months before the visit. The computer tomography (CT) image taken at that time appeared to show that the patient had a herniated intervertebral disc at the 4-5th lumbar spine and spondylolysis at the 5th lumbar spine. According to the physical examination, right radicular leg pain was developing along the dermatomes of the 4, 5th lumbar nerve roots. In the straight leg raising test, the degree was limited to 45 for the right leg and the pain was aggravated by extension and flexion of lumbar spine part. Neither distinct tender points nor abnormality in the motor, sensory, and reflexes response was found. The pain was 8, according to the verbal numerical rating scale (VNRS). The pain was slightly relieved to VNRS 6 after the caudal epidural block and posterior division of spinal nerve block at the 4-5th lumbar spine by blind method on admission, but movements were still impossible. On the third day of admission, a lumbar spine MRI was taken and the results showed degenerative change at the 4-5th lumbar spine intervertebral disc, posterolateral intervertebral disc extrusion, slight spondylolytic spondylolisthesis at the 5th lumbar spine and neural foraminal stenosis at the 5th lumbar spine-first sacrum part (). After consulting with neurosurgery to decide on an operation by neurosurgical diagnosis, an emergency operation was performed for the 4-5th lumbar spine intervertebral disc extrusion on the fourth day of admission. When the lamina was removed by the surgical field, it was found the dural sac had been torn and the nerve root was greatly swollen. There was only a slight intervertebral disc extrusion and an extruded disc was not observed. Taking the possibility of a mistaken patient, MRI film, or operation site into account, the operation team and the anesthesiologist checked the information a second time, but no problem was found. The possibility of the migration of the extruded nucleus pulposus was also considered, but that was not observed, either. After explaining the status to the patient's caregiver, hemilaminectomy of the lamina at the 4-5th lumbar spine, and vertebral medial facetectomy were performed. However, the patent's pain remained at VNRS 6-7 after the operation. Thus, postierior fusion using screws for spondylolytic spondylolisthesis was performed in an operation two weeks later, after which, the symptom turned to VNRS 2-3. The patient was discharged two weeks after the operation. A follow-up MRI was recommended to the patient and the caregiver after a consultation with the surgical operator, but it was not performed because they did not want it.
A 35-year-old Korean woman admitted to the in-patient clinic of our institution presented with swelling, pain, and rigidity of the left breast that began 4 days previous. She reported a fever that had lasted 1 day. Physical examination revealed a palpable tender mass, erythema, and swelling in the upper half of the left breast, extending to the nipple. There was no nipple discharge or pyrexia. A clinical impression of mastitis was made. She had no previous history of trauma, operation, or family history of breast cancer; further, she was not immunocompromised.\nPrior to admission, the patient had a history of recurrent breast infections beginning in July 2007. She was treated for mastitis of her right breast with pus formation, and she made complete recovery. The second infection occurred 8 months later, in March 2008. She underwent breast biopsy for a mass on her right breast, and a fluid sample was cultured. Based on the culture results, the lesion was diagnosed as an NTM infection, and the patient was treated with combined antibiotic therapy for 12 months. The third infection appeared 9 months after the last treatment, in December 2009. She was admitted for a palpable mass in the left breast. The patient underwent biopsy for this lesion as well, which was also diagnosed as an NTM infection. After 4 months of combined antibiotic therapy, she made a complete recovery. The patient was admitted to the hospital for her fourth mastitis event.\nWe performed routine breast ultrasonography, which revealed a 2.8 cm, ill-defined, partially multilobulating contoured mass with heterogeneous internal echogenicity in the subareolar area, with diffuse edema of the left breast (). No significant vascularity was observed. Several small lymph nodes less than 1 cm in short diameter were visible in the left axilla level I.\nThe patient also underwent bilateral dynamic contrast-enhanced magnetic resonance imaging of the affected breast to further evaluate the extent of the lesion and the potential for hidden malignancies (). Dynamic contrast-enhanced magnetic resonance imaging revealed a 2.4×2.4 cm iso- to high-signal intense mass on T2 WI and iso-intense on T1 WI, which showed peripheral rim enhancement after contrast injection. Associated findings included diffuse parenchymal enhancement of the upper outer to central portion of the left breast with thickening of the overlying skin. This lesion appeared to be an abscess associated with mastitis.\nTo exclude the possibility of hidden malignancies, a biopsy was performed. Considering the previous histopathologic findings in 2008, 2010, and 2012, granulomatous mastitis was suspected (), with no acid-fast bacilli visible on Ziehl-Neelsen staining. Although we could not confirm the identity by specimen culture, paraffin-embedded tissue samples were positive for NTM by polymerase chain reaction. Based on the clinical course of recurrent infections over 5 years, previous histopathologic findings, and positive polymerase chain reaction results, a clinical diagnosis of NTM infection was made. Clarithromycin (1,000 mg/day) was administered in combination with ciprofloxacin (1,000 mg/day) for 1 year. Because the lesion progressed to pus formation, surgical drainage was also performed. The patient underwent a follow-up breast ultrasonography after 1 month that showed lesion improvement. She has been followed up for 1 year with no clinical or radiological evidence of recurrence.
A 40-year-old male presented to the emergency department with the complaint of left lower extremity pain and swelling for three weeks which had acutely worsened. His past medical history was significant for PE and DVT, most recently five months prior to presentation. He was on daily Coumadin but had difficulty consistently maintaining a therapeutic INR. His most recent INR was 3.9 three days prior to admission. He had been instructed by his primary care physician to hold Coumadin for two days and then restart, which he did the day prior to presentation. Physical exam revealed a warm, erythematous left lower extremity. He was tender to palpation of the calf and had 2+ pitting edema distally from his knee. Distal pulses of his left leg were intact, and he had full strength and range of motion of the knee and ankle.\nA high frequency 7.5–10 MHz linear array transducer was used to perform the lower extremity ultrasound. Standard, water-soluble ultrasound gel was applied to the patient's groin. The femoral region was scanned in the transverse plane, proximally from the level of the common femoral vein (CFV) just proximal to the junction of the long saphenous vein, distally through the division of the superficial and deep femoral veins. The vein was compressed every 2-3 cm in the usual fashion. The ultrasound demonstrated full compressibility of the proximal segment of the common femoral vein, with loss of coaptation distally from the division of the superficial and deep femoral arteries. Additionally, echogenic material was seen within the vessel lumen in the distal portion of the superficial femoral vein and was not seen more proximally though the vessel did not completely collapse. The patient's INR was found to be subtherapeutic at 1.5. Ultrasound examination of the right lower extremity demonstrated full compressibility of the veins. Given the acute exacerbation of the patient's symptoms and the lack of echogenic material within the proximal vessel lumen, he was started on heparin infusion for treatment of presumed acute-on-chronic DVT. The patient was admitted to medicine, and a full venous duplex bilateral lower extremity ultrasound was performed by radiology, demonstrating occlusion of the left superficial femoral vein extending through the popliteal vein with partial thrombosis within the common femoral vein. He was transitioned from heparin to Lovenox as a bridge for his subtherapeutic INR and subsequently discharged home after an uncomplicated hospital stay.
A 61 year-old Caucasian woman was referred to our colorectal clinic with an 18-year history of severe intermittent anal pain and constipation. She described experiencing intermittent anal spasms lasting around 15 minutes. These episodes were worse when sitting down for longer than 45 minutes or when lying in bed. The frequency of these anal spasms was increasing with time and occurring every hour at night at the time of presentation. Her constipation symptoms constituted experiencing difficulty in defecation and a sensation of incomplete evacuation. She had no response to amitriptyline or topical diltiazem. Her past medical history was unremarkable apart from four normal vaginal deliveries. Her sister had colorectal cancer diagnosed at the age of 49 and had previously been treated for an undiagnosed anal sphincter problem. There was no other relevant history of note.\nShe initially underwent a flexible sigmoidoscopy and magnetic resonance imaging (MRI) of her perineum. The endoscopy was reported as normal, whereas the MRI showed edema of the IAS. She subsequently had an endoanal ultrasound which confirmed that her IAS was abnormally thick and greater than 5 mm (Fig. ). Anal manometry revealed that although resting and squeeze pressures were within normal limits there were periods of a significant increase in anal resting pressure lasting longer than 2 minutes (Fig. ). Pressures during this period were in excess of 200 mmHg which settled spontaneously. These pressures were even higher than the maximum recorded squeeze pressure (Fig. ).\nShe had an examination of the anal canal under anesthetic which showed a very prominent sphincter complex. She also received Botox injections (Dysport™) at the 3 and 9 o’clock positions of the IAS which led to no subsequent resolution of her symptoms. She then underwent a lateral internal anal sphincterotomy by dividing half of the length (1 cm) of the IAS on the left lateral aspect. A biopsy of the IAS taken at the time of surgery was sent for histology which confirmed polyglucosan body myopathy of the IAS (Fig. ). At 3-month follow-up, she had complete resolution of her symptoms and has not contacted our department with any concerns for more than 1-year postoperatively.
The patient is a 22 year old African American female with a past medical history of sickle cell trait and asthma who presents to the orthopedic clinic with aching right hip pain. She-like her father- has sickle cell trait. Throughout her life so far, she has not had any acute episode of sickle cell-related symptoms like severe, acute chest pain. However, she states about a year prior, she had the same hip pain. She went to her primary care provider, who gave her hip cortisone injections. These helped for a few weeks. She then went on vacation a month later. Her feet became swollen during this time, prompting her to visit her primary doctor again. At this time, she was referred to the orthopedic clinic. She had severe groin pain with internal and external rotation of her hip. X-rays were done of her hip, which showed an area of necrosis suggestive of stage 1 or 2 AVN in the head of the right femur. An MRI was done and showed stage 2 or 3 AVN. This can be seen in Fig. .\nShe was then prescribed bisphosphonates, told to walk with no weight bearing on the right leg, and scheduled for a decompression procedure several weeks later. The plan after surgery was to be minimal weight bearing for 6 weeks as well as continuing therapy with Alendronate, a bisphosphonate. After decompression, the patient’s pain subsided. Two weeks after surgery, the patient presented for follow-up and suture removal. She was in high spirits as her pain and overall anxiety had subsided. She had not felt pain free in quite some time. Her hip x rays were normal at this time. Figure shows x- rays at two weeks post op. At six weeks post-op, she was feeling like she could bear weight on the hip. There was no pain provoked on range of motion testing or internal and external rotation. She was then scheduled to begin physical therapy soon thereafter.\nHowever, at eight weeks post op, she presented to the clinic for follow-up stating new onset pain. She had weight-bearing but the pain had started again in her hip and groin. There were also new x-ray findings (AP Pelvis and Frog Hip views), which showed a serpiginous line which was consistent with progression of her AVN with no collapse of the femoral head. Even after bisphosphonates and decompression, the patient’s AVN had now grown to involve the majority of the head of the femur. At 3 months status post- surgery, MRI showed that the head of the femur was beginning to flatten as well as loss of volume and bone marrow edema, which is seen in Fig. . Further progression of her AVN can be seen with follow up x-rays at her later appointment 5 months post decompression in Fig. .\nAt this point, there were no other conservative options available for this patient. The dilemma is her age. Osteotomy is sometimes a treatment for AVN, but given the area of necrosis of this patient’s femoral head, this procedure is not indicated. The plan for this patient is to continue non- weight- bearing. The only definitive treatment for this patient would be a total hip arthroplasty (THA). Because this patient is so young, the patient was referred to a hip joint revision specialist with plan to follow-up again 6 weeks later. At her age, it would be challenging to do a THA, given that she would most likely have to undergo the same procedure several more times throughout her life. Hip replacements have an average life of 15–20 years, so the prospect of conserving as much of the joint as possible and not undergoing THA at such a young age is paramount. It would be devastating for the patient to have to have 4–6 hip replacements in her lifetime. Time will tell if conservative therapy such as minimal weight-bearing, bisphosphonates, and vitamin D will have any appreciable effects on this patient’s hip. The progression from seemingly successful surgery - clinically and radiographically - to the onset of pain spanned two months. Everything will be done to buy her time and avoid THA.
A 34-year-old Caucasian female, who had originally undergone an uneventful laparoscopic adjustable gastric band 4 years ago, presented to the bariatric surgery clinic with inability to tolerate solids. A work-up revealed that the laparoscopic band remained in good position but the patient had oesophagitis and gastritis, causing swelling of the mucosa at the band site. The fluid was removed from the reservoir, and the patient was treated conservatively with anti-reflux medication and a full liquid diet. After 2 weeks of treatment the patient’s symptoms improved. After careful consideration, she wished to undergo revisional surgery converting the laparoscopic adjustable gastric band to a laparoscopic vertical sleeve gastrectomy. The patient moved through the appropriate multidisciplinary team approach and was found to be an appropriate candidate for surgery. She underwent laparoscopic removal of the adjustable gastric band and conversion to a laparoscopic vertical sleeve gastrectomy without complications. Her post-operative course was uncomplicated and she was discharged on post-operative day 3.\nOn post-operative day 12, the patient was readmitted to an outside tertiary care hospital for lightheadedness and shortness of breath and was found to have leukocytosis, with white blood cell count of 18,000 cells μl–1. The work-up included a CT scan with intravenous contrast of the chest, abdomen and pelvis, and the patient was diagnosed with a pulmonary embolism. The patient was immediately transferred to our centre for definitive care. When the patient arrived at our centre, the CT films from the outside hospital were reviewed by our radiologists and there was concern that there was air and a faint suggestion of oral contrast outside of the suture line (). Given this finding, an UGI evaluation was ordered. During the early phase, no leak was observed, owing, in part, to the slow passage of 30 ml oral non-ionic contrast (). Some residual contrast from the outside hospital CT was present in the transverse and descending colon. Only after delayed imaging and with administration of additional non-ionic contrast for a total of about 65 ml (approximately 2 h after the start of the fluoroscopic examination) was there a faint suggestion of extravasated contrast, best seen below the left hemidiaphragm (). Follow-up CT scan with oral contrast confirmed the obvious leak ().\nThe patient was treated definitively with endoscopic stent placement and clipping using an Ovesco clip (Ovesco Endoscopy AG, Tubingen, Germany) to close the leak. After an extended hospital course, she was discharged and is presently doing well.
A 64-year-old woman was referred to our clinic with a 9 cm left liver mass, biopsy proven to be consistent with metastatic breast cancer, . The patient had a 17-year history of metastatic invasive ductal carcinoma of the left breast to the small bowel and liver. Over a span of several years, she underwent multiple small bowel resections before developing a solitary left liver metastasis. Over time, it was observed that her tumor biology was unusual not only for its temporal nature (slow progression), but also its location (small bowel) for progression. Due to this unusual nature, as well as the fairly rapid growth of her liver tumor, resection was considered her best treatment option by a multidisciplinary group of oncologists.\nAn extended left hepatectomy including caudate lobe resection and cholecystectomy was performed. The parenchymal transection in the area of segments 4b/5 went down to the bifurcation of the right and left pedicles in order to gain adequate tumor clearance. The left hepatic duct was divided separately with an endovascular stapler very close to the bifurcation of the right and left portal pedicles. During the operation, there were no immediate complications, including bile leak. The estimated blood loss was 150 mL, and the patient was discharged on the fourth postoperative day.\nOn postoperative day 15, she was admitted with abdominal pain, fevers, an elevated total bilirubin, and leukocytosis. CT scan demonstrated a collection in the hepatic fossa (), as well as a dilated right posterior bile duct (). A percutaneous 10 Fr Felima pigtail drain was placed (Boston Scientific, Natick, MA) to drain the biloma. She then underwent endoscopic retrograde cholangiopancreatography (ERCP), where it appeared on cholangiogram that she had a leak from the left hepatic duct stump (). A biliary endostent was inserted with the tip in the right anterior sectoral ductal system in an attempt to occlude the left hepatic duct stump. In followup, she was noted to continue to have a high amount of bilious output from the percutaneous drain, indicating an uncontrolled leak. Two weeks later, a transhepatic cholangiogram was performed through a catheter in the right posterior sectoral ductal system. This cholangiogram demonstrated that the right anterior sectoral duct containing the endoscopic stent was not in continuity with the posterior sectoral duct. The posterior duct was draining through the cut liver surface (). We concluded there was anomalous biliary anatomy with the right posterior sectoral duct draining into the left hepatic duct. An external catheter was placed in this posterior duct. Over time, the percutaneous abdominal catheter stopped draining, indicating complete control of the fistula. The patient's sepsis was controlled and she recovered. The cut edge of the liver surface at the site of the transected posterior sectoral duct eventually sclerosed, making the catheter in the posterior sectoral duct no longer in communication with the abdominal cavity. A second operation to restore her biliary system and provide enteric drainage would be necessary. However, this operation posed a significant technical challenge to locate this aberrant duct in a reoperative field. It was decided that a combined interventional surgical approach would be necessary to identify the biliary anatomy intra-abdominally, create a new tract through the regenerated liver surface, and provide a stent to facilitate a new enteric anastomosis.\nThe tip of the catheter that was left in the right posterior sectoral duct was not placed in the extrahepatic space of the cut liver surface but rather was pulled into the liver, so we anticipated that this bile duct would have fibrosed in the several month period of time between operations. This would make it nearly impossible to find at reoperation. To facilitate identifying this catheter in the operating room, we first had the catheter injected with contrast in the interventional radiology department on the morning of surgery in an attempt to advance the catheter into the extrahepatic space. This no longer revealed an extravasation of contrast as when the catheter was initially placed, thus indicating there was no communication of the catheter with the peritoneal cavity. Next, the patient was moved to the operating room, where we performed an exploratory laparotomy; however, the sheath containing the posterior sectoral catheter was left in place to allow further manipulation in the operating room. At operation, we appreciated a large amount of fibrosis around the liver in the area of her previous biliary abscess. Next, the anterior biliary duct endostent was identified by palpation. Dissection around the anterior biliary duct led to the finding of a disruption of this duct at the confluence. This represented site of the leak of the left hepatic ductal stump was initially detected in .\nWe next searched for the posterior sectoral catheter but could not identify or palpate it. This was expected. At this point, the interventional radiology team came into the operating room to provide fluoroscopic guidance for the location of the biliary catheter in the posterior duct. This revealed that the distance between the tip of the catheter and the cut liver surfaces was approximately 2-3 cm likely from regenerated liver. To traverse this distance, a tunnel would need to be made. Using the posterior sheath, we then placed a 16-gauge Colapinto needle with a 9 Fr Sheath (Cook Medical Inc., Bloomington, IN) and tunneled this out into the extrahepatic space, (). Using the same catheter system, we tunneled a catheter into the anterior ductal system retrograde from the duct orifice through the parenchyma and out the abdominal wall. We had two internal/external biliary catheters in both the anterior and posterior sectoral systems, (). We then fashioned a roux limb of jejunum and performed two separate anastomoses over these stents using interrupted sutures of 5-0 polydioxanone (PDS). The anterior anastomosis was a true hepaticojejunostomy with duct sewn to bowel; however, the posterior sectoral anastomosis was from the jejunum to a layer of fibrous tissue overlying the regenerated liver surface. As this was not a true hepaticojejunostomy, we buttressed this anastomosis using interrupted sutures of 3-0 PDS. The patient tolerated the procedure well and was discharged home on postoperative day 6.\nIn followup, the anterior internal-external biliary drain was removed after 4 weeks. The posterior internal-external drain was exchanged after 12 weeks for a permanent internal stent, which was composed of two overlapping SMART stents 14 mm × 6 cm and 14 mm × 4 cm (Cordis, Miami Lakes, FL, ) across the biliary enteric anastomosis. This was done to prevent future closing of the tract between the posterior sectoral duct and the jejunum that would likely happen, as there was approximately two centimeters of liver tissue not lined by biliary epithelium.
An 81-year-old male patient was referred to our department with dysphonia. There was no history of smoking. A status past multiple myeloma was known in his medical history that was in complete remission at the time of presentation. The patient denied dyspnea, dysphagia, pharyngalgia, and fever. Laryngoscopy revealed a diminished mobility of the right vocal cord and a thickening of the right vestibular fold so that a microlaryngoscopy with tissue sampling was performed. The histological examination of specimens obtained from this region revealed fibrosis. Computed tomography (CT) scans of the neck and the thorax were without any pathologic findings. The patient was discharged to outpatient care.\nThree months later, the patient was admitted with progressive dyspnea along with inspiratory stridor. The clinical examination revealed now a complete paralysis of the right vocal cord and a remaining glottic cleft of only 1 mm due to a supraglottic protrusion of the right vestibular fold. The CT scan () showed now a tumor of the right vocal cord extending to the right piriform sinus.\nAfter tumor debulking in order to expand and secure the airway, the excised material that consisted of several red brown elastic tissue fragments measuring together 24 × 12 × 10 mm was sent for pathological examination. Histologically, one could see tight lymphoid infiltrates. The cells had large nuclei and were irregularly shaped, and the proliferation was strongly enhanced in the staining for Ki67 (50%). The immunohistochemical analyses showed a negative result for CD20 and CD3, and a positive staining for CD138. BCL2 and CD10 were coexpressed (). The clonal light chain restriction for lambda chains substantiated the diagnosis of a multiple myeloma. These results were consistent with laryngeal involvement from the patient's previously diagnosed multiple myeloma.\nThe patient was referred to the Department of Hematology and a systemic therapy with the proteasome inhibitor Bortezomib was discussed. Ultimately, instead of that, a local radiation therapy with 60 Gy was performed. In a control laryngoscopy with tissue sample taken after the radiotherapy, the myeloma could not be verified anymore. The patient is in continuous otorhinolaryngological and oncologic follow-up. To date, almost two years later, no recurrence of the myeloma has occurred so far.
A 27-year-old male patient presented as multiple fistulas along with pain and swelling of the left hand since 2 years. He was a daily laborer and remembered a history of trauma to his hand around 2 years ago. He received different antibiotics but was left without cure. There was no history of any immunodeficiency or underlying disease. Physical examination was normal except a swelling in the left hand that extended from wrist to metacarpophalangeal joint of all the fingers, along with multiple discharging sinuses at the dorsal and palmar aspects of the hand [Figures and ]. The discharge was scanty and purulent with an offensive odor. The swelling was immobile in all directions and was fixed to the underlying structures. The movement at the metacarpophalangeal joint was restricted.\nAn initial clinical diagnosis of tuberculosis was made due to endemicity of the disease in Odisha, India. The routine biochemical and hematological tests including erythrocyte sedimentation rate were within the normal range. The X-ray of the upper extremity revealed no significant abnormalities. Swabs collected from the discharging sinuses were subjected to microbiological studies. Few pus cells and no bacteria were detected in the microscopy. Microbiological cultures for aerobic and anaerobic organisms showed growth of only Staphylococcus aureus which was sensitive to linezolid. Based on acid fast staining and culture, tuberculosis was ruled out. Hence, patient was advised with oral 600 mg of linezolid twice daily for 10 days, which yielded only a partial, but not complete relief. Finally, curettage and biopsy of the draining sinuses was made, which revealed many neutrophils with some colonies consisting of radiating filaments, surrounded by eosinophilic hyaline material creating a sun-ray pattern, similar to that of actinomycosis []. There was no evidence of lung disease, tooth problems or gingivitis in patient. Hence, a diagnosis of primary actinomycosis of hand was made for which he was treated with surgical debridement [] and intravenous and oral penicillin therapy for 6 months to which patient showed excellent response.
A 69-year-old Korean male was transferred from a nearby clinic after presenting with metastatic adenocarcinoma of unknown primary site confirmed with a perineal mass biopsy. At the time of admission to the oncology department on March 2016, the patient's general condition was good with an Eastern Cooperative Oncology Group performance status of 1, and he did not have any specific disease history. He complained of a palpable left inguinal mass (), and histology of the resected inguinal mass revealed invasive breast cancer of ectopic breast origin. Immunohistochemistry analysis revealed it to be hormone receptor-positive and HER2-negative. The tumor was 28 mm in size, and the resection margin was clear. Subcutis and muscle involvement were noted, but there was no lymphovascular or perineural invasion. The tumor cells had an estrogen receptor (ER) score of 8, a progesterone receptor (PR) score of 8, and a Ki-67 labeling index of 10%. The histologic grade was 3 (). The patient had no family history of breast or ovarian cancer, and no pathogenic germline breast cancer susceptibility gene (BRCA) 1/2 mutations were identified in the peripheral blood. However, an unclassified genetic variation of BRCA2 was detected (). Although 4 cycles of doxorubicin plus cyclophosphamide (AC) regimen followed by twelve cycles of weekly paclitaxel were planned as adjuvant chemotherapy, the patient completed only 8 cycles of weekly paclitaxel after 4 cycles of AC because he developed grade 2 neuropathy. Thereafter, tamoxifen was started without evidence of disease relapse at that time.\nIn October 2016, enlargement of the left inguinal mass was noted, and further analysis revealed adenocarcinoma with abundant mucin pools. The recurrent tumor cells showed an ER score of 8, a PR score of 8, HER2-negative, and a Ki-67 labeling index of 10%. After undergoing radiation therapy for local relapse, tamoxifen treatment was continued because there was no evidence of disease relapse and his health insurance did not cover for the use of aromatase inhibitors at that time. In September 2018, a 1-cm sized single nodule was identified in the right upper lung during a routine follow-up imaging study; this nodule was considered evidence of metastasis. The patient underwent stereotactic radiosurgery, but other metastatic nodules were found in both lobes of the lung. After receiving permission from the institutional multidisciplinary board, the patient was started on letrozole (2.5 mg orally once daily) plus goserelin (3.6 mg subcutaneously every 4 weeks) and palbociclib (125 mg orally once daily for 21 days followed by 7 days off treatment in 28-day cycles) in March 2019 based on the cumulative evidence of its benefits in female breast cancers. Recently, the patient completed his 12th cycle of palbociclib, letrozole, and goserelin combination therapy without any severe toxicity, and follow-up chest computed tomography showed a slight decrease in metastatic lung lesions (). This study was approved by the Institutional Review Board of Kyungpook National University Chilgok Hospital (KNUCH 2020-04-012), and informed consent was obtained.
A 35-year-old African American female without significant past medical history presented to the orthopedic clinic for evaluation of a right knee mass measuring about 5 cm × 9 cm × 6 cm at distal thigh that had been growing in size over the past six months.\nA magnetic resonance imaging (MRI) of the knee showed a 5.6 cm × 9.1 cm × 6.0 cm tumor of the distal right femur, and biopsy revealed high-grade osteoblastic osteosarcoma. Further imaging studies including (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (CT) did not indicate distant metastatic disease, and she was referred to medical oncology clinic for pre-operative chemotherapy. At the time of her pre-treatment evaluation, the patient had no chronic medical issues and was not taking any medications. There was no cancer or cardiovascular disease in her family. She had normal complete blood count and comprehensive metabolic panel results. CT scan of chest showed no evidence of pulmonary metastasis, and baseline transthoracic and dobutamine stress echocardiogram showed normal cardiac function with normal right ventricular systolic function and left ventricular ejection fraction (LVEF) 60%-70%.\nThe patient underwent three cycles of cisplatin and doxorubicin before undergoing resection of the tumor and a total right knee replacement. She had a follow-up echocardiogram after 2 cycles of chemotherapy which again showed normal cardiac function with LVEF 70%. Additionally, she had serial blood tests done for troponin and brain natriuretic peptide (BNP) during hospitalization for neutropenic infection with respiratory symptoms after cycle 2 chemotherapy, and dehydration with hypokalemia after cycle 3 chemotherapy; all the troponin levels were within normal limit except transient increase in BNP with subsequent normalization was noted after cycle 3 chemotherapy. Surgical pathology showed 5% tumor necrosis, and restaging CT and bone scan after surgery showed no evidence of metastatic disease. The patient subsequently completed three more cycles of cisplatin and doxorubicin with good tolerance. While on chemotherapy treatment, she experienced fatigue, nausea, alopecia, and neutropenic infection despite using granulocyte colony stimulating factor, prophylactic antibiotics, and other supportive care measures. She was evaluated every 3-4 wk with history and physical examination, as well as routine laboratory tests.\nApproximately two months after her last chemotherapy, she was seen in the medical oncology clinic with an unremarkable history and physical examination. One week later, she presented to the emergency department with complaints of sudden onset of dyspnea, palpitations, and left-sided chest pain. CT angiography of chest showed no pulmonary embolism, but found new right lower lobe indeterminate nodules, measuring up to 7 mm, a small focus of airspace disease in the peripheral right lower lobe, and mild interstitial pulmonary edema. Echocardiogram showed LVEF 5%-10% with severe decrease in right ventricular systolic function. Her serial serum troponin levels were significantly and persistently elevated.\nNo significant past medical history.\nNo cancer or cardiovascular disease in her family.\nA 5 cm × 9 cm × 6 cm tumor was noted at the distal right thigh.\nNormal complete blood count and comprehensive metabolic panel results.\nAn MRI of the knee showed a 5.6 cm × 9.1 cm × 6.0 cm tumor of the distal right femur, and biopsy revealed high-grade osteoblastic osteosarcoma. Further imaging studies including (18)F-fluorodeoxyglucose positron emission tomography/CT did not indicate distant metastatic disease, and she was referred to medical oncology clinic for pre-operative chemotherapy. At the time of her pre-treatment evaluation, the patient had no chronic medical issues and was not taking any medications. CT scan of chest showed no evidence of pulmonary metastasis, and baseline transthoracic and dobutamine stress echocardiogram showed normal cardiac function with normal right ventricular systolic function and LVEF 60%-70%.
A 47-year-old Hispanic man initially presented in Mexico 6 years prior to referral to our office. In Mexico, he had sebaceous cyst like masses, which were removed from his upper back and left chest. The patient was unaware of the pathologic diagnosis and healed uneventfully. Years later, appearance of larger lesions of a similar character in the same anatomic locations prompted evaluation at a community hospital in the United States. When an excisional biopsy of both sites revealed sebaceous carcinoma with positive margins, he was referred to our institution for evaluation and management.\nOn presentation, his primary complaint was discomfort and the slow steady growth in size of his upper back lesion (). No other significant medical history and family history were reported. On examination, he had a well-healed anterior chest wall incision and an approximately 9 × 9 cm2 tender, raised heterogeneous region on his upper mid back. He underwent a fludeoxyglucose-positron emission tomographic (FDG-PET) scan and an endoscopic workup to rule out Muir-Torre syndrome. The FDG-PET scan indicated only avidity in the back mass, and the endoscopic workup was negative for any additional findings.\nThe patient was then scheduled for a wide local excision of his back and chest lesions with planned defect reconstruction by plastic surgery. First, the preexisting scar on the chest was excised with 2 cm margin and primarily closed. The back lesion required a radical resection due to invasion into the trapezius muscle. A 14 × 7 cm2 area was ultimately resected and a temporary vacuum dressing was placed over the large back defect awaiting final pathologic margins. A smaller 0.5-cm lesion identified on his inferior back was also removed and closed primarily. One week later, he underwent a trapezius myocutaneous flap with local tissue rearrangement for coverage (). On subsequent postoperative visits in the weeks following, more small nodular lesions were identified on his back with varied pathologies from basal cell carcinoma to a new sebaceous carcinoma nodule. He was later found to have Muir-Torre syndrome–related genetic mutations.
A 57-year-old man was referred to our hospital due to an abnormal chest X-ray. His previous history included hypertension and subcortical intracerebral hemorrhage that was conservatively followed up without surgery. Chest X-ray demonstrated an enlarged mediastinum without loss of cardiac and diaphragmatic outlines (). Computed tomography revealed a giant posterior mediastinal tumor composed of a well-circumscribed solid compartment with small calcifications, encapsulated by a fat-density compartment (). The tumor extended longitudinally from the aortopulmonary window to the level of the diaphragm (). The heart was deviated anteriorly by the tumor; however, the patient had no cardiac symptoms. The esophagus was completely involved in the fat-density compartment (). Magnetic resonance imaging also indicated that the solid mass was surrounded by a fatty compartment ().\nSurgical resection was indicated, but we needed to decide the approach to the tumor carefully. Because the tumor was situated right behind the heart, it seemed difficult to remove the tumor via an anterior approach such as median sternotomy. Also, the tumor extended horizontally to bilateral thoracic cavities with close association to the vital anatomical structures such as the aortic arch, the pulmonary artery, the esophagus and the descending aorta (); therefore, en-bloc resection either by unilateral thoracotomy seemed to be unsafe. Consequently, we chose a bilateral approach in order to mobilize the tumor from the esophagus in left thoracoscopic surgery and then to completely remove the tumor using left thoracotomy. First, the patient was placed in the right lateral position. Four 5-mm access ports were created, and the subsequent procedures were performed under complete thoracoscopic technique with CO2. The soft lipomatous component of the tumor was bluntly and sharply dissected from the descending aorta and esophagus using laparoscopic dissectors and LigaSure™ laparoscopic sealer (). After complete mobilization of the tumor (), a chest drainage tube was inserted into the left thoracic cavity, and the left side procedure was finished. The patient was then placed in the left lateral position, and right posterolateral thoracotomy was performed using a 13-cm skin incision with muscle-sparing plus one 5-mm access port. The tumor was well encapsulated (). The border of the tumor was easily determined because the most part of the posterior border of the tumor was mobilized by the left VATS. The anterior border of the tumor was bluntly dissected from the inferior vena cava (), the inferior pulmonary vein and the pericardium (). During the dissection procedure, we occasionally observed systemic hypotension by contracting the heart anteriorly. The tumor was then successfully resected en-bloc. Operation duration was 7 h and 12 min, with 960 g of bleed loss. The patient was discharged uneventfully on postoperative day 10.\nThe tumor weighed 1233 g and measured 22 × 15 × 9 cm (). Pathological examination demonstrated scattered atypical mesenchymal cells with enlarged hyperchromatic nuclei consistent with the diagnosis of the ALT (). There was no complication including swallowing problem or local recurrence in 26 months of follow-up.
A 76-year-old immunocompetent Caucasian male presented to the emergency department with 1 week of left hand clumsiness. Physical examination was consistent with mild left upper extremity neglect but otherwise benign. The patient had no relevant past medical history. Computed tomography (CT) scan demonstrated a large hypodense lesion in the right parietal lobe suspicious for neoplasm (). Subsequently, MRI revealed a heterogeneous thick-walled peripherally enhancing lesion of the right parietal lobe with central necrosis and an extensive degree of surrounding vasogenic edema (). Neither T1-weighted imaging nor gradient echo sequences demonstrated evidence of subacute hemorrhage. Initial differential diagnosis included glioblastoma, anaplastic astrocytoma, metastasis, or PCNSL. A metastatic workup was negative. The patient was started on dexamethasone (16 mg per day for 5 days) while hospitalized with improvement in his presenting neurologic symptomatology. Upon discharge, he was prescribed a 6-day dexamethasone taper to 1 mg per day to continue until outpatient follow up. Per patient preference, stereotactic debulking of the lesion was scheduled for 5 weeks from his initial presentation.\nThe patient was admitted to the hospital 4 weeks later (1 week prior to scheduled surgery) with new onset lethargy and respiratory distress. Repeat CT compared to 4 weeks prior demonstrated a dramatic reduction in vasogenic edema and apparent size of the lesion (). The patient was diagnosed with bacterial pneumonia and remained hospitalized for medical treatment and optimization. One week later, a repeat MRI was ordered to evaluate the significant changes seen on repeat CT as well as to determine extent of future operative intervention. Repeat MRI compared to 5 weeks prior revealed a dramatic reduction in contrast enhancement, vasogenic edema, and apparent size of the lesion (). These imaging findings raised suspicion for PCNSL. As such, a stereotactic biopsy was planned to attain tissue diagnosis. Biopsy samples were sent as frozen sections to surgical pathology, which revealed pleomorphic glial cells, nuclear atypia, microvascular proliferation, and palisading necrosis consistent with a diagnosis of glioblastoma (). The decision was then made to proceed with debulking of the tumor.\nMolecular genetic studies revealed wildtype isocitrate dehydrogenase (IDH) 1 and 2, promoter methylation of O6-methylguanine DNA methyltransferase (MGMT), non-amplified epidermal growth factor receptor (EGFR) by fluorescence in situ hybridization, and poor p53 expression with 1% tumor cell staining on immunohistochemistry. Adjuvant radiotherapy and chemotherapy were planned to start 3 weeks post-operatively. However, the patient developed worsening lethargy and fatigue 2 weeks after his operation. Post-operative imaging was unrevealing for acute intracranial pathology (). Infectious workup remained negative; however, he failed to improve clinically. As such, his clinical demise was attributed to rapid disease progression of recently diagnosed glioblastoma. He was transferred to hospice care and expired 1 month from the date of initial surgery.
A 21-year-old male involved in a motorcycle crash presented to a Level 1 trauma center. He was helmeted and arrived in hemodynamic shock. Intubation was performed for airway protection and respiratory distress. The only visible injury was a fracture deformity to his left hand. An initial chest radiograph (CXR) demonstrated a widened mediastinum (Fig. ). An abdominal ultrasound was positive for free fluid and the patient was taken immediately to the operating room for an exploratory laparotomy.\nDuring the abdominal exploration, multiple mesenteric injuries were identified and repaired. An abbreviated damage control laparotomy with packing was performed. A left-sided chest tube was inserted and drained ~800 ml of blood without continued hemorrhage.\nHe was taken directly for a computed tomography angiogram (CTA) of the chest and body for evaluation of the mediastinum. The CTA confirmed a 5.9 cm × 3.9 cm × 6.9 cm contained rupture of the descending thoracic aorta (Fig. ). The vascular and interventional radiology team took the patient immediately for an angiogram with aortic endograft stenting.\nBilateral femoral arteries were accessed and an aortic endovascular stent was deployed to cover the area of injury. During the procedure, the patient developed significant hemorrhage from the left chest and became hypotensive. An emergent left thoracotomy was performed and the mediastinum was packed temporarily while the vascular team deployed an additional two stents over the area of injury, including the origin of the left subclavian artery. This resulted in exclusion of the aortic injury with no signs of radiographic leak.\nThe patient required massive transfusion resuscitation and cardiopulmonary resuscitation was performed for the exsanguinating hemorrhage. The patient had multiple episodes of cardiac arrest and required internal defibrillation as well. Due to persistent severe cardiac and respiratory failure, the cardiac surgeons placed the patient on veno–arterial ECMO emergently. The hemorrhage from the chest was controlled with packing. The patient remained very unstable and subsequently required an additional venous cannula in the right internal jugular vein. The resultant veno–veno–arterial (VVA) ECMO finally improved his oxygenation. Flows were adjusted in order to maintain adequate oxygenation. The abdomen required open decompression and was managed with a temporary abdominal dressing. He was transferred to the intensive care unit in very critical condition.\nThe patient remained on continuous VVA ECMO without heparin due to the massive hemorrhage and coagulopathy. Continuous veno–venous (VV) hemodialysis was started for renal replacement therapy. On postop day 3, the patient went back to the operating room for a washout of the chest and abdomen. There were no signs of hemorrhage from the chest and it was closed (Fig. ). By postop day 8, the patient continued to slowly improve and the arterial cannula was removed allowing for VV ECMO only. The abdomen was closed in a skin only fashion and a tracheostomy was performed.\nHe slowly improved and by postop day 11, the ECMO cannulas were discontinued. He later developed a pericardial effusion which required open drainage (postop day 18); however, the respiratory and renal failure eventually resolved. He later required surgery on his left hand fracture and subsequent debridement of the left groin. He was transferred to inpatient rehab on hospital day 35 and was discharged home by hospital day 44 without gross neurologic sequela.
This is a 40-year-old female patient diagnosed with lower extremity CRPS type-I in the right ankle and foot, based on the IASP Budapest Criteria.[ The patient did not have any history of psychological disorder, seizure disorder or neurological abnormality. Physical examination in the first presentation showed the presence of well-healed incision scars from the previous surgeries in the dorsum of the right ankle and foot. There were mild color changes. There were moderate skin texture changes and trophic changes in the nails. The patient had excessive sweating both on inspection and palpation in the entire right foot. There was hyperesthesia and hyperalgesia of the entire dorsum of the foot (Fig. ). Right foot skin temperature was 3°C colder than the left foot. The patient had 4/5 weakness of the right foot extensors and toe flexors. Right ankle range of motion was moderately limited secondary to pain. The patient did not have any visible or reproducible involuntary motor movement in her history or physical examination. The patient underwent a first LSB with the same technique and medications as described in Case 1, but on the right side. LSB was performed under local anesthesia and the patient was given lorazepam 1.5 mg orally as a sedative prior to procedure. Temperature measurements of bilateral plantar skin as well as pulse amplitude of the right big toe with pulse oximetry were monitored continuously. Adequate sympathetic blockade was achieved after the block with confirmation of at least 2°C increase from the baseline temperature. The patient developed muscle spasms of the entire ipsilateral lower extremity in the recovery room 15 minutes after the completion of the first LSB (Video 2). These muscle spasms were not as intense as the Case-1, but significant enough that the patient was complaining of increased pain and was unable to stand. The patient was initially treated with 2 mg of midazolam IV. The patient did not respond to treatment with midazolam. As the presentation was very similar to Case-1, the patient was treated with IV DPH 50 mg. The patient responded immediately with abrupt resolution of muscle spasms.
We present a case of 28-year-old man who suddenly went into coma for 9 hours preceded with seizures that latest for 10 minutes. He was initial managed in a periphery hospital before presenting at our facility. The seizures where tonic clonic in nature with no fever, vomiting or micturition. He had no focal neurological signs. Past medical history was unremarkable. Physical examination did not yield much. Neurological examination revealed normal cranial nerves. Power as well as reflexes were present and normal. Routine laboratory as well as other ancillary investigation were normal.\nReferral images indicated acute cerebral hemorrhage near the left frontoparietal lobe extending to the frontal horn of the left ventricle with brain edema around the hemorrhagic lesion and midline shift of the brain to the right (). The hematoma was mostly centralized at the left parietal lobe. He was admitted in the local hospital for one (1) week prior to referral. MRI done a week later at our facility revealed a cerebral ring enhancing lesion of about 4.6×3.4×4.0 cm in diameter at the left frontoparietal lobe which appear hypo-dense on Tl and hyperdense on T2. On FLAIR, however the images showed slightly mixed signals with no significant enhancement after administration of contrast agent. There is significant peripheral edema and swelling of the adjacent brain tissue as well as a little blood clot at the right side of the falx. The frontal horn of the left ventricle is compressed by the lesion while the right ventricle appears normal with a slight midline shift of the falx to the right (). The skull is normal. There is no significant increment of the lesion comparing the initial CT-Scans and the current MRI. CT-angiography done revealed stenosis of main intracranial arteries with no obvious signs of ectasia or any vascular abnormalities (). Base on the finding above, a working diagnosis of left frontal cerebral hematoma was made to rule out neoplastic lesion because of the ring like nature of the lesion. After taking the patient and his family through a series of education and counselling surgery was scheduled.\nWe used the left pterion approach. After removing the bone flap, we saw a small AVM with curved nidus on the dura. Intraoperatively we saw hematoma at the left frontoparietal lobe which was mostly centralized at the parietal lobe and surrounded by a pale-yellow jelly-like tissue which was large in size measuring about 4.6×3.4 cm with rough edges making it very difficult to different from the normal brain tissue. We excised a chunk of the of lesion and secured total hemostasis. The bone flap was replaced with screws and plates and the subcutaneous tissues, temporalis muscle as well as skin was closed in layers. Postoperative CT-scan revealed total evacuation of the hematoma (). Postoperative management was uneventful. Immunohistochemical staining of sample at the pathology department revealed tumor cells that are GAFP (+), Oligo2 (+), EMA (- ), IDH-1 (+), ATRX (+), P53 (+) and 40% Ki-67(+) rate. The findings above is consistent with GBM (WHO, grade 4) (). The sample was found to be MGMT gene methylation promoter and TERI gene mutation was seen in progress. The patient was discharged home 10 days after surgery and radiotherapy as well as chemotherapeutic sessions initiated a month after surgery. The patient is currently doing very well with no obvious complication.
A 50-year-old female presented with hoarseness, dysphagia, and left ear pain on February 10. She was diagnosed with a common cold and received medication from a clinic. Her symptoms did not improve and she visited our hospital on February 14. Physical examination demonstrated significant weakness of the left soft palate with a deviation to the right side during phonation. There was no sign of herpetic eruption within the region surrounding her ear, face, and oral cavity. Her facial sensation was normal and no facial weakness was observed. Laryngoscopy revealed paralysis of the left vocal cord and saliva pooling in the left piriform sinus (). There were no vesicles or erosion on the pharyngolaryngeal mucosa. She showed normal hearing level by pure tone audiometry and her stapedius reflex was normal. No nystagmus was observed. Magnetic resonance imaging (MRI) showed no lesions of brain stem.\nAt this point, the diagnosis was idiopathic associated laryngeal paralysis. However, we considered the possibility of VZV reactivation from the presence of facial discomfort and ear pain, in spite of the lack of typical skin rash or mucosal eruption. The patient was admitted to our hospital and treatment with antiviral therapy and a short course of oral corticosteroids was started according to our therapeutic strategy for RHS. Seven hundred fifty mg of intravenous acyclovir per day for a week and 60 mg of prednisolone per day for 5 days were administrated and the dose was tapered. On the second hospital day, she complained of left facial weakness, and mild facial nerve palsy with House-Brackmann (HB) grade II was observed. Eight days later, the soft palate and vocal cord were beginning to show movement, the hoarseness was improving, and the facial nerve palsy showed no change from HB grade II. Three weeks later, her facial weakness was improved. Paralysis of the soft palate and vocal cord was completely resolved six weeks later.\nOn the first and 15th day, ELISA for VZV and herpes simplex virus (HSV) was undertaken as HSV can also produce lower cranial nerve palsies. Although ELISA for VZV IgM was negative at the first examination, a slight elevation was observed in the paired sera (1.10, negative <0.80). Results for VZV IgG showed a significant increase from 10.5 to >128. From these results, we made a diagnosis of reactivation of VZV. Both the first and paired sera were negative for HSV IgM and IgG.
A healthy 36-year-old woman with no past medical and familia histories presented to the clinic with a chief complaint of dyspnea since three months ago. The dyspnea was persistent during the time without limiting the daily activities. Also, there were no aggravating and alleviating factors. Vital signs at the presentation were stable. The patient had normal breath sounds in all segments of the lungs. Initial paraclinical evaluations including complete blood tests, blood biochemistry assessment, and COVID-19 PCR test were all normal. Chest radiograph showed a mediastinal widening, indicating the presence of a mediastinal mass. Therefore, a CT scan was performed that demonstrated a heterogeneous lesion in the right anterior mediastinum (Figure ). The lesion measured 84 × 47 mm, which was reported to be suggestive of thymoma or teratoma, and biopsy or excision was recommended. Other CT scan findings consisted of a 5 mm pulmonary nodule at the lateral segment of the left lower lobe, fibrotic bands at lower lobes, and splenomegaly. There was no opacity, volume change, pleural effusion, or chest wall abnormality. An invasive thymic tumor or soft tissue tumor with high vasculature was suspected mainly because of its location and a radiological extent, biopsy was not planned due to high risk of major bleeding, and tumor excision through median sternotomy was performed by an attending thoracic surgeon at our institute. Because a complete resection was feasible, no intraoperative frozen section examination was executed (Figure ). The postoperative course did not have a mentionable event, and the patient was discharged on the fourth postoperative day. According to the pathology report, the macroscopic findings of the specimen were one piece of light-tan tissue measuring 10 × 10 × 6 cm, containing solid cystic parts with hematoma inside. Microscopic examination of 12 pieces in 12 blocks demonstrated thymic tissue with encapsulated neoplasm consisting variable sized and dilated vascular sinusoids, lined by endothelium containing blood and pertinacious material (Figure ). The conclusive pathological diagnosis was cavernous hemangioma of mediastinum.
A 45-year-old woman presented to our hospital with multiple lung nodules. She had a history of poorly differentiated thyroid carcinoma, diagnosed 7 months prior to admission, at an outside hospital. The patient was healthy otherwise and reported no radiation exposure or any family history of thyroid cancer. The initial work-up at the time of discovery of the right thyroid nodule included fine needle aspiration and core biopsy, with findings consistent with poorly differentiated thyroid carcinoma. The patient then underwent a total thyroidectomy and central neck lymph node dissection. The pathologic diagnosis from the outside hospital reported a 2.8 × 2.4 × 1.1 cm tumor in the right thyroid without extrathyroidal extension or lymph node metastasis. However, both capsular invasion and extensive vascular space invasion were noted. Based on the tumor size, tumor extension and lymph node status, the tumor was designated as Stage II (pT2 pN0 pMx). IHC staining showed that the tumor cells were positive for thyroglobulin and thyroid transcription factor 1 (TTF1). An immunostain for p53 was also performed at the outside hospital and showed a small focus (< 1 cm) with p53 positivity, suggesting a diagnosis of anaplastic thyroid carcinoma.\nAt our institution, the diagnosis was revised, based on review of both the primary thyroid tumor and the current lung metastases. Both tumors were remarkable for biphasic malignant components: the carcinoma and the sarcoma. The carcinoma component showed a poorly differentiated microfollicular type thyroid carcinoma, composed of sheets and islands of tightly packed thyroid follicles with dense colloid. The tumor nuclei were small and round with vesicular chromatin, resembling those of typical poorly differentiated follicular thyroid carcinoma. Admixed with the epithelial component were malignant spindle cells with small round blue cell type morphology. Focally, rhabdomyosarcoma-like cells with eosinophilic cytoplasm were appreciated. No heterologous cartilage or bone components were identified. The IHC staining performed at the outside hospital showed that the thyroid carcinoma (epithelial) component was positive for thyroglobulin, PAX8 and TTF1 (Fig. ). The sarcoma (spindled) component was negative for all thyroid carcinoma markers (TTF-1, thyroglobulin and PAX8), but was positive for vimentin and focally positive for myogenin (supporting skeletal muscle differentiation) consistent with mesenchymal differentiation. Interestingly, the foci of vascular space invasion contained both epithelial and mesenchymal components as well.\nThe patient received Taxol with Carboplatin for 7 weeks followed by radiation therapy. Her thyroglobulin level rose from 1.2 ng/mL to 25.40 ng/mL 5 months after completion of the chemo-radiation therapy, suggesting progression of the disease. A follow-up CT scan of the chest showed multiple newly developed nodules (ranging from 1 to 2 cm) in the right lung, highly suspicious for metastases. The patient underwent a right thoracotomy, right lung resection/metastasectomy. The surgery was uneventful with negative resection margins. However, the patient’s general condition deteriorated and she succumbed to the disease 4 months later.\nHistological examination of the lung nodules revealed similar tumor morphology and tumor differentiation when compared to the original thyroid tumor, which is somewhat unusual for a biphasic carcinosarcoma (Fig. ). Tumor necrosis was also present. Mutational analysis using a next-generation sequencing based assay showed that the neoplastic cells from the lung metastasis were devoid of genomic alterations for known thyroid cancers, including BRAF, RAS family (KRAS, NRAS and HRAS), EGFR, PTEN, TERT, PI3Kinase or RET. BRAF or RAS family are known as the most commonly altered genes in papillary thyroid cancers. Other molecular mutations reported in the development of anaplastic thyroid carcinoma include p53, PAX8/PPAR gamma rearrangement []. None of the mentioned gene mutations were identified in our patient.\nHowever, an interesting finding in this case is the presence of a point mutation in DICER1 (E1705K) that has previously been associated with differentiated thyroid carcinoma [, ]. Whether the DICER1 (E1705K) mutation is the underlying genetic event leading to the initiation of tumorigenesis or is downstream to other gene alterations in tumor development is largely unknown. Additional mutations of unknown significance were also detected in this tumor including FLCN (R239H), POLD1 (Q684H) and SYK (R217L). These variants have not been adequately characterized in the scientific literature and their prognostic and therapeutic significance is unclear.
A 61-year-old African American female was diagnosed with left breast cancer with multiple bone and liver metastases in April 2009. She was treated with chemotherapy and intravenous bisphosphonate therapy with zoledronic acid. A follow-up bone scan redemonstrated the multiple bone metastases, now with a new focus of increased radiotracer activity in the left mandibular angle. Radiological interpretation suggested that this focus most likely represented either severe dental disease or a metastatic focus. Few months later, the patient developed severe pain in her mandible, for which dental evaluation led to a tooth extraction. However, following the tooth extraction, the patient's jaw pain progressed with worsened swelling of the left lower jaw. CT scan of the mandible () demonstrated a mandibular body bony lesion on the left with adjacent soft tissue stranding, again interpreted to be concerning for a metastatic bone lesion. Bone scintigram () demonstrated expansion of the mandibular lesion and slight progression of the multiple other skeletal metastases.\nA referral was made to radiation oncology due to worsening jaw pain unresponsive to narcotic medications and imaging findings suggestive of a metastasis. Without exposed bone on physical exam, it was felt that she would benefit from palliative radiotherapy (RT) for her presumed mandibular metastasis. She underwent RT to her jaw lesion to a total dose of 2000 cGy in 5 fractions of 400 cGy each using a 3D-conformal technique. However, after the RT, the patient's jaw pain continued to worsen. Despite negative blood and bone cultures, she received courses of cephalexin and clindamycin, for a presumed jaw infection with no improvement.\nSince the presentation was atypical and there was no therapeutic response, a bone biopsy of the mandibular lesion was obtained but revealed no evidence of metastatic disease. In light of the negative pathology and lack of clinical response, the diagnosis was now felt to be most consistent with BRONJ. Repeat CT () and bone scan () findings were also thought to be consistent with osteonecrosis of the jaw.
Our patient is a male infant who was born term and presented to the emergency room of our hospital when he was 9 weeks old. His complaints were recurrent fever since discharge from our newborn special care unit at 1 week of birth. He also had developed recurrent vomiting that was usually postprandial with associated significant weight loss. Birth history revealed that he was macrosomic with a birthweight of 4.5 kg. He was born via caesarian section due to cephalopelvic disproportion. Other important perinatal histories were that of meconium-stained liquor, perinatal asphyxia (APGAR 4, 5, 7), and neonatal seizures on 1st day of life. During the initial newborn admission at about 4th day of life, mother noted that the patient had extensive purplish, nontender, firm subcutaneous nodules of uncertain diagnosis. The nodules were localized to the buccal fat region where they were first noted and then later spread to involve the neck, arms, forearms, thighs, and calves (Figures , , and ). After discharge he visited several health facilities seeking help for this skin pathology including dermatology consult. During this period he was noted to be having recurrent fever and vomiting. He received several antibiotics before presenting to the emergency ward with the same complaints. At the time of presentation, most of the body swellings had regressed in size. The general appearance of the limbs with subcutaneous nodules was now at this admission less massive compared to the first week of life (). Further examination revealed an axillary temperature of 38.1°C, slightly depressed anterior fontanelle but normal skin turgor. He still had residual facial nodular swelling that was flat, firm, attached to overlying skin, reddish, and measured about 4 cm in its widest diameter. Some of the child's initial nodules that were noted in the first week of life had substantially regressed and were now only noted as areas of hyperpigmentation as was seen on the skin of the right thigh measuring about 1 cm by 2 cm (). His weight loss was evidenced by loose skin folds (arm and thigh) and a weight drop from previously documented 6.1 kg to current weight of 5.3 kg. A complete blood count showed a haemoglobin level of 10.2 g/dL, total WBC 18,300 (neutrophil 48%, lymphocytes 47%, monocytes 2%, and eosinophils 3%). The total platelet count was 534,000 and he had an elevated total ionized calcium level (iCa) of 1.72 mmol (1.12–1.32). A dipstick urinalysis showed nitrite +, leucocyte ++ which suggested a possible urinary tract infection. A follow-up urine culture was not done as child had been on several antibiotics up to the time of this admission. The routine kidney function results were within normal limits. Immediately following admission into emergency room, dehydration was corrected and parenteral broad spectrum antibiotics commenced. On the 4th day of admission on obtaining the initial calcium result, steps to manage the hypercalcemia were taken. Formula feeding was initially stopped while continuing breast feeding; he was commenced on intravenous fluid hydration therapy of 10% dextrose in 0.45% saline combined with diuretic therapy for 48 hours. The iCa level repeated thereafter was 1.65 mmol and after 2 weeks had dropped further to 1.25 mmol. Skin lesions continued to regress and he continued to do well clinically. With the normalization of calcium levels and the good clinical progress further calcium assays were not continued. He was being followed up in our outpatient clinic at the time of this report.
A 24-year-old female patient was diagnosed with scar-granulating tracheal stenosis after tracheostomy complicated by esophageal-tracheal fistula. On August 20th, 2014 as a result of a car accident the patient had severe concomitant injury. In the postoperative period for 22 days the patients underwent mechanical ventilation. After waking up in the early rehabilitation period the patient exhibited stridor. On suspicion of tracheal stenosis the patient was transferred to the ENT clinic, where she underwent tracheoplasty on the T-tube. However, in the postoperative period, the patient began to experience the phenomenon of aspiration while taking liquid food. At the control examination ENT doctors revealed that after removing the T-tube on the rear wall of the trachea in the projection of tracheostomy a tracheo-esophageal fistula with a size of 3 to 5 mm was determined. Endoscopists performed installation of a nasogastric tube and laser photocoagulation of the fistula from the trachea side and from the side of the esophagus to cause the growth of granulation tissue which may contribute to the closure of the fistula. However, the control examination after 2 months by removing the T-tracheal tube despite nasogastric enteral nutrition and performance of laser coagulation showed that the fistula hole was not closed. The patient was directed to the surgeons for open surgery for closing the tracheo-esophageal fistula. In November 2014 the patient underwent the operation of liquidation of the esophageal-tracheal fistula by cervical access. The medical records indicated that was separation of the fistula by suturing and ligation, followed by placing a flap of sternocleidomastoid muscle between the esophagus and the trachea in the projection of the eliminated fistula channel. However, the early postoperative period was marked by the failure of the suture, recurrence of the fistula with an increase in its size and suppuration of postoperative neck wounds. The patient within 6 months had aspiration respiratory complications of the fistula. In April 2015 the patient came to our center. Complaints of the patient referred to: dyspnea on exertion, the presence of a tracheostomy tube, cough with difficult expectoration, the presence of a nasogastric tube, the inability to eat by mouth, and inability to breathe through the natural airway. The patient was evaluated by bronchoscopy and computed tomography. The studies found:\ndefect of the frontal wall of the trachea and the soft tissue on the neck after the earlier projected tracheoplasty, size 15 to 35 mm,\npronounced postoperative scars on the neck after suffering several operations of tracheoplasty attempts to eliminate the fistula and postoperative wound festering (),\nscar-granulation narrowing of the trachea in the projection of tracheostomy and progression of the tracheal stenosis in 20 min after the removal of the T-stent due to lack of skeleton (frame) of the trachea and the presence of tracheomalacia (),\nthe presence of a fistula channel between the cervical trachea and esophagus with the size of 6 × 8 mm (),\nright-side aspiration pneumonia, purulent bronchitis.
An 85-year-old Caucasian male was admitted after sudden onset of expressive aphasia and weakness in both legs lasting 20 seconds. He was athletic, self-reliant and had no cognitive impairment. During the last 28 years, he had experienced 8-10 heterogeneous episodes of acute neurological symptoms, such as central facial palsy, hemiparesis, and non-fluent aphasia, lasting from seconds to 3-4 hours. Precerebral duplex and electrocardiography (ECG) were performed several times with normal results, and EEG registration and 24-hour Holter monitoring had been normal. Previous MRI scans showed no abnormal restricted diffusion, as seen in acute cerebral infarcts, but infarct sequelae in the left temporal lobe and both thalami. Several years later, three additional infarct sequelae were detected in the cerebellum. The patient was treated with platelet inhibitors, and medications and dosages were adjusted after new episodes. There was no suspicion of lack of compliance. Except from age, migraine, and previous smoking, with cessation 35 years ago, he had no known risk factors for cerebrovascular disease. On the current admission, he presented with reduced motor speed in his left arm and leg. Electrocardiography and Holter monitoring showed no signs of atrial fibrillation. CT and MRI revealed multiple, cortical infarct sequelae in the anterior and posterior circulation territories of both hemispheres, and MRI also detected two acute embolic infarcts in the right occipital lobe and one in the left parietal lobe (Figure ). CT and MRI angiograms and duplex sonography did not show significant plaques or stenoses, and pre- and intracerebral flow were normal with asymmetrical vertebral arteries, which were considered a normal anatomical variant. Cortical infarcts in several vascular territories strongly suggest cardioembolic etiology, but transthoracic echocardiogram showed no cardiac sources of emboli, and there was no sign of left atrial enlargement, which may be seen in the presence of atrial fibrillation. The patient concurred to further diagnostic tests aiming to determine the cause of recurrent cerebral emboli, although he was informed that the results would not necessarily alter treatment recommendations. We performed a transcranial Doppler (TCD) bubble test with 10 mL air-mixed saline injected into the left cubital vein while the left middle cerebral artery was insonated with a 2-MHz probe. Injection at resting state produced no microembolic signals, while injection after Valsalva maneuver resulted in a shower of microembolic signals followed by single signals persisting for over 30 seconds. The result implied the presence of a latent right-to-left shunt, and transesophageal echocardiography verified a large patent foramen ovale (PFO; Figure ). In agreement with the patient, we decided on non-operative treatment. Due to previous failure of antiplatelet treatment, we changed to a direct oral anticoagulant (dabigatran 110 mg twice daily), intended as a lifelong treatment. He had no subjective complaints at discharge.
A 66-year-old Japanese man undergoing hemodialysis for chronic renal failure was referred to our hospital with suspected duodenal cancer. On physical examination, his abdomen was soft and flat without symptoms. Tumor markers were within normal limits, and laboratory findings were normal except for renal dysfunction due to chronic renal failure. Upper gastric endoscopy revealed a giant polypoid-type tumor extending from the duodenum bulb to the pyloric ring; its main location was thought to be the duodenum bulb (). The surface of the tumor was rough, but its outline was clear. A biopsy of the tumor showed atypical papillous epithelium containing goblet cells, and nuclei in the epithelium were p53-positive. An endoscopic ultrasound test suggested that the tumor might invade the muscular tunic (). A computed tomography scan revealed a slightly enhanced lobular tumor (54 mm × 34 mm) protruding into the duodenum bulb, although serosal invasion was not detected (). Positron emission tomography showed an accumulation of 18F-fluorodeoxyglucose (60 mm × 34 mm, maximum standardized uptake value = 5.6) in the area extending from the antrum of the stomach to the duodenum bulb (). Because indications of endoscopic mucosal resection were not favored, the giant polypoid-type early gastric cancer that was expressed on the pyloric ring and confined within the mucosal layer was curatively removed via abdominal surgery. We performed a submucosal resection via an incision in the gastric anterior wall. The resected tumor was localized in the anterior wall of pyrolic ring. Intraoperative histopathological diagnosis with a frozen section suggested that the tumor contained adenocarcinoma components; therefore, we performed distal gastrectomy followed by Billroth II reconstruction. The extent of resection was from the lesser curvature of stomach, which was 5 cm from the pyrolic ring, to the duodenum, which was 4 cm from the pyrolic ring. The resected lymph nodes were number 3b, number 4d, number 5, and number 6. The histopathological diagnosis was papillary adenocarcinoma, and the invasion depth was the mucosal layer without vascular invasion (Figures and ). There are no metastases in the removed lymph nodes and the numbers of resected lymph nodes were number 3b (0/1), number 4d (0/3), number 5 (0/1), and number 6 (0/4). The pathological stage was T1aN0M0- pStage IA. The postoperative course was uneventful, and the patient was free from recurrence 1 year after the surgery.
Our patient is a 28-year-old G2PO female who presented to our institution in labor for the birth of her first child. At time of presentation, the position of the baby was cephalic. The patient denies antecedent pelvic pain or difficulty with ambulation prior to delivery. Active labor was initiated with Pitocin augmentation. She was provided an epidural spinal anesthesia. Following 3 hours of pushing, the patient delivered a baby boy of 6 lb 11.2 oz (3040 grams). The patient did sustain a grade 1 peroneal tear which was closed primarily with suture.\nTwo hours following delivery, the patient was evaluated by her obstetrics physician for persistent and worsening anterior pelvic pain and low back pain with inability to ambulate. She was then evaluated with an AP radiograph of the pelvis which revealed a complete pubic symphysis diastasis of 5.6 cm with widening of bilateral sacroiliac joints posteriorly () which is redemonstrated with 3D CT reconstruction (). That evening, the orthopedic surgery team was asked to evaluate the patient. Following evaluation, a generic pelvic binder was placed on the patient and repeat imaging showed no significant improvement in her diastasis nor did the patient experience a reduction in her pain. The patient was left in a pelvic binder with constant skin assessments and was allowed to weight bear as tolerated. Considerations were given for both operative open reduction with anterior internal plate fixation and continued nonoperative management; however, the patient and family elected to continue nonoperative management with close observation.\nThe patient was transferred to the orthopedic surgery floor of our institution the following day where she worked with physical therapy twice daily for assistance with mobilization, beginning the following day post diagnosis. The patient had persistent pelvic pain and difficulty ambulating. On hospital day 8, as patient was only able to sit on the side of the bed and ambulate several feet with the assistance of a walker device, she was transferred to inpatient rehabilitation where she spent 15 days before being discharged home able to walk with minimal pain with assistance of the walker device. The patient was seen back in office for her first clinic follow-up 6 weeks following her delivery. At that time, the patient's AP pelvic X-ray revealed 2.0 cm of residual pubic diastasis (), and the patient was using an occasional walker when on uneven ground but able to do stairs and perform ADLs. She continued to work with outpatient physical therapy for a total of 6 months before returning to full-time work. At her 1-year follow-up, she is back to full-time work, ambulates both inside and outside the home without assistance, and is able to do stairs, perform ADLs, and care for her baby with only mild intermittent low back pain managed by over-the-counter anti-inflammatories.
A 45-year-old female with Behcet's syndrome presented with the chief complaint of shunt tubing protruding from her vagina after urination. The patient stated that approximately 1 month earlier, she had an episode of urinary incontinence and was treated for a urinary tract infection. Over the past 2 weeks, she has also complained of scant urinary leakage. The patient denied other symptoms, such as headache, neurologic changes, abdominal pain, or fever. Her past medical history was significant for a VPS insertion in 2001 for pseudotumor cerebri and a complete revision 13 months before presentation due to a Proprionibacterium acnes infection of the VPS. At that time, a general surgeon placed the distal shunt catheter into the abdomen using laparoscopic visualization, and a postoperative abdominal X-ray [] was obtained for confirmation. Further history included a total abdominal hysterectomy in 2003 for endometriosis and a gastric bypass in 2004. Prior to the hysterectomy, the patient had three full-term spontaneous vaginal deliveries.\nOn gynecologic examination, the patient was found to have approximately 15 cm of VPS catheter protruding from her vaginal apex. The patient had no other significant physical or neurological examination findings. An abdominal X-ray [] found no discontinuity in the tubing, but also confirmed the finding of the VPS catheter coursing through the abdomen and out of the vagina. A computed tomography scan of the head revealed no change in ventricular size or catheter location.\nThe patient was taken to the operating room where the cranial incisions were opened. A cystoscopy was performed that revealed an intact bladder with no evidence of any erosion of the shunt into the bladder, nor concern for any fistula formation. The vaginal cuff was grossly intact with the VP shunt coming directly through the central portion of the cuff. The VPS was sectioned distal to the valve and the peritoneal catheter was pulled out through the vagina without difficulty. The small opening in the vaginal apex was closed primarily using a 3.0 polysorb suture. The ventricular catheter was removed from the head, and an external ventricular drain was inserted. Cultures from the operating room revealed no growth in the cerebrospinal fluid (CSF) and diphtheroids from the catheter tip (RBC-1264, WBC-0, Glucose-54, Protein-15). A definitive shunt was not placed during this operation because of the patient's history of shunt infections and we wanted to monitor serial cultures to rule out a P. acnes infection. One week later, a new shunt was inserted, with the distal end placed into the pleural cavity. The patient was discharged from the hospital on 2 weeks of empiric antibiotic and antifungal coverage.\nAt 1 month follow-up, patient was doing well from both a gynecological and neurosurgical standpoint; however, her cranial incision did show signs of superficial breakdown. At 3 months, aside from two pinpoint scabs, her wounds had healed completely and she had no gynecological complications. Given her history of Behcet's syndrome and chronic wound healing problems she will be monitored closely.
A 23-year-old male was referred to our hospital in May 2008 due to severe traumatic brain injury caused by a traffic accident and was diagnosed as brain dead shortly after admission. Dextrocardia was found during physical examination and situs inversus totalis was verified by further X-ray and ultrasonic inspection. During the retrieval of donor organs, it was found that the liver, pancreas, and stomach were located in the opposite positions. The descending aorta was located directly in front of the spine and the inferior vena cava was found in the front left of the spine. Organ procurement was smoothly performed without great difficulty even though the procedure took a little longer due to the operator's habitual thinking about the anatomy. During preparation of the donated liver, the anatomical relations were clearly identified, that is, liver artery locating in right side and common bile duct in the left, and portal vein still being behind common bile duct and liver artery. The hepatic superior and inferior vena cava was cut to angle well in preparation for vascular anastomosis.\nA 58-year-old female recipient was diagnosed with end-stage liver disease caused by type B hepatitis. Preoperative condition was evaluated with Child-Pugh (class A) and MELD (4.3). The liver transplantation was performed in May 2008. The incision was made double subcostally. Following isolation of porta hepatis and hepatic ligament, the retrohepatic inferior vena cava was partially clamped and then the diseased liver was removed preserving the inferior vena cava. The right hepatic vein was suture ligated while preserving the left and middle hepatic veins. At the point of left hepatic vein entering the hepatic superior and inferior vena cava, a transection was taken on an anterior wall of the interval between the left and middle hepatic veins, and meanwhile, the anterior wall of inferior vena cava was cut downward 2 cm, thereby forming a “T” type anastomotic rim in preparation for hepatic venous outflow reconstruction.\nLiver transplantation was performed with a modified piggyback technique. The donor liver was directly placed into the recipient's right upper quadrant without rotating adjustment, that is, the right hepatic lobe was positioned in the recipient's left side and the smaller lobe was positioned in the recipient's liver fossa. The hepatic superior and inferior vena cava was directly anastomosed to recipient's inferior vena cava with 3-0 vascular suture. Portal veins were end-to-end anastomosed with 6-0 vascular suture followed by albumin solution perfusion. The residual UW solution (University of Wisconsin solution) in the donated liver was flushed away with albumin solution. Then, the intrahepatic vena cava was completely ligated and the clamps were removed from portal vein and vena cava, thereby ending an hepatic phase. Cold and warm ischemia times were 7 hr and 2 min, respectively. For artery reconstruction, the cut off at the junction of the proper hepatic artery and gastroduodenal artery (recipient) was anastomosed with the cut off at the junction of common hepatic artery and splenic artery (donor) with 7-0 vascular suture. Biliary reconstruction was performed by duct-to-duct anastomosis between recipient's common hepatic duct and donor's common bile duct with 6-0 vascular suture without placing a “T” type drainage tube. The total operation time was 6.5 hr and life support was withdrawn at 6 hr after operation. illustrates the status of the transplanted liver after reconstruction of the portal vein. The immunosuppression was induced with anti CD25 antibody and maintained with FK506/MMF. The patient recovered well postoperatively with normal hepatic function in 2 weeks and discharged from hospital at day 20 after transplantation. By now, the patient has been followed up for 36 months. The liver function remains normal without biliary complication and rejection reactions.
This is a 40-year-old female patient diagnosed with lower extremity CRPS type-I in the right ankle and foot, based on the IASP Budapest Criteria.[ The patient did not have any history of psychological disorder, seizure disorder or neurological abnormality. Physical examination in the first presentation showed the presence of well-healed incision scars from the previous surgeries in the dorsum of the right ankle and foot. There were mild color changes. There were moderate skin texture changes and trophic changes in the nails. The patient had excessive sweating both on inspection and palpation in the entire right foot. There was hyperesthesia and hyperalgesia of the entire dorsum of the foot (Fig. ). Right foot skin temperature was 3°C colder than the left foot. The patient had 4/5 weakness of the right foot extensors and toe flexors. Right ankle range of motion was moderately limited secondary to pain. The patient did not have any visible or reproducible involuntary motor movement in her history or physical examination. The patient underwent a first LSB with the same technique and medications as described in Case 1, but on the right side. LSB was performed under local anesthesia and the patient was given lorazepam 1.5 mg orally as a sedative prior to procedure. Temperature measurements of bilateral plantar skin as well as pulse amplitude of the right big toe with pulse oximetry were monitored continuously. Adequate sympathetic blockade was achieved after the block with confirmation of at least 2°C increase from the baseline temperature. The patient developed muscle spasms of the entire ipsilateral lower extremity in the recovery room 15 minutes after the completion of the first LSB (Video 2). These muscle spasms were not as intense as the Case-1, but significant enough that the patient was complaining of increased pain and was unable to stand. The patient was initially treated with 2 mg of midazolam IV. The patient did not respond to treatment with midazolam. As the presentation was very similar to Case-1, the patient was treated with IV DPH 50 mg. The patient responded immediately with abrupt resolution of muscle spasms.
A 14-month-old male child presented to the emergency department of our hospital at 6.30 pm with irritability and the child was continuously crying. The child had ingested a small metallic toy – a decorative item attached to the upper pocket of his shirt – about an hour ago. We found that the vital parameters (pulse, blood pressure, and respiratory rate) were normal and stable. However, the child had continuous drooling of saliva, potentially indicating an inability to swallow. Based on these findings, our primary goal was to determine the position of the FB by a radiological examination and manage the child appropriately.\nWe found that the metallic body in the shape of a cycle was lodged in the upper esophagus []. We decided to remove FB endoscopically using an esophagoscope under general anesthesia. The child was placed in a supine position with an extended neck. Two anesthetists monitored the child for vital parameters (heart rate, blood pressure, and respiratory rate) and management of endotracheal tube ventilation. The FB was dislodged from the esophageal wall, and the procedure was atraumatic. Due to the shape of the metal, we faced difficulties during removal. Thus, we used meticulous and gentle manipulation around the edge of the metallic FB and performed the procedure over a sufficient amount of time so as to dislodge the body from the impacted esophageal mucosa without causing any trauma or bleeding from the adjacent site. On removal, we found that the FB was about 1.5 inches in size []. The object was made of aluminum with a probable mixture of other unknown metals. We finished the removal of the FB in 20 min. The entire procedure from intubation to extubation lasted for 45 min. The oxygen saturation was maintained at 100% for the entire duration of the procedure.\nThe child was conscious immediately after the procedure, was fed in the postoperative period, and was advised overfeeding for the initial 6 h. The child tolerated these feeds well, and there was no breathlessness or irritability. We did not repeat a radiological examination as the child was stable, the FB was completely removed, and we did not want to expose the child to additional radiation.\nThe child was placed under overnight observation in the hospital. The stay in the hospital was uneventful, and the child was discharged the next day. The child was advised to follow-up if there were any symptoms of breathlessness or difficulty in swallowing. The child had not followed up with any complaints till the time of manuscript preparation.\nWe have taken a written consent from the legal representative for publication of the clinical presentation and images.
This case involves a 15-year-old male patient with no pertinent orthopaedic past medical or surgical history. He sustained an initial injury to his left hip six weeks prior to presentation following a direct lateral impact during a lacrosse match. The patient felt pain but was able to return to play. Two weeks later, he was running in a lacrosse match and sustained a non-contact left hip injury. He was unable to ambulate and was taken by ambulance to the emergency room, where he was diagnosed with a posterior hip dislocation. He underwent uncomplicated closed reduction within two hours of the injury and was referred for follow-up to the senior author’s practice. Upon examination, his left hip had good range of motion, demonstrated no joint laxity and had a negative dial test. There was no laxity in his elbows, wrist, hands or knees. His hip range of motion was symmetric to his contralateral side with internal rotation to 10 degrees and external rotation to 65 degrees. His radiographs showed a concentric reduction with no fracture (). He was instructed to limit weight bearing to 30% for 4 weeks, and to start a physical therapy program focusing primarily on hip stabilization and gluteus medius activation. He was also given standard instructions for posterior hip precautions to limit flexion to 90 degrees, adduction to neutral and to limit internal rotation. He was not braced, and the risks of avascular necrosis were discussed. He was instructed to follow-up with our clinic in 6–8 weeks.\nApproximately 4 weeks after his clinical evaluation, he dislocated his hip in his sleep. He was evaluated in the Emergency Room where a magnetic resonance imaging (MRI) scan was ordered due to the lack of clinical suspicion for hip dislocation. It showed the left hip to be dislocated posteriorly with the ligamentum teres absent (). The hip was reduced with closed reduction techniques, and he was instructed to follow-up with our clinic. Radiographic evaluation in our clinic showed a non-arthritic joint with reasonable lateral coverage and a lateral centre edge angle of 32 degrees with no crossover sign. His overall acetabular volume was low with small anterior and posterior walls and neutral acetabular version. A CT scan was ordered to assess the volume of the cup and, specifically, integrity of the posterior acetabular wall (). Distal cuts were not made through the knee so femoral version was not analysed. Both the anterior and posterior walls were small and there was a mild flattening to the posterior wall, on a cephalad cut on the CT scan there was small ossification (). It was not felt to be a fragment of the acetabular wall, but rather possibly some early heterotopic ossification. He was sent to an Orthopaedic Traumatologist for confirmation, and he was sent back to our clinic for definitive treatment.\nBoth he and his family were very concerned about the stability of his hip and requested a surgical procedure to correct the problem and prevent it from happening again. A periacetabular osteotomy to increase acetabular coverage and bony stability was ruled out as it was felt that his acetabulum was in an optimal position for a low volume cup. His lateral X-ray showed mild CAM-type femoroacetabular impingement with an alpha angle exceeding 60 degrees (). His MRI showed a labral tear and no evidence of avascular necrosis. He and his family were offered hip arthroscopy to address both the labral tear and the ligamentum teres deficiency, understanding the possibility of reconstruction of both.
Our patient is a 62-year-old Caucasian female who initially presented with right arm and hand numbness with history of previous carpal tunnel release. A more recent carpal tunnel release surgery did not lead to resolution of symptoms. She developed a cough approximately 1 month later and received chest x-ray (CXR) at the hospital which showed a new right apical mass. Chest computed tomography (CT) confirmed mass most consistent with malignancy. CT guided biopsy showed clear cell tumor with areas showing possible chondroid features. This sample was negative for HMB-45 which is typically indicative of clear cell carcinoma. The differential diagnosis at this time was clear cell carcinoma versus hamartoma. PET-CT showed single lesion of soft tissue mass in the right upper lung measuring 6.2 cm with no evidence of metastasis. The decision was made to refer patient to a tertiary center to develop a treatment plan in conjunction with surgical input. Repeat biopsy was considered necessary and EBUS (endobronchial ultrasound) demonstrated histopathological evidence for chordoma.\nPatient received CT (), MRI (), and CTA () before surgery which were reviewed to determine the optimal approach for a joint procedure by neurosurgeons and thoracic surgeons. MRA demonstrated anterior displacement of right vertebral artery along with involvement of right C8–T1 nerve roots and extending from C7 to T2. Anterior approach was determined to allow better surgical resection due to vascular exposure. A hemi-sternotomy down to the second rib was performed followed by a neck and chest dissection separating the tumor from the innominate vein, right common carotid artery, right subclavian artery, right jugular vein, and right vertebral artery. The vertebral artery was noted to be coursing through the tumor. Tumor was noted to involve T1 and T2 nerve roots and entered the neural foramen along with brachial plexus involvement. The inferior portion of the tumor was dissected free from the pleura, but small remnants remained attached to the pleura. The tumor was dissected away from the vertebral artery to the extent possible. Tumor was attached to posterior portion of first and second rib and it was freed from the ribs and taken primarily en bloc and was dissected as far into the neural foramina as able.\nThe patient had no complications from surgery. She followed up with her oncologist and surgeons. She has completed proton therapy for the residual mass left on her posterior thoracic wall and has had no side effects of surgery. Follow-up imaging done 8 months after proton therapy completion demonstrated aggressive growth of the residual chordoma (). Molecular testing also identified no therapeutic targets that could be exploited.
Our patient was a 68-year-old, left-hand-dominant man who presented with a chief complaint of left thumb numbness with a palpable mass along the flexor surface of his thumb. The patient noted tingling in his left hand, mainly at night, for the last 3 years. He had difficulty performing simple tasks of daily living with the left hand due to thumb numbness. The patient was, significantly, an avid bowler in the past and reported weakened grip while bowling since the onset of his symptoms. At the time of presentation, the mass had been present for 2 months and was tender to palpation. The patient denied any history of hand trauma or previously diagnosed pathologic nerve compression. His medical history included gastroesophageal reflux disease, chronic obstructive pulmonary disease, and mild arthritis. He denied any history of diabetes or having hypothyroidism.\nPertinent positives on patient's physical examination included a positive Tinel's sign over the left thumb mass and also at the carpal tunnel bilaterally. The patient had a positive carpal compression test on the left. He also had decreased range of motion at the neck but a negative Spurling's maneuver. Static 2-point discrimination was at least 5 mm at all digits except at the ulnar digital nerve of the left thumb, which was greater than 15 mm. There were no motor or vascular abnormalities.\nThe patient underwent electrodiagnostic testing, which was negative for any compressive neuropathy or cervical radiculopathy. Magnetic resonance imaging of his left hand demonstrated no definite abnormal signal or lesion at the region corresponding to the palpable mass. Once the diagnosis of bowler's thumb was made, the patient underwent a trial of splinting for 1 month with no change and then opted for surgical intervention.\nAt time of operation, a Bruner incision was marked out over the proximal aspect of the ulnar side of the thumb with an extension into the palm. The ulnar digital nerve of the left thumb was exposed, revealing extensive scar tissue and fibrosis surrounding approximately 3 cm of the nerve (). While freeing the nerve from the surrounding fibrosis, branches of the ulnar digital nerve were encountered and preserved. Neurolysis of the ulnar digital nerve was completed ( and ) and the nerve was then wrapped with an AxoGuard Nerve Protector (AxoGen, Inc, Alachua, Fla) cut to size (). The nerve protector was placed in 2 different locations, both proximally and distally at the nerve, and loosely sewn into place with 8-0 interrupted nylon sutures. The incision was then closed with 4-0 nylon interrupted horizontal mattress sutures.\nThe patient was seen 6 days postoperatively. At this time, the patient already reported alleviation of his pain and numbness. On physical examination, the patient's 2-point discrimination was found to be 5 mm at the ulnar side of the thumb. At subsequent visits, the patient continued to report resolution of his symptoms and ability to return to his regular activities. Tinel's sign at the thumb web space after the procedure was no longer present.
An 81-year-old Caucasian woman was presented to the emergency room of the University Hospital of Ioannina after a head-butt caused by a bully goat with a large hematoma at the right side of her neck and with severe dyspnea. From her medical history, she reports an “undefined” thyroid nodule discovered 15 years ago with gradually increasing dimensions over the last years. The patient was also hypertensive for many years.\nClinical examination revealed normal body temperature, heart rate at 118 beats per minute, and a blood pressure 95/75 mmHg. Physical examination of the neck revealed the presence of an extensive hematoma. The patient was barely speaking and her breath was noisy. Saturation of the arterial blood was 81%. The patient was intubated endotracheally (Figures and ) in order to ensure a secure airway. She was then immediately transferred to the radiology department for an urgent CT scanning which revealed the extensive hematoma at the right area of the neck and a voluminous suspect thyroid nodule. There was no vertebral injury associated with this trauma. The performed angiography revealed a slight injury of the external carotid artery.\nThe laboratory evaluation showed a hemoglobin level at 6,9 g/dL and hematocrit at 23%. The biochemistry profile of the patient was within normal limits. She was, then, transferred to the operating room where she was operated on by a vascular surgeon and a general surgeon. An extended incision along the anterior border of sternocleidomastoid muscle was made, which provided an excellent exposure of the damaged area. After the hematoma was drained the injured wall of the external carotid artery was revealed and the damaged arterial vessel was immediately ligated (). Due to the presence of an oversized nodule on the thyroid gland, a partial thyroidectomy was performed. The postoperative period was uneventful and the patient was discharged from the hospital on the fourth postoperative day, in a good health. On a follow-up, six months later, the patient remained in an excellent condition ().
A ten-year-old girl was admitted to our general hospital with numbness of her left palm and fingers in the last 5 months before admission. At that time, she was hit by a car while she was riding a bicycle. The car was coming from opposite side, and she fell with her left forearm was sliced by licensed plate of the car. There was a semicircular open wound with active bleeding on the left forearm, and she was in pain. She was brought to a nearby clinic and had her left forearm sutured. After the pain subsided, she felt numbness of her left hand and fingers. In addition, she could not extend her fingers. Finally, the patient decided to seek medical attention and get further treatment at our general hospital.\nFrom physical examination, there were claw hand deformity with thenar and hypothenar atrophy as well as a scar on the anterior side of distal forearm (). Sensorium loss of the palm and third, fourth, and fifth fingers was impaired. No tenderness was found. Capillary refill of the fingers was normal. Range of motion of the fingers was altered with limitation of finger abduction and thumb apposition (). Moreover, range of motion of the wrist was within normal limit.\nRoutine laboratory examination was within normal limit. The patient was taken for wrist and forearm radiographs and, similarly, there was no abnormality depicted on either bones or soft tissue.\nThe patient also underwent electromyography examination which showed median and ulnar nerve lesion at the left forearm with total axonal degeneration. No signs of reinnervation of both peripheral nerves were detected.\nThe patient was diagnosed as ulnar and median nerve palsy of left forearm, and then we planned to perform surgical exploration of the nerves and to repair with sural nerve graft, Zancolli procedure and sural nerve graft.\nIntraoperatively, skin incision was made on the previous surgical scar. Injury site was explored, and complete rupture of both ulnar and median nerves was found. Degeneration of both nerves was also seen, with neuroma rising from both the proximal stumps. The proximal and distal ends of both ulnar and median nerves was cut until nerve fascicle was visible. The distance between proximal and distal stump was measured: for ulnar nerve the distance was 7 cm, while it was 8 cm for median nerve. Sixteen centimeters of ipsilateral sural nerve was harvested, and the ulnar and median nerves were repaired using the nerve graft. Then Zancolli procedure was performed: skin incision was made along the palmar crease, A1 pulley was identified around metacarpophalangeal joint, longitudinal incision was made on the pulley, flexor digitorum superficial tendon was retracted laterally, metacarpophalangeal joint capsule was identified, an elliptical incision was made over the joint capsule, and capsulodesis was performed. Postoperatively the wound was closed and immobilized by elastic bandage ().\nWe followed the patient at 3-week postoperatively, and the patient had improvement of her claw hand (). She was advised to continue her rehabilitation of her hand to further improve her hand function, especially opposition and key pinch. At 6-month follow-up, she had improved grip strength and normal functional level of her left hand. At 2-year follow-up, she could handle daily activity as before the accident and was satisfactory with her condition. ()
A 6-year-old boy reported to the Department of Pediatric Dentistry with a history of fall while playing 2 days ago. After the fall the child did not lose consciousness, had no history of vomiting or convulsions. There was a history of bleeding from gums, difficulty in the closing mouth and chewing food.\nClinical examination revealed a diffuse extraoral swelling in the right lower one-third of the face causing a asymmetry of the face, difficulty in opening and closing the mouth, and a cut on the chin and the lower lip. Intraoral examination revealed a vertical fracture line between right mandibular primary lateral incisor and primary canine associated with medially displaced left mandibular dentoalveolar segment with step deformity and altered occlusion leading to an open mouth appearance []. Preoperative orthopantamogram (OPG) was taken [], which confirmed right parasymphisis fracture. There was an associated fracture present on the left mandibular angle region.\nUpper and lower arch alginate impressions were taken, and stone casts were poured. An acrylic splint was fabricated, and mandibular fracture was immobilized, fixed with the acrylic splint that was retained by circum mandibular wiring. Circummandibular wiring was done under general anesthesia by placing a small-stab incision on the inferior border of mandible on the right and left side 3–4 cm from the midline. The mandibular bone awl was used to enter lingually along the body of the mandible and piercing lingual mucosa the wire was fed and passed onto buccal sulcus along the body of the mandible. Wire held together and stent stabilized by winding wire in a clockwise direction at 83.84 region. The same procedure was repeated on the left side []. Another circum mandibular wire was placed at the left body region to stabilize the fractured fragment at the lower border of mandible. Postoperative OPG was taken with circum mandibular wires in place []. The patient was reviewed every week and on the fourth postoperative week, the circum mandibular wiring and splint was removed under ketamine sedation, and OPG is taken [Figures and ]. No mobility was present at the fracture site. Postoperative recovery was uneventful and occlusion achieved was satisfactory.
A ten-year-old girl was admitted to our general hospital with numbness of her left palm and fingers in the last 5 months before admission. At that time, she was hit by a car while she was riding a bicycle. The car was coming from opposite side, and she fell with her left forearm was sliced by licensed plate of the car. There was a semicircular open wound with active bleeding on the left forearm, and she was in pain. She was brought to a nearby clinic and had her left forearm sutured. After the pain subsided, she felt numbness of her left hand and fingers. In addition, she could not extend her fingers. Finally, the patient decided to seek medical attention and get further treatment at our general hospital.\nFrom physical examination, there were claw hand deformity with thenar and hypothenar atrophy as well as a scar on the anterior side of distal forearm (). Sensorium loss of the palm and third, fourth, and fifth fingers was impaired. No tenderness was found. Capillary refill of the fingers was normal. Range of motion of the fingers was altered with limitation of finger abduction and thumb apposition (). Moreover, range of motion of the wrist was within normal limit.\nRoutine laboratory examination was within normal limit. The patient was taken for wrist and forearm radiographs and, similarly, there was no abnormality depicted on either bones or soft tissue.\nThe patient also underwent electromyography examination which showed median and ulnar nerve lesion at the left forearm with total axonal degeneration. No signs of reinnervation of both peripheral nerves were detected.\nThe patient was diagnosed as ulnar and median nerve palsy of left forearm, and then we planned to perform surgical exploration of the nerves and to repair with sural nerve graft, Zancolli procedure and sural nerve graft.\nIntraoperatively, skin incision was made on the previous surgical scar. Injury site was explored, and complete rupture of both ulnar and median nerves was found. Degeneration of both nerves was also seen, with neuroma rising from both the proximal stumps. The proximal and distal ends of both ulnar and median nerves was cut until nerve fascicle was visible. The distance between proximal and distal stump was measured: for ulnar nerve the distance was 7 cm, while it was 8 cm for median nerve. Sixteen centimeters of ipsilateral sural nerve was harvested, and the ulnar and median nerves were repaired using the nerve graft. Then Zancolli procedure was performed: skin incision was made along the palmar crease, A1 pulley was identified around metacarpophalangeal joint, longitudinal incision was made on the pulley, flexor digitorum superficial tendon was retracted laterally, metacarpophalangeal joint capsule was identified, an elliptical incision was made over the joint capsule, and capsulodesis was performed. Postoperatively the wound was closed and immobilized by elastic bandage ().\nWe followed the patient at 3-week postoperatively, and the patient had improvement of her claw hand (). She was advised to continue her rehabilitation of her hand to further improve her hand function, especially opposition and key pinch. At 6-month follow-up, she had improved grip strength and normal functional level of her left hand. At 2-year follow-up, she could handle daily activity as before the accident and was satisfactory with her condition. ()
A 17-year-old man presented to the emergency department with increasing leg pain associated with swelling at the site of the pain. He had been experiencing pain of moderate intensity in the mid third of his left thigh for ~7 days. Symptoms gradually worsened over the last 2 days.\nHe was a factor V leiden carrier and had a history of cerebral venous thrombosis. He was being treated with therapeutic anticoagulation. He had no other comorbidities. He had no history of smoking had no history of trauma or surgery.\nOn physical examination, he was tachycardic (103 bpm) with a blood pressure of 130/70 mmHg. We demonstrated a large pulsatile mass of the left upper leg (). His pulses were palpable and there was no evidence of distal embolization.\nUltrasonography (US) of the left thigh showed an aneurysmal dilatation of the SFA measuring 67 × 50 × 80 mm () on the anterior aspect of the proximal third of the thigh. Computer tomography angiogram (CTA) confirmed a 64 × 80 × 87-mm PSA developed on the anterior side of the proximal left SFA (). The other arterial axes were healthy and normal. Supplementary imaging examinations did not identify any additional aneurysms.\nAfter a multidisciplinary discussion, we decided to wait until the effect of anticoagulation ceased before operating on the patient.\nDuring operative intervention, a hematoma was observed involving muscle tissues in the anteromedial region of the thigh. There were no obvious signs of active infection. The proximal control obtained, the aneurysm incised and the distal control obtained. The aneurysm resected and samples collected for anatomopathological and microbiological analyses (). Reconstruction was performed by interposition of the ipsilateral great saphenous vein in reverse, with end-to-end anastomosis taking into consideration the diameter of the femoral artery (). Intraoperative tissue cultures were negative and the anatomopathological analysis showed a histopathological aspect corresponding to a PSA of the femoral artery, with the absence of the arterial wall and without specific character.\nAt 2-month follow-up, the patient had palpable distal pulses and was free from pain or other problems. The control echodoppler shows triphasic flow within the left common and superficial femoral arteries.\nAt 3-month follow-up, he presented to emergency room with a popliteal and left calf pain that has been worsening for 2 days. The echo Doppler revealed a popliteal and femoral deep vein thrombosis, and a left SFA PSA (15 × 18 mm) circulating with a 5-mm collar ().\nThe CTA confirmed a PSA measuring 13 mm in diameter ().\nIn view of the size of the PSA and the asymptomatic character, we decided to treat it by endovascular procedure.\nUnfortunately, in the meantime, he presented to the emergency room for a swelling of his left thigh since the morning. He had no pain. He was hemodynamically stable. His hemoglobin was 13 g/dl. We examined a large pulsatile mass of the left upper leg. The CTA showed a PSA (8.3 × 10.7 × 9 cm) of his left SFA and a hematoma with active bleeding on the anterior aspect of the left thigh, in close contact with the left SFA ().\nThe patient was operated as an emergency. A voluminous hematoma was observed involving muscle tissues in the anteromedial region of the thigh. Proximal control was obtained, the aneurysm incised and the distal control obtained with a fogarty catheter. The hematoma was evacuated and the PSA was resected. The anatomical structures are hardly recognizable and deformed due to the presence of this important hematoma. Our old venous bypass was not visualized, probably compressed and evacuated with the hematoma. The reconstruction performed by interposition of graft (Dacron 6 mm), with end-to-side anastomosis.
The case we present here is about a 22-year-old female patient referred to the Department of conservative dentistry and endodontics with the chief complaint of pain in the left lower back tooth for the past 2 days. The pain is of mild, intermittent, and throbbing nature. Her medical history was noncontributory and she gave a dental history of root canal treatment was done in that tooth before 2 months in a dental clinic. On clinical examination, it was found access opening was done in a grossly decayed left mandibular second molar. The tooth was tender on vertical percussion. On palpation in buccal and lingual vestibule, there was no tender on palpation. Tooth mobility and periodontal probing around the tooth were within normal limits. 2% lignocaine in 1:100000 adrenaline local anesthesia was given as inferior alveolar nerve block. The treatment was continued by complete caries excauation and canal exploration after rubber dam isolation. On microscopic exploration of the floor of the pulp chamber a canal was found present between mesial and distal roots on buccal side. On radiographically, the file placed in it was found as extra root like RE. RE is an extra third root in mandibular molars present on the lingual side, which is shorter in length than other two roots. However, here, it is seen on buccal side called as RP. On careful exploration on mesial root, presence of three canals was suspected and the middle mesial canal was identified. The distal root had single canal. After working length estimation done [], all the canals were enlarged until 20 size K file and biomechanical preparation was completed by protaper rotary systems. All three mesial canals were enlarged until F1, distal canal until F3 and the extra third root on buccal side until F2 with copious irrigation of saline simultaneously. Then the master cones checkup were done as shown in . Then the final irrigation was done with 17% ethylenediaminetetraacetic acid, 3% sodium hypochlorite and by saline. Canals were dried with paper points and obturated with Gutta-percha cones of respective sizes with kerr sealer. Then the access was closed with zinc oxide eugenol cement []. shows the post obturation magnified view of floor of the pulp chamber showing the five canals with RP in middle.
A 41-year-old Caucasian gentleman with a background of surgical closure of atrial septal defect aged 2 years old underwent routine echocardiography (surgical details unknown). The study was remarkable for the presence of a dilated right coronary ostium. No previous imaging was available for comparison, reflecting the remote nature of the patients' previous surgery. There was no history of collagen vascular diseases. There was no suggestion of an episode typical of Kawasaki disease in childhood. The patient was asymptomatic with preserved effort tolerance. Physical examination was normal. Specifically, there was no evidence of cardiac failure and no murmur was noted on examination. Transthoracic echocardiography demonstrated aortic root dilatation at the level of the sinus of Valsalva (4.9 cm) with an appearance suggestive of right coronary artery ostial dilatation; the proximal ascending aorta measured 4.1 cm. The remainder of the echocardiogram was within normal limits. There was no evidence of resting ischaemia or previous infarction. Given these findings, CT coronary angiography was performed which demonstrated dilatation involving the right sinus of Valsalva extending into the ostium of the right coronary artery (). The remainder of his right coronary artery and the left sided coronary arteries were of normal calibre and had minor irregularities only noted. Subsequent diagnostic cardiac catheterisation confirmed the appearance of severe dilatation of the right coronary ostium (). There was no obvious stenosis noted distal to the aneurysmal dilatation.\nDue to concerns regarding possible subsequent coronary artery dissection, aneurysmal thrombus formation, and aneurysm rupture, the patient underwent surgical intervention.\nFollowing redo sternotomy, a transverse aortotomy was performed. Inspection confirmed a right coronary sinus of Valsalva aneurysm involving the right coronary ostium. A bovine pericardial patch was placed between the aortic annulus and sinotubular junction excluding the aneurysm. The true ostium of the right coronary artery was then anastomosed to a saphenous vein graft; the internal mammary artery was of insufficient length to serve as a conduit. The postoperative course was uneventful.\nPostoperative echocardiography was within normal limits. Repeat CT imaging confirmed bypass graft patency and no residual right coronary ostial dilatation ().
A 1 year 3 month old Chinese male child was referred to our pediatric department for pain and swelling on his left side of face for past 2 weeks. In the past two weeks, the baby was suffering from a gradually severe soft tissues swelling on his left face. Two days before admission to our hospital, the pain and tenderness of left face became worse. As a result, the patient was referred to our hospital for examination and treatment. There was no history of any trauma to head and neck. Physical examination showed the patient had a mild soft tissues edema on his left upper face and severe pain was elicited upon pressure. There was no fever, weight loss and no palpable lymphadenopathy or organomegaly. The laboratory results, including blood count, differential, liver and renal function, were within the normal range. A computed tomography (CT) scan of the head revealed multifocal osteolytic lesions in the facial bones, including left zygomatic bone (measuring 1.5 × 1.0 × 1.0 cm in size), left orbital bone (measuring 0.5 cm in diameter) and right maxillary bone (measuring 1.0 cm in diameter). The most of left zygoma was observed to be destroyed and associated soft tissue mass was also noted (Figure ). The lesions showed moderate enhancement after meglumine diatrizoate injection. There was no enlarged lymph node found in head and neck. A CT scan of neck and abdomen showed no pathologic findings, particularly no lymphadenopathy could be observed. A CT guided needle biopsy was performed on left zygomatic bone initially, but histopathological examination showed pieces of fibrosis with infiltration of inflammatory cells. From the clinical and radiographic evaluations, the lesion was preoperatively diagnosed as Langerhans cell histiocytosis (eosinophilic granuloma) of bone. The patient underwent curettage of the zygomatic and maxillary lesions. Because the margin of the lesions was ill-defined, the curettage was extensive. The postoperative phase was uneventful, and no additional treatments were undertaken. The pain resolved postoperatively and the patient was on regular follow-up for 24 months after discharging from hospital. A follow-up CT scan at 6 months after surgery revealed unchanged lesion of left orbital bone and there was no sign of recurrence of tumor and lymph node enlargement.\nThe surgical samples were routinely fixed in 10% neutral buffered formalin. The tissues were embedded in paraffin. Four micrometer-thick sections were stained with H&E. Immunohistochemical analyses were performed using the ChemMate Envision/HRP Kit (Dako, Glostrup, Denmark). The antibodies used in this study included a broad panel of antibodies against cytokeratin (AE1/AE3), epithelial membrane antigen (EMA), vimentin, desmin, smooth muscle actin (SMA), CD31, CD34, D2-40, CD1a, CD68, S100 protein, Langerin, and Ki-67. The antibodies were obtained from Dako Cytomation (Glostrup, Denmark) and Santa Cruz Biotechnology (Santa Cruz, CA, USA).\nUnder microscopic examination, both zygomatic and maxillary lesion showed an ill-defined neoplasm within the osseous fragments. The lesions were composed of multiple delicate interconnecting vascular channels with papillae formation which projected into the lumen lined by atypical plumped endothelial cells. Some of those papillae contained hyalinized core. The vascular channels were also lined by plump cuboidal endothelial cells with focal hobnailed or “match-head” appearance. In some areas, endothelial cells formed solid-appearing aggregates with vessel lumens. A variable number of lymphocytes are seen within and around the vascular channels. Mitotic figures were rare and necrosis was not observed in the lesions (Figure A-C).\nImmunohistochemistry stains done on these lesions were positivity for CD34 and CD31. Staining for CD31 was stronger than that for CD34. Endothelial cells of lumens expressed CD31, CD34 and D2-40, but the intraluminal tumor cells were negative for D2-40 (F). These lesions did not express CD1a, S-100 protein, cytokeratin (AE1/AE3), EMA, langerin, CD68 and SMA. The Ki-67 labeling index of the lesions was low, accounting for 2% of the tumor (Figure D-F). Based on the pathological findings, the mutifocal intraosseous lesions of facial bones were diagnosed as papillary intralymphatic angioendothelioma (PILA) according to WHO diagnostic criteria [].
A 23-year-old French man of African origin, an elite football player, sustained a midshaft anterior cortex tibial stress fracture 2.5 years ago. Initially, he was treated with cast immobilization, no weight bearing for 3 months, ultrasound stimulation, and electromagnetic field therapy. The fracture did not heal; he had pain during gait, so he continued no weight bearing for 3 additional months. After that period, the fracture site still was not healed, so he underwent an operation performed by his team doctor. In this operation, the medullary canal of his tibia was reamed and an im nail was inserted.\nUnfortunately, the fracture site did not consolidate again, even 18-months postoperatively, so he presented to our clinic for counseling. It was obvious from the X-ray (Fig. ) that a nonunion of the fracture had occurred.\nHe did not smoke tobacco and he had a free medical history. When he presented to our clinic, the area at the fracture site was swollen and painful when palpated. The pain got worse when he attempted to walk with full weight bearing, so he had to use crutches. An examination of the peripheral nervous system of his lower extremities did not provide us with any pathologic findings. In addition, the laboratory examinations for possible endocrine or metabolic disorders were negative (Table ), so he was advised to have a reoperation to address this nonunion. The treatment options for such cases include nail exchange, drilling of the fracture site, bone grafting, or removal of the nail and internal fixation with a plate. We performed a tension band plate fixation, which is a technique already described for the treatment of anterior tibial stress fractures that failed non-operative treatment [], with bone grafting and without removing the nail.\nA longitudinal incision was made just lateral to the anterior tibial crest centered over the fracture site. The fascia over the tibialis anterior was divided, the muscle lifted off and the fracture site was visualized. The necrotic bone and callus at the fracture site was debrided with the use of an osteotome and a curette. Transverse drilling around the fracture site was done to promote healing and osteoblastic activity. Bone marrow from the ipsilateral iliac crest was inserted into the fracture site and a tension band plate was applied over the im nail.\nWe used a 6-hole, 4.5 mm locking compression plate. The plate was prebended and the screws were placed in a compression manner to achieve a tension band effect to the fracture site. A cortical screw was put first to the distal hole closest to the fracture site and then a cortical screw to the closest hole proximal to the fracture site to ensure compression of the fracture. Consequently, one unicortical locking screw was inserted proximally to the fracture site and the other two distally. With the use of locking and non-locking screws we minimized the pressure at the periosteum, which can damage blood supply to the poorly vascularized bone. The screws were angled in a different axis in order to bypass the nail (Fig. ).\nPostoperatively, our patient was advised to wear an orthotic boot and to not bear weight for 6 weeks. Range of motion exercise involving knee and ankle and isometric exercises were initiated immediately postoperatively. After 6 weeks he progressed to weight bearing as tolerated. At 3 months postoperatively he was pain free and started light jogging, swimming, and plyometric and core stabilization exercises. At 6 months postoperatively the complete radiologic union of the fracture was evident (Figs. and ). He was symptom free; he resumed at that time a full training program and he returned to play football 6 months postoperatively at his preinjury high competition level.
A 59-year-old male underwent uneventful DDLT for decompensated hepatitis B-related liver cirrhosis with a MELD score of 19. The transplant surgery and postoperative course were uneventful. He was discharged on the 11th posttransplantation day with stable liver function. Immunosuppressive protocol was as per standard institution protocol. The patient was admitted after 6 weeks in an emergency department with hypotension, vomiting, and altered sensorium associated with oliguria. Liver functions were grossly elevated, and he had a systolic hypotension of 70 mmHg. Emergency abdominal ultrasound scan showed mild hepatomegaly and an echogenic thrombus in the retrohepatic IVC near the suprahepatic anastomosis () which was confirmed by computed tomography (CT) angiography that also revealed renal vein and iliac vein thrombosis as an incidental finding.\nThe patient was admitted in ICU and started on anticoagulation therapy, and a digital subtraction inferior venacavogram was done. This showed a focal severe stenosis approximately 70% in the inferior vena cava at the level of the T12 vertebra. There was an associated thrombus 6 × 3 cm within the retrohepatic and suprahepatic inferior vena cava with complete cut-off of the inferior vena cava 3 cm proximal to its junction with the right atrium. Intravascular thrombolysis using urokinase 50,000 IU was immediately instituted, and the patient was maintained on 100,000 IU/hour of urokinase infusion in the IVC with repeated mechanical thromboaspiration. The patient remained stable during the thrombolysis, and there was reestablishment of blood flow across the previously occluded part of the IVC. Post procedure abdominal ultrasound and Doppler ultrasound were done after 48 hrs, and both still showed the presence of a thrombus. Abdominal CT scans also showed severe stenosis in the suprahepatic inferior vena cava just proximal to the right atrial junction with mild to moderate ascites and splenomegaly. The patient had another angiography done which confirmed a 2 cm short segment severe stenosis of about 95% in the IVC at its junction with the right atrium (). The IVC was twisted along its long axis in this region.\nHe then underwent inferior vena cava venoplasty, and an endovascular stent was inserted whereby a balloon-mounted stent was deployed across the stenosis site to a size of 18 × 32 mmm (). Post stenting, there was improvement in the calibre of the IVC and it was untwisted (). There was no pressure gradient proximal and distal to the stenosis.\nFollowing the procedure, the patient was given low molecular weight heparin 2500 IU subcutaneously for 3 weeks. The patient made uneventful recovery and was discharged 2 weeks post stenting on warfarin with a target international normalized ratio between 2 and 2.5. The liver functions were normal at the time of discharge.\nFollowing the procedure, the patient was given low molecular weight heparin 2500 IU subcutaneously for 3 weeks. The patient made uneventful recovery and was discharged 2 days post stenting on warfarin with a target international normalized ratio between 2 and 2.5. The liver functions were normal at the time of discharge.\nSix weeks after discharge, he was reviewed and had no complaints. An abdominal ultrasound done showed no thrombus in the inferior vena cava and the rest of the abdominal organs were normal as well as his liver and renal function tests.
A 25-year-old male patient who is otherwise healthy referred to our Sarcoma Multidisciplinary Clinic with the suspicion of a primary bone lesion, as we are the regional center for treatment of benign and aggressive musculoskeletal tumors. He complains of progressive left middle finger swelling. His family first noticed the swelling after an incident of direct trauma to the finger during early childhood. Before that, there were no abnormalities seen by the parents. The swelling was progressive in size until he underwent a local excision procedure, at the age of four years. Despite surgical intervention, the swelling recurred. The swelling was painless but continued to enlarge in size with age, with no restriction of range of motion or neurological symptoms. His main concern was cosmetic as he feels it's causing him a psychological burden: no family history of any genetic disorders, nor any similar musculoskeletal deformities. Physical examination revealed a left middle finger healed scar over the dorsal aspect of the finger; a soft tissue mass can be appreciated distal to the proximal interphalangeal joint (PIPJ) with fatty looking lobules and macrodactyly with no signs of inflammation. Full proximal and distal interphalangeal joint range of motion, fingernail neurovascular examination is within normal (Fig. ). No lymphadenopathy, systematic review is unremarkable particularly signs of neurofibromatosis. All blood investigation showed no abnormalities.\nPlain X-ray films of the left hand showed a heterogeneous lobulated soft tissue mass on the volar aspect of the middle finger involving mainly the middle and distal phalanges, no arthritic changes in the joints. Furthermore, left hand MRI with IV contrast media showed a distal fatty overgrowth with striation and no capsulation surrounding the middle and distal phalanges of the middle finger, more at the palmer aspect (Fig. ).\nThe treatment plan was discussed with the patient in the form of left middle finger soft tissue excision with the possibility of a skin graft or local flap coverage with the assistance of the plastic surgery team. With the placement of a tourniquet under general anesthesia, an elliptical incision made including the previous surgery scar crossing the volar aspect of the middle finger (Fig. ). Dissection around the soft tissue mass, the ulnar digital artery identified and preserved, the digital nerve is visualized proximally and found encased into the mass hence was sacrificed. The lipomatous mass was found to be thick with associated fibrous component, it was completely excised, and sent for histopathology examination. At the time of surgery, the plastic surgery team was present in case more advanced soft tissue management techniques were required. Thankfully closure was successful with the aid of a Z-Plasty, and there was no need for coverage by a skin graft. Skin closure by 5.0 Nylon suture done and wound dressing applied. The surgery performed by the author. Distal neurovascular examination within normal. Post-operatively patient was pain-free with good distal capillary refill and discharge home in a stable condition. Advised for limb elevation and keep dry dressing. Stitches removed after two weeks and patient started on range of motion therapy to avoid joint stiffness. He was compliant and tolerated the post-operative plan with no reservations. Pathology report came back with the diagnosis of lipofibromatous hamartoma of the nerve, macrodystrophia lipomatosa of the finger (Fig. ). The patient was on regular follow up in the clinic, and last clinical visit was two years following surgery and showed no tumor recurrence an excellent cosmetic as well as functional result with full finger joints range of motion (Fig.).
A 34-year-old male was admitted to the hospital with recurrent episodes of retrosternal chest pain, fatigue, and shortness of breath with an elevated troponin T. He had suffered an acute episode of myocarditis four years previously requiring hospital admission. He had no other relevant medical history and no family history of cardiac disease. He is a nonsmoker and consumed alcohol occasionally. Clinical examination was unremarkable and did not show any evidence of heart failure or systemic disease. ECG showed normal sinus rhythm without any ischemic changes, and chest X-ray showed no evidence of infection or heart failure. Routine blood tests including antinuclear antibody, creatinine kinase (CK), rheumatoid factor, and C-reactive protein were all within normal limits apart from an elevated cardiac troponin T with a peak value of 2700 ng/l (<14 ng/l). Further extensive inflammatory, viral, and autoimmune screening was carried out and found to be negative. Subsequent coronary angiogram showed normal coronary arteries, and transthoracic echocardiography demonstrated left ventricular ejection fraction (LVEF) >55% with trace mitral regurgitation. Cardiac magnetic resonance imaging (MRI) demonstrated extensive subepicardial and midwall late enhancement typical of myocarditis in the anterior, lateral, and inferior walls along with extensive fibrosis with normal LVEF ().\nA short course of steroids and anti-inflammatory medication as an inpatient resulted in the resolution of his myocarditis symptoms. The troponin T level normalized and the patient was discharged with a plan to repeat cardiac MRI in six months. On follow-up as an outpatient, it was decided to refer the patient to rheumatology for an opinion regarding ongoing immunomodulatory therapy. At this juncture, the patient stated that he also had symptoms of stiffness and aching in his calf muscles for quite some time but he did not consider it to be relevant. Despite persistently normal skeletal muscle enzyme levels, an MRI of the lower legs was performed and this showed active myositis involving the gastrocnemius muscles bilaterally (). As the patient was demonstrated to have ongoing myositis despite minimal symptoms, and as he had accrued significant myocardial scarring from previous episodes of myocarditis, it was decided to commence long-term immunomodulatory therapy in the form of methotrexate and prednisolone. Clinically, the patient reported a significant improvement in his symptoms and a repeat of the lower limb MRI demonstrated a significant interval improvement in his skeletal muscle myositis. Six months later, a repeat of the cardiac MRI demonstrated resolution of myocarditis along with persistent, stable, and extensive myocardial fibrosis and preserved LVEF (). The patient is tolerating the immunomodulatory therapy well without major side effects, and he has returned to full-time work.
A 9-month old boy presented at a hospital in a south western state of Nigeria, with a swollen left upper arm adjoining the chest, low-grade continuous fever (38.1 °C), frequent passage of loose watery stool and persistent cries for more than 3 h. Child had been immunized about 24 h earlier. The mother reported that the symptoms were observed 2 h after the child was vaccinated with the measles vaccine at a private hospital. The child was one of three children reported to have been vaccinated with measles vaccine at a private hospital during the immunization clinic session.\nOn examination, he was mildly pale, febrile and anicteric. He was moderately dehydrated; mildly dyspnoeic with normal heart sound, heart rate of 148 beats/ min, breath sound was vesicular and respiratory rate of 54 cycles per minute. He was well nourished as the weight was appropriate for age. There was extensive swelling with skin discolouration (hyperemia) involving the entire left upper arm, sparing the distal third of the forearm and hand. There was also swelling of the upper part of the anterior chest wall. The swelling was firm and mildly tender. There was no history of adverse reaction to immunization or any form allergic reaction.\nA day after admitting the child, extensive erythema of the left upper arm and anterior area of the chest was observed with extensive scalded skin lesion involving the deltoid area, the upper chest wall and arm (Fig. ). Desquamation of the affected areas was observed presenting like severely burned skin from a hot liquid. There was darkening and hardening of the skin over the affected area on the arm with eventual severe necrosis up to a depth of about 5 mm thereafter (Figs. and ). A diagnosis of severe necrotizing fasciitis was made.\nRadical debridement of necrotic tissues was carried out under general anaesthesia. Child was also transfused with blood. Daily dressing of the wound was done and antibiotics administered were intravenous metronidazole (20 mg/ kg/ day in 3 divided doses) and ceftazidime (100 mg/ kg/ day in 3 divided doses). Child was referred to University College Hospital, Ibadan, a teaching hospital in a neighbouring state where skin grafting was performed. Presently, child have recovered and he is fully healthy.\nA causality assessment was conducted by the state AEFI committee using the detailed AEFI investigation forms using WHO AEFI causality assessment methodology [, ].Visits were made to the private hospital where the child was reported to have received the vaccine. The routine immunization focal person in the facility was interviewed. Assessment of available cold chain devices for vaccine storage was also carried out. The knowledge and skills of health workers in vaccine handling, management and administration were assessed [–]. In addition, the caregivers of two other children immunized during the session were recalled and interviewed. The case of interest was the first child to be vaccinated with measles vaccine during the immunization clinic while the second child, a 9 months old female who received vaccination from the same measles vial had fever and abscess formation at the site of immunization only however, the third child who was also vaccinated during the immunization clinic was healthy and without symptoms. The third child was found to be vaccinated with measles vaccine from a newly reconstituted measles vaccine vial different from the measles vaccine vial used for the other two children on the day of the immunization clinic. Incision and drainage procedure was carried out for the second child with wound dressing conducted for two weeks who thereafter recovered fully.\nThe findings from the investigation indicated that a programmatic error may have been responsible for the reactions.We found that two children were vaccinated with a measles vaccine that have been reconstituted for a period of > 6 h. The measles vaccine administered to these children was reconstituted 7 days ago and used during the previous immunization clinic with the left-over stored in a refrigerator within the hospital. This was due to poor knowledge and skill in vaccine management and administration among health workers who administered the vaccine. Other key issues identified includes poor documentation of vaccination activities using the recommended data management tools resulting in difficulty to tracked other children vaccinated with other vaccines for further investigation and poor vaccine storage system at the private hospital as the hospital lacks the recommended Solar Direct Drive (SDD) refrigerator for proper vaccine storage. Also, effort to retrieve the samples of the left-over doses of the vaccine in the opened vials for laboratory investigation proved abortive as the used/empty vial of the vaccine was said to have been discarded by the health workers immediately after the immunization clinic. Furthermore, blood samples collected from the child with NF by the attending physician during the preliminary case management at a local hospital for microbiological culture investigation shows contamination of culture plate as samples were not properly stored during the culture process due to lack of the required facility to perform the test at the hospital.
An otherwise healthy 43-year-old male, with no significant past medical history, presented to the pulmonary clinic for mild chest discomfort four weeks after being diagnosed with bronchitis at a walk in clinic. On physical exam, patient was active and pleasant with good air entry and clear breath sounds. There were normal cardiovascular findings with no murmurs noted. Imaging studies on presentation consisted of a PA chest X-ray positive for a left hilar density and a shadow alongside the right border of the heart (). The chest X-ray was compared to a noncontrast CT performed two years earlier which showed a questionable arteriovenous malformation. Subsequent computed tomographic angiography (CTA) of the chest was performed to rule out arterio-venous fistula. Results of the CTA concluded a diagnosis of scimitar syndrome based on a partial anomalous pulmonary venous return of the right upper, middle, and lower lobes into the suprahepatic IVC () by way of a large anomalous scimitar vein. A fistulous connection between the large anomalous pulmonary vein and the right inferior pulmonary vein which drains into the left atrium was also noted (). There is a congenital absence of the right superior pulmonary vein and corresponding hypoplastic right lung with mild dilation of the right atrium and right ventricle due to left to right shunting. A consultation with cardiothoracic surgery was obtained for cardiac catheterization to assess hemodynamic flow. Catheterization revealed anomalous pulmonary venous return from the right side, right ventricular and atrial enlargement, and significant left to right shunting with a Qp/Qs ratio of 2.1 to 1. Due to a potential pathway between the venous system and left atria, it was felt that the patient would benefit from surgical repair of the condition. This was performed using an anterolateral thoractomy approach. Utilizing cardiopulmonary bypass, the large scimitar vein was ligated, clipped, and anastomosed to the left atrium using a #16 Gore-tex interposition graft. The smaller anomalous vein draining as a fistula through the left atrium via the right inferior pulmonary vein was identified and left in place as with this correction it no longer provides a passage from the IVC to left atria. After surgery, the patient recovered without incident and is currently on Coumadin with target INR 2.0-3.0 for the next 6 months. Follow-up cardiac MRI revealed a patent interpositional graft with no significant gradient across the anastomosis and no left to right shunting, with Qp/Qs of 1.0.
Patient 1 was a 45-year-old man who presented with left flank pain. His medical history indicated that he had renal stone. His physical examination was positive for tenderness upon palpation of his left flank. The initial laboratory evaluation showed normal. The computed tomography (CT) scan of abdomen and pelvis showed left moderate hydronephrosis and an upper ureteral stone was measured at 1.3 cm. Our patient was diagnosed with left upper ureteral stone with moderate hydronephrosis. The procedure of PCNL was carried out. A ureteral catheter was inserted retrogradely into the left pelvic under ureteroscopy. The puncture target calix was the middle posterior calix. The puncture site of the target calyceal fornix was localized under C-arm radiological monitoring using contrast agent injected through ureteral catheter, producing a retrograde pyelography (RP). An 18 gauge, 2 piece entry needle was used. Clear urine was seen when the needle stylet was removed. When we injected the contrast agent into his left collecting system through the puncture needle, we were able to see his left renal vein (Fig. ). Moreover, we could identify that the location of the puncture needle tip was not optimal, the reason was that the puncture needle tip was located outside the collecting system near the calyceal infundibulum. At the moment, the patient had a hemodynamic stability and the puncture needle was maintained in its original place. Additional lower pole calix puncture was performed under radiological monitoring. Clear urine was also seen when the needle stylet was removed. Injection of contrast agent in his left collecting system through the later puncture needle showed the collecting system, without visualization of the renal vein (Fig. ). In the process of injecting saline into his left collecting system by ureteral catheter, we were able to see the light red drips through the former puncture needle, and the clear drips through the latter puncture needle. The former puncture needle was pulled out and simultaneous PCNL was performed. An 18 gauge, 2 piece entry needle was advanced into the lower pole calix under fluoroscopy guidance. A zebra guidewire was inserted into the collecting system. The tract was dilated with fascial dilators to accommodate an 18 French sheath. The renal calculus was removed uneventfully.
A 52-year-old female patient consults in 2007 for recurrent hematuria. Her medical history mainly indicates a stenosis of the right ureter in 2004 due to a lymph-node recurrence, located in the aortoiliac intersection, of a rectal adenocarcinoma which was treated by chemoradiotherapy and surgical resection one year earlier. Urine was diverted using a ureteral stent changed regularly.\nThe hematuria was scarce but persisted despite the establishment of a bladder catheter and irrigation. Suddenly, on the fourth day of hospitalization, a massive hematuria appeared. Physical examination revealed signs of right renal colic and a drop in blood pressure to 70/40 mmHg. A cystoscopy under general anesthesia after hemodynamic stabilization and clot removal was urgently carried out.\nIt showed a large clot externalized by the right ureteral meatus around the lower end of the ureteral stent. After its removal, pulsatile bleeding was observed by the right ureteral meatus along with a further drop in blood pressure. An arterioureteral fistula was mentioned.\nThe opacification of the renal pelvis and ureteral cavities showed many pelvic clots but no intravascular path. An ureteral dilatation balloon Ch6 10 cm (mark Bard Uroforce model, reference: 888510) was then positioned at the iliac intersection under fluoroscopic control (). After filling the ureteral balloon, bleeding stopped with normalization of the hemodynamic status.\nAn abdominopelvic CT confirmed the diagnosis of an arterioureteral fistula with the right common iliac artery and the proper positioning of the balloon catheter (). A covered stent-graft of the right common iliac artery was then set up about six hours later. A deflated balloon control verified the absence of bleeding at the ureteral fistula. The balloon catheter was replaced with a new ureteric stent after a period of 48 hours of observation with no recurrence of bleeding ().\nThe change was initially favorable but after a year the patient had an inguinal and retroperitoneal abscess associated with an externalization of the stent and thrombosis of the iliac artery. The external and internal iliac arteries were perfused by numerous collaterals. The prosthesis was then removed and the artery bound.\nEight years after treatment of the fistula, the patient showed no vascular sequelae but, urologically, things had evolved towards a gradual destruction of the functional capacity of the right kidney after repeated episodes of pyelonephritis. The ureteral stent had to be removed due to local septic complications and a right nephrectomy was performed in March 2015, with no complications.
A 46-year-old woman presented with a daily headache from onset that began 13 months prior. The daily headache started as a thunderclap headache. She was playing bingo and she suddenly developed the worst headache of her life which peaked immediately to 10/10 in intensity without latency. This was associated with vomiting and dizziness. The peak headache lasted for approximately 24 hours and thereafter she was left with a persistent lower grade headache which never waned. She denied having any further thunderclap headaches. With the original thunderclap headache she did not seek emergency attention. She saw her PCP the following day and had a brain MRI with and without gadolinium within 7 days which was reportedly normal with no evidence of subarachnoid blood. No lumbar puncture was ever completed. Her persistent daily headache was typically of moderate severity (4-5/10 VAS) and was localized to the right occipito-nuchal region. There was never any pain free time and she experienced intermittent associated symptoms including nausea and photophobia. She never experienced any cranial autonomic associated symptoms. The patient denied any headache triggering or alleviating maneuvers. She could not identify any precipitating event just prior to the onset of her daily persistent headache including no viral infection, stressful life event and she had not had any surgical procedures. She was on citalopram at the time of headache onset although she denied the use of marijuana, ecstasy or pseudoephedrine. In addition to head pain the patient also complained of having issues with numbers including doing simple addition and subtraction, recognizing the order of numbers and even recognizing certain numbers. She had to change her pin number multiple times because she could not place the numbers in the correct order on a keypad. She was even unable to copy down telephone numbers. She worked as a pharmacist and was actually very proficient in mathematics so the issue with numbers and calculations was very troubling to her and she was at risk of losing her job. Her acalculia (part spatial, part anarithmetria) started the same day as her daily headache. Her neurologic examination on presentation to the headache clinic was intact including a normal neurovascular examination, normal language examination, normal ability to read and write, but on serial 7 s testing she could not get below 93 when starting at 100. She also could not copy numbers in a correct order when they were presented to her verbally. In addition she had right greater occipital notch and occiput based pain to palpation although she stated this palpable tenderness was not her true pain which was “deep” to the skull. As the patient already had brain neuroimaging, cerebral vessel imaging was ordered to complete the evaluation for thunderclap headache and this included CT angiography of the head and neck vessels as well as brain venography and all studies were negative including no evidence for aneurysms, vessel dissection, vasospasm or thrombosis. An EEG was also completed and this was a normal study. Prior failed therapies which were minimal before coming to the dedicated headache clinic included near daily over the counter analgesics which were minimally effective, topiramate which lowered daily headache intensity but did not provide any pain free time and did not alter calculation issues, and oral prednisone which reduced but did not eliminate her headache (of note sedimentation rate and c-reactive protein were normal). The patient was given a diagnosis of NDPH as she met ICHD-3 beta criteria [] which began as a thunderclap headache. Her headache did not meet criteria for hemicrania continua although it was one-sided. She also had persistent acalculia. As nothing was noted on imaging the authors surmised that this may be a syndrome of persistent vasospasm and possibly even reversible cerebral vasoconstriction syndrome (RCVS) induced by citalopram and the acalculia was caused by persistent oligemia to the cortex. Citalopram was discontinued. Nimodipine was started for preventive therapy at a dose of 30 mg PO BID and within 4 days of starting therapy the patient became headache free. After 3 weeks on nimodipine her acalculia resolved. On re-evaluation two months after her initial visit she remained pain free. After 4 months on medication the patient decided to taper off her nimodipine and her daily headaches returned almost immediately although the calculation issues remained resolved. Nimodipine was restarted at 30 mg bid and within 3 days her headaches again ceased. This verified that the nimodipine had cured her headaches and it was not just being off citalopram. Over time she has been able to reduce the dose to 30 mg one time per day and still she remains headache free. She is hesitant to come off the medication in fear the pain will return. She has been followed for almost one year.
A 76-year-old Chinese male presented to the emergency department with a 12-hour history of acute central and lower abdominal pain which was constant and colicky in nature. He denied any nausea or vomiting; he had opened his bowels normally that morning and was still passing flatus. He was noted to be at postoperative day 28 following laparoscopic radical left nephrectomy. This was performed for a mass found in the upper pole of the left kidney and was completed via a transperitoneal approach.\nHe is a lifetime nonsmoker and denies regular alcohol consumption. He is fully independent and still works as a taxi driver. His past medical history includes a D1 duodenal ulcer with a recent admission for upper gastrointestinal bleeding. He also takes regular medication for hypertension, hyperlipidaemia, benign prostatic hypertrophy, and gout.\nOn presentation to the emergency department he was afebrile and had a blood pressure of 156/69 and a heart rate of 87 beats per minute. On examination he had a soft abdomen with central tenderness and no guarding. Hernial orifices were normal and on digital rectal examination the rectum was empty and no masses were palpable.\nInitial abdominal X-ray showed no dilated bowel loops and the working diagnosis was adhesion colic in view of his recent operation. Within 24 hours of admission a contrast enhanced CT scan was performed in view of clinical deterioration, rising lactate, and worsening metabolic acidosis and acute kidney injury. At CT the findings were small bowel obstruction, suggestion of 2 transition points in the left hemiabdomen (distal ileum and duodenojejunal flexure), and no evidence of ischaemia ().\nAn emergency exploratory laparotomy was performed after review of the CT findings. Findings at laparotomy included almost complete small bowel herniation up to distal ileum through a descending colon mesenteric window. There were 2 transition points. The first was at the distal ileum at the point of herniation; the second was 40 cm from the duodenojejunal flexure where the jejunum was adherent to the retroperitoneum at the site of the left nephrectomy pedicle. There were omental adhesions noted to mesh in the right inguinal region consistent with previous laparoscopic transabdominal preperitoneal inguinal hernia repair. The small bowel was distended but healthy and the colon was healthy.\nThe operative procedure consisted of reduction of the small bowel through the mesenteric window and division of jejunal-retroperitoneal adhesions. An inadvertent enterotomy was made at the adhesion site causing some peritoneal soiling. The small bowel was decompressed through the enterotomy site and after resection of a short segment of jejunum a functional end-to-end stapled anastomosis was made.\nPostoperatively the patient was treated with intravenous antibiotics for a presumed aspiration pneumonia thought to have been caused by vomiting during induction of anaesthesia. He was managed for postoperative ileus which resolved on postoperative day 4 and was discharged from hospital on postoperative day 12. The patient was readmitted on postoperative day 25 and managed conservatively for ileus. CT of the abdomen and pelvis on admission showed a 2.3 × 3.6 × 6.6 cm abscess in the left retroperitoneal region abutting the psoas muscle (). The abscess was treated with intravenous antibiotics and percutaneous drainage withheld as clinically the patient improved and ileus resolved. He was discharged on postadmission day 7. Interval CT of abdomen and pelvis shows reduction in the size of the retroperitoneal abscess.
Patient 2 was a 67-year-old woman with vaginal cuff recurrence of stage IA grade 1 endometrioid endometrial cancer who had initially undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy showing inner half myometrial invasion, grade 1 disease, and no lymphovascular invasion, who subsequently developed a vaginal cuff recurrence one year later and was treated with whole pelvis external beam radiotherapy to a dose of 45 Gy, followed by vaginal cuff brachytherapy to a dose of 15 Gy over three fractions to the surface. Two years later, she developed a second vaginal cuff recurrence as well as distant metastatic disease and was referred for palliative brachytherapy to a 2.4 × 2.7 cm necrotic vaginal cuff mass causing progressive vaginal bleeding. Due to her prior treatment, the vaginal canal was very stenotic, and our narrowest commercial applicator could not be comfortably inserted. We therefore decided to print a vaginal cylinder applicator of 2 cm diameter, with a central catheter channel as well as six evenly spaced longitudinal surface grooves for interstitial brachytherapy to the vaginal cuff mass (). Distance between surface grooves was 1 cm. We used the same printing process and equipment as described for patient 1.\nAt the time of treatment, two marker seeds were placed at the vaginal cuff. The patient underwent free-hand trans-rectal ultrasound (TRUS)-guided interstitial brachytherapy. During this procedure, trans-rectal ultrasound was used to guide free-hand placement of flexible 30 cm interstitial catheters into the para-vaginal and vaginal cuff tissue. Additional catheters were placed along the surface and central channels of the vaginal cylinder to allow further dose modulation. The cylinder was secured to the vagina using sutures, and the catheters were secured to the cylinder using dental putty. For this patient, the final implant consisted of nine interstitial catheters, with six surface catheters around the cylinder, one central catheter, and two paravaginal catheters (). She received 36 Gy over two implants, with 6 Gy per fraction and three fractions per implant prescribed to the CTV. CT-simulation and inverse planning were used, incorporating pre-operative MRI scan to guide tumor delineation. The CTV, bladder, rectum, and bowel were contoured. IPSA was used for planning. The IPSA class solution was designed to maximize the volume of the CTV receiving at least the prescription dose, minimize hotspots in the CTV (V150%), and keep the V75% of the bladder, rectum, and bowel below 1 cm3.\nThis patient also received two interstitial hyperthermia treatments, once during each implant. Hyperthermia was delivered using the BSD 500 System (BSD Medical Corporation, Salt Lake City, UT, USA), with MA-251 interstitial microwave antenna and temperature monitoring sensors inserted within selected implant catheters. Target temperatures of 39.5-45 C for 60 min were prescribed, to be delivered immediately following treatment of either the first or second brachytherapy fraction. Hyperthermia treatment parameters included four or five microwave antennae with 4-6 W applied power per antenna, and four temperature sensors within adjacent catheters.
CP is a 42-year-old female who presented to our institution after falling from a tree complaining only of right hip pain. Physical exam revealed palpable pedal pulses in the bilateral lower extremities and normal sensorimotor examination in the femoral and sciatic nerve distributions. Pain was elicited with internal and external rotation of her right hip. No paresthesias, swelling, or pain with passive stretch of the bilateral lower extremities was noted. Radiographs revealed a comminuted subcapital femoral neck fracture (). No other injuries were identified on secondary examination.\nThe patient was taken to the operating room approximately 11 hours after injury. She was positioned supine on an OSI flat top table with the left leg in a well-padded well leg holder, positioning the knee and hip at 45 degrees of flexion to facilitate fluoroscopic imaging. A sequential compression device (SCD) was placed on the noninjured calf. Open reduction was carried out through a Smith-Peterson approach. A lateral approach to the femur was utilized for provisional fixation and placement of a 135-degree hip screw side plate and a 7.0 mm partially threaded cannulated screw (). Upon fluoroscopic confirmation of reduction and final implant placement, the well leg was placed flat on the operative table by the circulating nurse. Surgical wounds were closed, and the patient was transferred into the recovery area. Total time with the well leg elevated was 109 minutes.\nWhile recovering, the patient reported new anterior leg pain and paresthesias over the dorsal foot of the well leg. On exam, she was found to have diminished sensation over the dorsal foot, pain with passive flexion of the ankle and great toe, and edema isolated to the anterior and lateral compartments of the leg. She had no pain with passive dorsiflexion of the ankle and great toe and no pain with palpation of the deep and superficial posterior leg compartments. The well leg was elevated, ice applied, and the patient was closely monitored over the course of an hour. Over this time period, her pain continued to worsen despite increasing doses of opioid analgesia and ketorolac.\nThe diagnosis of compartment syndrome was made, and the patient returned to the OR for selective fasciotomies of the anterior and lateral compartments. The muscle of the anterior and lateral compartments was mildly edematous, contractile, and bleeding. The skin incision was closed with a suture to allow for quick suture removal should muscle swelling worsen. The patient reported immediate improvement of her pain and paresthesias.\nThe remaining postoperative course was uneventful. She was able to bear weight on her left leg following fasciotomies and went on to an uneventful recovery of her femoral neck fracture. On the follow-up at 6 months postoperatively, she reported no hip pain with normal sensation in both legs and a healed fracture ().
The patient was a 23 year old female with a history of recurrent syncope and suspected seizure disorder who experienced a SCA associated with loss of consciousness while at work during a meeting. She was externally defibrillated by members of the local fire department, and taken to a local hospital where she was found to have a prolonged corrected QT interval of 560 ms. She was diagnosed with idiopathic ventricular fibrillation vs. possible long QT syndrome. Five days after presentation, a dual chamber single coil ICD (Medtronic Inc., St. Paul, MN) was placed for secondary prevention, and she was discharged following a 1 week hospitalization. Three months later, she experienced her first ICD shock. She was sitting down, and began to feel lightheaded, then lost consciousness. She was shocked a total of three times, though she does not remember this. Upon waking, she noticed a pain in the anterior chest radiating to her arm. Interrogation of her ICD revealed she had also received an appropriate shock for an episode of ventricular fibrillation while asleep several days earlier, though she had no memory of this. Device interrogation revealed that the patient had exhibited antitachycardia pacing during defibrillator charging, which had disorganized the ventricular tachycardia into polymorphic ventricular tachycardia and ventricular fibrillation. She was hospitalized for defibrillator threshold testing, in order to ascertain the likelihood that her ICD could successfully terminate a sustained ventricular tachyarrhythmia. Unfortunately, due to a high defibrillation threshold, 6 attempts to elicit ventricular tachycardia termination were unsuccessful. To decrease the risk of recurrent ventricular arrhythmias requiring ICD shocks, the patient was referred for consideration of BCSD.\nNotable for recurrent syncopal episodes with loss of consciousness dating back to high school. On one occasion she may have been noted to bite her tongue, prompting a diagnosis of a seizure disorder, and prescription of phenytoin. There was no history of neurological workup including electroencephalogram (EEG). Nine months prior to first SCA, the patient had a successful vaginal delivery without complications.\nThe patient was employed as an assistant restaurant manager. She was married with a 1 year-old daughter. She had received an associates degree in culinary arts. There was no family history of psychiatric illness or cardiovascular disease or syncope or sudden death. No history of substance abuse.\nAt the initial evaluation, the patient was prescribed the following medications: Metoprolol 25 mg BID, Phenytoin 300 mg qHS and KCL 10mEq daily.\nAfter undergoing a structured clinical interview utilizing MINI International Neuropsychiatric Interview, the patient met DSM IV-TR diagnostic criteria for an adjustment disorder with mixed anxiety and depressed mood. We assessed the degree of severity of the patient's symptoms using several quantitative clinical measures. These indicated “severe” levels of general anxiety (via BAI) and borderline clinical depression (via Beck Depression Inventory, BDI) (Beck and Steer, ) (Table ).\nThe patient underwent a neurology consultation including EEG, to evaluate the possibility of a seizure disorder. The EEG was conducted with the patient in the awake and asleep states. Hyperventilation and photic stimulation were not performed as activating maneuvers, and no sedation was given. While maximally awake, the posterior dominant rhythm was 9–10 Hz, which was symmetric, synchronous and reactive to eye opening and eye closure. Three brief periods of high amplitude theta activity (4–7 Hz) were captured and reported as paroxysmal in nature. They appeared generalized, without a focal cortical distribution, lasting approximately 1–2 s. These slowings occurred in the wakeful and/or drowsy state, with no evidence of epileptiform behaviors at the time. They were interpreted as potentially consistent with physiological drowsiness. In one instance the slowing appeared notched, which could indicate possible epileptiform activity. However, as a fast alpha variant was present at the same time, it was considered suggestive against an epileptic etiology. Vertex waves signifying drowsiness were noted later in the recording, but not at the time of the paroxysmal slowing. This was also considered suggestive against an ictal semiology. Overall, the EEG was judged to be normal in wakefulness and stage II sleep, without any clear electrographic features of seizure. No epileptiform behaviors were identified during clinical observation.\nDespite the lack of clear electrographic evidence of a seizure disorder the periods of high amplitude generalized slowing and the reported phenomenology of her episodes were felt to be possibly consistent with a seizure disorder. Seizure prophylaxis was continued, but switched from Phenytoin to Levetiracetam 1000 mg BID.\nAfter further consultation, the patient elected to undergo BCSD. The resection covered the lower half of the stellate ganglion and the bodies of sympathetic chain from T2 through T4. Discharge medications included Levetiracetam 1000 mg BID and Propranolol 40 mg TID. Evaluation of the patient's symptom scores at 1 month post-BCSD revealed clinically significant decreases in depression (via BDI), anxiety (via BAI) and shock catastrophizing (via SCS) (Figure ). Clinical evaluation at 1 month post-BCSD, revealed that she had not experienced any further shocks, and no further ICD events had been detected. The patient the patient reported her mood and anxiety symptoms were much improved. She declined the recommendation to seek further psychiatric follow up, and as she was subsequently lost to follow-up no further psychometric data are available.\nContinuous measures of skin conductance level (SCL), systolic blood pressure (SBP), and diastolic blood presssure (DBP) were recorded during psychophysiological assessment using Biopac MP150 hardware and Acqknowledge 4.3 software (Biopac, Santa Barbara, CA). Two isotonic 1-cm diameter gel electrodes were attached to the thenar and hypothenar eminence of the subject's nondominant hand to assess SCL. This tonic measure of galvanic skin resistance was selected as a measure of sympathetic arousal due the prolonged time intervals examined (Naqvi and Bechara, ). Blood pressure was continuously assessed using the CNAP 500 Monitor (CN Systems, Graz, Austria) with finger cuffs, which were placed between the proximal and distal interphalangeal joints of the third and fourth digits of the subject's nondominant hand. Heart rate was not examined due to the presence of atrial pacing in both patients, which kept the heart rate constant.\nThe psychophysiological assessment began with a 5-min resting baseline during which the subject was seated in a chair and instructed to remain at rest and minimize movement. Psychophysiological measures (SCL, SBP, and DBP) were assessed during the 5-min baseline. As the pre-BCSD testing occurred in an inpatient setting, the first 2 min of the 5-min baseline period were discarded in order to account for possible environment-related influences on autonomic tone. Data for each measure for the final 3 min was averaged to provide a baseline value for that session. Additional interventions to reduce outside distraction included closing the door of the patient's single occupancy room, and silencing the alarms of monitoring equipment. The resting baseline period was followed by 3 tasks in the following order: a valsalva task, a handgrip task, and a mental arithmetic task.\nThe valsalva task involved performing two sustained valsalva maneuvers while in a seated position. The subject was given the following instructions, “During this task, I will place my hand on your abdomen. The goal is to push my hand away as far as you can by protruding your abdomen. Hold this position for as long as you can. Remember to keep breathing while bearing down.” The procedure was demonstrated by the assessor, practiced once by the subject, and then performed twice by the subject. Each trial period lasted approximately 15–25 s. Psychophysiological measures were assessed during the two valsalva trials, and scores on SCL, SBP, and DBP were averaged across the two trials.\nThe isometric handgrip task involved a hand dynamometer held by the subject's dominant hand. The following instructions were provided before performing the task, “During this task you will squeeze a hand dynamometer for 2 min at a specific grip strength level with your dominant hand. I will first determine your maximum grip strength level by asking you to squeeze the dynamometer with as much force as possible.” Following determination of subject's maximum grip strength, the dial on the dynamometer was placed at 30% of the maximum grip strength, and the subject was instructed to squeeze the grip at that level for 2 minutes. Values on SCL, SBP, and DBP were averaged across this 2-min period.\nThe mental arithmetic task was selected as a cognitive stressor and adapted from the Trier Social Stress Task (Kirschbaum et al., ). This modified protocol consisted of a 5-min period during which the subject was instructed to consecutively subtract by 13's starting at 1022, in front of two experimenters. The subject was told to perform this task aloud as quickly and accurately as possible, was corrected each time an error was committed, and then told to start over at 1022. Mean SCL, SBP, and DBP were assessed across the 5-min period.\nAcqknowledge software, version 4.3, was used to process all data collected during the psychophysiological assessment sessions. Using Acqknowledge, SCL was averaged across the pre-specified 2 min resting baseline and specified periods during each task described above. The Acqknowledge blood pressure classifier analysis feature was used to identify SBP and DBP at each heartbeat. Means for SBP and DBP were determined for resting baseline and for specified periods during each task. This study was approved by the Unversity of California Los Angeles Institutional Review Board, and all participants provided informed consent prior to participation.\nMean values of the autonomic testing in Case 2 are displayed in Table . Figures – show changes in each measure from the resting baseline value pre- and post-BCSD. Compared with before BCSD, the patient demonstrated clear declines in baseline adjusted systolic and diastolic blood pressure response for the valsalva and handgrip tasks, but less so with the mental arithmetic stressor, which did not show robust changes at either time point. Comparing pre- vs. post-BCSD, the patient demonstrated prominent declines in baseline adjusted SCL for all tasks (Figure ).

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