text
stringlengths 746
31k
|
|---|
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 7-year-old boy was referred to our outpatient clinic for evaluation of his abdominal mass, which was found at a local clinic by use of abdominal ultrasound. He underwent laparoscopic biopsy of his abdominal mass and the mass was finally diagnosed as an embryonal rhabdomyosarcoma in the retroperitoneum. The size of the mass was 18 cm×16 cm×7 cm, and after 4 cycles of chemotherapy for 5 months, the mass size was reduced to 5 cm×2 cm×3 cm. Surgical resection of the mass was then performed and the patient was followed up for 2 years. Abdominal computed tomography showed no remnant mass of the tumor. We found no evidence of recurrence of the tumor for 1 year after surgery. After 1 year, however, follow-up computed tomography showed a newly developed mass (3.3 cm×3.0 cm in size) surrounding the right lower ureter along the right iliac artery, resulting in hydronephrosis of the right ureter (). We diagnosed the mass as a recurrent retroperitoneal rhabdomyosarcoma and we decided to perform surgical resection. The operation was performed through a midline vertical incision and the anatomy was confirmed by direct inspection. The mass had severe adhesions with the surrounding tissues and it completely encircled the right lower ureter along the right iliac artery. After resection of the mass, direct end-to-end anastomosis of the ureter was not possible owing to the length of the resected segment (). Therefore, we decided to perform ureteral substitution by using the appendix to repair the ureteral defect. The cecum and the right colon were mobilized. The vermiform appendix was assessed. It was 6 cm in length from the base to the tip and no macroscopic abnormalities were noted. The appendix was divided at its base and the stump was ligated and conventionally inverted. Care was taken to preserve the appendicular artery, which was identified as running in the short triangular mesoappendix. The isolated appendix was mobilized to the retroperitoneum and positioned in an antiperistaltic manner to avoid strangulation. Tension-free end-to-end anastomosis with 5-0 Vicryl was performed between the spatulated end of the ureter and the tip of the appendix (). A ureteral stent was placed by using a guide wire before completing the anastomosis. The resected mass was 4.5 cm×3.0 cm×1.0 cm in size and it grossly revealed no central necrosis. The mass was finally diagnosed microscopically as retroperitoneal rhabdomyosarcoma. The patient's postoperative recovery was uneventful. The ureteral stent was removed 6 weeks postoperatively and retrograde pyelography revealed a patent appendiceal interposition and no extravasation. Intravenous urography showed no definite stricture point and improvement of the hydronephrosis that was seen before surgery (). This patient died at 6 months postoperatively as the result of multiple metastases of rhabdomyosarcoma. |
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 was a 77 year old Caucasian female who experienced a mechanical fall onto her right side and presented to our emergency department. On physical examination, the patient had a shortened and externally rotated right lower extremity that was painful to log-roll and axial load. Otherwise the patient was neurovascularly intact. The initial radiographs showed a 3- part inter-trochanteric hip fracture with the lesser trochanter as a separate fragment (Fig. ). The patient was taken to the operating room after medical clearance for a closed reduction and insertion of a short Gamma 3 nail (125 degrees × 11 mm × 180 mm, Stryker, Kalamazoo, MI) according to standard technique. A 100 mm lag screw was inserted close to the subchondral bone but without penetrating the femoral head with a total Tip to Apex Distance (TAD) of 13 mm (AP = 5 mm and Lateral = 8 mm). After confirmation of firm fixation of the lag screw, a distal locking screw was inserted in the dynamized position of IM nail. A set screw was then placed to prevent rotation of the lag screw. There was no intra-operative complications and post operative anterior-posterior and lateral hip radiographs are seen in Figs. and . Post-operatively, the patient was discharged to rehab facility on day 3.\nOn the sixth week post operative visit, the patient had no complaints and she has been weight bearing as tolerated. Anterior posterior right hip radiograph shows some callus formation and compression of the lag screw without medial migration (Fig. ). At the ten week follow up visit, right hip radiographs revealed that the lag screw along with the short IM nail construct had migrated medially through her femoral head and through the medial wall of her acetabulum (Fig. ), however, the patient have been ambulating on her right lower extremity and did not complaint of hip pain or have any neurovascular deficits. Patient was subsequently admitted and underwent revision surgery with removal of the lag screw and placement of a shorter lag screw after intra-operative stress confirmation of no visible fracture motion. An accessory cannulated screw was then placed anterior and parallel to the Lag Screw to provide de-rotational component (Fig. ). The distal locking screw of the IM nail was then removed to provide axial dynamization of the nail. The patient tolerated the procedure well and continued to do well clinically at the one year follow-up (Fig. ) and currently back to full activities with full weight bearing and cane assisted ambulation. |
A 69-year-old Filipino man with history significant for hypertension and hyperlipidemia presented to his primary care physician with hematuria with weight loss of 1 month’s duration. He did not have any flank pain, burning on urination, or increased urinary frequency. He did not endorse any symptoms of fatigue or night sweats. His only medication was atenolol for his hypertension. He did not smoke tobacco, drink alcohol, or do any recreational drugs. He was unemployed at time of interview. He did not have any family history of cancer. His vital signs were within normal limits. On physical examination, he was well appearing and in no acute distress. He had no palpable mass and had an otherwise normal cardiovascular, respiratory, and neurologic examination. Laboratory work showed normal cell counts and normal electrolytes; the results of his kidney and liver function tests were normal. A computed tomography (CT) – intravenous pyelogram was performed as a diagnostic work-up for his hematuria, which demonstrated a large mass in the left collecting system and proximal ureter. He was seen by urology with plans for surgical resection 1 month later. Three weeks later he was admitted to the Emergency Department with nausea and vomiting. He was tachycardic to 110 beats per minute but maintained a normal blood pressure. His laboratory results were notable for hemoglobin to 12.1. His sodium was 134. At that time, a CT scan of his abdomen and pelvis showed interval enlargement of the left renal mass. An ureteroscopy with biopsy was performed, which showed necrotic tissue with rare crushed degenerating atypical cells. A screening chest CT scan was also obtained which showed a small 3 mm nodule in the lower lobe of his left lung. A follow-up interventional radiology-guided left kidney biopsy showed a cellular neoplasm with sheets of pleomorphic round cells with hyperchromatic nuclei, irregular nuclear outlines, and inconspicuous nucleoli with scant and delicate cytoplasm which is consistent with SCC. The tumor cells were positive for the neuroendocrine markers synaptophysin and CD56 with focal staining for chromogranin and dot-like positive staining for cytokeratin (AE1/AE3), supporting the diagnosis of SCC (Fig. ). A bone scan did not show any metastatic lesions. Shortly afterwards, he developed dizziness and an MRI of his brain was obtained revealing a 1.6 cm partially hemorrhagic round mass with surrounding edema in the midline superior vermis potentially representing metastatic disease. An additional 4–5 mm hemorrhagic metastatic focus was seen in the right occipital convexity. The cerebellar mass was resected and probably represented a renal origin due to the absence of lung masses along with clinical and radiographic correlation. He was started on whole brain radiation therapy during his in-patient stay. An out-patient oncology referral was made but he was unable to establish care due to frequent hospitalizations. He had several hospital admissions for nausea and vomiting and continued to decline functionally. He developed chronic hyponatremia during these hospitalizations which were attributed to SIADH. He originally presented with sodium of 119 and was stabilized to a sodium level of 128 with the use of salt tablets. He declined chemotherapy when it was offered by the oncology team during in-patient consultation due to poor quality of life and functional status; he died within 8 months of presentation at his nursing facility. The cause of his death was unknown. An autopsy was not performed. |
The patient is a 41-year-old Iranian man who has been in good health except mild diarrhea until 36 months ago, when he was suddenly afflicted with severe generalized abdominal pain and rebound in abdominal physical examination. He was attended by surgeon and was operated on. Surgical diagnosis was perforated duodenal ulcer. After discharge, he was prescribed omeprazole for four weeks without any investigation for H. pylori infection. He hasnot had any past medical or drug history before operation but he mentioned mild watery diarrhea and decreased appetite without weight loss since a few months ago. One month after termination of omeprazole course, acute upper GI bleeding as melena occurred and he was again admitted in another hospital. Endoscopy was done. A small bulbar ulcer was the cause. Rapid urease test (RUT) was positive. Triple anti-H. pylori therapy was completed, and omeprazole was continued for another one month. Twenty days after termination of second course of omeprazole therapy urease breath test was done which was negative for active H. pylori infection. No further medication was administered. Approximately ten days later, another bout of upper GI bleeding in the form of melena occurred. He was admitted again in the hospital. Endoscopy revealed duodenal ulcer. RUT was negative. Regarding the history and unusual accumulation of peptic ulcer complications in spite of usual management, hypersecretory states such as gastrinoma were suspected. The result of serologic tests at that time is shown in .\nAbdominal computed tomography (CT) scan revealed a 10 × 8 mm lesion in head of pancreas with peripheral enhancement (in favor of an islet cell tumor) and three superficially located enhancing lesions in both hepatic lobes, in favor of hypervascular metastasis (). CT-guided biopsy of pancreatic lesion was done. Pathologic result was as follows: section reveals fragments of tissue including pancreas with a benign neoplasm composed of monotonous cells looking like gland islets with preservation of the regular cords. No any nuclear atypia was seen (compatible with gastrinoma) (). Angiography and chemoembolization of hepatic metastatic lesions were done using gel foam, Lipidial, Mitomycin, and Adriablastin. A short while after the procedure, the patient felt severe abdominal pain, that was managed symptomatically with opioid analgesics, and omeprazole 20 mg daily was continued. Now, after 36 months, the patient is in good health and receives omeprazole 20 mg daily. New CT images showed a questionable faint enhanced lesion which shows decreased size and diminished enhancement compared to pre-embolization study. The pancreatic head is prominent without any apparent mass lesion (). |
A 72 year-old man presented in the emergency department with right upper quadrant and epigastric pain, nausea and vomiting. On examination, the patient was sweating and pale with a tender right upper quadrant. A tender 5 × 5 cm2 mass was also noted in the right flank. The provisional diagnosis of acute cholecystitis with incidental finding of abdominal mass was made and further investigation in the form of computerised tomography (CT) of his abdomen and pelvis was performed. The scan confirmed the presence of 50 × 55 mm2 mass in the retroperitoneum on the right side of the urinary bladder but separate from the small intestinal loops without any evidence of local infiltration. The radiological differential diagnosis included carcinoid lesion and teratoma of a right undescended testis. However, undescended testis was ruled out with a fully grown testis on the right side of the scrotum. The patient underwent exploratory laparotomy, open cholecystectomy and also excision of the pelvic mass. Intra-operatively, the mass was found to be approximately 8 cms in size, partly haemorrhagic and covered by peritoneum. It was situated lateral to the right ureter and superior to the right iliac vessels. This mass was excised en-block without any intra-operative complications. The patient had an uneventful post-operative recovery and was discharged on the 10th post-operative day. Histological diagnosis of intranodal palisaded myofibroblastoma was confirmed. He did not reveal any signs of recurrence in seven years of follow up. The histopathological findings are described as follows.\nA Solid mass measuring 80 × 80 × 50 mm3 with surrounding attached fatty tissue measuring up to 100 mms in maximum dimension was noted. On slicing, a well defined nodule with partially firm, white and solid areas, alternating with haemorrhagic areas, was found. At the periphery there was some calcification. The microscopic study was performed on extensively sampled solid and haemorrhagic areas including the resection margins. The gall bladder was 105 mms with a thick wall and a few tiny stones.\nThis represented encapsulated, a well defined nodular lesion with variable cellularity. The cells were spindle shaped with slightly wavy nuclei forming short interlacing fascicles, exhibiting areas that were reminiscent of AntonyA/Antony B area (figure ). No significant nuclear pleomorphism was visible however mitosis was rarely noted in 1 in up to 30 high power field (× 40 objective). Areas of fresh as well as old haemorrhages were present. At the periphery, reactive lymphoid infiltrate and focal calcification were also noted (figure ). The tumour showed a prominent fascicular growth pattern with many short and long interlacing fascicles of tumour cells (figure ). Amianthoid fibres were easily identified though in few areas of the tumour (figure ).\nThe spindle cells were positive for Smooth muscle actin (SMA) (Figure ), Calponin and Vimentin but did not express Desmin and h-Caldesmon. The tumour cells showed strong nuclear expression of Cyclin D1 (figure ). The cells were negative for neurofilament, cytokeratin. The staining for S100 protein, CD34, CD99, Bcl-2 and CD117/C-kit were negative in the tumour cells. Immunostaining for Alk-1 and HHV 8 were negative in these cells (figure & 8). |
In 1998 a 45 year old female patient presented with complete left sided hemiparesis after a cerebral embolism. While focusing on the reason for this clinical presentation a large mass lesion was found in the atrium via echocardiography whereby suspicion of atrial myxoma was raised. The patient was referred to our department and operative resection of the large myxoma was performed which was predominant prolapsed into the left ventricle at the distal roof of the left atrium above the mitral valve. Both intraoperative and inpatient course progressed without complications and the patient was rapidly discharge for early neurological rehabilitation.\nThree years later, a left atrial tumor was seen in a routine cardiological echocardiography follow up and the suspicion of a relapse of the atrial myxoma was raised. A resection of the two-hazelnut-sized myxoma at the posterior wall of the left atrium was performed again. The operation and inpatient course again proceeded without complications and the patient was rapidly discharged again.\nAfter a period of four years an echopenic structure with freely moving component parts was found at the left side during a transesophageal echocardiography and the suspicion of a second relapse was raised. Making additionally there were found sutures of the previous operations at the septum. But making a clear differentiation between a thrombus at the previous suture line and a myxoma relapse was not possible; therefore a three months oral anticoagulation with phenprocoumon was started.\nWith a positive family history for myxomas (the patients's brother and grandfather) and multiple lentigines an evaluation of the presence of Carney complex, an autosomal dominant disorder, was conducted. After genetic analysis the diagnosis of Carney complex type I with a deletion mutation in the PRKAR1A gene was detected. Carney complex type I is characterized by recurrent atrial myxomas, skin, conjunctiva and lips lentigines, subclinical hypercortisolism and nodular thyroid changes.\nAfter three months of effective oral anticoagulation the structure at the atrial septum was not increased in size. A conservative approach was agreed while maintaining oral anticoagulation and regular echocardiographic follow up. Three years later an echocardiographic study revealed a new tumor, however this time the location was the right atrium. The left sided structure was unchanged. An operative resection was carried out again via re-sternotomy with an oscillating saw after preoperative evaluation (computed tomography (CT) scan of the thorax, transthoracic doppler echocardiogram, doppler examination of the femoral vessels, and lower limb arteries). The cardiopulmonary bypass with systemic 32°C mild hypothermia was established via ascending aortic and bicaval cannulation. The right atrial tumor (approximately 3 cm in diameter) was located at the confluence of inferior vena cava and the lateral atrial wall. An atrial myxoma was confirmed histologically with a tumour-free resection margin. The postoperative course was again without complication. During the last echocardiographic follow up a progressive left atrial structure was seen and the decision was made to resect the fourth atrial myxoma (Figure ). Again the postoperative course went without complications. |
A 62-year-old female patient, presented to the dental clinic with a chief complaint of bad breath along with bleeding gums, difficulty in mastication and inability to maintain deposit free teeth in relation to the right lower back region. On clinical examination, there were local factors present and she had faulty tooth brushing practice. An isolated Miller's Class III recession defect[] was observed in relation to the mesial root of 46 []. Tooth 45 was missing and un-replaced. The edentulous space was slightly collapsed due to mesio-buccal tilting of 46. There was visible food impaction in between 46, 47 and 48. Dental caries was diagnosed distal to 46 and 47. Patient was systemically healthy without any deleterious habits.\nPhase 1 therapy consisting of thorough oral prophylaxis and root planning was performed on 46 and caries was restored. Vitality check showed a non-vital 47. Root canal treatment was done for 47. Oral hygiene practice was corrected and the patient was recalled after a month. Patient maintained a good oral hygiene. LPF was planned for the root coverage and was explained to the patient and an informed consent was obtained.\nThe gingival recession was in relation to the mesial root of 46 and was measured. The dimensions were 4 mm wide and 8 mm deep. Donor site was adjacent edentulous area in relation to 45. There was sufficient width, length and thickness of keratinized tissue present. Oral hygiene and patient maintenance was satisfactory.\nNumber 15 blade was used to make a crestal incision on the adjacent edentulous area in relation to 45 and was extended to make a crevicular incision that crossed the apical area around the gingival recession. Vertical releasing incisions were performed on both sides, one distal to the mesial root of 46 and the other distal to 44. The pedicle flap size was 1.5 times wider than the area of the recession. Vertical incisions were extended to the alveolar mucosa so that the pedicle flap could be reflected sufficiently to enable the lateral displacement without tension. A full thickness flap was then reflected sufficiently from the donor site and displaced without tension at the recipient site. Suturing was done using 4-0 non resorbable silk suture. Area was cleaned and Coe pack applied [Figures –]. Cap Amoxicillin 500 mg tid, tablet meftal forte tid and chlorhexidine mouth wash thrice daily for 5 days were prescribed. Patient was advised to have a soft diet and avoid brushing in the area of surgery. Sutures were removed after 10 days. Healing was satisfactory.\nAfter completion of the procedure, approximately 7 mm of recession attained clinical attachment gain and adequate width of attached gingiva was appreciated []. After 6 months, coverage increased to 8 mm probably due to creeping attachment []. On review the periodontium looked healthy and the maintenance was satisfactory even after the 3rd year. Hence the next phase of treatment was started.\nFollowing crown preparation, a 4-unit bridge was constructed from 44 to 47 []. Follow-up visits were scheduled 2 months post-operative and subsequently after 4, 5 and 6 years [Figures –]. Maintenance was satisfactory and the gingiva maintained the same level of attachment throughout 6 years without any clinical sign of inflammation. |
A 56 year old previously healthy Caucasian woman and non-smoker, presented to the outpatient chest department with symptoms of episodic bouts of dry cough associated with an occasional wheeze for 12 months and upper thoracic back pain for 3 months. She had no history of chest trauma. On examination, she was not breathless or wheezy and she had a normal temperature. The chest radiograph revealed an area of gas-filled tissue in the upper right mediastinum (fig. ) and a Computer Tomography (CT) scan confirmed a loculated air-filled collection predominantly anterior to the trachea and extending below the carina with no evidence of fluid within the locules. There was no air tracking into the neck or the abdomen. (fig. ). The patient had no recollection of having the cyst diagnosed in the past. The patient was stable and a wait and watch approach was taken, and the patient was to be reviewed in 3 months.\nShe was readmitted 2 months later with severe chest pain. On examination she was breathless with an expiratory wheeze and was febrile (37.5°C). The patient was not in shock. A repeat chest radiograph (fig ) and CT scan (figs. and ) demonstrated a 9 × 5 cm loculated mass containing fluid and gas, encasing the lower trachea and the main proximal bronchi and extending from the innominate vein to the left atrium consistent with a mediastinal abscess. Bilateral pleural effusions were also present. The lungs were normal. The patient was treated with broad spectrum antibiotics and then had an open thoracotomy three days later with complete resection of the mass. The air-fluid level seen on the CT scans would suggest a tracheobronchial communication but no such communication was found during the operation. Histopathological examination of the mass revealed a collapsed thick walled cyst about 55 mm in diameter. The cyst wall consisted of fibrous and granulation tissue with heavy, chronic active inflammation. There were fragmented seromucinous glands on the inner surface of the cyst wall. These findings were consistent with an infected cyst likely to be bronchogenic in origin. Culture results of the cystic contents were however negative. The patient recovered from the surgical operation uneventfully and had no recurrence of her previous symptoms when reviewed 3 months later |
A 50-year-old man visited our hospital for a 3 month-follow-up examination after coronary bypass graft surgery. In this surgery a left internal thoracic artery (LITA) graft to the distal left anterior descending artery (LAD), and a right saphenous venous Y graft from the LITA to the diagonal branch and posterior descending artery (PDA) was performed through sequential anastomosis. The cardiac adenosine stress perfusion MR imaging revealed two perfusion defects at the mid-anterior and mid-inferior walls (, Movies I, II). One perfusion defect at the mid-anterior wall was reversible on rest perfusion images. However, the other perfusion defect at the mid-inferior wallwas persistent on rest perfusion images. But later it disappeared on both stress and rest perfusion images. On the myocardial single-photon emission computed tomography, the inferior wall showed a mild degree of perfusion decrease which was considered as due to the diaphragmatic attenuation effect rather than an ischemic perfusion defect while the mid-anterior wall showed a reversible perfusion defect indicating a reversible ischemia (). On cine images no regional wall motion abnormalities and on late gadolinium enhancement images no delayed myocardial enhancement were observed.\nSignal time curve analyses at stress and rest perfusion MR were performed at three different regions: normal myocardium at the mid-lateral wall and two perfusion defects at the mid-anterior and mid-inferior walls (). From the data, the perfusion index and ratio index of each region were calculated using a previously described method (). In brief, a smooth-fit corrected signal-time curve within the time window of the first pass was analyzed using the gamma-variate function after subtraction of the baseline signal intensity (SI) value from the mean SI of each region. The time window of the first pass was determined from the SI curve of the left ventricular cavity. The time window of the first pass in the myocardium at the same level as the left ventricular cavity was determined by shifting the time window determined from the left ventricular cavity to when the SI in the myocardium started to rise. The maximal upslope indicating the perfusion index was computed from the peak value of the time derivatives of the fit function in the myocardial region, normalized by the maximal upslope in the left ventricular cavity. The ratio index, widely accepted to represent myocardial perfusion reserve, was defined as the ratio of maximal upslope at stress to that at rest (). To calculate perfusion parameters an in-house software was developed using MATLAB 2012a (MathWorks, Natick, MA, USA).\nThe corrected signal-time curves demonstrated that the maximal upslope of the anterior wall decreased from 0.089 during rest to 0.022 during stress perfusion with a ratio index of 0.25, indicating typical reversible ischemia (). In contrast, the maximal upslope of the mid-inferior wall was similar to that of normal myocardium during stress and rest perfusion. But the time to delivery and time to peak enhancement were delayed 7 seconds on both stress and rest images approximately (). The maximal upslope of the mid-lateral wall increased with a ratio index by 1.10 from 0.094 during rest perfusion to 0.104 during stress perfusion. Also for the mid-inferior wall the maximal upslope increased with a ratio index by 1.10 from 0.079 during rest to 0.087 during stress perfusion (). Coronary angiography revealed a focal tight stenosis at the anastomosis site between the right saphenous venous graft and diagonal branch, limiting the flow to the diagonal branch. With this can be explained the reversible ischemia at the apical to the mid-anterior wall on perfusion MRI. However, there was no significant stenosis at the right saphenous venous graft to the PDA. The contrast delivery in the right saphenous venous graft was slightly delayed compared to the LITA to distal LAD graft. It may indicate that the early perfusion defect at the mid-inferior wall was a result of delayed contrast media delivery due to the wide and long pathway of the bypass graft (). Six-month follow-up images showed still a persistent perfusion defect without significant stenosis of the saphenous venous Y graft in the mid-inferior myocardial wall (). |
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 63-year-old right-handed woman sustained a right intra-articular comminuted distal radius fracture with dorsal displacement (), a right femoral shaft fracture, and a hemothorax in a motor vehicle accident. Open reduction and internal fixation was performed using 3.5-mm T-LCP for the distal radius fracture at 12 days after the trauma, and the plate was covered by the pronator quadratus after fixation. Immediate postoperative plain radiographs revealed acceptable restoration of radial inclination, radial length, and volar tilting, except an approximate 2 mm step-off of the articular surface. The plate was placed tightly to the distal radius without any gap, and even though the distal edge of the plate was very close to the transverse ridge of the distal radius, it did not reach the distal portion of the transverse ridge. Plain radiographs at 8 months after surgery revealed bony union without further collapse of the distal fragment compared to that of the immediate postoperative radiographs, and range of motion of the right wrist was normal. Accordingly, we recommended plate removal, but the patient refused, stating that she was experiencing no specific discomfort.\nShe visited our hospital at 40 months after surgery and reported that she had a sudden thumb flexion limitation during washing 10 days ago. She had no associated pain and no warning symptoms such as tendon irritation. A physical examination revealed that she could not actively flex the right interphalangeal joint of her thumb, although the range of motion of her other joints and sensory findings were normal. Radiographic findings revealed no definite interval change (). Ultrasonographic findings showed that the FPL tendon had ruptured, and the proximal stump was found at the radiocarpal joint. We performed a surgical exploration and found that the distal edge of the plate was exposed even though the pronator quadratus was nearly completely covering the plate. The FPL tendon had ruptured over the distal edge and was frayed (). We performed complete debridement of the granulated and frayed tissue in the ruptured margin, removed the plate, and performed a primary repair of the tendon using the modified Kessler method. The patient wore a thumb spica cast for 3 weeks and then began passive-motion exercises. The patient had no movement restriction of the right thumb at 6 months after surgery. |
The patient is a 76-year-old woman with a two-year history of left elbow pain empirically diagnosed as gout. When her symptoms failed to improve with appropriate management, radiographs were obtained, demonstrating a lesion in the proximal radius () characterized as a mildly expansile lucent lesion with a thin zone of transition but no sclerotic rim. Internal osseous septations were present and there was cortical thinning but no visible cortical breakthrough, periosteal reaction, calcified matrix, or soft tissue mass. The initial differential diagnosis included metastasis, multiple myeloma, and other less common entities such as a primary sarcoma of bone or atypical infectious process. She was referred to our tertiary care hospital to consult with an oncologic orthopedic surgeon. Further history obtained at that clinic visit elicited that 3 years previously she had incidentally discovered lytic lesions in her skull and left clavicle that were evaluated in another medical system. Biopsy of both lesions performed at that time was inconclusive showing a mix of inflammatory and fibrous cells per report. The pathologic specimens were not available for further review. Physical exam at her clinical visit was unremarkable with no palpable lymphadenopathy and no visible abnormality at the symptomatic left elbow. SPEP and UPEP tests were negative.\nHer initial imaging work-up included CT of the chest, abdomen, and pelvis; contrast-enhanced MRI of the left forearm; and nuclear medicine bone scan. Her CT scan showed no findings of primary malignancy and—pertinent to her eventual diagnosis—showed no lymphadenopathy or vital organ abnormality. Bone scan demonstrated marked radiotracer uptake at the site of the lytic lesion in the proximal left radius as well as at the previously biopsied skull and left clavicle lesions (). The MR scan of the left forearm showed a marrow replacing lesion within the proximal diaphysis of the radius (). The lesion was T1 isointense, T2 hyperintense and demonstrated avid enhancement. Cortical thinning and small areas of cortical breakthrough not visible on the radiographs were apparent on the MRI. No associated soft tissue mass or perilesional edema was present.\nAt the request of the orthopedic oncologist, a fluoroscopy-guided percutaneous biopsy was performed by Musculoskeletal Interventional Radiology. This rendered only tiny fragments of tissue that were nondiagnostic at histologic review. The patient then underwent open biopsy and curettage of the lesion with Orthopedic Surgery for both diagnostic and treatment purposes. Lesion histology demonstrated features diagnostic of RDD including emperipolesis (engulfment of intact lymphocytes contained with the cytoplasm of histiocyte cells) and positive S100 immunohistochemical staining (). At her follow-up clinic visit 8 weeks after surgery, the patient reported resolution of her left elbow pain, and repeat radiographs demonstrated partial filling in of the lesion with healing bone (). She was discharged from clinic and instructed to follow up if she developed recurrent left elbow symptoms or similar symptoms at a new site. One year later, she has not sought further care at our institution. |
A 65-year-old ambulatory male farmer from Bihar presented to our outpatient department with painless swelling of his left leg of two months that was insidious in onset and gradually progressive. The swelling started from his thigh and now involved the entire limb. He had no identifiable risk factors for a deep vein thrombosis. He had no bowel or bladder symptoms. The patient did not report any previous surgery or trauma to the region. He had worked as a hired farm worker all his life and gave no history of exposure to asbestos in his occupation.\nOn examination he had stable vitals, and had pitting edema of the left leg. His right lower leg was normal. The ankle and knee joint were normal. No ulcers were seen on his leg. A difference in measurement between the two limbs of 5 inches over the thigh and 4 inches over the calf was noticed. He had inguinal lymphadenopathy on the left side, but no nodes were apparent to palpation on the right.\nA diagnosis of deep vein thrombosis and elephantiasis were entertained at initially. An examination of the abdomen revealed a hard palpable mass of size 5 * 4 cms in the left iliac fossa. This was a hard globular smooth nontender mass with lower margins disappearing below the inguinal ligament. On leg raising test the lump was found to decrease in prominence. The spermatic cord was palpated as a hard and cord like structure. The scrotal skin was normal. The left testis was found to be enlarged as a single hard mass of 10*5*4 cms. The testis was not tender and testicular sensation was preserved. The swelling was not fluctuant and not trans-illuminant. Per rectal examination did not reveal any abnormality.\nThe initial diagnosis was now revised to suspect a testicular tumor – probably a seminoma or a lymphoma of the testes.\nThe initial investigations revealed normal blood picture with a hemoglobin of 13 g/dL, a slight leukocytosis of 11200/cmm with neutrophilic predominance. He had normal renal and liver functions and the electrolytes were found normal. No abnormality was revealed on the chest radiograph and the color Doppler of the lower limb showed no evidence of deep vein thrombosis.\nThe echocardiograph of the patient showed normal rhythm and no atrio-ventricular blocks were identified. The ultrasound examination of the abdomen and scrotum showed multiple well defined hypoechoic lymph nodes in the pre and para aortic regions along the left common iliac vessels. Right testis measured 3.2*2.1*2.4 cms and a right sided hydrocele was noticed. The left testis was enlarged 3.9*3*3.2 cms showing diffusely heterogenous echo-texture and irregular nodular surface with irregular hypoechoic thickening of the scrotal wall with left sided hydrocele. A separate hypoechoic lesion was visualized in the anterior scrotal wall. There was left sided hydrocele. The epididymis was normally visualized. The prostate was normal with a size of 2*3.5*2.7 cms.\nUS guided FNAC from the left iliac mass were performed which revealed cells suggestive of a malignancy but were inconclusive for characterization.\nComputerized tomographic scan of the abdomen and the chest revealed few fibrotic lesions in Right Upper and apical segments of the right lower lobes of the lung. Multiple conglomerate lymphnodes (largest 5*4 cms) were seen in the retroperitoneal and pre pancreatic locations. A large (9*7*7 cm) lymph nodal mass was seen in the left hemi pelvis encasing left common iliac and left external and left internal iliac vessels. Pelvic and superficial inguinal lymphnodes (~2 cm) were also found to be enlarged. A simple cyst was visualized in the left kidney\nAlpha fetoprotein was found to be 4.64 ng/ml (normal < 10) and beta human chorionic gonadotropin level was found to be 0.29 mIU/ml (normal < 4)\nTrucut biopsy of the left iliac mass showed features of a squamous cell carcinoma. However, this was not consistent with the final diagnosis achieved after immunomorphological studies.\nFine needle aspiration cytology from the scrotal mass was performed which showed tumour cells of similar morphology present singly in monolayered sheets and in three dimensional fragments. The tumour cells were polygonal in appearance with abundant cytoplasm and nuclei with vesicular chromatin, mild pleomorphism and eosinophilic nucleoli. The tumour cells were found positive for cytokeratin, epithelial membrane antigen (EMA) and calretinin. The overall immunomorphological features suggested a malignant mesothelioma likely to have arisen from the tunica vaginalis. The cytopathological findings of this case have been reported in detail by Mathur et al []. |
A 35-year-old gravida 2 para 1 female, with a history of one spontaneous abortion and one prior cesarean delivery in August 2016 presented to the clinic for prenatal care at 13-weeks gestation. Co-management with maternal-fetal medicine (MFM) was established due to advanced maternal age and a history of prior cesarean section. A transvaginal ultrasound performed by MFM during the twenty-third week of gestation revealed an area with increased vascularity near the prior cesarean section scar. A T2 MRI performed at 24 weeks gestation revealed an anterior and right lateral placenta with the anterior left inferior portion having a focal area of outpouching with secondary loss of the T2 low signal intensity. The MRI further confirmed increased vascularity in the region of the prior C-section scar tissue. The estimated placenta volume was 466.6 cc with 12.76 cc being abnormal placenta implantation (approximately 2.66% of the total placenta volume).\nAfter reviewing the imaging results and discussing with the patient, cesarean delivery with the desire of uterine preservation was mutually agreed upon. Due to the precision and minimal energy spread, a helium plasma focused RF energy device was utilized to obtain hemostasis without damaging the healthy layers beneath the level of placental invasion. The patient was counseled on the risks of undergoing conservative treatment for MAP.\nOn the day of cesarean delivery, manual extraction of part of the placenta was performed but was not successful due to adherent portions at the site of the prior c-section scar. The uterus was quickly exteriorized and retracted to achieve optimal visualization, as seen in Figure . The helium plasma RF device was used for 30 seconds on the endometrial surface to fulgurate the area of the retained placental tissue. The hand-held 5 mm diameter probe with a single push-button activator facilitated the mechanical and thermal energy via plasma flow to aid in the dissection of tissue []. While the standard device settings of 10% power and 4L/min are adequate to initiate energy, we utilized 40% power and 4 L/min for 25 seconds to increase the amount of heat and ensure effective treatment of the targeted tissue []. The light energy facilitated visualization of the target area, while the kinetic energy from heated helium plasma at the tip of the blade was employed to coagulate and fulgurate the uterine tissue []. A radius of 3 cm was created, and hemostasis was confirmed visually. Successful hemostasis was achieved with the thermal effect of helium plasma RF energy, as visualized in Figure .\nCarboprost 0.25 mg was administered locally at the site of accreta to maintain uterine contraction and prevent further bleeding. The uterine incision was approximated and closed in a horizontal mattress fashion and the uterus was replaced into the pelvis. The patient was transferred to the post-anesthesia care unit for close monitoring. The quantitative blood loss was 560 cc. The preoperative hemoglobin of 10.5 g/dL decreased to 8.9 g/dL within 24 hours postoperatively. The patient remained hemodynamically stable and was discharged on postoperative day two. Blood transfusions and supportive care were not required. She did not develop endometritis and had no complications at the six-month follow-up.\nWe present another patient case of a 35-year-old gravida 3 para 2 female with two prior cesarean sections who presented at six weeks and two days of gestation with a low-lying placenta. MFM consultation was requested was established, and the patient completed two visits throughout the pregnancy. A biophysical profile without stress test was performed at 27 weeks and three days due to vaginal bleeding, revealing a placenta with rounded configuration, concerning for a circumvallate placenta. The biophysical profile (BPP) score was 8/8. Evaluation of the partial placenta accreta was performed by MRI at 30 weeks and three days. The placenta was found to be anterior/right lateral, extending to the fundus and with a thickness of 4.1 to 5.0 cm in AP. The signal intensity of the placenta was intermediate on the T2 weighted images and demonstrated increased vascularity in the retro-placental space. Towards the upper and right lateral portion of the placenta, there was a questionable focal small area of loss of the retro-placental vascular space as well as the loss of the thin T2 dark uteroplacental interface. The findings were indicative of a focal area of placenta accreta.\nThe patient underwent a repeat cesarean section with a low transverse incision at 38 weeks and six days gestation with fulguration of the partial placenta accreta with the helium plasma device. On the day of surgery, the placenta was manually extracted and oxytocin was administered. Although most of the placenta was removed, a small area of placenta accreta on the middle aspect of the anterior uterus was identified. Methylergometrine and carboprost were administered at the placenta accreta site. The helium plasma technology was utilized at 40% power at 4L/minute to fulgurate the remaining tissue on the endometrium. An additional 0.25 mg of carboprost was administered to the area of fulguration. Quantitative blood loss was 450 cc. Pre-operative hemoglobin was 13.6 g/dL and post-operative hemoglobin was 12.7 g/dL. The placental pathology report revealed a placental disc weight of 391 grams. The singleton placenta measured 15.2 x 14.7 x 2.8 cm, with an eccentrically located 3-vessel umbilical cord without abnormalities. The patient remained hemodynamically stable, without postoperative complications. |
In the examination of a 52-year-old Caucasian woman with a 2-year history of right flank pain and lower urinary tract symptoms, a cystic mass was observed in her right kidney in ultrasonography. The cystic mass was diagnosed as a renal hydatic cyst in computed tomography. The patient was hospitalized with the diagnosis of renal hydatic cyst and no abnormality was found in laboratory and urine testing. No laboratory analysis was performed for a hydatic cyst; however, a renal hydatic cyst was diagnosed as a result of radiological findings. The patient’s history revealed no close relationship with animals. It was learned that the patient received medical treatment because of cerebrovascular disease and that she had no neurologic deficit for the time being. She had only taken medical treatment due to collagen tissue illness for 15 years. Subsequently, she was accepted to our clinic for surgery and open complex cyst removal was done under general anesthesia. The kidney was sutured watertight. However, in the postoperative period, a ureteral double j stent was placed because the drainage did not stop in the following 3-week duration. Because drainage of 250cc daily continued without any decrease the week following the double j stent placement, intravenous pyelography (IVP) was applied and urinary leakage was found (Figure\n). Urinary drainage was more prominent at night than during the day (250 versus 50cc). Subsequently, oral desmopressin was started at a dosage of 0.2mg/day in order to decrease the nocturnal urinary drainage; no abnormal situation was observed in serum electrolytes (specifically hyponatremia). The patient’s drainage decreased dramatically to a daily total of 50cc and she was discharged on the fifth day of the medical treatment after the drainage had stopped. After 1 week when the patient came for follow-up, the desmopressin treatment was ended. IVP was applied 3 weeks after the patient was discharged, and a urogram showed that the two kidneys were active and the double j stent was removed because no urinary leakage was observed (Figure\n). |
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 66-year-old male with chronic hypoxemic respiratory failure secondary to advanced interstitial pulmonary fibrosis, coronary artery disease, pulmonary hypertension, systemic lupus erythematosus, hypertension, and obesity presented for a single right lung transplantation which was performed with end-to-end anastomosis. His operation was uneventful with no significant major intraoperative complications or use of extracorporeal membrane oxygenation. He was extubated within 24 hours posttransplant after an airway and anastomosis inspection via flexible bronchoscopy was unremarkable. The patient was treated with antibiotics for methicillin-sensitive Staphylococcus aureus of the donor lung; other cultures were negative. The patient was to receive tacrolimus, mycophenolate, and prednisone for immunosuppression and nebulized amphotericin and intravenous valganciclovir for fungal and cytomegalovirus prophylaxis. No primary graft dysfunction was reported in the first 72 hours after surgery. CT without contrast was obtained on postoperative day 5 to evaluate a right lung basilar opacity, which showed extensive ground-glass opacities in the transplanted right lung, concerning reperfusion edema versus acute rejection. The patient was given diuretics, and glucocorticoid dosing was increased from prednisone 5 mg daily to methylprednisolone 40 mg intravenously twice a day. His postoperative course was further complicated by hypoxemia, for which a CT angiography was performed and showed a small distal pulmonary embolism in the right lower lobe, decreased ground-glass opacities in the right lung, and increased patchy basilar platelike peribronchial opacities for which rejection could not be ruled out. The patient received three days of pulse glucocorticoid dosing of methylprednisolone 250 mg IV daily, which was subsequently decreased. Persistent abnormalities on chest radiography and continued hypoxemia led to additional imaging. CT of the thorax on postoperative day 15 showed right allograft opacities, for which glucocorticoids were continued out of concern for rejection. Subsequent bronchoscopy on postoperative day 17 showed an abnormal area of eschar around the anastomotic site with a pale yellow-brown mucosa suggestive of ischemia. Cultures from the bronchoscopy were negative. A transbronchial biopsy of the right lower lobe was performed, and pathology showed organizing pneumonia without evidence of rejection. Donor-specific antibody serology did not suggest antibody-mediated rejection. Steroids were continued and tapered in an attempt to balance treating his organizing pneumonia while hoping to avoid the complications given the presence of anastomotic eschar on bronchoscopy.\nOn postoperative day 26, the patient developed chest pain. Vital signs were as follows: temperature was 36.9 degrees Celsius, blood pressure was 108/61 mmHg, heart rate was 67 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 97% on 20 liters of high-flow nasal cannula with fraction of inspired oxygen of 60%. On physical exam, the patient had rhonchi at the right base and right-sided subcutaneous emphysema on the anterior chest with no respiratory distress or accessory muscle use. A portable anterior-posterior chest X-ray showed right-sided subcutaneous emphysema with a small right-sided pneumothorax (). CT of the thorax showed a moderate-sized right pneumothorax with spontaneous decompression into the anterior chest wall with subcutaneous emphysema, a sentinel pocket of air adjacent to the anastomotic site, and interstitial emphysema around the right lower lobe proximal bronchus, all of which were concerning bronchial dehiscence (). The patient was transferred to the medical intensive care unit and was intubated for bronchoscopy for airway inspection. Bronchoscopy showed partial dehiscence of the right mainstem bronchus surgical anastomosis directly opposite to the right upper lobe orifice and distal to sutures with a surrounding stable hematoma and no bubbling apparent when flushed with saline (). Retrospective evaluation of the prior CT thorax two weeks after transplantation showed air tracking along the bronchovascular bundle, suggestive of interstitial emphysema (). Repeat bronchoscopy 32 days posttransplantation, seen in , showed right mainstem bronchus surgical anastomotic dehiscence with the International Society for Heart and Lung Transplantation (ISHLT) grading as follows: ischemia and necrosis (extent I-a, location I-a), dehiscence (extent D-a, location D-c), stenosis (location S-a), and malacia (none). The right mainstem bronchus anastomotic dehiscence was managed conservatively with a reduction in glucocorticoid dosage, addition of prophylactic antibiotics, and serial bronchoscopy. |
A 22-year-old male reported to the Department of Periodontics, complaining of a swelling in the upper right jaw region, which caused discomfort while eating. The patient reported that he noticed the swelling 2 years ago, which was painless and gradually increased in size, during this period he had visited a medical doctor who had given him gum paint for application. He had stopped brushing the area due to bleeding from the area.\nOn extraoral examination, there was no visible swelling on the right side of the maxilla. Intraoral examination revealed a large sessile lobulated gingival overgrowth extending on buccal surfaces of 15, 16, 17 and 18. It was reddish pink in color with white patches and was approximately 21 mm × 44 mm in size. The surface was smooth no ulcerations were seen and it appeared ovoid in shape []. Buccally it extended beyond the occlusal plane of the teeth giving an appearance of missing teeth []. Oral hygiene was poor and the mouth showed large amounts of calculus. Teeth associated with it did not show any mobility. Radiographically, there were no visible abnormalities and the alveolar bone in the region of the growth appeared normal []. Routine hemogram was found to be normal. A provisional diagnosis of pyogenic granuloma was made. The differential diagnosis included peripheral ossifying fibroma, peripheral giant cell granuloma, hemangioma and fibroma.\nThe patient did not have any systemic problems and so the case was prepared for surgery on the basis of the clinical and radiographic evidence. Oral prophylaxis was completed and the lesion was excised under aseptic conditions. Excision of the lesion up to and including the mucoperiosteum was carried out under local anesthesia using a scalpel and blade, followed by curettage and through scaling of the involved teeth. Periodontal dressing was placed and the patient was recalled after 1 week for removal of the pack and checkup. The excised tissue [] was sent to the Department of Oral Pathology for histologic examination.\nHistopathological report revealed parakeratinized epithelium, stretched in some places and showed proliferation toward the base of the lesion. The underlying connective tissue stroma showed dilated and engorged blood vessels, extravasated red blood cells, angiogenesis, few inflammatory cells and bundles of collagen fibers []. The diagnosis pyogenic granuloma was histologically confirmed.\nThe patient was recalled every 3rd month for maintenance and to check for possible recurrence. This case was followed up for a period of 1 year and there has been no recurrence so far []. |
A 66-year old gentleman in otherwise good general health was admitted to the neurosurgical department due to a skull deformation in the left frontoparietal region, which was growing progressively. He first noticed it approximately seven months ago and complained of dull headaches, located in the left half of the head that were noticed a few times weekly. No other complaints in connection with his health status were reported at the admission.\nThe neurological status during the clinical examination was normal. Locally, a skull tumour of 5 cm in diameter was felt. It was immobile and insensitive on palpation and the skin covering it was normal.\nThe computer tomography (CT) and magnetic resonance (MR) imaging revealed an intracranial expansive lesion of 8 cm in diameter, compressing the cortex and invading the skull bone and subcutaneous tissue ( and ). The CT angiography did not show any signs about sinus invasion. Surgery was indicated.\nThe operation was performed via midline incision. In the subcutis, the tumour mass growing through the bone was seen, infiltrating the periosteum and galea (). A round section of the skull bone was performed, encircling the tumour first. Then, the bone in the very vicinity of the tumour was drilled in such a way that two circular bone flaps were formed around the tumour as it was not possible to elevate the first bone flap due to the tumour adhesion to the bone without damaging the bridging veins and the dura. The tumour was then microsurgically removed, carefully dissected and elevated off the brain substance (). The tumour origin was in the dural convexity over the left motor and premotor cortex. The cortex was relatively spared, though severely compressed and the superior sagittal sinus was also compressed but otherwise intact. However, the bone was porotic and invaded by the tumour, which spread through the periosteum into the galea. The tumour was completely excised together with all infiltrated extracranial tissue.\nExtensive defects of the dura mater and bone were well reconstructed with dura replacement material (lyophilised dura) and water tightly sealed with fibrin glue in order to avoid liquorrhea. Artificial bone was modelled in vivo from two component polymethylmetacrylate material, which was moulded and modelled according to the shape of the removed bone just before closure ( and ). The original bone flap was used as a template. The fit was very good, giving an excellent cosmetic result as well as brain protection. The new artificial bone flap was fixed to the skull bone with titanium plates. Finally, the wound was closed in layers. After the operation, the patient was neurologically intact. The control CT scan showed a good position of the implant with no fluid collection underneath (). The rest of the postoperative course was uneventful.\nHistology showed that the tumour was a conventional fibrous meningioma, WHO grade 1. It indeed originated from the dural convexity and spread through the bone into the subcutis (). No additional treatment was recommended. |
A 48-year-old woman was evaluated as a potential kidney donor for her son. Blood and urine investigations were within normal limits and ultrasound revealed normal sized kidneys without any abnormality. A diethylene triamine pentaacetic acid renal scan revealed a glomerular filtration rate of 51 ml/min on the right side and 44 ml/min on the left. Computed tomography (CT) renal angiography showed a normal suprarenal IVC with infrarenal duplication. The left renal vein inserted to the normally located right side IVC, and the left IVC was draining into the left renal vein []. Both gonadal and lumbar veins were opening into the left IVC, whereas the adrenal vein was opening into the left renal vein. There were one left and two right renal arteries. Due to the presence of multiple renal arteries and a better function on the right side, it was decided to perform left donor nephrectomy. The patient underwent a retroperitoneoscopic donor nephrectomy. The left renal artery was dissected as usual. The adrenal vein was controlled using a 5-mm LigaSure® probe. The left renal vein and cephalic portion of the duplicated IVC just below its confluence with the renal vein were dissected. Two hem-o-loc clips were applied to control the left IVC just below its confluence with the left renal vein []. Gonadal and lumbar tributaries of the left IVC were preserved to allow for collateral drainage. Subsequently, the artery and renal vein were controlled and the kidney was removed. At bench surgery, the hem-o-loc clip was removed and the large opening in the left renal vein was repaired by continuous running suturing of 6/0 polypropylene. The renal allograft was uneventfully transplanted into the right iliac fossa of the recipient using external iliac vessels for revascularization. The length of the graft renal vein with segment of IVC was adequate and allowed easy anastomosis with the external iliac vein. The donor made an uneventful recovery requiring minimal analgesics and was discharged on the second postoperative day. There were no complications in the recipient. Serum creatinine achieved was 1.21 mg % on day 7 and 1.08 mg % at 1 month. |
A 53-year-old woman with a long medical history, including Crohn's disease with two intestinal surgeries (one of them due to an intestinal perforation), psoriatic arthritis and mild chronic renal failure was referred for consultation because of a solid mass on the left flank. The CT scan showed a subcutaneous tumor in the left lateral abdominal wall and multiple giant bilobar liver metastases which consisted in a 13.5 cm tumor in segment VII and a 9.5 cm tumor in segment IVb (Fig. ). The only related clinical record was the resection of a lipoma in that same area (left lateral abdominal wall) 12 years ago. An ultrasound-guided core-biopsy was performed on the subcutaneous lesion located in the left lumbar region and also on one of the focal lesions of the right hepatic lobe. Histologically, both samples were practically identical, which confirmed that the liver lesions were metastatic. The pathology showed a fusocellular proliferation of highly cellular mesenchymal lineage, with eosinophilic cytoplasm cells and ovoid nucleus with finely granular chromatin, without evident mitotic images. The Ki67 proliferative index was 20%. Immunohistochemical staining was positive for STATS6. After a multidisciplinary discussion, the preferred strategy proposed was an upfront resection of the primary tumor and liver metastases, without neoadjuvant chemo or radiotherapy due to lack of evidence as do its usefulness. The extend of the liver involvement precluded a complete resection in one procedure, so we designed a two stage strategy consisting in resection of the primary tumor and left hepatic metastases, followed by portal vein embolization and subsequent right hepatectomy. The liver function test prior to the surgery included a direct measure of the portal systemic gradient via transjugular catheter, and indocyanine green clearance (IGC) test, both favorable to perform a major resection (4 mmHg gradient; PDR 25; R15: 2). The first surgical procedure was carried out as planned, including metastasectomies of lesions located in segments IVa; IVb and particularly bulky one in segment I, and radiofrequency ablation of a lesion in segment II. Right portal vein embolization (PVE) was performed in the same hospital admission by interventional radiology using cyanoacrylate-lipiodol and particles (PVA: 350–500 and 500–700 microns). The postoperative course was uneventful and the patient was discharged at 7 postoperative day. The anatomopathological characteristics of these samples coincided with the findings described in the previous biopsies: a neoplasic mesenchymal proliferation, hypercellular, solid-growth, with a storiform pattern consisting of spindle cells with imprecise boundaries, with ovoid nuclei with finely granular chromatin, without atypia, which are accompanied by medium-sized blood vessels, some with deer horn morphology, branched, showing thin walls and unaltered endothelium. No vascular or perineural invasions were observed. A Ki67 proliferation rate of 15% was also noted, with a low rate of mitosis (2 mitosis/10HPF). Immunohistochemical staining remained positive for STAT6 and CD34 (Fig. ). A CT scan was performed one month after the PVE and the volume estimate of FLR was insufficient, (35%) (Fig. ). In the meantime the patient had severe Crohnʼs exacerbation which coursed with digestive bleeding and required hospitalisation for more than two weeks, intensive corticoid treatment and the commencement of biological therapy with Adalimumab. It was decided in the multidisciplinary committee to perform a TARE-Y90 on the right liver in order to avoid tumoral progression and to try to increase the FRLV (Fig. ). In the following months, the patient needed hospital admission due to a septic shock caused by an urinary tract infection. She also suffered malnutrition in the context of Crohn's disease and the second stage of the liver surgery was postponed for six months until the patient was sufficiently recovered. In the reevaluation study for the second liver surgery, the CT-scan showed voluminous hepatic masses in the right lobe with diameters up to 10 cm, particularly in the posterior sector with areas of necrosis and reduced contrast enhancement as a sign of response following modified RECIST criteria []. There was no sign of recurrence in the remnant left lobe, nor distant metastases. The volumetric study showed an important left hepatic lobe hypertrophy (FLR 50%) (Fig. ). With this information, a right hepatectomy was planned. The surgery was particularly difficult mainly due to the adherent syndrome caused by previous surgeries. We utilized an anterior approach with hanging maneuver in order to avoid tumor spreading during the right liver lobe mobilization (Fig. ). The postoperative course was uneventful and the patient was discharged at 7th postoperative day. The pathologic study showed images of necrosis representing up to 80% of the tumoral volume. The mesenchimal cells had few mitotic images, and were positive for CD34, BCL2, and STAT-6, with a proliferative index, measured with Ki67, of 10%. Currently, 30 months after the first liver surgery, the patient is asymptomatic and free of active disease. |
A 66-year-old female was referred to our clinic with left facial palsy, diplopia, and vertigo six days after the onset of left ear pain and headache. The patient underwent a severe emotional stress due to her sister's death at the time of onset of left ear pain. The clinical manifestations developed gradually over a few days. Physical examinations revealed vesicular eruptions with crusts on left auricle, left facial palsy, left abducens nerve palsy, and mild right beating spontaneous nystagmus. The degree of FNP was House-Brackmann (HB) grade V (). Diplopia was present in the primary position and was more prominent on attempted abduction of the left eye (). Audiogram showed sensorineural hearing loss on her left ear (). Vestibular function test was performed on the fourth hospital day when the patient no longer complained of dizziness, and videonystagmography showed no evidence of spontaneous nystagmus. The size and response to light were normal on both pupils. Except for cranial nerves VI, VII, and VIII, examination for other cranial nerves revealed intact function. Magnetic resonance imaging showed no sign of tumor, infection or other demyelinating diseases of the brain. Serology results for VZV IgG antibodies were positive, but negative for VZV IgM antibodies. The patient had no associated immunocompromised condition including immunosuppressant drug use or immunodeficiency syndrome. A diagnosis of RHS with CP was made based on the patient's characteristic presentation, and from a clinical point of view cranial nerves VI, VII, and VIII were found to be involved. Systemic administration of steroid and antiviral agents was started. Sixty mg of prednisolone was initially given to the patient and tapered orally for 14 days, and 3000 mg of acyclovir was administered intravenously for 7 days. No immediate or delayed side effects were observed during and after the treatment. Among symptoms, dizziness improved most rapidly within several days. During 3 weeks from the start of treatment a gradual improvement of the facial weakness and diplopia was observed. Four months after the treatment, FNP recovered to HB grade I and the abducens nerve palsy completely improved without diplopia (). |
An 81-year old female with a history of coronary artery disease, hypertension, and thrombocytosis suffered a witnessed trip and fall onto a nightstand. The patient took 75 mg of clopidogrel daily in addition to an 81 mg aspirin tablet. She reported a mild headache however had no change from her baseline mentation per family members with no evidence of obvious injury aside from a small area of ecchymosis near a small forehead laceration. She remained up and ambulatory with no further complaints. Ten hours after her injury the patient presented to the Emergency Department with stridorous and agonal respirations with a profoundly decreased level of consciousness. She was noted to have developed extensive ecchymosis on the anterior portion of her neck and chest. Her symptoms had begun rapidly shortly prior to arrival while lying in bed. Family reported that she had been in the constant company of her husband with no further falls or injuries that had occurred since her fall. The patient was intubated upon hospital arrival due to respiratory extremis with obvious swelling and crepitus noted on neck examination. A noncontrast CT scan of head was unremarkable while there was demonstration of a large retropharyngeal hematoma measuring 3.6 cm by 5.3 cm by 20 cm on a CT of the cervical spine with no evidence of fracture. Her hemoglobin was 9.5 gm/dL and platelets were 1234 per deciliter, with an INR of 3 and a slightly below normal and activated partial thromboplastin time of 23.9 seconds (reference range 25-35 seconds). A CT angiogram of the neck was subsequently obtained demonstrating active bleeding from the anterior ligaments of the vertebral column that was not felt to be amenable to embolization (). Given the extent of the hematoma intraoral surgical evacuation was performed with bleeding from the anterior vertebral spine controlled with Bovie cauterization, placement of topical thrombin, and drain placement. No reaccumulation of hematoma was noted during her hospital course. The patient unfortunately expired 12 days from the date of admission from presumed aspiration pneumonia and multisystem organ failure. |
A 38-year-old man, with no significant past medical illness, was brought to the emergency department initially, after he sustained an episode of generalized tonic-clonic seizure. On further questioning after being recovered from seizure, he complained of suffering from generalized headache for a duration of 10 days prior to the presentation. He denied having any weakness or numbness and denied any complains of speech or swallowing difficulties. On arrival, he was hypertensive up to 170/101 mm Hg and was hemodynamically stable otherwise. Neurological examination did not reveal any cranial nerve or cerebellar deficits and had no focal deficits, with normal symmetrical reflexes overall. Other system examinations were within normal limits.\nOn further investigation, initial CT brain was done, which did not reveal any abnormalities, and so he was admitted to the neurology critical care unit for further management. As a workup for seizure, MRI brain was performed, which revealed a right cerebellar small acute ischemic infarct (Figures –). Subsequently, an MR angiography of the brain and neck was performed, which revealed filling defects causing focal narrowing in the origin of the internal carotid artery bilaterally. Routine brain EEG did not reveal any seizure activities.\nUpon admission to the neurology unit, he was started on aspirin and atorvastatin for treatment of stroke. Carbamazepine was introduced in view of seizure due to focal organic cause. He was worked up thoroughly for his stroke considering his young age with complete collagen vascular disease and thrombophilia workup. He was initially found to have thrombocytopenia as low as 50,000 platelets per microliter. A transthoracic echocardiography revealed a pedunculated and lobular left atrial mass (Figures -), which was measuring around 1 × 1.5 cm and was freely mobile across the mitral valve, oscillating across the left ventricular inflow. This finding was subsequently confirmed by a transesophageal echocardiography, with differential diagnosis of atrial myxoma at the top of the list. Cardiothoracic surgery opinion was sought and was planned for surgical removal of the atrial mass. Prior to transferring the patient to the surgical care center, his thrombophilia workup revealed to be positive for antibodies of antiphospholipid syndrome. Cardiolipin antibody immunoglobin G was positive in high titer >120 units/mL, and B2 glycoprotein IgG level was 90 units/mL. Lupus anticoagulant 1 (LA1) screen was positive for 109.30 seconds, aPTT LA was 153.8 seconds, hexagonal phase neutralizing timing was 25 seconds, LA1 mixing time was 88 seconds, and lupus anticoagulant 2 (LA2) confirmation timing was 38.46 seconds, giving a LA1/LA2 ratio of 2.84. Based on these findings, it was confirmed that dRVVT screen and aPTT are prolonged. The dRVVT mixing study was prolonged, consistent with an inhibitor effect. Hexagonal phase and dRVVT ratio were both significantly elevated, consistent with phospholipid dependence. Overall, the findings are consistent with a strong lupus anticoagulant. Lupus anticoagulants may be transient. According to the International Society of Thrombosis and Hemostasis, if positive testing is observed on two or more occasions, at least 12 weeks apart, this may be indicative of an anti-phospholipid antibody syndrome, if observed in the right clinical setting. Based on this recommendation, it was decided to repeat the testing after 12 weeks. Apart from these findings, the anti-nuclear antibody results came negative, with normal ESR and CRP levels.\nAn opinion was sought from the rheumatology department, and finally the diagnosis of APS was confirmed. It was decided to start the patient on anticoagulation treatment but was delayed until the patient went for the surgery. However, on the days prior to the scheduled surgery date, he was kept on low molecular weight heparin at treatment dose and then was suspended on the operative day. The patient underwent successful surgical removal of the mass, which looked like a thrombotic clot rather than a tumor mass. Histopathological analysis confirmed that the mass is made up of a fibrinous clot, with no evidence of any tumor cells (Figures -). He was started on full anticoagulation treatment with warfarin and was followed up regularly in the clinic, where he did not have any further complications from the disease. Shortly after the treatment and follow-up for 2 months, the patient repatriated back to his home country and to continue treatment there. So, it was not possible to repeat the LA and aPL studies after 12 weeks as recommended as he lost follow-up with us. |
A 60-year-old male was referred to our department, complaining about gradually worsening hoarseness, during the last 8 month period. Occasional dysphagia and foreign-body sensation were also reported upon referral. The patient was a heavy smoker for more than 20 years, reporting an average of 20 cigarettes per day. Alcohol was also a factor, and although no real alcohol abuse or indulgence was noted, the patient was a rather frequent user.\nMedical history only revealed arterial hypertension under treatment with beta blockers. Haematological and biochemical tests did not show any significant abnormalities.\nPhysical examination included a full head and neck examination, complemented with flexible fiberoptic laryngoscopy. Typical ear, nose and throat examination did not reveal any abnormal findings and neck palpation was negative. However, fiberoptic laryngoscopy revealed a lesion affecting both vocal cords and anterior commissure, while vocal cord mobility appeared impaired. On these grounds, a cervicothoracic and upper abdomen computed tomography (CT) scan with intravenous gadolinium was decided and the patient was scheduled for direct microlaryngoscopy and biopsy of the lesion under general anaesthesia.\nImaging confirmed the laryngeal lesion, yet it also indicated a second lesion about 2 cm below the inferior end of the primary one, arising somewhere between the first and second tracheal ring. Intermediate tissue appeared grossly normal (). No signs of enlarged cervical lymph nodes were noted and laryngeal cartilages showed no abnormal findings.\nOn the other hand, histopathological examination after biopsy of the lesion under general anaesthesia confirmed the diagnosis of squamous cell carcinoma. The lesion was carefully mapped and proved to be a glottic carcinoma affecting the anterior commissure and appearing in strong correlation with the thyroid cartilage. The lesion infiltrated the left and the first tertile of the right vocal cord. No subglottic extension was noted. In this context, the patient was informed and consent for radical surgical therapy was obtained.\nThe patient underwent total laryngectomy and wide excision of the trachea which included the second tumour within safe limits (). The procedure was complimented with left thyroid lobectomy and bilateral selective neck dissection (Robin’s levels II–IV). Paratracheal lymph nodes (Robin’s level VI) were also carefully dissected. The overall postoperative course was uneventful. The patient was discharged from our department on day 16 with very good swallow function and was decannulated after 1 week. Surgical resection was followed by postoperative radiation therapy (6400 cGy/32 fraction).\nThe final pathological report was of crucial importance in our case. First of all, the surgical margins of resection were found to be free of disease. Second, histological sections from the tumour of the glottis showed the characteristic morphology of squamous cell carcinoma. Cancer cells were large in size and polygonal in shape with eosinophilic cytoplasm and nuclei with moderate variation in size and shape. There were a moderate number of mitoses and keratinisation could be focally observed. Cancer cells showed an infiltrative pattern consisting mainly of nests and trabeculae that invaded the vocalis muscle in both the vocal cords. The perichondrium of thyroid cartilage was focally invaded by cancer cells. Histological sections from the tumour of the trachea showed morphological features identical to those of the tumour of the glottis. An upward infiltrating pattern could be noticed. Moreover, a comparative immunohistochemical study of the two tumours showed strong positivity of cancer cells in stains for keratins AE1/AE3 and 34βΕ12 and moderate positivity in stains for CK5/6, CK8/18 and epithelial membrane antigen. Immunohistochemistry for D2-40 antigen (podoplanin) illustrated the positivity of the lymphatic endothelium. Immunohistochemical stains for other vascular endothelia (CD31 and CD34 antigens) were also performed, and were negative. In the region between the two tumours, many lymphatics containing neoplastic emboli could be observed (). Finally, two tumour-infiltrated lymph nodes (the larger being of 1.2 cm diameter) with extracapsular spread were found in the left neck dissection specimen. A pT4a(m)N2b stage, according to eighth edition TNM staging, was established. |
A 49-year-old man was referred to our hospital with a four-month history of severe neck pain during posture changes, as well as mild paresthesia in his left arm. Because of his severe neck pain, he could not walk or remain standing or sitting. He had undergone surgery, and chemotherapy for gastric cancer 19 months previously. Metastases to the left adrenal gland and diaphysis of the right femur were diagnosed after he received chemotherapy. Physical examination was normal except for exaggerated deep tendon reflexes in his upper and lower extremities.\nRadiography and computed tomography (CT) of his cervical spine showed irregular osteolysis at C2, and magnetic resonance (MR) imaging revealed a mass lesion with an apparent intensity change occupying the entire anterior part of C2. The mass had marked and homogeneous enhancement after intravenous injection of gadolinium-DTPA (). Further investigations, including technetium scintigraphy and MR imaging of the whole spine, revealed no evidence of other spinal involvement. The metastatic tumor of C2 was thought to be a candidate for his severe neck pain during posture changes, and surgical stabilization for the lesion was planned.\nThe patient received radiotherapy to the neck with a total dose of 30 Gy. Because his severe neck pain during posture changes had been taken worse in spite of the radiation therapy, he required surgical intervention despite his refusal at first. The preoperative anaesthetic assessment was not suggestive of any risk for airway obstruction. 2 weeks after the radiation therapy, occipitocervical fusion (C0-5) following removal of the posterior arch of C1 and laminectomy of C2 via the single posterior approach was performed.\nDuring the procedure for decompression and pedicle screw insertion, the upper cervical spine was fixed with a Mayfield clamp in a flexed position to obtain a wide view of the C1 posterior arch. Before fixation, the flexed position of the cervical spine was changed to obtain an adequate fusion angle using the X-ray image intensifier. The operation was performed without any significant events, though hemorrhage from the tumor located at the edge of C2 laminectomy and venous plexus surrounding that was difficult to control. The operation time was 6 hours 42 minutes, the estimated blood loss was 2900 mL, and intraoperative transfusion of red cell concentrate (8 units), fresh frozen plasma (8 units), and platelet concentrate (20 units) was performed.\nAlthough his face and neck were edematous after surgery, he was extubated in the operating room with an adequate weaning profile and clear consciousness. However, immediately after extubation, the patient was noted to be making respiratory effort, but he appeared to be obstructed. Oxygen supply with a facemask was not effective, and reintubation using rocuronium bromide was impossible to perform due to the severe swelling of the retropharyngeal soft tissue and upper airway. Oxygen saturation started to decrease to less than 30% within a few minutes. In view of the urgency of the situation, the injection needles (18 G) were inserted below the cricoid cartilage. With oxygen supplied through the needles, oxygen saturation started to increase quickly to normal, and then emergency tracheostomy was performed. He was admitted to the intensive care unit to control his breathing by continuing sedation and continuous positive airway pressure. On postoperative day 4, he could breathe by himself thorough a tracheostomy tube without mechanical ventilation assistance.\nLateral radiography and CT of his neck showed disappearance of the middle pharyngeal space along with thickening of the pharyngeal wall. Fiberscopic examination of the airway also showed reduction of the middle pharyngeal space. These findings did not improve well during the patient's postoperative course (). A trial of weaning from the tracheostomy tube at 6 weeks postoperatively failed because of airway blockage by sputum after removal of the tracheostomy tube. Furthermore, the patient continued to require a stomach tube, because of dysphagia caused by severe pharyngeal pain on swallowing solid food or drinking water that had been observed postoperatively. However, the patient's severe neck pain during posture changes had improved postoperatively, and he could walk with a walker or move on a wheelchair until severe right neck pain, thought to be caused by C2 radiculopathy, occurred 2 months postoperatively. The patient died 4 months after the fusion surgery because of multiple organ failure caused by metastases. |
This patient is a 62-year-old female who works in city government. Her main job is to maintain order and serve as the directory consultant for various exhibitions. Approximately one year before the start of this study, she experienced dizziness, ringing in the ears and swollen scalp symptoms when moving her head. In addition to these symptoms, she also felt unbalanced when walking fast. The symptoms were particularly severe when she moved her head from right to left. She experienced nausea and even vomiting when looking out the window while riding public transportation. She participated in a vestibular rehabilitation program for 3 weeks approximately 11 months prior to the start of this study. Her symptoms improved slightly, and she returned to work immediately. However, she was still unable to tolerate her workload and therefore volunteered to participate in this study. The caloric test showed 37% left-sided canal paresis on initial examination.\nAt the beginning of the training program, she was only able to perform training while seated in a completely steady position. She started feeling nauseous and the urge to vomit whenever her head movement speed exceeded 90o/s after approximately 30 seconds. After the second week, she gradually became able to perform training with speeds of 100-120o/s while seated. She also began video game training in a standing position, and she gradually extended her training time to 3-5 minutes per training session. However, significant upper body movement was still observed. On the 4th week of training, the patient was able to maintain her training performance with head movement speeds of 120o/s in a tandem stance. The balance board and tilt board were gradually added to interfere with her standing balance. She was able to tolerate the challenge by the second training session in the 6th week and was able to maintain good balance as well.\nWhen examined 1 month after training, the patient quickly completed the DGI and POMA assessments. Although she still exhibited an aberrant distance between her feet while walking, her movement speed was clearly improved. The patient also did not experience any dizziness when looking out of windows while riding public transportation. She did not report feeling any uncomfortable symptoms, such as dizziness, when she increased her concentration while quickly turning around in a crowded environment. She felt that it was much easier to perform her job because her walking speed and stability had both improved. |
An 8-year-old girl was referred to the Department of Paediatric dentistry, College of Dental sciences, Davangere for a routine dental check-up. Extraorally, she had a balanced face with a pleasant profile, with the maxillary dental midline coincident with the facial midline. There was no deviation of chin from the facial midline, and the entire maxillary right and left posterior segments were tipped palatally. She presented in the mixed dentition stage with Class I left and half-cusp Class II right molar relationships. An anterior crossbite involving all the maxillary anterior teeth except permanent left lateral incisor, and bilateral posterior crossbite were evident (Figures and ).\nAn early interceptive treatment approach was essential to alleviate both anterior and posterior crossbite in the above said patient. This can be achieved either with a removable expansion appliance with jack screw or a fixed appliance such as hexa helix. Removable appliances were not preferred in these situations as they tend to get displaced as the turning frequency decreases following activation. Moreover, poor patient compliance with removable appliance can cause relapse of the previous expansion and poor success rate. Therefore, a fixed appliance was chosen.\nThe fixed appliance planned was hexa helix; a modification of quad helix in which both anterior and posterior crossbites can get corrected simultaneously. The traditional quad helix consists of a pair of anterior helices and posterior helices. The free wire ends adjacent to the posterior helices are called outer arms. They rest against the lingual surface of the posterior teeth and are soldered on to the lingual aspect of the molar bands. In our case, we incorporated an additional helix to the traditional design on either side of the outer arm. This additional helix was utilized to correct the anterior crossbite.\nOrthodontic bands were adapted on either side of maxillary permanent first molars and maxillary primary first molars, followed by fabrication of appliance with 0.036 stainless steel wire as per the above mentioned design. The appliance was activated prior to insertion and then cemented (). The helices were activated with a three prong plier once every 3 weeks. A posterior bite plane using glass ionomer cement was placed on the occlusal surfaces of mandibular posterior teeth for the time being to make the bite open anteriorly so that the anterior teeth that are in crossbite can be moved labially, following which they were removed. Within a period of 6 weeks almost all the anterior teeth were corrected out of crossbite except maxillary permanent right lateral incisor as there was not enough sufficient space. Hence selective grinding was done on maxillary right primary canine to make room for lateral incisor. Following this lateral incisor moved labially uneventfully. However most anterior helices were left intact to act as retentive appliance. Regarding posterior teeth, there was a transverse expansion of 5 mm achieved which was sufficient enough to bring the maxillary posterior teeth to normal relation with their mandibular counterpart (Figures and ) which took approximately 15 weeks. Following this the appliance was left in the mouth for 3 months for retention. Post treatment exhibited class I molar relation. Two years post treatment patient has a functional occlusion without crossbite. |
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. |
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 24 yr old man reported in March 2007, with complaints of swelling and pus discharge from right side of cheek since 3 weeks. The patient was apparently well 8 years back when he first noticed slight asymmetry of right cheek region. The swelling slowly increased in size for next three years and was latent since then (about 5 years). Recently, he had toothache in relation to right maxillary molar teeth and noticed pus discharge from the same quadrant. This prompted him to seek treatment and was then referred to our institution by a general physician. He appeared to be a well built young man with no history of any systemic diseases. There was an obvious swelling over the right side of maxilla extending over the body of zygoma. The infraorbital rim was expanded but ocular level in the vertical and horizontal plane was unaltered.\nOn intraoral examination, a full complement of teeth was present in the right maxillary quadrant. Teeth #17 was grossly carious with a small sinus tract in the alveolus of tooth #15 and 16. On palpation, the swelling was hard, non tender and appeared to blend with the right zygoma and uninvolved surface of right anterior maxilla []. There was no paresthesia over the distribution of infraorbital nerve. Conventional Radiographs showed haziness and opacification over the region of right maxilla and zygomatic bones, containing an ill-defined radiolucency with another small central radiopacity anteriorly. Overall the radiopacity was homogenous and generally appeared to blend with the adjacent bone except for that portion of radiolucency circumscribing another small central diffuse radiopacity. CT scan showed enlargement of right zygomatic and maxillary bones with a diffuse ground glass appearance obliterating the maxillary sinus []. There was an irregular small cavity in the alveolar process of right maxilla around the roots of teeth #15 and 16. A stellate shaped bony sequestrum was seen inside this cavity with a sinus opening on the buccal surface of tooth #16 [].\nLaboratory investigations like serum alkaline phosphatase, serum calcium, phosphorus and complete blood count were normal. A clinical diagnosis of osteomyelitis superimposed on fibrous dysplasia of right maxilla and zygoma was formed. It was decided to perform facial recontouring and curettage with extraction of involved teeth as a single stage procedure. After a brief course of antibiotics the patient was scheduled for surgery under local anesthesia.\nUnder right maxillary nerve block supplemented with local infiltration for haemostasis, a mucoperiosteal flap was raised and the lesion was exposed till the infraorbital rim superiorly and body of zygoma posterosuperiorly. In the alveolar region the buccal cortex was destroyed and replaced by thick cystic lining. Teeth #14-17 were extracted and cystic lining was curetted out. The cystic lining contained little bit of pus and three small pieces of necrotic bone. Then the residual bone was curetted particularly over the anterior surface of maxilla, body of zygoma and infraorbital rim []. Since there was no paresthesia or compression symptom in infraorbital nerve, the rim of bone surrounding it was left untouched.\nOn histopathology, the bony pieces retrieved after recontouring revealed uniformly distributed curvilinear trabeculae in a fibrocellular stroma with numerous fibroblasts and a few blood vessels, overall picture appeared to be consistent with mature stage of fibrous dysplasia [].\nThe lining exhibited a nonkeratinised stratified squamous epithelium with proliferating and arcading rete ridges and an underlying connective tissue capsule showing intense infiltration by chronic inflammatory cells chiefly lymphocytes and plasma cells []. The three pieces of bone contained within the lining were necrotic i.e. sequestrum []. Thus a diagnosis of osteomyelitis with coexisting epithelialised cyst in fibrous dysplasia was confirmed.\nOne year postoperatively good symmetry was maintained in the frontal view but slight expansion was still visible on the worm's eye view. No recurrence of cystic cavity was observed in one year post operative CT scan and the bony defect healed completely. Three years postoperatively the patient came back seeking correction of facial asymmetry caused by bony growth in the same region []. Facial recontouring was performed again and the bone pieces removed showed microscopic picture consistent with fibrous dysplasia. No cystic lining or avascular bone was observed. |
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. |
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. |
Our patient was a 35-year old Caucasian woman with CP of unknown etiology. Her main complaint at the time of the consultation was severe chronic abdominal pain refractory to narcotic pain medication. Additionally, she was experiencing nausea and vomiting. Her pancreatic function was normal, with a hemoglobin A1C level of 5.4% and basal C-peptide level of 1.3 ng/mL. The history of her present illness was significant for several episodes of recurrent pancreatitis over the past six years after undergoing an open cholecystectomy with subsequent removal of a retained common bile duct stone by endoscopic retrograde cholangiopancreatography (ERCP). Her past medical history was also significant for psoriasis and heavy alcohol consumption, which likely contributed to the subsequent development of CP, although she reported abstinence for the past year.\nAt the time of her admission, an ERCP was performed and demonstrated the presence of a previous sphincterotomy and a dilated common bile duct of approximately 11 mm without filling defects. A stricture of her main pancreatic duct was observed at the level of the ampulla of Vater; dilatation of the remaining portion of the pancreatic duct was present. An endoscopic ultrasound was performed and revealed sonographic changes consistent with mild CP (2.5 mm pancreatic duct, heterogeneous parenchyma) according to the Cambridge classification []. Magnetic resonance cholangiopancreatography and computed tomography of her abdomen were also performed and demonstrated findings consistent with those observed in the ERCP. Given the young age of our patient, we gave priority to surgical therapy to avoid additional endoscopic procedures. After discussing the various therapeutic options with our patient, she chose an RA-PPPD, for better drainage of the distal pancreas and pain relief. Additionally, in consideration of her young age and the future unknown fate of the pancreatic remnant, our patient was offered AIT to preserve endocrine function.\nAfter induction of general anesthesia, our patient was placed in the lithotomy position, with slight reverse Trendelenburg, and her abdomen was prepared and draped in the usual sterile fashion. Trocars were placed as indicated in Figure . The Da Vinci robotic surgical system (Intuitive Surgical, Inc. Sunnyvale, CA, USA) was docked into position, with a viewpoint from our patient's head. We mobilized the right colonic flexure, exposed the second portion of her duodenum and completed mobilization of the pancreatic head. The pancreatic head was enlarged and fibrotic. Next, her hepatic hilum was dissected, her common hepatic artery was exposed and her right gastric artery was ligated. The origin of her gastroduodenal artery was prepared with a vessel loop but not divided (Figure ) to preserve the blood supply to the head of the pancreas. The dissection of her gastrocolic ligament was completed, exposing the inferior border of her pancreas and the pancreatic neck. The neck of her pancreas was prepared and her superior mesenteric vein was widely exposed. Next, the pylorus was prepared; her right gastroepiploic artery and vein were divided. The first portion of her duodenum was divided 2 cm distal to the pylorus using a stapling device. The first loop of her jejunum was transected using a stapler device as well. Her duodenum was retracted, exposing the uncinate process. Subsequently, her common bile duct was transected and the dissection was conducted in the neck of her pancreas, dividing the pancreatic neck with the Harmonic scalpel. Her pancreatic duct was enlarged, measuring approximately 3 mm to 4 mm. The dissection proceeded cautiously until the entire head of her pancreas was connected only to her gastroduodenal artery and superior pancreaticoduodenal vein. Immediately before the transection, a small Pfannenstiel incision was made; a hand access device (Lap Disc, Ethicon, Cincinnati, OH, USA) was inserted with the aim of preserving the pneumoperitoneum. At this point, her gastroduodenal artery and superior pancreaticoduodenal vein were clipped and divided (Figure ). The specimen was placed in an endobag and extracted immediately through the mini laparotomy previously performed. Her pancreas was flushed with University of Wisconsin solution on the back-bench and brought to the islet isolation facility in a sterile bag on ice for processing.\nIn the interim, the reconstruction phase of the operation was initiated. A pancreaticogastrostomy was performed. Next, a retrocolic end-to-side hepaticojejunostomy was created with the first loop of her jejunum. The last anastomosis was an end-to-side two layer pylorojejunostomy, 40 cm distal to the hepaticojejunal anastomosis. Once the reconstruction was completed, her inferior mesenteric vein was dissected and canulated with a 16-gauge canula in preparation for the islet cell infusion.\nThe islet isolation procedure was conducted as previously described []. In brief, the pancreatic duct was canulated and injected with a purified collagenase solution (Serva, Heidelberg, Germany). The pancreas was cut into small pieces and placed into a modified Ricordi digestion system. Under microscopic control of repeat samples, the digestion was stopped by dilution and cooling as soon as 50% of the islets were free from the exocrine tissue. The digest was collected and washed under repeat centrifugation. After a quality assessment the islet preparation was placed into several syringes and brought into the operating room. The islets were successfully infused into the portal stream and her inferior mesenteric vein was subsequently ligated (Figure ). To conclude, two Jackson Pratt #10 drainages were placed - one adjacent to the pancreatic anastomosis and one underneath her liver.\nOur patient tolerated the procedure well. The weight of the resected pancreas portion was 47 g, after trimming of non-pancreatic tissue. Fifteen milliliters of tissue containing 134,727 islet equivalent (IEQ; 2867 IEQ per gram of pancreas or 2449 IEQ per kilogram of the recipient body weight) were collected. The viability of the tissue was 97%, as measured by propidium iodide and cytogreen fluorescent staining. The operation lasted six hours and thirty minutes, with an estimated blood loss of 200 mL. Our patient was maintained on an intravenous insulin drip during the first two days after the operation. She was subsequently transitioned to 4U to 6U of long-acting insulin daily. Our patient's recovery was uneventful; her C-peptide level on the eighth postoperative day was 2.2 ng/mL. She was discharged home on the ninth postoperative day with pain improvement and was maintained on low dose insulin. During her last follow-up 45 days after the surgery, she was normoglycemic without any insulin injection and reported complete resolution of her pain. |
A 60-year-old female patient had been operated on for a left mucinous ovarian cyst 20 cm in diameter in another center in February 1998. Mucinous material had disseminated into interloop spaces through the right subdiaphragmatic region. Total abdominal hysterectomy + bilateral salpingooophorectomy and peritoneal toilet had been performed. She was rehospitalized for abdominal distention and underwent surgery with diagnosis of pseudomyxoma peritonei in December 2001. A 4 cm defect over the incision was observed, and a hernia repair using polypropylene mesh was performed. Abdominal distention recurred by time and gave a rise to an incisional hernia in Pfannenstiel incision in May 2004. She was operated on again for decompression and repair, but the operating team could not achieve this intent because of sticky adhesions and simply closed the incision. As the hernia became gigantic to limit the patient's daily life within the next 2 years, the patient was referred to our department for operation. Her abdominal girth remarkably enlarged. A very large hernia, mostly located on the left side, existed (). MRI dated 2006 displayed a large incisional hernia including bowel loops, and the abdomen was full of massive intra-abdominal mucinous material deposition (). She denied a reoperation first; however her complaint got worse and a CT dated 2006 displayed a further increase of herniation (). She then accepted a surgical intervention. In the operation, a meshoma was found. Abdomen was full of a large amount of mucinous fluid and gelatinous material. Following abdominal decompression the bowel loops put back into the abdominal cavity. A prosthetic hernia repair with an onlay 30 × 30 cm polypropylene mesh was performed. The patient was discharged on the postoperative 5th day following an uneventful recovery. Although abdominal distention has become a problem again after the operation she is doing well at the postoperative 9th month with no sign of recurrence in physical examination and no fascial defect on ultrasound. Nevertheless it was known by phone call that she died of disseminated disease 18 month after the operation. |
In December 2007 a 68-year-old man presented to our institution as an emergency case with abdominal pain, intractable vomiting and weight loss. There was no family history of breast cancer or of other tumors; neither was there any sign of exposure to epidemiologic risk factors.\nHis relevant past history included an infiltrating ductal carcinoma of the left breast for which he underwent a left mastectomy with Halsted procedure in 2004. Prior to the mastectomy, assessment had included a chest X-ray, bone scan and an abdominal ultrasound, all of which were negative. His carcinoembryonic antigen (CEA) and CA 15-3 results were in the normal range. A review of the histology from his mastectomy specimen showed an infiltrating ductal carcinoma of the left breast. The tumor was 36 mm in maximum diameter infiltrating the muscular tissue and ulcerating the skin; there was a distance of 2 mm from the resection margins. Nine out of 22 lymph nodes isolated from the axillary cavity showed evidence of metastases. Both estrogen and progesterone receptors were positive. The expression of human epidermal growth factor receptor 2 (HER 2) protein was positive (2+). However, a single focus of cribriform carcinoma was found in the central lump.\nThe patient refused chemotherapy and was only treated with hormonal therapy. Forty months after his first operation, symptoms of upper intestinal obstruction appeared.\nA CT scan of his head, chest and abdomen did not show any signs of metastases. A gastroscopy revealed a hemorrhagic duodenal ulcer with stenosis. This was treated successfully with proton pump inhibitors (PPI); no biopsies of the ulcer were taken in consideration of the hemorrhagic risk, while biopsy of the gastric antrum showed an helicobacter pylori (HP) negative gastritis. The patient was discharged from the hospital with a scheduled follow-up gastroscopy in one month.\nThe esophagogastroduodenoscopy (EGD). performed in January showed the healed ulcer with duodenal substenosis; the patient's clinical condition improved and there were no signs of intestinal obstruction. The benign nature of the lesion was hypothesized and it was decided that biopsy was not needed. Further, an endoscopic follow-up was scheduled in three months.\nIn March 2008, the patient was again admitted to the hospital with the same symptoms. A clinical examination revealed a distended abdomen. The patient underwent a gastroscopy that showed a duodenal stenosis with hemorrhagic ulcer. A barium upper gastrointestinal (GI) study confirmed the diagnoses. An endoscopic dilatation was attempted without success.\nA few days later the patient underwent exploratory laparotomy, subtotal gastrectomy and resection of the first portion of the duodenum. No signs of peritoneal carcinomatosis were detected. On histopatological examination of the gastroduodenectomy, a poorly differentiated carcinoma composed of nests or single strands of atypic cells was identified in the duodenum (Figure ). Lymph nodes of greater and lesser curves did not show evidence of metastasis. The proximal and distal resection margins were tumor-free.\nImmunohistochemical stains were positive for cytokeratin (CK) 7 and estrogen receptors (ER) (Figure ), whereas staining with CK20 and CDX2 was negative (Figure ). On the basis of the histological and immunohistochemical patterns of the tumor, a diagnosis of metastatic breast carcinoma was made.\nThe patient's recovery after the operation was uneventful. The patient is alive and well and is responding well to the systemic therapy. There have been no signs of recurrence five months after surgery. |
46-year old male patient presented to his local dentist complaining of pain and swelling associated with his upper teeth. Routine dental diagnostic procedures and periapical radiographs failed to determine the origin of swelling and he was referred to the department of Oral & Maxillofacial Surgery at Suleyman Demirel University, Faculty of Dentistry. A firm swelling was seen to involve on the left side of the maxillae. An incisional biopsy was performed and this revealed the mass to be a Squamous Cell Carcinoma (SCC). The decision following the consultation was to resect the tumor and to obturate the defect with an immediate prosthesis. The patient was informed about the treatment procedure and the immediate obturation which would minimize the alteration of his appearance. Prior to surgery impressions of the maxilla and mandible were obtained and the cast models were attached to a semiadjustable articulator. The predicted excision was performed on the maxillary model. An immediate obturator with 1 cm extension into the resected side was constructed with adams retention clasp on the right second molar teeth in the preserved side. Under general anesthesia the left side of the maxillae was resected together with the lower third of the nasal septum. After the removal of the tumor, tissue conditioning material was placed over the extension of the immediate obturator to fit the surgical defect accurately and to support the defect area and split-skin grafts (Fig. ). Greater retention and stability was achieved with peridental ligatures. The patient demonstrated good postoperative progress and 10 days after the surgery the immediate prosthesis was subsequently replaced by an interim obturator (Fig. ) which was then replaced with a definitive prosthesis after three months (Fig. ). Little soft tissue collapse was observed in the medial part of the zygoma as the region failed to support the lateral extension of the permanent obturator. The problem was tolerated by the patient and he has been satisfied with his appearance (Fig. ) as well as the functions. |
A 49 year old Caucasian male with HIV/AIDS was admitted with a four-month history of soft tissue swelling in the left proximal thigh. He initially noticed a small red nodule on the skin over the left thigh which eventually increased in size and ruptured with yellowish-green drainage. He reported that he had visited the emergency room at that time and was diagnosed as having a left thigh abscess which was incised and drained. No cultures were obtained during that visit. He was seen in follow-up at the HIV clinic where cultures of the drainage were obtained and he was given a prescription for minocycline. He had resolution of the drainage but relapsed 1 month later with pain and drainage from the left hip while still taking minocycline. He presented to the hospital in a "desperate attempt to seek medical attention" secondary to the persistent pain, swelling, yellowish drainage and difficulty with ambulation requiring the use of crutches.\nOn review of symptoms, the patient reported severe pain of the left lower extremity and hip which had gradually worsened to a severity scale of 10 out of 10. He denied any trauma to the site, associated fevers, or chills. No other acute symptoms were reported by the patient.\nPatient denied any significant past medical history except HIV which was initially diagnosed in 2000. His nadir CD4 was 247 cells/mm3 and he was started on antiretroviral therapy in 2001. At his last clinic visit less than 3 months prior, he had an absolute CD4 count of 540 cells/uL and a HIV RNA viral load of < 50 copies on his current regimen of zidovudine/lamivudine and lopinavir/ritonavir He reported no known drug allergies. In reviewing the out-patient records, patient also had a history of a positive tuberculin skin test in 2002 for which he reportedly took 6 months of isoniazid and vitamin B6. The outpatient records also indicated that he had complaints of swelling and drainage from the left hip as far back as 2002. He had one bacterial culture growing Stenotrophomonas spp. for which he was treated with trimethoprim-sulfamethoxizole and ciprofloxacin with partial resolution of drainage. Subsequently he had multiple negative bacterial cultures from this drainage, and multiple courses of antibiotics between 2002 and 2003. Specimens for acid-fast bacilli were sent in 2002 for which the smears were negative but the sample was insufficient for AFB culture. Since 2003 and the time of this presentation he has had episodes of exacerbations and remissions of the current problem but lacked funding for further diagnostic work-up. He smoked one pack of cigarettes per day but denied any alcohol or recreational drug use. He denied any recent travel or exposure to any animals. The patient had been homeless for several years, but denied history of incarceration.\nOn evaluation the patient was thin and poorly nourished, but in no acute distress. The blood pressure was 110/50 mm Hg, pulse 74 beats per minute, temperature 97.9°F, and respirations 18 breaths per minute. In general, he appeared to be cachectic. His cardiovascular, gastrointestinal and respiratory system examination was normal. A 7 cm × 4 cm fluctuant, tender soft tissue swelling was present on the lateral aspect of the left proximal thigh. A sinus tract was present distal to the left greater trochanter with yellowish green drainage oozing from the sinus and it could be probed with a swab to a depth of approximately 5 cm. There was no erythema of the surrounding skin. Motor and sensory examinations were normal and there was no lymphadenopathy noted in the inguinal areas.\nRoutine laboratory data were normal, including complete blood count, renal and liver function tests. Erythrocyte sedimentation rate (ESR) was 255. Plain x-ray images of the left hip and femur were negative for any bone abnormality. Blood cultures were negative.\nCT scan of the left lower extremity showed a 25 mm × 40 mm × 140 mm fluid collection with peripheral enhancement involving the gluteus medius and vastus lateralis muscles (Figure ).\nThe patient was admitted with a diagnosis of left thigh soft tissue abscess with sinus tract. A bedside incision and drainage procedure was performed by General surgery. Cultures from the incision and drainage initially grew Streptococcus agalactiae and treatment was started with clindamycin IV by the primary team. Due to the chronicity of the wound, further evaluation with a MRI was pursued specifically to rule out underlying tumor or osteomyelitis.\nMRI of the left thigh showed a sinus tract within the proximal left thigh communicating with a loculated fluid collection contiguous with the gluteus medius and pyriformis muscles. It also revealed increased bone marrow signal intensity consistent with osteomyelitis of the proximal femur. (Figure and )\nThe differential diagnosis considerations included chronic pyogenic osteomyelitis, primary bone tumor, secondary metastasis, inflammatory arthritis, sarcoma, or tuberculous osteomyelitis.\nThe antibiotics were changed at this time to meropenem, vancomycin and levofloxacin to empirically treat the most common etiologic agents of osteomyelitis while awaiting a more definitive diagnosis. Although tuberculous osteomyelitis was considered, it was lower on the differential and levofloxacin was added to give adequate therapy for pseudomonas as a potential pathogen. The patient then underwent a CT-guided percutaneous biopsy of the left greater trochanter to confirm the diagnosis. Cultures of the bone biopsy were negative for aerobic and anaerobic organisms as well as fungi. Acid fast bacilli smears were also negative. The histopathology on the CT-guided bone biopsy did not reveal any active osteomyelitis. The patient was transferred to our long-term care unit with the plan to complete a 6-week course of empiric treatment for osteomyelitis with piperacillin/tazobactam, vancomycin and levofloxacin. The cultures eventually grew Mycobacterium tuberculosis at 5 weeks.\nThe patient was then started on a 4-drug anti-tubercular therapy with isoniazid, rifampin, ethambutol, pyrazinamide and vitamin B6, based on the susceptibility pattern of the Mycobacterium tuberculosis isolated. A work-up to evaluate for pulmonary tuberculosis was negative. The patient was discharged with follow-up by a home wound care team, as well as, outpatient directly-observed therapy for tuberculous osteomyelitis for a total duration of nine months.\nAt his out-patient follow-up visit at our clinic he has shown good clinical improvement with complete closure of the sinus tract. He does, however, continue to complain of left hip pain but is able to ambulate without any assistive device. The Orthopedic service did not recommend any immediate surgical intervention and he will be followed up by orthopedics also as outpatient. |
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. |
An 18-year-old female patient presented with fever and weakness in the upper limbs with right hand affection more than the left. Two years before presentation, she used to have fever in the evening and, gradually, she developed a persistent fever in the last 6 weeks without cough or weight loss.\nShe gave a past history of hypertension, which had been diagnosed when she was eight years old. She was regular antihypertensive medication (amlodepine and aldomet). The dosage of her medications had been decreased gradually by her physician over the last few months and were finally stopped completely based on a belief that her hypertension was spontaneously cured! She also gave a history of abdominal operation at the age of 8 years for a right suprarenal mass after discovering her hypertension, and the histolpathological report revealed fatty tissue changes and not pheochromocytoma, as was believed to be, before the operation. The hypertension was not cured after the operation and the antihypertensive medications were resumed.\nThere was no family history of the same illness or TB in her family members.\nThe patient looks ill, pale, underweight (body weight was 45 kg, height 162 cm and BMI = 17). The right upper limb pulsation was absent while it was normal in the left arm, with high force and volume in both lower limbs. Carotid pulsations were present in both sides. Blood pressure (BP) measurement was taken in the four limbs and was recorded as the following: no BP in the right upper limb, 110/70 mmHg in the left upper limb and 200/130 mmHg in both lower limbs.\nThe neck examination showed a significantly enlarged right cervical lymph node measuring 3.5 cm × 2.8 cm, which was firm, not tender and not fixed to the underlying structures.\nCardiac examination showed normal heart sounds at the apex of the heart with a loud S2 at the base and systolic bruit at the left supraclavicular fossa. Other systemic examinations were within normal limits. Chest and abdomen examinations revealed no abnormal findings.\nHemoglobin was 9 gm/dl, ESR = 120 mm in the first hour, C-reactive protein was 20 mg/dl, total white blood cells was normal with predominant lymphocytosis and normal platelet count. The serological study for ANA, cANCA and pANCA were all negative, her liver function test, renal function test, thyroid function test and urine analysis were all within normal limits. The Mantoux test for TB was performed and it was strongly positive (25 mm).\nECG showed sinus tachycardia with left axis deviation and signs of left ventricle enlargement.\nThe chest x-ray and abdominal ultrasound were normal. Echocardiography showed left ventricular hypertrophy with normal other internal dimensions and normal valves. Duplex vascular ultrasound revealed total total occlusion of the right subclavian artery with poststenotic flow pattern while the left subclavian artery was significantly narrowed.\nAn aortogram revealed normal aortic arch with total occlusion of the right subclavian artery [], with significant narrowing of the left subclavian artery []. Abdominal aorta angiography showed right renal artery stenosis with normal left renal artery []. It also showed good collaterals for right upper limb and a nonsignificant lesion at the origin of the left common carotid.\nHistolpathological report of the right cervical lymph node biopsy showed caseating tubercles suggestive of granulomatous tuberculous lymph adenitis.\nStandard anti-TB treatments with steroid were given in addition to antihypertensive medications and aspirin. The patient was improved significantly and the symptoms and cervical lymph nodes disappeared. She was discharged, to be followed-up in the outpatient clinic. |
A 46-year-old female presented in the orthopedic outpatient department of our tertiary health-care center in Central India with the chief complaints of swelling over the front of the right index finger for 1½ years. The swelling developed spontaneously without any previous trauma or thorn prick. It increased gradually in size and caused little discomfort in day-to-day and household activities. The patient visited another tertiary care center in the area, where fine-needle aspiration cytology (FNAC) examination of the swelling was done, but further treatment could not be done, after which the patient visited our center.\nExamination revealed a 2 cm × 1.5 cm firm swelling situated on the palmar aspect of the right index finger over distal part of middle phalanx and proximal part of the distal phalanx (). There was no local rise of temperature or involvement of the skin. Swelling was well defined, its surface was smooth and consistency uniformly firm. The swelling could be moved sideways easily, but its mobility from proximal to distal was limited. There was no involvement of bone clinically. The swelling moved on movement of the finger.\nX-ray of the hand AP and oblique views showed localized soft tissue shadow over distal part of middle phalanx and proximal part of the distal phalanx of the right index finger (). There was no indentation on bone or bone involvement in any way. Ultrasonography of the finger showed soft tissue mass on the palmar aspect in the distal phalanx area. Blood investigations including hemoglobin, total and differential cell counts, random blood sugar, kidney function tests, and liver function tests were within normal limits. FNAC examination done in the previous hospital reported the swelling as GCTTS.\nThe patient was planned for excisional biopsy of the swelling. Under sedation and local block anesthesia, tourniquet prepared by cutting the little finger of sterilized surgical glove was used. The tumor was excised in one piece easily. It was lying deep to fascial plane and was attached to the sheath of the slip of flexor digitorum profundus tendon. Closure was done in two layers and tourniquet released. The cut section of the tumor showed whitish, reddish fibrofatty tissue of size 2cm ×1cm (). Histopathology showed few multinucleated giant cells interspersed in a stroma of round to polygonal histiocytes, fat, and fibrous tissue, () typical of GCTTS. Post-operative period was uneventful. The patient has completed 6-month follow-up without any clinical recurrence of swelling. She continues to be asymptomatic but has terminal 10° restriction of palmar flexion of distal interphalangeal (DIP) joint of the finger with normal movement at metacarpophalangeal and proximal IPjoints. Ultrasonography of the finger did not show any evidence of abnormal soft tissue swelling or erosion in the underlying bone of the distal phalanx. Normal vascularity was detected on Doppler study. |
A 15-year-old male presented to the clinic with a complaint of right hip pain and decreased range of motion of his hip. A detailed history was performed, which included the patient recalling an injury 18 months prior when he was playing in a nonorganized soccer match. He felt a muscle pull in his right groin. He took a break from playing but resumed after a 10-minute rest. Due to continued pain he eventually stopped playing for the day. Over the next year, he noticed an increased difficulty with hip flexion especially with squatting and kicking a soccer ball with an associated increase in pain. He presented to our clinic for evaluation 18 months after the initial injury. We were the first doctors to see him regarding his right hip injury.\nOn physical examination, there was a large hard mass in the area of his right groin. His hip flexion was limited to 70 degrees on the injured extremity compared to 120 degrees on the contralateral side. He had 0 degrees of external rotation. However, he still had 40 degrees of internal rotation.\nImaging with X-rays was remarkable for a large heterotopic bone mass at the AIIS that extended 117 mm distal to the AIIS and a maximum lateral distance of 64 mm (). Computed tomography (CT) imaging was obtained, which confirmed our suspicion of the diagnosis of an AIIS avulsion fracture with a 117 mm × 65 mm bony “mass” (Figures and ). At this time, his diagnosis was consistent with extra-articular subspinal impingement. The patient failed 6 months of conservative management including physical therapy, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs). Therefore, surgical treatment for excision of the mass was offered.\nWe proceeded to the operating theater and removed the heterotopic ossification through an anterior Smith-Peterson approach to the hip (). We found that a large part of the origination of the rectus femoris was still attached to the distal aspect of the mass. This was detached and tenodesed. Postoperatively, the patient was placed on a course of indomethacin for 1 month. He returned to playing soccer after his two-month follow-up visit. The postoperative X-rays at one-year follow-up demonstrated no new bone deposition (). He had 120-degree hip flexion and full internal and external ranges of motion at his two-year follow-up visit. Importantly, the patient rated his pain at 0/10 at his 2-month, 12-month, and 24-month postoperative visits. |
A 27 year old nulliparous woman presented in November 2008 with a 2 month history of intermenstrual/postcoital bleeding. All previous smears were negative and she is a non-smoker. Clinically on examination there was a 2 × 2.5 cm exophytic lesion on the anterior lip of the cervix. Biopsy taken was inconclusive but suggestive of severe cervical glandular intraepithelial neoplasia (CGIN). The patient was subsequently seen in colposcopy clinic in December 2008 and a superficial LLETZ (12 × 10 × 8 mm) was performed which revealed a moderately differentiated adenocarcinoma of the cervix (10 mm horizontal width × 5 mm depth), incompletely excised, with lymphovascular space invasion (LVSI). The patient was then referred to a cancer centre with the expertise to perform fertility-sparing surgery.\nAt the cancer centre review the pathology and MRI of the pelvis were suggestive of stage 1b1 cervical cancer with a suspicious right obturator node. An endovaginal MRI pelvis was performed in order to obtain the following two measurements to determine that the correct cervical length was excised: the endocervical canal measured 2 cm and the length from the internal os to the top of the uterine cavity 4.2 cm. At the time of referral the patient was not pregnant and detailed counselling of the patient and her partner not only included the standard treatment but also fertility-sparing surgery. They were warned about the risks of prematurity but also the need for completion treatment by chemoradiation.\nIn January 2009 the patient underwent a laparoscopic pelvic lymphadenectomy and all 39 nodes were negative. At that time the pregnancy test was negative. In February 2009 a radical vaginal trachelectomy was scheduled but on the morning of her operation the pregnancy test was positive despite having used condoms for contraception. The first day of her last period was 28/12/08.\nThe case was re-discussed at the weekly multidisciplinary meeting and the following options were discussed:Termination of pregnancy would delay the subsequent procedure of radical vaginal trachelectomy for there would be a 6 week interval to allow for healing and resolution of artefact. This would defeat the purpose of preserving fertility and against the wishes of the couple. Radical vaginal trachelectomy during second trimester. A glandular tumour with positive margins requires removal of the endocervical canal in its entirety i.e. up to the isthmus. This is associated with an increased risk of rupturing membranes and thereby miscarriage at the time of the procedure. Obstetric advice was sought and by performing the procedure during the second trimester would minimise the risk of miscarriage associated with the first trimester. Neoadjuvant chemotherapy which would be implemented during the second trimester to avoid the greater teratogenic risk of treatment in the first trimester.\nAt 16 weeks' gestation a radical vaginal trachelectomy was performed and the specimen measured 40 mm × 40 mm × 38 mm. The maximum tumour dimension was 32 mm in addition to a tumour dimension of at least 10 mm in the LLETZ specimen. There was no evidence of LVSI in the trachelectomy specimen though it was evident in the LLETZ specimen. The anterior margin was close to the resection margin. The lateral and distal margins were well clear as was the proximal isthmic margin. By reviewing the reports in order to reconstruct the cervical cancer and estimate the size of the tumour, the conclusion reached was a diameter of 42 mm The final stage was stage 1b2 moderately differentiated adenocarcinoma of the cervix.\nIn an attempt to prevent uterine contractions a prophylactic nifedipine patch was administered at the time of the procedure and continued for a further 24 h. There is a significant risk of preterm labour in this group and an empirical course of erythromycin 250 mg qds was administered for 10 days and repeated at 24 weeks. Elective steroid administration was administered at 24 weeks' gestation to accelerate foetal lung maturity. Bed rest was preferable at home rather than a prolonged hospital stay between 22 and 26 weeks. At 25 weeks' gestation she had ruptured her membranes and was admitted to her local hospital for conservative management with monitoring of inflammatory markers and received a course of antibiotics. The patient was admitted 10 days following rupture of membranes with an antepartum haemorrhage. However, there was clinical and biochemical evidence of chorioamnionitis and she underwent an emergency classical caesarean section. A live female infant weighing 830 g was delivered at 26 weeks' gestation with Apgar scores of 6 and 10, at 1 and 5 min, respectively. Neonatal complications included respiratory distress syndrome, chorioamnionitis, and necrotising enterocolitis. The infant was discharged at a corrected gestational age of 36 weeks weighing 2440 g.\nAt 3 months postpartum the patient underwent a staging examination with multiple random biopsies. There was no evidence of disease recurrence either clinically, radiologically, or histologically. It is now 46 months following primary treatment for cervical cancer and there is no evidence of recurrence as assessed clinically and radiologically. |
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. |
A 76-year-old man fell down and was transferred to our hospital. He complained of right hip pain and inability to walk. The right hip joint exhibited contracture at 20° of adduction and 10° of flexion. A plain radiograph revealed an intertrochanteric fracture and severe deformity of the right hip joint (). Indeed, the patient had undergone hip arthrodesis surgery 56 years previously for a right femoral neck fracture, which had necessitated bone transplantation and the use of a cast for 6 months. This treatment resulted in an ankylosed rather than arthrodesed hip joint. Computed tomography (CT) imaging of the right hip joint revealed a displaced intertrochanteric fracture under the ankylosed hip joint and marked atrophy of the gluteus muscles (). Significant ectopic ossification and osteophyte development around the hip joint was suggested to be the cause of the limitation in the range of hip joint motion at all angles. Based on these findings and the radiographic images, he was diagnosed not with a simple intertrochanteric fracture, but an intertrochanteric fracture under an ankylosed hip joint. We carefully discussed the appropriate operative procedure for this condition in detail because there are few previous cases similar to this one. Gamma nail fixation was performed 8 days after the fracture. Preoperative fluoroscopic images with the patient under spinal anesthesia showed that the right hip joint was still totally immobile and fixed in adduction at 20° and flexion at 10°. The instrument used was a gamma nail (Stryker Howmedica) (). For 4 weeks after the operation, the right hip joint was set in a cast extending from the trunk to the right femur because there could be considerable stress at the fracture site. Partial weight bearing was allowed 2 weeks after surgery, and full weight bearing with the use of double crutches was allowed 4 weeks after surgery. One year after the operation, bone union was completely achieved, and the patient was satisfied with his ability to walk with double crutches (). |
A forty-year-old male welder with no past history of knee injury presented to another institution with left knee pain in September 2000. He underwent an arthroscopic partial menisectomy of the medial meniscus. In December 2004, 4 years after the primary surgery, he had a second arthroscopic partial menisectomy of the medial meniscus. However his left knee pain was not reduced. The radiographs of his left knee revealed a narrow medial joint space, femorotibial angle of 178 degrees, and posterior tibial slope [] of 9 degrees. In January 2005, when he was 44 years old, he received an opening-wedge HTO using a Puddu plate with a 15-mm opening block and osteochondral transplantation of the medial femoral condyle. The femorotibial angle was corrected to 170 degrees after the osteotomy, while the posterior tibial slope increased to 20 degrees. The Puddu plate was removed at 18 months after the osteotomy; however, he still had severe knee pain.\nIn January 2007, the patient first visited our institution for a second opinion, because he was recommended for another revision surgery to convert to total knee arthroplasty by the former hospital. He was unable to walk without a cane due to the left anteromedial knee pain. Physical examinations revealed quadriceps atrophy and no ligamentous laxity of the left knee. The range of motion was 140 degrees of flexion and -20 degrees of extension in the left knee, and 150 degrees of flexion and 0 degree of extension in the right knee. Severe left knee pain was observed with extension. The radiographs demonstrated complete bony union at the osteotomy site, a femorotibial angle of 169 degrees and posterior tibial slope of 20 degrees on the left side (Fig. ), and 178 degrees and 8 degrees on the right side. The mechanical axis of the left leg passed through the middle of the lateral femorotibial compartment. We concluded that the increased posterior tibial slope limited his knee extension, and that was the cause of the pain. We discussed with the patient the treatment options to reduce the knee pain that was his chief complaint. Since the patient was young and had a physically demanding job, we choose a medial closing wedge osteotomy to recorrect the posterior tibial slope rather than conversion surgery to total knee arthroplasty. Under arthroscopic examination, the transplanted cartilage on the medial femoral condyle was preserved; however, the medial meniscus was down-sized by the prior debridement. Degeneration of cartilage was evident due to impingement of the anteromedial edge of tibial plateau and medial condyle of femur with the extension of knee. The cartilage fibrillation observed on the medial femorotibial compartment was classified as grade III according to a modified Outerbridge classification []. The patellofemoral joint showed no arthrosis change, and lateral femorotibial joint surface had normal appearance, confirming a suitable indication for realignment osteotomy. A longitudinal skin incision was made on the previous operative scar over the anteromedial aspect of the tibia. The pes anserinus covered with scar tissues was dissected, and the superficial medial collateral ligament was exposed and detached from the tibia. The osteotomy guide wires were then inserted from the medial tibial cortex and were stopped at 1 cm short of the lateral cortex and 1 cm below the joint line. Two additional parallel guide wires were inserted to the proximal and distal of osteotomy line directed from anterior to posterior in the sagittal plane (Figs. ). These guide wires were used to estimate the correction angle of the posterior tibial slope. The osteotomy was performed, first from the medial cortex in the lateral direction according to the osteotomy guide wires, and second in the anteroposterior direction to remove the tibial bone in wedge shape and obtain full extension of the knee (Fig. ). The angular correction of the posterior tibial slope was achieved by closing the bony space that was created by osteotomy, applying a knee extension torque manually. At the end of the corrective procedure, the 2 guide wires made an angle of 15 degrees and full extension of the knee was obtained (Fig. ). Finally, a locking plate (LCP T-plate, Synthes®) was placed on the anteromedial tibia and fixed with 4 locking and 2 unlocking screws. Soft tissue releases were not performed due to the chronicity of the patient's flexion contracture. The postoperative radiographs showed 172 degrees of femorotibial angle and 8 degrees of posterior tibial slope (Fig. ). No immobilization was applied and range-of-motion exercise using a continuous passive motion machine was started from the day after the surgery. Partial weight bearing was permitted at 4 weeks and full weight bearing was achieved at 6 weeks. The patient returned to pain-free daily life including running and stair ascending and descending with -5 degrees of extension and 135 degrees of flexion. The bone union was completed and the postoperative alignment was maintained for 2 years after the revision osteotomy. The knee score of the American Knee Society [] was improved from 49 points of knee score and 35 points of functional score to 95 points and 90 points, respectively. |
A 21-year-old unmarried lady with history of brownish discharge per vagina and lower abdominal pain for the past 2 months presented with acute retention of urine. There was no history of mass per abdomen or mass per vagina. Her last menstrual period was 2 months back. The previous menstrual cycles were regular. There was mild pallor on examination. The abdomen was soft and no mass palpable. Ultrasonography showed large soft tissue lesion embracing the uterus all around. Bilateral ovaries were normal. Computed tomography scan showed a large well-defined heterogeneously enhancing mass lesion measuring 10.4 × 11 × 14 cms. This appeared to arise from the vagina extending superiorly up to the level of the pelvic inlet (). The lesion was seen engulfing the uterus and broad ligament and accompanying blood vessels superiorly. It was also seen compressing the bladder anteriorly and the rectum posteriorly (). Vaginal examination under anesthesia showed large polypoidal mass distending the vagina and occupying the whole pelvis. The vaginal walls appeared free from the mass. The exact origin of the mass could not be made out as it was not possible to get above the mass. Histopathology of the biopsy taken from the vaginal mass showed benign epithelial and mesenchymal components suggestive of adenofibroma. The tumor markers like alphaetoprotein, CA 125, and beta HCG were within the normal range. The exploratory laparotomy was planned after ureteric stenting. Preoperative ureteric stenting could be achieved only on one side. On the other side ureteric orifice was not accessible due to anatomical distortion by the pelvic mass. Intraoperatively, a large pelvic solid tumor mass was seen burying the uterus. The bilateral tubes and ovaries were seen projecting out. The tumor mass was firmly impacted in the pelvis. There were no dense adhesions to adjacent structures. Total hysterectomy with bilateral salpingectomy was done. The buried uterus was exposed along with the mass only after clamping and cutting the uterine pedicles and vagina. The size of the mass was approximately 14 × 10 cms. The outer surface of the tumor showed numerous polypoidal masses, which on cut section was seen to arise from the cervix (). Histopathology showed tumor arising from the cervix in the form of molded papillae lined by cuboidal epithelium and subepithelium showing scattered glands with surrounding stroma containing fibroblasts (). The tumor does not appear to invade the cervical tissue. The diagnosis of cervical adenofibroma was made. Her postoperative recovery was uneventful, and she was discharged on the 14th day. She was healthy in her follow-up visits. |
This case of a 42-year-old female patient reported to the outpatient department with a chief complaint of swelling in the lower right back tooth region. The patient was of average built and normal gait. The patient had a habit of chewing tobacco 4–5-times a day for 20 years.\nThe right submandibular and submental lymph nodes were palpable (IB and II). The extraoral swelling extended from the right corner of the mouth to the lower border of the mandible, including the lower left third molar region. The swelling was approximately 5 cm by 5 cm in dimension []. The patient gave a history of extraction of molars and a subsequent increase in the swelling.\nAfter blood investigations, the patient was advised advanced investigations which revealed that the patient was HIV (positive).\nIntraoral clinical examination revealed a soft tissue growth on the right buccal mucosa, soft inconsistency. The lesion extended from the lower right canine to the lower right third molar and was accompanied by symptoms such as pain, bleeding, swelling and paresthesia of the right side of the lower lip. The swelling was present intraorally for 6 months according to the history given by the patient. The swelling was flat in appearance with no ulceration present on it, mixed in color and the approximate size of the lesion at the time of biopsy was <5 mm.\nRadiographic examination was done including orthopantomogram (OPG) and computed tomography (CT) of the spine + brain + three-dimensional (3D) reconstruction. The OPG revealed an extraction socket with 46, 47, 48, compression of the inferior alveolar nerve canal, caries approaching the pulp with 17 and 18 along with resorption of the lower border of the mandible on the right side.\nThe CT-C spine + brain + 3D reconstruction showed lytic destruction in the body and ramus of right mandible, cortical erosion, enlarged soft-tissue mass on the right side and the overall picture was suggestive of malignancy of the mandible [].\nThe gross examination of the specimen included multiple bits of soft tissues measuring 0.2 cm × 0.1 cm and 0.5 cm × 0.3 cm in dimension, white in color, soft to firm in consistency with irregular surface and borders [].\nHistopathology [] showed hyperplastic squamous mucosa and underlying connective tissue showing sheets of oval cells with eccentric nucleoli which were suggestive of plasmacytoid cells. These cells revealed a high mitotic activity and appeared pleomorphic, hyperchromatic with prominent round nucleoli surrounded by moderate cytoplasm and vesicular nuclei and moderate cytoplasm. As the overall histopathological picture was ambiguous, immunohistochemistry was advised since there was a definite involvement of the submental and submandibular lymph node.\nA panel of immunohistochemical markers suggested were as follows: MiB1, CD3, CD138, leukocyte common antigen (LCA) and cytokeratin (CK).\nMib1 is a proliferative marker [] and in this case showed increased mitosis, loss of pattern, prominent nucleoli and nuclear pleomorphism. This had taken up a brownish hue suggesting positivity.\nCD3 is a T-cell antigen marker [], and the brownish color indicated positivity for malignant plasma cells.\nCD138 or syndecan is a marker [] of plasmacytic differentiation and showed abundant plasma cells forming clusters, which was seen as a brownish color and hence marked increased expression.\nLCA and CK negativity [Figure and ] in the connective tissue ruled out the hematogenous and epithelial origin, respectively, of the malignancy.\nThe immunohistochemical panel showed\n90%–95% positivity in tumor cells with Mib-1 CD3-positive in reactive T-lymphocytes and negative in tumor cells CD138-positive in tumor cells LCA- and CK-negative in tumor cells.\nBased on these findings, the confirmatory diagnosis of PBL was given. |
A 67 year old man of Greek origin attended the emergency department with a two hour history of dull central chest pain that radiated into his back. There were no other symptoms and he was normally in good health. Examination and investigations (chest radiography, ECG, full blood count, and biochemistry screen) were thought to be normal. His pain subsided apart from some discomfort on swallowing and he was discharged home. She re-attended the department six days later. He complained that he had been cycling up a hill and had developed severe chest pain radiating into his jaw together with some sweating. Moreover, the discomfort of which he had previously complained had persisted. On examination he had a pulse of 98 per minute, BP 142/72 mm Hg, SaO2 97% on air and temperature 37.5°C. There were no cardiovascular or abdominal signs. There was no surgical emphysema in the supraclavicular fossae. On examination of the chest breath sounds were equal bilaterally for the upper lung fields, but absent for the right lower lung lobe. Chest x-ray confirmed the findings of physical examination and demonstrated right pleural effusion, but no radio-opacity was detected and there was no evidence of pneumomediastinum or subcutaneous emphysema (Figure ). At this point, a small amount of free air in the right hemithorax was overlooked and the patient admitted to the hospital with the diagnosis questioned for a basal pulmonary pathology.\nBecause of an erroneous belief that pulmonary complication was the cause of this specific clinical picture, the diagnosis of esophageal perforation was not suspected. The original diagnosis of esophageal perforation was delayed because of misinterpretation of right pleural effusion as a basal pulmonary pathology. Finally, three days after admission clinical deterioration with increased respiratory distress and discomfort, fever and chest pain did arouse suspicion of an esophageal perforation. At this point with a thoroughly history taken, the patient admitted to having had eating fish 12 days ago and the pain begun a few days after (he was attending to Emergency Department three days after), although he had not knowingly swallowed a fish bone.\nThe investigations were repeated and he now had a raised white cell count (16.3 × 103/ml with a neutrophilia) (reference range, 3.9-10.7 × 103/ml), a somewhat lower haemoglobin concentration (12.8 g/dl previously 14.6 g/dl) and an increased C reactive protein concentration (46 mg/l previously <8 mg/l). The ECG was normal. By this time, the pain was pleuritic and gradually become unbearable. Accordingly, he was given analgesia and high dose intravenous antibiotics. The patient underwent a complementary evaluation, with esophagogram, chest x-ray, and contrast enhanced CT scan tomography revealing a right-sided, distal esophageal rupture, with the coexistence of ipsilateral hydropneumothorax.\nA subsequent hypaque swallow study failed to demonstrate extravasation of contrast medium (Figure ). Erect chest x-ray a few hours later demonstrated contrast medium extravasation accompanied with large pleural effusion (Figure ). Subsequent CT scan demonstrated right sided pneumothorax, extended right sided pleural effusion and a small amount of air in the mediastinum (Figure ).\nFurthermore, a confirmative esophagogastroduodenoscopy revealed a small distal esophageal perforation (Figure ). Fasting was implemented. However, fever subsequently developed (maximum temperature, 38.9°C). The white blood cell count was 19.0 × 103/ml. The patient was treated conservatively with intravenous cefuroxime (750 mg every 8 hours), ampicillin (500 mg every 8 hours), and metronidazole (500 mg every 8 hours) to cover the oral bacterial flora.\nA large thoracostomy tube (32 gauge) was immediately placed in close proximity to the rupture site for pleural effusion drainage and the patient was transferred to our surgical unit promptly. A covered self-expanding metallic stent (Ultraflex, Boston Scientific) was inserted endoscopically, across the tear site to prevent ongoing local infection (Figure ). Oral fluid intake was allowed in increasing amounts and viscosity. Fever decreased rapidly to approximately 38°C and subsided after 2 days. The patient's condition improved and 1 week later there was no leak demonstrated by contrast radiography.\nThe intravenous antibiotics treatment was discontinued after 5 days, and right-sided chest drain was removed on the 7th day. He recuperated uneventfully and was discharged home 8 days later. The metal stent was removed endoscopically 4 weeks later. Because the stent crossed the lower esophageal sphincter, for the entire treatment time, a high dose of proton pump inhibitors was administered to reduce gastroesophageal reflux. Follow up 3 months after discharge showed the patient to be recovering with no complains (Figure ). |
A healthy two-year-old white boy sustained a blunt injury to his right eye after hitting against a sideboard in September 2008. He was asymptomatic till a month later when he presented to a local Casualty Department with a red and painful right eye. Upon referral to a children's hospital, he had light perception vision in his right eye and strongly objected to occlusion of his fellow eye. Examination of his right eye under anesthesia revealed conjunctival injection, corneal stromal haze, an intense anterior chamber reaction with fibrinous reaction and iris deposits, lens opacity as well as a raised intraocular pressure of 30 mmHg. The corneal diameters were 12 mm bilaterally. Examination of the posterior segment was difficult due to significant media opacity but the retina appeared attached. Examination of his left eye was unremarkable. He was otherwise systemically well without any previous medical or ophthalmic history.\nAn anterior chamber tap was performed and this revealed small round cells in clumps. As the specimen was poorly preserved, no further evaluation was possible. There was no mass lesion seen on a magnetic resonance imaging scan of the right orbit. An ultrasound scan showed clumps of hyperechogenic material over the temporal lens surface, which was found to be adjacent to but not apposed to the ciliary body and extruding into the anterior vitreous. This was associated with a cataractous lens and the presence of cyclitic membranes. The diagnosis of a traumatic cataract with severe uveitis of the right eye was made and intensive topical steroid therapy was started to treat the inflammation. He later underwent a right lensectomy and anterior vitrectomy on January 2009 (four months after initial presentation) and was left aphakic.\nPostoperatively, the intraocular pressure in his right eye became increasingly difficult to control despite the use of gutt Cosopt and Travatan. The cup-disc ratio in his right eye was then noted to be 0.5 (compared to 0.1 in the left) and the right axial length 23.6 mm (compared to 21.2 mm in the left). The angle was closed in all 4 quadrants and an ectropion uvea was observed. There was no rubeosis. A limited trans-scleral cyclodiode laser was performed to the right eye two weeks later. He then underwent a right Baerveldt shunt (350 mm2) with 0.4 mg/mL Mitomycin-C in September 2009 due to further glaucoma progression, as evident by an increase in the cup-disc ratio (0.7), axial length (25.8 mm), corneal diameter (14 mm), and intraocular pressure measurement (39 mmHg).\nIn February 2010 (about 15 months after initial presentation), his parents observed a rapidly enlarging mass lesion in the inferotemporal part of the child's right eye over a week's duration. On examination of his right eye, a solid flesh-coloured fibrovascular inferotemporal ciliary body mass was seen in the presence of sentinel vessels () and this was associated with significant vitreous seeding. An iridocorneal touch at the 7 o'clock position and the presence of an ectropion uvea were observed. His right vision remained light perception and intraocular pressure was controlled at 12 mmHg. Ultrasound imaging revealed an irregular-surfaced mass with heterogeneous echogenicity measuring 8 mm in length by 11.3 mm in width by 5.4 mm in thickness (). No satellite mass was seen. A diagnosis of ciliary body medulloepithelioma was made based on the clinical appearance and location of the lesion as well as its ultrasonographic features. Prompt enucleation of the right eye was then performed in view of a possible malignant transformation due to its rapid clinical growth as well as an underlying poor visual prognosis. Histology revealed a locally invasive anterior ciliary body tumor comprising of undifferentiated highly mitotic cells and in keeping with the clinical diagnosis of a ciliary body medulloepithelioma. No rosette was seen. Due to the histologically malignant features as well as a previous Baerveldt tube implant (increased risk of periorbital tumor seeding), he was further treated with six cycles of chemotherapy using vincristine, etoposide, and carboplatin. No recurrence was observed after 14 months of followup. |
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. |
A 33-year-old Asian woman in her fifth month of pregnancy presented with discomfort and redness in her left eye. The patient had history of penetrating keratoplasty in both eyes secondary to corneal melting of unknown cause 15 years previously. She had been on the prolonged self-use of steroid eye drops at that time. Despite extensive screening, no immune-mediated or infectious condition was identified. The patient was not pregnant at that time. Thereafter, she had recurrent episodes of corneal melting in the right eye and underwent two more penetrating keratoplasties and one corneoscleral grafting procedure in the right eye. Every episode was accompanied by spontaneous corneal melting without obvious inflammatory signs. She remained asymptomatic for the next ten years, until her fifth month of her first pregnancy. She had no history of ocular trauma or systemic disease, and her pregnancy was uncomplicated.\nExamination revealed several round infiltrations in the peripheral cornea in the left eye, accompanied by limbal edema and conjunctival injection (). Her right eye remained stable (). We prescribed topical prednisolone eye drops four times per day for her left eye. Two weeks later, the inflammatory signs and symptoms in her left eye completely subsided (). Meanwhile, her right eye developed corneal melting beginning in the superior part of the cornea (). No inflammatory signs or symptoms, such as pain, conjunctival injection, or corneal infiltrates, were observed. Systemic screening for rheumatologic diseases was performed; all test results were negative. Schirmer test revealed normal tear production in both eyes, and her lid function was normal. We prescribed oral prednisolone 30 mg per day after consultation with an obstetrician, and we performed amniotic membrane transplantation. Despite these efforts, the spontaneous corneal melting progressed, and Descemet's membrane became visible in the superior half of the cornea (). In the patient's seventh month of pregnancy, we performed penetrating keratoplasty in the right eye for tectonic purposes (). Corneoscleral grafting was also performed for the extremely thinned part of the peripheral cornea.\nThe left eye presented with diffuse conjunctival injection and multiple, round infiltration in the inferotemporal periphery of cornea, suggesting marginal keratitis (A). The inflammation was completely resolved after two weeks of topical prednisolone therapy (B). Meanwhile, the right eye, which was totally opaque but remained stable for ten years after having undergone three penetrating keratoplasties (C), developed corneal graft melting without inflammation signs and symptoms (D, arrowhead). The graft lysis progressed over the next two months (E). Amniotic membrane transplantation was performed to stop the lysis of corneal graft, which failed (F). Descemet's membrane was visible in the superior half of the cornea (G, arrow). Eventually, the full-thickness corneal transplantation with tectonic corneoscleral grafting was performed (H). |
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 51-year old gentleman with a background history of autistic spectrum disorder, depression and obsessive-compulsive disorder was admitted to the intensive care unit (ICU) following transfer from a referring hospital where he initially presented 6 days previously with a 24-hour history of vomiting and abdominal pain following ingestion of a lye detergent. There was no evidence of airway damage, and no initial evidence of esophageal perforation, and he was managed conservatively. On day 5 post admission he became septic, and imaging revealed air and contrast in the mediastinum and right thoracic cavity (Figure ).\nHe was then transferred to this tertiary centre. On initial admission to ICU he was septic, with fever and hypotension, and signs of progressive respiratory failure. He was intubated and large-bore intercostal drains were inserted bilaterally. Esophagogastroduodenoscopy showed diffuse esophageal mucosal injury and but no obvious sign of perforation, and a repeat CT showed no obvious leak of contrast from the esophagus. A naso-jejunal tube was inserted for nutritional support. A percutaneous tracheostomy was inserted due to an anticipated requirement for prolonged ventilation. On day 30 in the ICU, gastric fluid leakage of 500 ml emerged from the right-sided chest drain. A repeat endoscopy revealed a large esophageal perforation in the lower esophagus opening into the right thorax, and the tip of the chest tube could be seen through this defect in the thoracic cavity.\nThe decision was made to insert a T-tube endoscopically (see Additional file ). The original intention was firstly, to insert the guide-wire in a retrograde direction through the chest drain into the thoracic cavity and secondly, to use the biopsy forceps that is passed endoscopically from the esophageal side to grasp the guide-wire and finally, to pull it out through the mouth. Since the tip of the chest drain was in continuity with the perforation, the guide-wire was firstly, inserted in an antegrade direction into the esophagus and out onto the chest wall through the right-sided chest drain (Figure ). Secondly, the T-tube was attached to the guide-wire outside the mouth and then pulled through orally into the esophagus with the main stem of the T-tube pulled out onto the skin after the chest drain had been removed (Figure ). Finally, the proximal and distal limbs of the T-tube were positioned in the esophagus and stomach respectively with the help of biopsy forceps (Figures &).\nA follow up tubogram showed good flow of contrast into the stomach and esophagus via the T limbs with no leak of contrast from the site of perforation (Figure ). The T-tube was left on free drainage and allowed tract to mature. The patient's condition gradually recovered and he was transferred to the ward on day 45. Oral nutrition was tolerated well without sequelae. The T-tube was removed on day 60 and the patient discharged well. He remains well at 6 months of follow-up. |
A 32-year-old female visited our hospital with a complaint of right knee pain. She had come three months ago for similar symptoms and had been diagnosed with OCD of the right knee based on clinical presentation and imaging studies obtained at that time. At the latest presentation, the pain increased in severity and the patient required a cane for ambulation due to a catching sensation in her right knee. Physical examination revealed moderate swelling and stiffness of the right knee. Localized tenderness was noted on the lateral and medial joint lines and twenty degrees of passive extension was lost.\nStanding weight-bearing posterior-anterior radiographs were obtained and revealed irregularities of bilateral femoral condyles in both knees on the weight-bearing portion of the femur (). Magnetic resonance imaging (MRI) showed a fragment in the center of the both femoral condyles with bone marrow edema. A fissure between the articular fragment and femoral bone base was also seen. Additionally, a 2.8 cm by 2.5 cm displaced articular loose body shadow was noticed on the lateral femoral condyle.\nThe patient was brought to the operating room and prepped and draped in the standard sterile fashion. Arthroscopic examination was performed first and findings revealed a 2.8 cm by 2.5 cm displaced osteochondral fragment from the lateral femoral condyle. The OCD defect was 0.5 cm in depth and contained a subchondral cyst and degeneration. A similar sized loose osteochondral lesion was also found on the medial femoral condyle with degenerative subchondral bone. It was decided that there would be a lower potential for healing if the fragments were simply re-attached. A decision was thus made to proceed with ACI for the lateral lesion and OAT for the medial lesion. Chondrocytes were harvested and the patient was brought back for subsequent operation five weeks later. An 8-cm midline skin incision was made on the right knee and an arthrotomy was performed. The lateral femoral condyle defect was treated with ACI (). Four osteochondral grafts were obtained from the superior aspect of the femoral condyle and trochlea using a special chisel (OATS; Arthrex, Naples, FL, USA). After implanting the donor cylinders using a press fit technique on the medial femoral condyle, the free space between the grafts was filled with remnant chondrocytes from the ACI. The patient was not allowed weight-bearing for six weeks and passive and active range of motion exercises were performed during this period. The patient was followed up for two years after surgical treatment. Her Lysholm score and visual analogue scale score were improved from 32 preoperatively to 90 at the last follow-up and from 9 preoperatively to 1 at the last follow-up, respectively. |
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. |
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. |
A 48-year-old man, who was diagnosed with advanced primary HCC with right atrial metastasis and sought medical treatment, was admitted to our hospital. A computed tomography scan revealed a large mass (approximately 7.6 × 7.6 cm in size) in the right lobe of the liver and intracavitary metastasis to the right atrium, an extremely rare secondary cardiac malignancy of primary HCC metastasis (Fig. ). According to the classification of IVCTT as previously described,[ the present case was intra-cardiac type III IVCTT with a cardiac TT above the diaphragm that extended to the right atrium of the heart. The patient underwent surgical treatment on September 25, 2018, during which time right atrial metastasis in the heart was actually observed, extending from the right liver via the IVC to the right atrium (Fig. A); the gross specimen of resected cardiac mass is shown in Figure B.\nAfter full assessment, surgical treatment, consisting of hepatectomy, resection of the involved IVC and right atrium thrombus, and reconstruction of the resected IVC, was performed in this patient. After blocking the right Glisson pedicle and marking the ischemic line at the junction of the left and right half liver, the liver was split along the line under the blocking of the first hepatic hilar and subhepatic IVC. The right Glisson's pedicle was then dissected. Subsequently, the chest was opened, the mediastinum and the diaphragm muscles around the hepatic IVC were cut, the pericardium was opened, allowing fully exposure of the heart, and cardiopulmonary bypass (CPB) was performed in the patient. In the following operative procedures, the right atrium was cut, the right half liver was removed at the root of the right hepatic vein; a longitudinal 8-cm long incision was made on the surface of the superior hepatic IVC, followed by complete removal of the IVCTT and secondary thrombosis. The right atrium incision was closed and the resected IVC was then reconstructed in which autologous pericardial tube graft was selected and used for suitability mainly due to its low thrombogenicity, low risk of narrowing, and contracture. The patient agreed to the treatment plan, and the operational procedures were performed by a surgical team of hepatic and cardiothoracic surgeons under the condition of beating heart CPB (Fig. C). The entire operation lasted nearly 9 hours with no major procedure-related complications.\nUpon completion of surgical treatment, whole exome sequencing was performed to identify specific targeted cancer therapies for the patient. Levotinib, a tyrosine kinase multitarget inhibitor, was orally administered 12 mg once per day. Fourteen days after surgery, the patient was discharged from the hospital. Notably, the follow-up examination of serum alpha-fetoprotein (AFP) levels showed that they were within normal range (Fig. ). Fortunately, the patient did not show any clinical signs or symptoms of recurrence during follow-up, and he is currently cancer free nearly 10 months after surgical treatment combined with targeted cancer therapy. |
A 52-year-old male with a past history of hypertension and bony fusion of the thoracolumbar spine (from 11th thoracic to 2nd lumbar vertebrae) due to tuberculous spondylitis, was presented to the department of orthopedic surgery. He was a heavy smoker and complained of right foot pain, claudication in his right calf, impaired gait functions, and muscle wasting on the right lower limb, which had begun 7 months prior to the visit.\nMagnetic resonance imaging (MRI) of the thoracolumbar spine showed severe kyphotic curvature in the thoracolumbar spine, and central canal stenosis on the 10th and 11th thoracic vertebra level with a relatively well preserved lumbar spinal canal ().\nThe first impression of his attending surgeon was that he had spinal stenosis, related to severe thoracolumbar kyphosis. However, his symptoms were not well correlated to the MRI findings; and his condition did not improve, despite undergoing two weeks of medication. Subsequently, he took an electrophysiologic study at the department of neurology. The nerve conduction study revealed reduced amplitude of the right tibial and peroneal compound motor action potential, and the sural sensory nerve conduction study result was within the normal range (). Needle electromyography showed abnormal spontaneous activities in the right tibialis anterior, peroneus longus, short head of the biceps femoris, gastrocnemius, extensor digitorum brevis, and the abductor hallucis. On volition, the giant motor unit action potential was noted in the tibialis anterior (). These electrophysiologic findings were suggestive of partial right sciatic neuropathy. They concluded that the patient's foot pain and claudication were caused by sciatic neuropathy, combined with lumbar spinal stenosis, and maintained medication for neuropathic pain.\nTwo months later, he visited the department of rehabilitation medicine for an impairment rating and disability determination, and was still complaining of right foot pain and right leg claudication. We focused on the previously diagnosed non-traumatic right sciatic neuropathy noting his medical history; and performed an extended examination to reveal an undiscovered cause of neuropathy, or other possible causes of his symptoms. He described right leg intermittent claudication affecting the buttocks, and a burning ache radiating to the calves and foot. His claudication was exacerbated during walking and slightly relieved when resting. Upon physical examination, we were able to palpate diminished femoral and popliteal pulses on the right lower limb compared with the other side. On neurologic examination, the sensory test showed hypesthesia in the right lateral knee and foot, and sole of the foot. The motor power of the right lower limb was above grade four in all tested muscle groups, but was slightly weaker than the left side. Atrophy was also found in the right calf, anterior leg and foot muscle, and deep tendon reflexes were hypoactive in the right lower limb.\nComputed tomography (CT) angiography was performed to rule out the possibility that the symptoms were caused by ischemic disease. CT angiography of the lower extremities showed an occlusion of the infrarenal abdominal aorta, and bilateral common iliac and right external iliac arteries; and collateral circulations to both the internal iliac arteries and left external iliac artery were also observed. However, there were no significant findings that could cause sciatic neuropathy, such as mass lesions (). These findings were compatible with Leriche syndrome. Therefore, we concluded that our patient had Leriche syndrome causing ischemic injury of the right sciatic nerve.\nHe was referred to the department of surgery and underwent a bilateral axillo-femoral and femoro-femoral bypass graft. After the bypass surgery, his symptoms including claudication and right foot pain were relieved; but hypesthesia and motor weakness of the lower limb arising from sciatic neuropathy persisted at the time of the last follow-up visit, 8 months after the surgery. |
The first case report is about a young 11-year-old female patient who came to the hospital on a Saturday to the cardiothoracic unit out-patient department (OPD) and was diagnosed to be a patient of atrial septal defect. She carried a blood group report of a hospital where her preliminary testing was carried out as O (ABO), Rh positive. As the blood group was readily available at our center, she was advised admission on Monday and her cardiac surgery was scheduled on Tuesday. Her blood sample for cross matching arrived at the blood bank with the request for two units of blood. Her blood group was also reported as O positive in the pre-transfusion testing at our lab. The matching was initiated and more than 10 red blood cell units of O positive were found to be incompatible. On repetition of the blood group, it was found that the pooled O cells were giving positive agglutination in the reverse grouping. Her red blood cells gave no agglutination with anti-H lectin. The probability that the patient was having the rare blood group, Bombay Oh phenotype was raised and further confirmation of the blood group was done by saliva hemagglutination inhibition test and the sample was also sent to a reference serology laboratory of Indian Institute of Immunohematology (IIH) at Mumbai, India and the report received later also confirmed the same. On taking further history, it was found that she was a tribal girl originally from a tribal state of India. Since this was the first case of Bombay phenotype, we decided to do blood grouping of her family members, but none of them were of the same group. However, her hemoglobin was 11.8 g/dl and the surgeon was explained about the rarity of the blood group as well the unavailability, the option of ANH was considered. She was successfully operated and withdrawal of one unit autologous blood was done with simultaneous hemodilution (ANH) in the operation theater and her course of stay was uneventful until her discharge from the hospital. |
Our first patient was a 67-year-old male with a medical history of diabetes mellitus type II, hypertension, and benign polyps in the colon (three polypectomies). The patient had a history of tobacco use during the last 50 years; at the time of reference, he smoked 10 cigarettes daily. He had no alcohol overconsumption. When referred, the patient had suffered from dysphagia for 2 months, and he only consumed fluids. Besides a weight loss of 8 kg (weight at referral 83 kg, weight loss corresponding to 9% of initial body weight), the first physical examination was unremarkable, as were the initial blood tests. The primary endoscopy revealed a mucosa covered with white plaques spreading from 30 to 40 cm from the incisors. In the distal part of the affected area, the mucosa protruded and covered almost 2/3 of the lumen and involved the entire circumference (fig. ). The finding was thought to be a candida infection. Biopsies showed severe acute inflammation with reactive changes but without dysplasia or malignancy. A computed tomography (CT) scan showed a thickened wall in the distal part of the esophagus. Since no malignancy was found, the patient was discharged.\nFour months later, the patient was referred again due to a further massive weight loss of 25 kg; at this time he weighed only 58 kg (weight loss corresponding to 36% of initial body weight). Gastroscopy and blood test were performed again, and human immunodeficiency virus, herpes, and HPV infection were ruled out. To rule out achalasia of the esophagus and gastroesophageal junction, a high-resolution impedance manometry examination was performed followed by a positron emission tomography (PET)-CT scan, but neither could explain the condition the patient suffered from. During this period of approximately 4 months, the patient was hospitalized at the Department of Infectious Diseases.\nSix months after the first visit, another gastroscopy was performed showing ulceration and a process protruding into the lumen. The biopsy revealed a squamous cell papilloma. In view of the severe weight loss and the poor condition of the patient, an esophagectomy was offered and accepted. The pathology report described a low-grade verrucous squamous cell carcinoma (fig. ). There was no dissemination into the lymph nodes or other organs. The patient was discharged after 2 weeks and is presently symptom free. |
A 14 years old female patient who came to the emergency room due to abdominal pain located in the LLQ (Left Lower Quadrant) and RLQ (Right Lower Quadrant). According to the patient, she had a mild pain in the epigastric area since the night that she took her Ranitidin and her pain was resolved, but she had sudden and sever pain in the hypogastric area since the morning so she woke up from pain. And simultaneously have nausea and vomiting. Due to severe abdominal pain, she did not have urinary symptoms and had no excretion since the night before the visit. Her mother said that she has had vague abdominal pain about two years ago, but no specific paraclinical examination was performed.\nThe patient was admitted for the treatment of appendicitis with primary diagnosis of acute abdomen. In the initial examinations, clear tenderness in the area of RLQ, LLQ, LUQ (Left Upper Quadrant) of abdomen and rebound tenderness was positive the examinations of other organs were normal and there was no other positive finding.\nExperiments were conducted in which leukocytosis was observed, but urinalysis and urine culture tests were normal (). An ultrasound scan was performed that showed no evidence of appendicitis, but in the spleen it was seen umbilical a cyst with an internal echo and septum, measuring 115 * 75 mm. Emergency surgical consultation was carried out. At the time of counseling, the pain of the patient was reduced and a slight tenderness was observed in the left side of abdomen, and the rebound tenderness was resolved and, according to surgical consultation, it was recommended that the CBC be repeated and CT scan be performed.\nIn the CT scan (), three large cysts were observed in the spleen; another surgical consultation was done and recommendation for splenectomy was made. The patient became hydrated and treated with ceftriaxone and metronidazole.\nPathology report\nMacroscopic. Specimen received in fixative consists of a spleen measuring 15*12*7 cm. The capsular surface shows irregular and cystic. Cut surface shows multilacunar cyst. Inner layer was gray white and smooth.\nOur patient was on the list of splenectomy surgery and received the necessary vaccines. After two weeks of vaccination, splenectomy was performed and the sample was sent for pathology. She is currently in good condition and does not have any complications. She now receives Penicillin V as a prophylactic antibiotic. |
A 42-year-old female presented to us with a primary complaint of pain in the left side of her face for 3 yrs. The pain was spontaneous and oppressive in nature. She had a history of burning, a pricking type of dysesthesia (pins and needles feeling), intermittent in nature and radiated to the left temporal and orbital region. The unremitting nature of pain often made her feel anxious and agitated with lack of sleep. No trigger factors and aggravating or relieving factors were disclosed in the history. She narrated a history of uneventful extraction of a decayed upper third molar and a restoration of carious tooth citing as a possible source of pain by her dentist.\nHer medical history was unremarkable except the ingestion of a cocktail of medicines alternating from analgesics, antibiotics, steroids, and antidepressants prescribed by multiple physicians for the unremitting chronic pain she was experiencing. An array of investigations was performed ranging from MRI brain, OPG, and cephalograms that turned out to be inconclusive. Vascular decompression, central pontine dysfunction, skull base, and metastatic tumor were ruled out following the normal slices seen in MRI and CT. Routine chair side diagnostic tests were done to rule out odontogenic pain.\nOn clinical examination, a sharp localized pain in the hamular region was evident on palpation due to the elongated hamular process that had a knife-edge bony projection (). The overlying palatal mucosa had no change in color or texture. A local anesthetic (1 ml of 2% lidocaine) infiltration was injected with subsequent impermanent relief of symptoms in a localized area. Her oral examination was nonremarkable on the affected left side with deep dentinal caries with respect to 18 () and pulp stones with respect to 16 on the right side (). Blood investigations carry less significance except in the possible diagnosis of cranial arteritis and for autoimmune disorders such as Sjogren's syndrome.\nFollowing a failure of conservative remedies in the past, a prominent elongated hamular process (18.53 mm) noticed on a cone beam computed tomography: axial section (), 3-D reconstructed view (), and a positive diagnostic block [], we opted for a surgical shaving in pursuit of pain relief ().\nA longitudinal incision of the mucosa was planned along with dissection up to the pterygoid hamulus followed by resection of the hamulus from its base. The gross specimen measured 13 mm in length and its shape resembled an arrowhead (). |
A 61-year-old male patient was admitted to our hospital with complaints of numbness in the lateral half of the 1, 2, 3, and 4 fingers of the right hand and decreased range of motion which started 1 day earlier and increased in severity. With the in-depth analysis of the patient's, he did not have any similar complaints before. An immunohistochemical examination of the biopsy material obtained from the mass on the right shoulder 1 month before the patient's numbness in his fingers was consistent with secondary amyloidosis.\nIn the physical examination of the patient, active and passive flexions of the fingers were found to be limited and numbness was noticed in the 1st, 2nd, 3rd, and 4th lateral half of the fingers, which is the innervation area of the median nerve. Even though no atrophy was seen in the thenar muscles, it was observed that the palm of the effected hand was hypertrophic compared to the other palm, and the Tinel and Phalen tests were both positive.\nBecause the direct radiographs of the patient were interpreted as normal, MRI was requested for further examination. MRI revealed excessive fluid collection and intense synovitis in the intercarpal, radioulnar, and ulnocarpal joints and surrounding para-articular soft tissue planes at the wrist level. The findings were thought to be compatible with amyloidosis, but rheumatologic diseases could also be compatible with the same findings. Because of this, further investigation has been done with clinical examination and laboratory findings. No rheumatologic diseases has been diagnosed after the investigation.\nIn the patient's EMG, the following are found: (1) The compound muscle action potential of the right median nerve was found to be low amplitude, and the amplitude of the muscle action potential combined with wrist stimulation decreased by more than 50 compared to palm stimulation (partial conduction block). Motor transmission speed was low in the palm-wrist segment. Motor conduction studies of the other nerves of both upper and lower extremities were found to be normal. (2) Sensory action potential of the right median nerve could not be obtained. In conclusion, these findings were consistent with acute carpal tunnel syndrome causing axon and myelin damage on the right upper extremity.\nThe patient underwent surgery the day after he presented to our outpatient clinic. Incision has been done in the volar side of the right hand following the palmar crisis, and the transverse carpal ligament was loosened completely; afterwards, biopsy was taken for pathology. The median nerve appear to be swelled. It was assured that the nerve was completely decompressed distally and proximally. Neurolysis was performed after the median nerve was loosened. Diffuse synovial thickening has been observed around the flexor tendons which were hypertrophic (). Synovectomy has been performed ().\nAccording to the results of the pathology samples sent during surgery, AA-type amyloidosis was detected in the samples taken from the median nerve sheath and from the synovial tissue on the flexor tendons (Figures and ).\nThe Tinel and Phalen tests were found to be negative, and numbness in the fingers disappeared and finger flexion movements were more comfortable after the operation. |
In this article, we report the case of a 9-year-old female patient with no previous medical history and no significant family history of osteosarcoma or any other bone tumor, who presented in our clinic on January 2016 with a 1 year history of pain in her low back and left lower limb. She was diagnosed with osteosarcoma of the left tibia with a solitary metastasis in her L3 vertebrae on February 2016. She was subsequently treated with a left below knee amputation and L3 corpectomy with posterior spinal fusion and instrumentation from L1 to L5 with decompression laminectomy at L2-3, and L3-4 through a posterior and left thoracoabdominal approach in March 2016 ().\nShe was found to have an abnormal bone scan with a lesion at the L3 level 3 months after completing chemotherapy in November 2016. MRI scan and ultrasound guided fine-needle aspiration cytology (FNAC) of right paraspinal psoas tissue confirmed recurrent osteoblastic osteosarcoma on December 2016 (). On physical examination, she was able to ambulate with use of a below knee prosthesis and demonstrated no neurological deficits. The patient was started on second line drugs, including two cycles of ifosfamide/etoposide. Previous implants were well in place. Imaging was performed with radiographs, CT scan, bone scan, PET scan, and MRI scan with contrast enhancement to confirm only a single metastatic site (). For therapeutic strategy determination, the patient was introduced to our local tumor board. Preoperative workup was completed, and surgery was planned for a complex en bloc resection of L2, L3, and L4 with removal of deep spinal implants with anterior and posterior spinal fusion and instrumentation (). The option of nonoperative palliative care was offered to the patient and her family, but they elected to proceed with en bloc resection to maximize her chances of survival, in spite of high surgical risk and an overall poor prognosis. They were informed preoperatively that a complete resection would require sacrificing her nerve roots at L2, L3 and L4. A palliative decompression was not offered for the revision procedure as a treatment option as the patient was not complaining of pain or neurological symptoms, and it would not have improved her life expectancy. |
A 31-year-old female presented to an orthopedician with bilateral leg pain since 1 year. Pain started in the right leg 6 months before the left leg, and at the time of presentation she had persistent pain on both sides, more on the right. She had no other site of pain. There was no history of fever, trauma or undue stress on the bones. There was no history of autoimmune diseases in her family. On examination, the patient did not have signs suggestive of vascular or muscular etiology of leg pain. There was no bony tenderness. She underwent a radiograph of both legs which showed cortical thickening of the diaphyses of both tibiae []. Keeping the differentials of shin splints/stress fracture versus chronic osteomyelitis in mind, she was referred for a bone scan. A three-phase 99mTc-MDP bone scan [] showed intense irregular uptake in the diaphyseal region of both tibiae in delayed static images. Increased tracer activity was also noted in blood pool images in both legs. There were no other sites of bone involvement. The bone scan raised suspicion of a bone dysplasia involving only the tibiae bilaterally. The patient further underwent magnetic resonance imaging (MRI) which revealed cortical thickening with bone marrow edema in bilateral tibial diaphysis along with minimal adjacent soft tissue edema []. The patient's hematological parameters were within normal limits. There was no leukocytosis. Serum and urine markers of bone metabolism were also nondiagnostic. The patient then underwent a tibial biopsy which revealed predominantly dense lamellar bone with irregular sized and spaced haversian systems []. The bony lamellae were thick, sclerotic with few osteocytes. Taking all the clinical, biochemical, imaging and biopsy features into account, a diagnosis of Ribbing disease was made. The patient was already on low-dose analgesics since 6 months. The dose of these was increased in view of incomplete relief from pain. She is currently under follow-up and may need medullary rimming in case of failure to respond to peak analgesic dose. |
A 42-year-old female presented to us with a primary complaint of pain in the left side of her face for 3 yrs. The pain was spontaneous and oppressive in nature. She had a history of burning, a pricking type of dysesthesia (pins and needles feeling), intermittent in nature and radiated to the left temporal and orbital region. The unremitting nature of pain often made her feel anxious and agitated with lack of sleep. No trigger factors and aggravating or relieving factors were disclosed in the history. She narrated a history of uneventful extraction of a decayed upper third molar and a restoration of carious tooth citing as a possible source of pain by her dentist.\nHer medical history was unremarkable except the ingestion of a cocktail of medicines alternating from analgesics, antibiotics, steroids, and antidepressants prescribed by multiple physicians for the unremitting chronic pain she was experiencing. An array of investigations was performed ranging from MRI brain, OPG, and cephalograms that turned out to be inconclusive. Vascular decompression, central pontine dysfunction, skull base, and metastatic tumor were ruled out following the normal slices seen in MRI and CT. Routine chair side diagnostic tests were done to rule out odontogenic pain.\nOn clinical examination, a sharp localized pain in the hamular region was evident on palpation due to the elongated hamular process that had a knife-edge bony projection (). The overlying palatal mucosa had no change in color or texture. A local anesthetic (1 ml of 2% lidocaine) infiltration was injected with subsequent impermanent relief of symptoms in a localized area. Her oral examination was nonremarkable on the affected left side with deep dentinal caries with respect to 18 () and pulp stones with respect to 16 on the right side (). Blood investigations carry less significance except in the possible diagnosis of cranial arteritis and for autoimmune disorders such as Sjogren's syndrome.\nFollowing a failure of conservative remedies in the past, a prominent elongated hamular process (18.53 mm) noticed on a cone beam computed tomography: axial section (), 3-D reconstructed view (), and a positive diagnostic block [], we opted for a surgical shaving in pursuit of pain relief ().\nA longitudinal incision of the mucosa was planned along with dissection up to the pterygoid hamulus followed by resection of the hamulus from its base. The gross specimen measured 13 mm in length and its shape resembled an arrowhead (). |
A 61-year-old female with past medical history significant for type 2 diabetes mellitus, hypertension, and dyslipidemia and family history of breast cancer in her brother and maternal aunt presented to the emergency room for recurrent chest pain. She also reported fatigue for the past few months and was being evaluated for worsening anemia by her primary care physician. Her hemoglobin was 6 gm/dl with iron panel consistent with anemia of chronic disease. Her electrocardiogram (ECG) at arrival showed an “RSR pattern” in V1 and V2 leads but was otherwise normal. She underwent a stress myocardial perfusion imaging (MPI) which was negative for cardiac ischemia. A transthoracic echocardiogram revealed a 1.6 cm × 1.5 cm atrial mass attached to the anterior wall of the left atrium, which appeared to cross the mitral valve in ventricular diastole. The left atrial mass was further characterized by a transesophageal echocardiogram (TEE) as a solid, irregularly shaped, partly mobile mass attached to the atrial septum and extending to the anterior mitral valve leaflet (). The segment attached to the septum measured 2.6 cm × 1.43 cm, and the segment attached to the valve measured 1.4 cm × 2.22 cm. In addition, MRI of the heart with gadolinium was done preoperatively which confirmed the circumscribed hypodense mass with speckled appearance which originated at the atrial septum and extended along the anterior mitral valve leaflet (). The mitral valve flow was normal with no evidence of obstruction, stenosis, or regurgitation. The patient underwent a minimal incision valve surgery for resection of the mass which was presumed to be myxoma due to its location. Intraoperatively, on open examination of the left atrium, it was noted that the mass originated from the fossa ovalis region of the interatrial septum and infiltrated the atrial wall down onto the entire anterior leaflet of the mitral valve. A fibrotic density that surrounded the tumor was also noted. The mass along with a portion of the interatrial septum and the mitral valve was resected. The mitral valve was replaced using a 27 mm Hancock II bioprosthetic valve. The atrial septal defect caused by the resection was repaired with a bovine pericardial patch. A postoperative TEE was performed which confirmed the successful placement of the bioprosthetic valve with no paravalvular leak. The patient had an otherwise unremarkable postoperative recovery and was discharged home after fourteen days of hospital stay.\nTwo weeks following discharge, the patient presented to the emergency with cough, diaphoresis, and palpitations. She was noted to have jugular venous distention and bibasilar crackles on auscultation of the lungs and was found to be in acute heart failure. An urgent transesophageal echocardiography demonstrated severe mitral regurgitation with paravalvular leak (Figures , , , and ). At the same time, the histopathologic examination of the atrial mass showed a high-grade sarcoma consistent with dedifferentiated liposarcoma. The tissue exhibited spindle cells with pleomorphism, multinucleated giant cells, and inflammatory cells. Immunohistochemical stains demonstrated that the neoplastic cells were positive for vimentin, focally positive for S-100, and weakly positive for CDK4 and negative for p53 (). FISH studies performed showed an MDM-2 gene amplification in 95–200 nuclei examined. The patient was aggressively treated with intravenous diuretics and afterload reduction using furosemide and nicardipine infusion. Blood cultures were obtained with suspicion of postsurgical infective endocarditis causing valvular dehiscence. However, cultures did not grow any bacteria. The patient clinically deteriorated due to new-onset atrial fibrillation and worsening heart failure despite medical treatment in CCU. CT chest obtained showed a 1.3 cm lytic iliac bone lesion and 3.1 cm × 2.5 cm right upper mediastinal soft tissue density. Due to high suspicion of metastatic disease, MVR and cardiac transplant were not offered until further evaluation for metastasis. Unfortunately, due to rapid clinical decline with a new diagnosis of high-grade cardiac tumor with possible metastases, the patient opted for hospice care. PET study was not obtained. |
A 41-year-old male patient presented with a chief complaint of discomfort in the flanks for the last 2 months. The pain was intermittent and undiffused, and there was no relief on taking rest. Up to this presentation, the patient has been healthy with no related symptoms. The patient was hospitalized for further diagnosis and treatment. It was found that the routine examination and tumor markerswere within the normal range. On magnetic resonance imaging (MRI), a lesion was observed in front of the psoas major muscle. This lesion could be a mesenchymal tumor or neurogenic tumor. Furthermore, computerized tomography (CT, Fig. ) identified a right retroperitoneal space that occupied the lesion, which was approximately 5.6 × 5.1 × 8.7 cm in size.\nBased on the preoperative medical history, physical signs and auxiliary examination, it was diagnosed as a case of posterior peritoneal space-occupying lesion. However, the nature of the tumor needed to be confirmed by pathological examination after resection. Thus, a retroperitoneal mass resection was planned. After careful separation in front of the tumor, it was observed that the tumor lifted the right ureter, and the right ureter continued to move downward, entering the tumor from the middle of the tumor and passing out from the bottom of the tumor. Since the tumor was severely adhered to the right kidney, the right ureter left a crevasse of approximately 0.3 cm when this was moved away from the tumor. However, considering that the resection of the tumor might have affected the ureteral stent implantation, the gauze was used to isolate this as the operator continued the separation. There was a gap between the tumor and blood vessels, such as the inferior vena cava, without obvious adhesion. After completely separating the tumor from the inferior vena cava and right iliac artery, the posterior wall of the tumor and psoas muscle could be closely observed. Then, the tumor was completely removed. Next, the urology surgeon performed ureteral stent implantation, and no leakage of urine or bleeding was found in the right ureter. The tumor (Fig. ) had a lobular mass of approximately 8.2 × 5.5 × 4.2 cm. On the surface of the mass, there was a suspicious bone tissue of approximately 2.0 × 1.5 × 0.9 cm. Postoperative pathological (Fig. ) evaluation revealed that it was a hardening type atypical lipomatous tumor/well-differentiated liposarcoma, with extensive ossification. There was no metastatic invasion in the vessels, nerves, and surrounding lymph nodes. The immune-histochemical results revealed the following: CD34(–); CD99(±); Desmin(–); SMA(part+); ki-67(5%+); STAT6(+); Bcl-2(–), CD117(–); Dog-1(–); S-100(diffusion+). CD34, SMA, Desmin, CD99, S-100 protein, and Ki-67 (cell proliferation markers) are often used in the diagnosis of soft tissue tumors. S-100 protein has a positive expression in well-differentiated and mucinous PRPLS, but has a negative expression in undifferentiated and polymorphous/mixed PRPLS. STAT6 has a positive expression in isolated fibrous tumors. K-67 is a recognized nuclear antigen that is specifically correlated to cell proliferation, and is mainly used to determine cell proliferation activity. The clinical diagnosis of PRPLS was established. Then, the patient was discharged from the hospital after a week (July 14, 2017). There was no report of relapse on the follow-up survey after 6 months and after 1 year. |
A 68-year-old man presented to the emergency department (ED) complaining of intermittent pleuritic chest pain for one week. His medical history included non-small cell lung cancer, treated with right pneumonectomy and chemotherapy nearly ten years prior, chronic obstructive pulmonary disease (COPD), requiring home oxygen, hypertenstion, and prior tobacco use. Ten weeks before presenting to our hospital he was diagnosed with new onset paroxysmal atrial fibrillation. Warfarin was prescribed, which he did not take. Six weeks prior to admission he had been admitted for a COPD exacerbation, requiring intubation.\nUpon presentation to the ED, a contrasted chest CT was performed which revealed a large thrombus in the right pulmonary artery stump with no evidence of pulmonary emboli (Figure ). Venous dopplers of his lower extremities did not reveal deep venous thrombosis. The patient had a chest CT with contrast done eighteen months earlier that did not show a pulmonary artery stump thrombus. He had also had two recent non-contrasted chest CT scans that were reviewed after the discovery of the right pulmonary artery thrombus. The routine scan performed three months earlier, for follow-up of his lung cancer, did not have any areas of increased density in the pulmonary artery stump, suggesting that there was no thrombus. However, review of the scan performed six weeks earlier, during his admission for COPD exacerbation, revealed an area of increased density in the right pulmonary artery stump, consistent with the location of the thrombus. These scans suggest that the thrombus developed during the period of clinical decline. An echocardiogram also performed at the time of the non-contrast chest CT, six weeks prior to his admission demonstrated a dilated right atrium with moderate right ventricle hypokinesis and elevated PA pressures of 40–45 mmHg consistent with mild pulmonary hypertension. The right ventricular hypokinesis was worse when compared to his previous echocardiogram two years prior. His echocardiograms were reported as being limited due to the dislocation of the heart within the chest cavity.\nThe patient was hemodynamically stable with a blood pressure of 120/82 mmHg and in atrial fibrillation at a rate of 83 beats per minute. He was admitted to a medical floor and anticoagulated with heparin and warfarin and his chest pain improved. In the following weeks he was hospitalized with an admission diagnosis of "COPD exacerbation" two more times. Despite the treatment goal of long-term anticoagulation, his INR was subtherapeutic at each of these admissions. A review of the patient's medical records from the four years prior to identification of the stump thrombus showed only a single previous admission for COPD exacerbation six weeks prior to his presentation to the ED. |
The first patient is a 58-year-old man who was a previous smoker who presented to an outside hospital with abdominal pain and was diagnosed with gallstone pancreatitis. However, despite having a laparoscopic cholecystectomy, he continued to have episodes of pancreatitis yearly for the next 3 years. Computed tomography (CT) scan demonstrated a pancreatic duct dilated throughout its course to a maximum size of 8 mm without a discrete pancreatic mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography confirmed a dilated pancreatic duct with a suspected filling defect of the common bile duct, after which the patient underwent sphincterotomy and stent placement.\nHe then presented to our institution for consultation. Further workup with endoscopic ultrasound (EUS) was performed, which also confirmed the dilated pancreatic duct, but noted irregular contour of the duct. In addition, free mucin was seen exiting the main papilla, and there was a papillary growth noted in the pancreatic duct in the head of the pancreas, all of which was consistent with a main duct IPMN (). Preoperative laboratory values, including CA19-9, were within normal limits. Of note, it was unclear if the dilatation of the pancreatic duct was secondary to obstruction from the mass in the pancreatic head or due to main duct IPMN involving the entirety of the duct.\nHe was scheduled for surgical resection after the stated workup. He was planned for a Whipple procedure (pancreaticoduodenectomy) with possible total pancreatectomy if intraoperatively the main duct was found to be involved by IPMN with high-grade dysplasia. Transection of the pancreatic neck identified cells of high-grade dysplasia free floating near the margin (although exclusive of the margin). In addition, upon probing the pancreatic duct in the tail of the pancreas, the probe did not slide smoothly, suggestive of additional growths in the duct. Due to his young age and high risk of developing pancreatic cancer, a completion pancreatectomy and splenectomy were performed. He was reconstructed in a Roux-en-Y manner. He recovered well from surgery without any postoperative complications.\nHis final pathology demonstrated a 1.4 cm moderately differentiated colloid carcinoma arising within main duct IPMN (intestinal type) with high-grade dysplasia in addition to multiple foci of pancreatic intraepithelial neoplasia. Staining of the tumor was strongly positive for MUC2 and weakly positive for MUC1 and MUC5. The tumor involved the peripancreatic soft tissue, but all margins were negative. 0 of 39 lymph nodes was involved with tumor. His final pathologic staging was pT3N0Mx. He was, therefore, referred for medical oncology consultation. He was recommended for adjuvant chemoradiation with gemcitabine before and after fluorouracil-based chemoradiation, which he is currently receiving and tolerating well. |
A 35-year-old male presented to a regional urban hospital two days following an assault-related blunt traumatic injury. The evening before arrival at the emergency department, he noticed swelling around his chest and neck. It was worse the next morning, precipitating his presentation to hospital. On initial assessment, the patient had a Glasgow Coma Scale of 15, and vital signs were BP 125/66, HR 92, and SpO2 95% on oxygen at 5 litres per minute via nasal cannulas. At the time of presentation, the patient displayed moderate subcutaneous emphysema on physical examination and subcutaneous emphysema on chest X-ray ().\nComputed tomography of the chest, abdomen, and pelvis revealed a left-sided pneumothorax and subcutaneous emphysema (Figures and ). Significant laryngeal swelling was also noted (). The patient was found to have multiple rib fractures, a lacerated scalp, and a Grade 1 liver laceration. A chest tube was not inserted at this time, after consultation with a thoracic surgeon at the nearby Level 1 trauma hospital. Upon reviewing the CT, it was suggested that the relatively small amount of pneumothorax for the degree of subcutaneous emphysema indicated potential pleural adhesions. The view of the thoracic surgery service and trauma was that an incorrectly placed chest tube at the regional centre may have risked entering the lung parenchyma. The patient was transferred to a Level 1 trauma centre 4 and 1/2 hours after presentation arriving 30 min later.\nThe extent of the subcutaneous emphysema was such that the patient could not be placed in a cervical spine collar for transport to the referral facility. His cervical spine was instead immobilized with towel rolls. Vital signs remained stable in transit, and the patient arrived at the trauma centre awake, alert, and breathing spontaneously on supplemental oxygen. The patient was assessed by the trauma service and thoracic surgery.\nOver the next two hours, the patient's condition deteriorated. While the patient had been ordered to get admitted to the trauma nursing unit, the emergency room physician wisely held the patient in the high observation area of the emergency department. Seven hours after initial presentation to the regional hospital and two hours after arrival at the trauma centre, the patient demonstrated altered phonation in addition to yet greater swelling around the neck. In order to obtain a definitive airway in a controlled environment, the patient was taken to the operating room for intubation with surgical standby.\nIn the operating room, the patient's oxygen requirements increased, with desaturation on 10 litres per minute, now via facemask. The patient was also becoming increasingly agitated. An attempt was made at awake fiber-optic intubation, but the posterior oropharyngeal anatomy, glottis, and larynx could not be visualized. Given the increasing oxygen demands and the challenging airway, after considering all options, an awake tracheostomy was performed with a Shiley XLT extended-length tracheostomy appliance. A left thoracostomy tube was then placed. Bronchoscopy in the OR did not reveal proximal tracheobronchial injury.\nThe patient was transferred to the intensive care unit where he remained for 21 days. He had complications of ventilator-associated pneumonia and delirium due to substance withdrawal. A repeat bronchoscopy on day 18 was normal, and he was successfully weaned from the ventilator that day.\nSubcutaneous decompression was achieved with continued suction via the thoracostomy tube inserted in the operating room at the time of the tracheostomy. Considerable subcutaneous air was also seen escaping from the tracheostomy incision. The subcutaneous emphysema had resolved by day 14. He was transferred to the trauma ward on day 21 and decannulated on day 22. A normal CXR was performed on day 23 (), and he was discharged on day 28. |
The patient was a 5-yr-old female with an uncomplicated birth history and normal development. For the first two years of life, she had frequent candidal diaper dermatitis that was responsive to topical antifungal therapy. Between the ages of 2 and 3 yr, she had recurrent oral thrush. That same year she was also evaluated by allergy/immunology for 4 mo of daily urticaria. There was concern at that time for an autoimmune etiology of the urticarial eruption, but it resolved without intervention shortly thereafter. At age 4, she was referred to dermatology for dystrophic nails of the right foot and right thumb. She was diagnosed with onychomycosis which was not responsive to griseofulvin or topical therapies.\nThree weeks prior to admission, the patient was noted to have abnormal movements of the upper extremities at school that were concerning for seizure activity. She was evaluated in the emergency room. An electrocardiogram (ECG) showed peaked T waves and a prolonged QT interval (QTc 486 msec, and normal is <450 msec), and the patient was referred to cardiology clinic. No laboratory studies were obtained at that time. She was seen by a pediatric cardiologist 1 wk later and a repeat ECG confirmed a prolonged QTc interval at 499 msec. Treatment with a beta blocker was initiated. A 24-h Holter monitor did not reveal arrhythmias. Five days prior to admission, the patient was evaluated in the emergency department (ED) for possible seizure activity. Her father observed 1 min of irregular eye movements associated with generalized hypotonia, followed by 30 min of presumed post-ictal behavior (fatigue and disorientation). The patient reportedly developed a fever earlier that morning and was discharged from the ED with a presumed febrile seizure. On the day of admission, the patient had an event at school where she fell with sustained contraction of her upper extremities lasting ∼20 sec. She was evaluated in the ED and laboratory studies were performed which were remarkable for calcium 4.8 mg/dl (reference 8.8–10.8), ionized calcium 0.58 mmol/l (1.10–1.35), magnesium 1.6 mg/dl (1.8–2.3), and phosphorus 12.3 mg/dl (4.1–5.4). Parathyroid hormone (PTH) was <4.0 pg/ml (8.5–72.5). Physical exam was notable for a positive Chvostek's sign. The patient was admitted to the Pediatric Intensive Care Unit (PICU) for management.\nThe patient was initially treated with intravenous calcium gluconate and magnesium sulfate. She was subsequently transitioned to enteral calcium carbonate and calcitriol. Hypocalcemia persisted; the doses of enteral medications were increased, and teriparatide (recombinant PTH) was added. Her calcium and ionized calcium levels subsequently improved, and intravenous replacement therapy was stopped. A morning cortisol level was within normal limits at 13.6 µg/dl (3.7–19.4). A repeat ECG demonstrated normalization of the QTc interval (433 msec) and T wave morphology following correction of hypocalcemia, therefore beta blockade was discontinued. The patient and her parents were enrolled for trio rapid whole-genome sequencing (rWGS) to determine the etiology of her hypoparathyroidism. She was discharged on enteral calcium carbonate and calcitriol. Follow-up 1 wk after discharge confirmed normal serum calcium levels on this medication regimen.\nThere was no family history of seizures, thyroid disease, or autoimmune disorders, and the parents denied consanguinity. |
46-year-old woman with 8 years of primary infertility was admitted to Clinart International Hospital for bilateral multicystic complex adnexal masses diagnosed 4 years ago as bilateral endometriomas. She had 7 IVF attempts and only in 3 cycles; embryo could be transferred with no clinical outcomes. She had a history of laparoscopic endometrioma surgery 8 years ago and endometriomas on both ovaries were aspirated and their capsules were excised together with the laparoscopic excision of a subserous myoma. Ca 12-5 and Ca 19-9 values had been high before the laparoscopic surgery. She had no other medical or surgical history and all biochemical serological and hormonal parameters were normal other than high Ca 12-5 and Ca 19-9 which supported the diagnosis of endometrioma.\nMRI investigation was carried out 2 years ago and bilateral endometriomas were reported without any radiological signs of malignancy. Patient was informed about the possible risks of malignant transformation of the adnexal masses at all times; she was admitted for fertility reasons but surgical intervention was rejected. All attempts for fertility were failed due to either the absence or diminished ovarian response to ovarian hyperstimulation by gonadotropins. Some cycles were monitored naturally with no collected oocytes. It was not easy to differentiate the follicular response by ultrasound and all oocytes retrieved from the follicles were aspirated through the endometriomas and endometriotic fluid was seen in the aspiration tubes. Oocyte retrieval (OR) by bypassing the endometriomas was not possible technically because the masses on both sides were huge and multilobulated and ovaries could not be discriminated easily. In two cycles the endometriomas were aspirated to reduce the size of the mass and to obtain oocytes easily under the suppressive antibiotherapy.\nShe decided to have the surgical operation and admitted for surgery at 31.03.2015. Pelvic MRI (), Ca 12-5, Ca 19-9, and all preoperative tests were carried out same day and open surgery under general anesthesia was planned and carried out at 01 04 2015 by a Pfannenstiel incision. The mass could easily be seen from the abdominal wall before making the incision. A huge lobulated smooth surface mass of 22 × 18 × 10 cm in size was seen by opening the peritoneum and the first impression of the surgical team was malignancy and peritoneal washing was aspirated for cytological evaluation in Figures \n and .\nThe mass was well vascularised and adherent and a very thick vascularised adhesion was separated by electrocautery and sutured. Then the mass was taken out and it was a great surprise for all the team that the huge mass was originating from the anterior surface of the uterus just below the right corn and was evaluated as pedunculated degenerated leiomyoma with a thick pedicle.\nThorough search of the uterus and ovaries revealed 4 subserous leiomyomas of different sizes and both ovaries were free from any endometriotic lesions and left fallopian tube was adherent to the posterior of the uterus. Left ovary was found atrophic and right ovary was found smaller than normal. No endometriomas or endometriotic lesions were seen on the ovaries, tubes, and the uterus. Multiple leiomyomas at different size were seen on the surface of the uterus and uterus myomatosis was diagnosed intraoperatively.\nShe was supposed to have bilateral endometriomas for long time and the mass was misinterpreted as endometrioma both clinically and radiologically. The reason why the mass was interpreted as multilobulated bilateral endometrioma was due to the chocolate coloured aspiration materials seen in oocyte pick up procedures and also high Ca 12-5 and Ca 19-9 values. The mass was excised from the uterus by sharp dissection and the uterus was sutured with 1/0 Vicryl. Macroscopical evaluation of the mass at the operating theatre revealed multiple small nodules and a small leiomyoma seen on the surface close to the pedicle of the mass. Intraoperative evaluation showed multiple blue discolorations on the mass and no solid component was seen within the excised mass. The other leiomyomas were excised and sutured and the adherent left side tube was released from the uterus by sharp dissection and following hemostasis, irrigation, and aspiration, abdominal wall was closed layer by layer. Total amount of blood loss was 150 mL and the duration of operation was one and a half hours and no surgical and anesthesiological complications were observed. The pathology lab was informed verbally about the case and detailed information was given and aspirated fluid and the extirpated leiomyomas were sent to the pathology laboratory for cytological and pathological evaluation.\nIntraoperative and postoperative macroscopic figures are shown in Figures –. |
A 19-year-old boy was referred to our center for systemic hypertension detected during an episode of viral fever. On examination, his heart rate was 70/min and the lower limb pulses were weak. The right upper limb blood pressure was 186/110 mmHg with a differential blood pressure gradient of 60 mmHg between the upper and lower limbs. A grade two mid-systolic murmur was noted in the left second intercostal space. Chest X-ray showed bilateral rib notching from the third to sixth ribs. The electrocardiogram showed left ventricular hypertrophy and normal QRS axis.\nTransthoracic echocardiography confirmed severe coarctation of aorta and left-sided aortic arch. Imaging from the suprasternal window demonstrated a double-barreled aortic configuration []. The superior arch gave rise to all three neck vessels. A caudally located arch connected the distal ascending aorta to the aortic isthmus. The arterial duct was not patent. Discrete isthmic narrowing at the confluence of both aortic arches amounted to severe coarctation with a peak gradient of 50 mmHg and diastolic tailing. The left ventricle was hypertrophied with good systolic function.\nCardiac computed tomography confirmed that the caudal arch connected to the ascending aorta just proximal to the origin of the right brachiocephalic trunk. The superior arch had critical narrowing immediately beyond the origin of the left subclavian artery. Stenosis at the confluence of both arches assumed a bifurcation lesion configuration []. Both the mid-transverse arch and the inferior arch measured 15 mm, and the descending thoracic aorta measured 17 mm at the diaphragmatic level. The narrowest portion at the junction of the inferior arch to the descending aorta measured 6 mm. Collateral vessels were identified between the branches of the subclavian artery and intercostal arteries.\nCardiac catheterization was performed under general anesthesia. A 30 mmHg pullback gradient was obtained across the coarctation. Aortic angiography confirmed that the lower arch was more in line with the descending aorta while the superior arch presented an acute angle at the confluence and gave rise to the neck vessels [ and ]. Hence, it was decided to stent the coarctation into the inferior arch. An Amplatzer superstiff wire was positioned in the proximal ascending aorta through the inferior arch. A 35 mm uncovered Andra XL (Andramed, Reutlingen, Germany) stent was mounted on a 16 mm × 40 mm Andra balloon XL (Andramed, Reutlingen, Germany) and delivered over a 12F Mullins sheath. The stent was positioned into the inferior arch and expanded to 16 mm []. The distal edge of the stent was flared with an 18 mm × 30 mm Tyshak II (NuMed Cornwall, Canada) balloon. The pressure gradient after stenting was 6 mmHg. Postprocedure angiogram confirmed satisfactory stent position [ and ] and no complications. The flow into the neck vessels was normal.\nSystemic hypertension resolved fully on follow-up with no differential blood pressure recording in any limb. The flow in the arch vessels was normal. He is doing well at latest follow-up at 9 months. |
The patient was a 38-year-old nulliparous woman who suffered from infertility of unknown origin. She had been treated with assisted reproductive technologies including artificial insemination and in vitro fertilization for over four years. During her treatment for infertility, cytological review followed by colposcopic biopsy revealed an invasive nonkeratinizing squamous cell carcinoma (SCC). A 1 cm mass was identified in the uterine cervix, but a pelvic MRI did not describe the cervical mass or parametrial invasion. Additionally, a submucosal leiomyoma of 15 mm in diameter was found in the uterus (). CT scans showed no signs of lymph node swelling or distant metastases. Based on these findings, she was diagnosed with stage IB1 cervical squamous cell carcinoma. We offered radical hysterectomy and pelvic lymphadenectomy as standard treatment although she strongly desired fertility preservation. The submucosal leiomyoma may have been the cause of her infertility, and she was keen to resect the myoma during the same procedure. Submucosal leiomyomas can usually be resected with hysteroscopy but was not advised in this case from the oncological viewpoint. As such, we obtained informed consent and performed an abdominal radical trachelectomy followed by abdominal myomectomy.\nDuring the surgery, we first drained the ascites in the pelvic cavity, resected bilateral pelvic lymph nodes, and sent them for intraoperative pathology. They were reported to be negative. The paravesical and pararectal spaces were then developed. The ureters on either side were resected to their insertion into the bladder. The uterine arteries were ligated and cut at the origin where they branched from the internal iliac arteries. Next, the uterosacral ligaments were divided. A colpotomy was performed circumferentially, and the cervical specimen was excised together with the parametrium at least 2 cm below the internal os. During the surgery, a frozen section procedure was performed for histology. The patient was found to have a 5 mm free cervical margin. A permanent cerclage was placed at the level of the isthmus. The uterus was then reanastomosed to the vagina. We then performed resection of the submucosal myoma via a uterine vertical incision. An intrauterine device (FD-1; Fuji Latex Co., Tokyo, Japan) was placed in the uterine cavity. The operation duration was 339 min, and blood loss was 500 ml. The surgery was completed with no complications.\nThe final histological specimen confirmed the diagnosis of squamous cell carcinoma, keratinizing type of cervix uteri, pT1B1. Exocervical, endocervical, and deep margin regions were negative. There was no metastatic lesion in the lymph nodes or lymphovascular space invasion. Leiomyoma of the corpus uteri showed no malignancy. No adjuvant treatment was administered, and no recurrence has been reported for at least 18 months postoperatively.\nSix months after the surgery, she became pregnant following the postoperative first embryo transfer. The fetus was appropriate for gestational age. At 21 weeks of pregnancy, she claimed vaginal bleeding, and her lower uterine segment lengths were shortened from 23 mm to 13 mm. She was diagnosed with threatened abortion, and tocolysis was started. At 25 weeks, preterm premature rupture of membranes occurred. She received antibiotics, and intramuscular betamethasone was administered. At 26 weeks, a male baby weighing 980 g was delivered with an Apgar score 3/5/7 by caesarean section due to chorioamnionitis. The baby received general care in a neonatal intensive care unit for four months and weighed 4520 g when discharged. He is now 6 months old and is well. There has been no recurrent disease of her cervical cancer for 18 months from the trachelectomy and myomectomy. |
A 23-year-old Palestinian male patient presented to our emergency department due to one-day duration of vomiting, diarrhea, and fever. The patient had FMF since the age of 3 years. The FMF was diagnosed by clinical manifestations and supported by genetic testing. The genetic test showed that the patient was homozygous for the pathogenic M694V MEFV gene mutation. Family history was significant for genetically confirmed FMF in father, two brothers, and one sister. The genetic tests for the sick family members showed that all patients were homozygous for the pathogenic M694V MEFV gene mutation.\nThe patient was maintained on 0.5–1 mg per day colchicine though the patient was not compliant with the medication. Although the patient was maintained on daily colchicine, the patient had a high-variable frequency of attacks. The patient developed FMF attacks on an average of 6–11 months though with an increased frequency when the patient aged 12 years. The FMF attacks were used to present as fever and abdominal and joints pain. These attacks were managed by NSAIDs administration with no change in the dose of the daily colchicine. The patient had no clue about any consistent triggering events. The patient had a past surgical history of appendectomy at the age of 9 years.\nOur patient had significant risk factors to develop AA amyloidosis included male gender, a positive family history, suboptimal daily dose of colchicine, and the patient's medication noncompliance. At the age of 17 years, the patient developed ESRD secondary to tissue-diagnosis amyloid nephropathy and started on regular hemodialysis and 2 mg per day colchicine. At the age of 21 years, the patient underwent right kidney transplantation and was started on immunosuppressants and continued the 2 mg per day regimen of colchicine. His current medications were 2 mg per day colchicine with good compliance, tacrolimus, prednisolone, and mycophenolate sodium. The sick family members were maintained on 1-2 mg per day colchicine with very good compliance and no signs of amyloidosis or renal disease.\nBefore admission, the patient had one-day duration of nausea, vomiting, diarrhea, weakness, and fever. He also complained of cough and chest tightness but no dysphagia. Physical examination showed an ill-looking, distressed and confused young patient with dry and pale mucous membranes and skin. The patient had no focal neurological deficits or meningeal signs. The neck was diffusely enlarged (). There was no pigmentation of mucous membranes or skin. There was no history of fine tremor, heat or cold intolerance, increased or decreased appetite, and/or weight loss or gain.\nBlood pressure, heart rate, and temperature were 50/30 mmHg, 110 beats/minute, 38.6°C, respectively. There were no added heart sounds or murmurs, or hepatosplenomegaly. Initial labs showed serum white blood cells count (WBC) of 34 × 109/L, creatinine (Cr) of 1.6 mg/dL, blood urea nitrogen (BUN) of 23 mg/dl, sodium of 132 mEq/L, potassium of 5.3 mEq/L, magnesium of 1.3 mg/dl, and C-reactive protein (CRP) of 102 mg/L. An arterial blood gas (ABG) test showed pH of 7.2, partial pressure of carbon dioxide (PCO2) of 49 mmHg, partial pressure of oxygen (PO2) of 95 mmHg, and bicarbonate (HCO3) of 19 mmol/L. Thyroid function tests were normal. A low-cortisol serum level was noted (0.2 μg/dl), but the adrenocorticotropic hormone (ACTH) stimulation test was inconclusive. Blood, stool, and urine cultures showed no pathogenic growths.\nThe patient was admitted to the intensive care unit (ICU) and received intravenous hydrocortisone, mineralocorticoid replacement with fludrocortisone, and aggressive fluid resuscitation. Antibiotics were also administered but discontinued given the negative cultures' results. Three days later, the patient was transferred to the medical ward where he was started on low-dose hydrocortisone and fludrocortisone.\nAbdominal ultrasonography (US) showed a mild increase in cortical echogenicity of the transplanted kidney and bilateral atrophied kidneys with loss of cortico-medullary differentiation but otherwise was unrevealing. Echocardiogram showed normal size left ventricle (LV) and right ventricle, ejection fraction of 62%, moderate LV hypertrophy, mild diastolic dysfunction, normal size inferior vena cava (IVC), and no pericardial effusion. It also showed granular sparkling of the myocardium wall suggestive of cardiac amyloidosis (). Neck US showed diffuse enlargement of both thyroid lobes and isthmus, retrosternal thyroid extension, and no enlarged lymph nodes. Fine needle aspiration (FNA) was negative for thyroid cancer and very suggestive for amyloidosis.\nThe patient's condition recovered rapidly and at the admission day 6, the patient did very well and was discharged home. During one year of follow-up, the patient did not develop any similar or significant conditions. |
An 8-year-old girl with a rapidly increasing valgus angle of the right elbow presented at the out-patient clinic of our hospital. No evident trauma of the affected elbow had occurred. In another hospital, she had been diagnosed with a unilateral congenital radial head dislocation of the right elbow at the age of 3 months, for which a conservative treatment was initiated. Besides the increasing deformity, the patient had no complaints of pain or limitations. On physical examination, the patient was found to have a full and painless ROM and a normal carrying angle of the left elbow. The right elbow showed a cubitus valgus with clinically a carrying angle of 32°. The dislocated radial head was not painful on palpation. The range of motion was nearly full: flexion 130°, extension 10°, pronation 75° and supination 80°, compared with a flexion of 140°, extension of 0°, pronation of 80° and supination of 80° of the contralateral elbow. Plain radiographic evaluation of the right elbow showed an anterior dislocation and deformation of the radial head, with a long narrow neck and a hypoplastic capitellum and an increased valgus angle (Figs. and ). The left elbow showed no abnormalities. Radiographs of both forearms show a mild ulnar bowing on the right side, as compared to the left side (17 and 12°) (Figs. and ). This is probably due to chronic dislocation of the radial head. CT imaging of the elbow showed the anterior dislocation of the radial head with an overgrowth of the radius of 8 mm and a normal ulnohumeral joint. There is a premature ossifying physis of the lateral humeral condyle (Fig. ). Whilst no complaints or limitations were present, treatment was non-operative with clinical observation. No restrictions in daily elbow use were advised. The result of this treatment strategy was satisfactory after a follow-up of 18 months. No increase in valgus angle was seen, and elbow function was not painful. Treatment of the valgus angle can be observational. In case of progression, a supracondylar varus osteotomy can be considered. |
The patient is a 50-year-old Hispanic male presenting to the ED with chief complaints of headache and right eye blindness. The patient had been working construction with a nail gun that had reportedly misfired resulting in a foreign body projectile into the calvarium. While the patient did not report losing consciousness, he was unaware of the misfire and did not know the reason for his new symptoms. X-ray of the skull and CT scan of the head demonstrated a foreign object resembling a nail extending through the right maxillary sinus into the right anterior skull base, penetrating the frontal lobe of the brain (Figure ). A CT Angiogram of the head was negative for any vascular abnormalities, therefore a diagnostic cerebral angiogram was deferred. The patient denied any neurological deficits with the exception of right eye blindness. No signs of cerebrospinal fluid (CSF) leak were present from the nose or into the mouth. A Maxillofacial CT demonstrated the nail passing through the right maxillary sinus, penetrating the floor of the orbit, but posterior to the globe. The trajectory of the nail was through the base of the skull, protruding significantly into the brain parenchyma. The tip of the nail was located adjacent to the right anterior cerebral artery (Figure ). Surgical removal was indicated due to the risk of CSF leak, nidus of infection, and potential further intracranial injury. The location of the head of the nail within the oral cavity necessitated the coordination of Neurosurgery with Oral Maxillofacial Surgery (OMFS) for a multidisciplinary approach for the removal of the foreign body. Preoperatively, the patient was provided with antibiotic coverage.\nA craniotomy was performed with extradural dissection continued anteriorly down the posterior orbital wall until the calvarial entry point of the nail was appreciated. The dura was dissected around the nail using a brain ribbon to retract the frontal lobe away from the skull. At this time, OMFS removed the nail through the oral cavity. Following removal, meticulous hemostasis was achieved. Ultrasound was used to confirm the absence of parenchymal hematoma after the removal of the nail. A pericranial flap was placed beneath the dural defect, overlayed by a piece of DuraGen™, and DuraSeal™ was applied extradurally to ensure against CSF leak (Figure ).\nThe patient continued to do well throughout the postoperative course, and was discharged after a period of observation. The patient presented to the clinic several weeks later with continued blindness in his right eye. |
A 59-year-old woman presented in July 2017 with extensive bleeding from her ileostomy site. Her history included locally advanced bladder cancer for which she had undergone pelvic exenteration and ileal conduit formation in November 2015. At that time, she had a known primary lung adenocarcinoma as well, but had no known liver metastases or other liver disease. Intravenous contrast-enhanced CT of the abdomen and pelvis performed in January 2016 raised the possibility of cirrhosis; however this was not biopsy-proven. In April 2016, she began to notice intermittent bleeding from her stoma which was initially thought to be mechanical tissue breakdown from the stomal flange. Concern for hepatic encephalopathy was raised when she had her first episode of confusion in December 2016. At that time CT of the abdomen and pelvis demonstrated strong radiographic suspicion for cirrhosis together with prominent vessels surrounding the urinary diversion site suspicious for portal hypertension. Despite not having a tissue biopsy, she was diagnosed clinically with cryptogenic cirrhosis in May 2017 during a hospitalization for fatigue, anasarca, and altered mental status. An upper endoscopy performed in June 2017 demonstrated portal hypertensive gastropathy but no esophageal varices.\nUpon presentation to the Emergency Department in July 2017 she had significant hemorrhage from her stoma resulting in hemodynamic instability. She was anemic with a hemoglobin of 8.3 g/dL that improved to 9.4 g/dL after blood transfusion, but gradually fell to 8.2 g/dL by the time of the procedure. Her MELD score was retrospectively calculated to be 19 at presentation, with an INR of 1.5 and total bilirubin of 4.3 mg/dl. She was emergently taken to the interventional suite for embolization with or without portal venous decompression via portosystemic shunt formation. A review of intravenous contrast-enhanced CT imaging showed extensive venous varices around the stoma involving the abdominal wall with a large draining varix arising from the portal system, likely the inferior mesenteric vein []. Also visualized was a variceal connection to the right common femoral vein. The portal and mesenteric veins were noted to be patent. Multiple approaches were considered for this patient. The transjugular intrahepatic portosystemic shunt (TIPS) and transjugular transhepatic approach with portosystemic shunt creation offered the benefit of portal decompression; however, the patient's recurrent hepatic encephalopathy was felt to be a relative contraindication. Transjugular transhepatic approach without formation of a permanent portosystemic shunt was also considered, since it would eliminate the risk of progressive hepatic encephalopathy. Percutaneous transhepatic approach would also eliminate the risk of progressive hepatic encephalopathy but was believed to pose increased risks of hepatic injury and bleeding. Transsplenic venous access to the portal venous system was considered as a viable, albeit technically challenging, option. The superficial nature of the abdominal wall stomal varix presented a less challenging and seemingly more time-efficient approach for access and was chosen as the target.\nUsing a micropuncture kit, the peristomal varix was directly accessed under ultrasound guidance and a micropuncture sheath was placed. Venography was performed and showed a large variceal collateral conglomerate around the stoma with variceal anastomosis with the right common femoral vein []. A wire was advanced and a 5F sheath was secured over the wire. A Kumpe catheter was introduced and advanced into the distal intra-abdominal aspect of the large draining varix. Catheter position was confirmed with repeat venography, and multiple coils were deployed []. This was followed by Gelfoam embolization. Postembolization venography showed sluggish flow in the draining varix with multiple filling defects within the visualized collaterals consistent with embolization []. The coils remained well-situated after placement and there was no evidence of migration. To ensure that there was no filling from the systemic venous system, the right superficial femoral vein was then accessed with a micropuncture kit and a femoral-iliac venogram and IVC venogram were both performed. These demonstrated brisk flow from the right common femoral vein through the iliac system and into the IVC. There was no filling of the stomal variceal collaterals visualized []. Hemostasis was thereby achieved, and the patient became hemodynamically stable shortly thereafter. At 6-month follow-up time no further imaging had been performed and the patient had not had any further episodes of hemorrhage from the ileostomy site |
A 54-year-old woman was referred to the University Hospitals Leuven with the preliminary diagnosis of a soft tissue tumor in the right upper leg identified as a mass of 43 mm × 62 mm on plain radiograph and echography. She had been complaining of irradiating pain on the lateral aspect of the right leg for 4 months and a one-week history of a palpable mass in the right thigh. There was no remarkable medical history and no recent significant trauma to the affected region.\nClinical evaluation revealed a well-defined nodular mass in the deeper aspect of the right tight, measuring about 5 cm. No concomitant tenderness, swelling, erythema, or other superficial skin lesions were found. The range of motion of the right hip and knee were unaffected and palpation for aberrant inguinal lymph nodes was negative.\nAt the time of referral, plain radiographs of the hip and pelvis showed crumbly calcification within a soft tissue mass posterior to the trochanteric region without a sign of bone erosion.\nEchography concluded on a non-growing, well-demarcated inhomogeneous muscular tumor without an argument for myositis (). Based on the clinic and first radiological characteristics, one decided for further investigation by means of magnetic resonance imaging (MRI) and a diagnostic ultrasound-guided needle biopsy. T1 sequences showed a high-intensity signal equal to that of the subcutaneous fat, mainly present in the periphery, confirming the fatty characteristic of this lesion. T2 sequences revealed diffuse dystrophic calcification deep in the mass (). Despite the proximity of the mass to the femur, no clear continuity with the adjacent femoral cortex or bone marrow was shown. Oedema and adenopathy were absent. Compared to a 2-years old computed tomography (CT) where the mass was overlooked, a minimal volume increase was noted with a current size of 94 mm × 53 mm × 66 mm. The retrospective protocol describes a lesion fully encapsulated by the right musculus quadratus femoris. Biopsy of the lesion demonstrated fibromyxoid to chondroid mesenchymal cells of unknown origin with no evidence of malign morphologic signs.\nBased on this information, a tentative diagnosis of pleomorphic/round cell lipoma was made, and marginal resection was performed. We used the Kocher Langenbeck-type approach with an incision placed slightly more posterior to facilitate exposure and dissection of the sciatic nerve. After muscle splitting of the gluteus maximus fibers with the division of the proximal half of the tendon at 1 cm of its insertions, the sciatic nerve was carefully dissected out and protected. The mass was fully encapsulated by a thin transparent membrane and strongly attached to the underlying femur. The surface of the specimen was stone-hard but smooth, with a yellow shine covering a homogeneous pattern of white and gray dots. The resected tumor was sent for histopathological analysis. Postoperatively, the patient showed no vascular or neurological complications. A mild limp was noted due to dissection of the abductors, which quickly resolved with physiotherapy. At the latest consultation (12 months post-operative), the patient reported manifest improvement of the original discomfort. Clinical examination and ultrasound scans did not show any signs of local recurrence. Plain radiographs did not show any calcified density to suggest local recurrence.\nMicroscopic examination revealed a well-circumscribed mesenchymal tumor consisting of mature hyaline cartilage islands contiguous with bony trabeculae embedded in mature adipose tissue (). No mitotic figure or cytological atypia was observed. Based on these results, we conclude on an osteochondrolipoma, completely excised with clear margins. |
Here, we present a 26-year-old male with junctional epidermolysis bullosa (generalized, intermediate form) who suffered from a skin lump on his neck, which surprisingly turned out to be a dermatofibrosarcoma protuberans. Informed consent was obtained from the patient prior to data acquisition.\nTwo years before presenting to our outpatient clinic, the patient noticed a skin lesion and subcutaneous swelling on the neck. The lump was neither painful nor tender or noticeable growing. The patient denied any previous trauma or inflammation. After first noticing the skin lesion, an MRI of the neck revealed an encapsulated tumor that was not at high risk of being a malignant process. Therefore, the primary institution did not initiate any therapy at this point. Due to further growth, the patient then underwent primary resection of the tumor without a prior biopsy. The histopathological evaluation revealed malignant skin sarcoma and inadequate safety margins. With the diagnosis of DFSP, the primary institution presented the patient to our interdisciplinary tumor conference for sarcoma. As shown previously for soft tissue sarcomas, revision surgery is mandatory for unexpected sarcoma diagnosis following primary surgery []. Two weeks after the first resection, the patient presented at the Department of Plastic and Hand Surgery for secondary resection and subsequent reconstruction. We then initiated an MRI to assess tumor infiltration preoperatively and performed a two-staged procedure with wide resection of the tumor one week after the initial presentation at our outpatient clinic. The extended safety margins needed for the resection are shown in Fig. . The resulting defect was closed temporarily with synthetic wound dressing (Epigard®). The histopathological examination showed a dermal infiltration of the classical DFSP and postoperative alterations in the deep dermal compartment with uninvolved epidermis and the complete removal of the DFSP with small residues (< 1 cm) of vital tumor cells and satisfying safety margins. In the histological workup, tumor-free margins were > 1 cm to all sides and 0.3 cm to the depth (R-classification: R0). The tumor consists of uniform spindle cells with minimal cytological atypia and woven nuclei arranged in a whorled growth pattern (Fig. ).\nThese safety margins were sufficient considering the initial resection, the complete removal, the small residues of vital tumor cells, and the immunohistochemical workup. Two weeks after the secondary resection, we addressed the remaining wound defect by utilizing a rhomboid skin flap (Limberg-Flap, Fig. ) []. A superficial wound healing disorder prolonged the postoperative course but eventually resolved with non-surgical wound therapy. After discharge, the patient followed up with his general practitioner and dermatologist. Besides oral pain relievers, the patient did not receive any particular medication postoperatively. The localization of the skin tumor and an overall prolonged wound healing resulted in an unsatisfying scar deformity. A secondary revision of the scar, performed by another physician at the patient’s place of residence, led to the visible alteration of the flap geometry (Fig. ). The recommended after-care included MRI imaging for local recurrence, clinical examination, and regional lymph node ultrasound every 3 months for the first postoperative year. At the last follow-up one year after resecting the DFSP, we did not observe any sign of recurrent tumor growth. Thus, the after-care interval extended to 6 months. |
A 17-year-old male patient was referred to our clinic for recurrent right knee pain with snapping that occurred during active extension and prevented the patient from completely extending his knee. However, when the knee was in a relaxed position, it could be extended fully by another person. The patient reported no recent traumatic events or previous surgeries. Physical examination showed a positive sign in the MPP test [], which was conducted with the patient in the supine position and with the knee extended. Using the thumb, force was applied to press the inferomedial portion of the patellofemoral joint, inserting the medial plica between the medial femoral condyle and the patella. While maintaining this force, the knee was flexed at 90°. The MPP test was defined as positive when the patient experienced pain with the knee in extension and eliminated or markedly diminished pain with the knee in 90° of flexion. In the present case, the pain subsided when the knee was in hyperextension. A tender band was palpable approximately a fingerbreadth medial from the patella, while rolling over the medial femoral condyle was palpable with the knee in motion (the rolling over sign). Preoperative MRI was performed, which revealed a hypertrophic MPP (Fig. a and b) along with an abnormal notch in the articular surface of the medial femoral condyle (Fig. c).\nArthroscopic surgery was performed. An MPP with a tight and hypertrophic margin was observed (Fig. ). The position and possible impingement of the plica were observed during knee motion and checked using an arthroscopic probe. An abnormal notch in the articular surface of the medial femoral condyle was observed beneath the MPP (Fig. ). The plica was excised at the zone of contact with the patella and medial femoral condyle (Fig. ). The cartilage was assessed using probe palpation, which revealed no pathological lesions. Full range of motion of the knee joint and full weight-bearing were allowed immediately after surgery. One day after the surgery, postoperative MRI confirmed MPP excision (Fig. d), and histologic examination using a light microscope (Olympus BX53, Japan) was performed. Histological findings revealed generalized fibrosis with stroma, as well as infiltration of inflammatory cells into fibrous tissues covered with synovial membrane cells (Fig. ).\nBefore surgery, the patient presented with pain (visual analogue scale [VAS] score: 5) in the medial margin of the patella and complained of palpable snapping during knee flexion and extension. The patient visited the clinic 2 weeks after the surgery and was satisfied with the improvement in his pain (VAS score: 0). |
A 45-year-old man who had been suffering from UC for about 20 years had a total colectomy and ileoanal canal anastomosis performed for rectal adenocarcinoma. About 1 year and 7 months after the operation, redness and erosion were observed around the anastomosis site, and a dysplasia-associated lesion or mass (DALM)-like elevated lesion developed about 4 months later. Regenerative mucosa or low-grade dysplasia was the diagnosis after repeated biopsies. Since symptoms of stenosis were severe, a resection of the ileoanal canal was performed 2 years and 6 months after the first operation.\nIn three tissues taken in a biopsy about 1 year and 7 months after the first operation, glands were sparsely distributed with background of mild inflammation. Some glands exhibited mild elongation with a decrease in number of goblet cells, but nuclei were uniform and located in the basal area. Regeneration was suspected (). In the second and third biopsies, about 2 years and 2 years and 1 month after the first operation, serrated glands were densely distributed. Nuclei were mildly enlarged. Background inflammation was mild. Within five tissues taken in each biopsy, there were no apparent findings that indicated invasion. Low-grade dysplasia was suggested, at least in part (). However, three tissues of the subsequent biopsy (2 years and 5 months after the first operation) looked like regenerated mucosa containing a few glands with little nuclear atypia. It was accompanied with mild-to-moderate inflammation ().\nIn the operated material, the anastomosis site was severely stenotic (). Although there were no apparent elevated masses, the mucosa around the anastomosis was rough and the intestinal wall was thickened hard extending over about 6 cm in length. Histologically, atypical glands proliferated from the mucosa to subserosa: glands tended to show a serrated appearance in the propria mucosa and were tubular below the submucosa (). Cellular atypia looked minimal, especially in the superficial area, where cells were uniform with low nuclear cytoplasmic ratio. In invasive glands, nuclei were somewhat irregular and enlarged (). In non-tumorous mucosa, there was mild-to-moderate inflammation consistent with UC, accompanying mild basal lymphoplasmacytosis. Glands were shortened and distorted ().\nTo investigate the characteristics of this tumor, representative sections were immunostained using the EnVision system (Dako, Grostrup, Denmark). The primary antibodies used are summarized in . On the operated specimen, p53-immunopositive tumor cells were a few and β-catenin was negative. There were many CK7-positive tumorous glands, but CK20 was positive only in some glands in the mucosa (). TNF-α and Aurora B were more intensively stained in tumorous glands compared to non-tumorous glands. Invasive glands tended to be stained stronger on immunostaining with CK7, TNF-α and Aurora B (). Immunoreactivity against the anti-CD44v6 antibody was focally reduced in tumorous glands in the propria mucosa, and disappeared in invasive glands (). By contrast, a disintegrin and metalloproteinase 17 (ADAM 17) were expressed more in invasive glands (). There were no apparent differences between tumorous and non-tumorous glands in other immunostains: Aurora A, cycloosygenase-2 (COX-2), and signal transducer and activator of transcription 3 (STAT 3) were positive or weakly positive, and others were negative.\nOn retrospective examination of biopsy specimens, atypical glands that suggested low-grade dysplasia were positive for CK7 and weakly positive for TNF-α and Aurora B (). Some atypical glands exhibited decreased membranous expression of CD44v6 (). CK20-positive glands were a few. There was no apparent positive reaction on ADAM17 immunostaining. |
A 9-month-old healthy male infant was brought for consultation for a “tail like” structure in the lumbosacral area since birth. On physical examination, the appendage was 5 cm long and was attached to the back tip of coccyx appearing like a human tail (). A dark pigmentation area in the low back was also found (). According to the parents, the tail was about 2 cm at birth and the size had been increasing with age. It was soft and nontender, covered with normal skin. No bony attachment or any voluntary movement was observed in the mass. His muscle strength, tone, and sensation were intact with normal reflexes present. There was normal rectal tone with an anal wink reflex present bilaterally. The infant was born after an uneventful pregnancy. There was no history of any illness, exposure to radiation, or taking any drug during pregnancy. He did not have any family history of congenital abnormality. Plain radiographs revealed cleft vertebrae of the ninth thoracic vertebrae, and bifid rib of the fourth rib (). Computed tomography (CT) scans showed split cord malformations, block vertebrae of the third and fourth vertebrae, and hemivertebra of the second sacral vertebrae (Figures and ). Magnetic resonance imaging (MRI) showed split cord malformations ( and ). With the impression of human tail coexisting with type I split cord malformations, operation of resection of the tail, removing of the septum and spinal cord untethered, was done with continuous intraoperative monitoring of sensory evoked potentials and electromyogram recording of lower extremity and sphincter muscles. The tail was elliptically excised, and the subcutaneous portion sharply dissected from the dorsal lumbosacral fascia. Despite careful inspection for a fascial defect and subfascial extension of the tail structure, none was observed, and the tail was removed enbloc. The lumbar fascia was opened and L4–L5 laminoplasty performed. A bony septum originating from segmented lumbar vertebrae was found to divide the spinal cord. Two hemicords were shown to course within two separate dural sleeves (). The spinal cord was untethered and decompressed by removal of the septum. The filum terminale was thickened and was transected. The other abnormalities of the spine were untreated. The infant was recovered uneventfully in the postoperative period. In the followup till 18 months, he was all right without any neurological deficit. His bowel and bladder habits were also normal. |
A 61-year-old male reported to the Department of Prosthodontics with chief complaints of difficulty in swallowing and impaired speech due to partial resection of the tongue. Three years back, the patient was diagnosed with squamous cell carcinoma involving the right lateral border of the tongue and just crossing midline in the anterior two-third of the tongue. The patient underwent anterior two-third glossectomy and neck dissection.\nThe patient had diabetes for the last 5 years and was under medication. Extraoral examination indicated that there was little collapse of soft tissue on the right cheek and the right side of the neck. The patient had adequate mouth opening (50 mm) as seen in . Intraoral examination depicted that the lingual sulcus was completely obliterated on the resected side. The patient was dentulous in both the jaws with few teeth missing [Figures and ]. The right-sided floor of the mouth is concave and essentially without function []. The floor of the mouth was reconstructed using a split-thickness skin flap from his thigh. The patient was wearing PAP for the last 1½ years which had a broken clasp. The prosthesis had helped the patient in speech and swallowing to some extent. The prosthesis did not have the required stability and retention. It was flat on the oral surface as seen in and it lacked the contours required for phonetics.\nThe floor of the mouth had altered posture and restricted movements. Whenever there is residual function in the remaining floor of the mouth, PAP is considered.[] The treatment plan thus included fabrication of PAP with oral surface being contoured by functional palatal impression technique using functional wax on the oral surface and reproducing the same in the final prosthesis.[]\nPrimary impressions were made in addition silicone material in a stock tray, and primary casts were made. A self-cure hollow prosthesis was fabricated to work as a base on which molten Korecta wax would be applied to make functional records []. The clasps’ design was also changed to make it more retentive and stiffer as compared with the previous prosthesis in which there was a long clasp arm, which resulted in increased flexibility making it prone to fracture. This prosthesis was checked for comfort and retention before the records were made. The tongue-palate contacts were evaluated according to the clarity of speech during specific sounds.\nThe wax was painted using a brush on the oral side of the hollow prosthesis, and the patient was instructed to functionally manipulate the wax by the floor of the mouth by repeating the linguovelar sounds /k/, /kh/, /g/, and /gh/ for the posterior palatal tracing. For the anterior palatal tracing, the linguoalveolar sounds /t/ and /d/ were used. This sounds enabled the tongue to articulate with the different positions on the palate. Additional wax was added to the anterior palatal region resulted in a significant improvement for the fricative and affricative (hard) linguopalatal sounds /s/, /sh/, /z/, /zh/, /ch/, and /jh/ as shown in .[] For tracing the swallowing patterns, the patient was asked to swallow saliva multiple times. Phonetics was checked again, and finally, a proper balance was achieved between speech and swallowing tracings.[] It should be checked that both functions are performed without any restriction. The prosthesis was finally processed with the heat cure acrylic resin. Laboratory putty index was made before flasking to make sure that the patterns recorded were not distorted by any heat or pressure generated [Figures –]. A smooth palate without rugae was preferred by the patient for easier removal of food during eating [].[] The rainbow passage especially designed for Indian population was used to assess the speech intelligibility without the prosthesis,[] with the previous prosthesis and with the new prosthesis.\nThe prosthesis was delivered to the patient and follow-ups were done after 24 h and 1 week. After 1 week, speech therapy and oral exercises were initiated to improve the efficiency of the prosthesis. The patient was asked to suck the saliva forcibly inside the pharynx to improve the swallowing abilities. He was also asked to do exercises involving muscles of cheeks, lips, and floor of mouth such as blowing and sucking exercises to improve articulation during speech.[] |
A 17-year-old male patient reported to the Outpatient Department of Maulana Azad Institute of Dental Sciences in July 2012 with the chief complaint of swelling on the right side of the face since 1 year that had rapidly increased in size since last 4–5 months. It was associated with occasional intermittent, spontaneous pain and continuous headache which aggravated on bending. Patient had a history of weight loss of over 15–16 kg with the loss of appetite over 1 year along with frequent epistaxis from the right nostril with feeling of stuffiness of nose and nasal discharge. There was a history of extraction of upper right second molar after the appearance of swelling.\nThe medical history was not significant. Physical examination along with cranial nerve examination did not reveal any abnormality. Extraoral examination [] was suggestive of a lobular swelling on the right side of the face extending from infraorbital margin to the lower border of mandible supero-inferiorly and from ala of nose and corner of the mouth to tragus of ear and ramus of mandible anteroposteriorly approximately 7 cm × 8 cm in size. The overlying skin was normal in color and texture. The swelling was smooth surfaced with well-defined margins and resilient in consistency. It was compressible, pulsatile, and tender on palpation. The swelling reduced in size on opening the mouth and on clenching, swelling became more prominent adjacent to ramus of mandible. The mouth opening was reduced with deviation toward right on opening. The right submandibular lymph nodes were found to be enlarged, tender and mobile on palpation.\nIntraoral examination [] revealed generalized brownish discoloration of teeth in a linear fashion along the cervical third of teeth with high arched palate. The buccal mucosa on the right side was swollen and lobulated extending from the corner of the mouth to the ramus of mandible with indentations on its surface. An ulcer was present in relation to maxillary right first molar, which had everted margins and an erythematous surface about 1 cm in size. Based on history and clinical findings, a provisional diagnosis of benign soft tissue tumor (nonodontogenic) was given. However, benign tumor of the parotid gland, low grade malignancy of parotid gland and lymphoma were considered as the other differentials. Routine hematological investigations were found to be within the normal limits. Fine-needle aspiration of the swelling and the lymph node was performed, which revealed only blood.\nOrthopantomogram [] showed erosion of the alveolar bone in relation to maxillary first molar region and maxillary tuberosity on the right side along with resorption of the anterior border of ramus and the effacement of right maxillary sinus, zygomatic arch and adjacent maxillary structures by the soft tissue mass without the presence of any well-defined lesion. All findings were suggestive of malignancy.\nContrast enhanced CT revealed a large, ill-defined enhancing soft tissue mass filling the nasopharynx, bilateral nasal cavity [Figures and ], and pterygopalatine fossa and sphenopalatine foramen extending into ethmoid and sphenoid sinus with erosion of its lateral wall and floor. There was an extension into soft tissue component into right buccal space and the infratemporal space [] with associated mass effects giving an impression of nasopharyngeal angiofibroma.\nMagnetic resonance imaging angiography showed similar findings with a large lobulated enhancing soft tissue mass measuring 5.4 cm × 8 cm × 8 cm in size in the right base of the skull adjacent to nasopharynx. The mass was seen as hypointense on T1-weighted image and heterogeneously hyperintense on T2-weighted image [] causing expansion of pterygopalatine fossa and sphenopalatine foramen with extension into the sphenoid sinus, ethmoid air cells and right nasal cavity. Anteriorly the mass was seen to be extending into the right infratemporal fossa and right maxillary sinus with remodeling of right zygomatic arch and part of body and ramus of mandible with elevation of subcutaneous tissue of right cheek. The mass was supplied by the right external carotid artery [].\nBased on history, clinical presentation, CT and MRI findings, the lesion was finally diagnosed as nasopharyngeal angiofibroma. Patient was referred to the Department of Neurosurgery for further management where it was planned to carry out the initial embolization of the lesion to be followed by surgery. |
A 71-year-old lady with history of poorly controlled hypertension was brought to the emergency room with complaints of sudden onset of loss of consciousness 12 h earlier with no improvement in sensorium since then. There was no history of seizures, decreased movements on one side of the body, or trauma. On examination she was unconscious, not opening her eyes to pain, and only localizing to deep central pain with both upper limbs. Her pupils were bilaterally equal and sluggishly reacting to light. Non-contrast computerized tomogram (NCCT) revealed a hematoma in the left cerebellar hemisphere measuring about 3 × 4 cm with effacement of the fourth ventricle and compression of the brainstem [] and hydrocephalus. She was operated emergently and a left sub occipital craniectomy was performed and the hematoma was evacuated. Postoperatively the patient was electively ventilated and after 6 h could localize pain with both her upper limbs. Postoperative NCCT showed a small residual hematoma in the left cerebellar hemisphere with operative site edema. The 4th ventricular effacement was persistent and ventriculomegaly had increased in comparison to the preoperative scan []. Hence, external ventricular drain (EVD) was inserted to allow temporary CSF diversion. The EVD was placed in the right Kocher's point using a twist drill, 1 cm anterior to the coronal suture and 2 cm lateral to the midline. The right frontal horn was hit at a depth of 4 cm in one attempt and clear CSF was drained. However, soon after the EVD placement, the patient stopped moving her limbs to pain, and her pupils became pin pointed with no reaction to light. The respiratory effort that she had developed on the ventilator also ceased. An emergency NCCT brain revealed a large hematoma in the left cerebellar hemisphere with compression of the brainstem and hemorrhage within the substance of the brainstem extending from the pons to the midbrain supratentorially [Figure and ]. The patient showed no further neurological improvement and died on the fifth postoperative day. |
A 3-yr-old boy presented with abdominal pain was referred to our institution for the evaluation of a progressive bulge in his right abdomen that his mother had first noticed seven days previous on February 12, 2009. A biochemical evaluation revealed no significant abnormalities. Serum levels of tumoral markers (AFP, CA19-9, CA125 and CEA) were within reference limits. A physical exam revealed a mildly tender mass in the right hypochondrium extending to the epigastrium; however, two lesions were found after a dynamic computed tomography (). The primary lesion (8.5 × 4.3 cm) was located in the head of the pancreas and partly herniated into the abdominal wall. While the secondary lesion (1.8 × 2.1 cm) was in the left abdomen near the spleen and the tail of pancreas, and well demarcated from the surrounding structures, and no calcifications were evident within them (). They all showed well-defined margins and inhomogeneous attenuation due to the presence of cystic and solid areas, in the venous phase () and the delayed phase (), a continuous enhancement was observed with a parenchyma density that was higher than that of the arterial phase. In addition, a large and distorted vascular shadow () inside of the tumors in the arterial phase in the primary lesion. There was no radiological evidence of nodal or distant metastases; however, there was a local infiltration of the adjacent abdominal muscle that required a laparotomy.\nSurgery revealed the primary lesion was firmly adhered to the adjacent omental and abdominal muscle; in addition, a local infiltration of the liver and stomach were also noted. The head of the pancreas was compressed and could be separated from the tumor due to well-defined margins. The bile duct, portal vein, and the inferior vena cava were also compressed but patent. The gross specimen showed a resected mass measuring 8 × 4 × 4 cm that was well circumscribed and solid with areas of necrosis and hemorrhaging. No calcifications were evident within the mass. The secondary lesion was also adhered to the adjacent omentum and spleen; however, it was well demarcated from the surrounding structures with no evidence of originating from the pancreas. A histopathological analysis revealed a resected mass measuring 3 × 4 × 3 cm, which was well encapsulated by omentum with no calcifications within the mass. The surgical resection was difficult due to the extensive nature of the tumor, but the two lesions were completely resected without the pancreas being damaged. In the final pathology report following surgery, the diagnosis of pancreatoblastoma was confirmed with histopathological results, and the secondary lesion histology and immunohistochemistry was consistent with the findings of the primary lesion ().\nAfter surgery, the patient was treated with adjuvant chemotherapy (vincristine, cyclophosphamide, and epirubicin) regularly. At the time of this report, 18 months after complete tumor resection, the patient is currently in good condition and without radiological evidence of recurrent tumor or metastases () with normal levels of CA 125, CA 19-9 and AFP to date. |
Reported patient is a 41-year-old male with a known history of meningioma that was first diagnosed at the age of 13 years for which he underwent resection of a right skull-based meningioma. He had a recurrence of his disease in 2007, at the age of 30 years. He had multiple surgeries for resection of his recurrent meningioma and subsequently right cranioplasty in 2009. In 2013, he developed a left frontal meningioma which was excised. His post-operative course was complicated by infection of the surgical site and he underwent removal of his right temporalis Medport which was placed in January, 2015. He also underwent debridement of the right zygomas and lateral maxilla with removal of the infected maxillary hardware in November, 2015.\nThe patient had progressively worsening right sided headache and magnetic resonance imaging (MRI) performed in April, 2017 showed recurrence of meningioma in the right middle fossa. While under consideration for enrollment in a clinical trial, survellance imaging showed that his meningioma tumor burden was rapidly progressing. Patient had a generalised tonic clonic seizure and an MRI peformed six months after his recent recurrence showed that the infratemporal component of meningioma had significantly enlarged and was extending intracranially through the foramen ovale. The middle cranial fossa component had also enlarged and measured 2.4 cm by 2.9 cm by 1.5 cm. The tumor resulted in severe compression of the right temporal lobe with associated progressive vasogenic edema throughtout the temporal white matter and orbitofrontal white matter. He was started on levetiracetam and a decision was made to proceed with surgical resection. Postoperative MRI showed plaque like dural thickening along the anterior frontal and temporal convexities but no residual meningioma in the operative bed.\nHistopathological analysis revealed that this was a WHO Grade II meningioma. Foundation 1 genetic testing revealed NF2 mutation. His tumor was microsatellite proficient and mutation burden was low. As recent phase II clinical trials have shown promising results with combination therapy with bevacizumab and everolimus in patients with NF2 mutated meningiomas, patient consented to proceed with this regimen. MRI performed after 4 cycles of combination treatment with bevacizumab and everolimus showed no new enhancing mass in the operative bed or the rest of the brain. |
A 21-year-old nulliparous lady was referred to our emergency by a general practitioner at 28 weeks of gestation with history of abdominal pain since one week. There was no history of any discharge per vaginum, loss of fetal movements, abdominal trauma, or any bladder or bowel disturbance.\nShe was gravida two with one spontaneous abortion at 3 months of gestation about one year back, for which a curettage was done. Rest of her medical and surgical history was unremarkable. Her present pregnancy had been uneventful till now and her early pregnancy scans were reported to be normal.\nOn admission, her general condition was poor, and there were signs of hypotension and tachycardia. Her upper abdomen was soft and non tender while there was guarding and tenderness in lower abdomen. Her uterus was 26 weeks gravid, with contour well made out. Fetal parts were made out with difficulty. The flanks were dull on percussion. Fetal heart sounds could not be auscultated. On per speculum examination, there was no bleeding. Her vaginal examination revealed a soft cervix with os closed, and a firm round nontender 4×4cm mass in the anterior fornix toward the right side of cervix.\nThe patient had undergone an magnetic resonance imaging (MRI) four days back as advised by the treating physician before presenting to this hospital. The MRI reported a didelphys uterus with a single fetus in left uterine body. The placenta was left lateral and there was no free fluid in abdomen []. It also reported the absence of left maternal kidney. Her blood reports at the time of admission showed mild anemia and normal platelet count. Ultrasound was done which showed a bicornuate uterus with a normal right horn and a live 26-27 weeks fetus in the left horn. The placenta was fundoanterior and myometrial continuity was well maintained all around. Free fluid was present in the abdomen which on paracentesis was confirmed to be blood. She was immediately shifted for exploratory laparotomy with a provisional diagnosis of pregnancy in a rudimentary horn with rupture of the horn.\nPreoperatively, there was hemoperitoneum of about 1.51. There was an enlarged gravid intact rudimentary horn and brisk bleeding was seen from the prominent blood vessels scattered all over its fundus []. The horn was connected to the left wall of the uterus just above the cervix by a thick fibrous band and the ipsilateral tube and ovary were stretched over the horn []. The fallopian tube and ovary of the right side were healthy. A live 950 g male fetus was extracted from the horn and handed over to the pediatrician. The rudimentary horn and ipsilateral tube and ovary were removed. Left sided kidney and ureter were found to be absent. Abdominal cavity was washed with saline and closed. Patient received two units of packed cells during the operation.\nHer postoperative course was uneventful. Pathological evaluation of the specimen confirmed the presence of placenta percreta invading the serosal layer. Microscopic examination confirmed the lack of any communication in the fibrous band connecting the rudimentary horn with the uterus. The neonate was discharged from the hospital after one and a half months in a healthy condition after gaining weight up to 1400 g. |
A 51-year-old man with liver cirrhosis was admitted to our hospital due to loss of appetite, recurrent abdominal distension for 1 year, and hematemesis and melena for 3 months. Upper endoscopy showed variceal veins in the fundus of the stomach, and 4 variceal veins 25 cm from the incisor tooth that extended down to the cardia (Fig. ). Polyglycol and tissue glue were injected intravenously, and endoscopic variceal ligation was performed (Fig. ). During the ligation procedure, the patient developed significant bleeding when the seventh elastic ring came loose.\nAn SB tube was inserted in an attempt to stop the bleeding; however, placement of the tube was difficult due to the 6 elastic rings that had already been placed. The patient soon developed dyspnea and subcutaneous emphysema, and the SB tube was withdrawn. The patient became hypotensive and tachycardia with a blood pressure of 80/60 mm Hg and a heart rate of 104 beats/min. An emergency splenectomy and pericardial devascularization was performed under general endotracheal anesthesia. The operation was successful, and the patient was transferred intubated to the intensive care unit. The cardiothoracic surgery team was consulted regarding the patient's subcutaneous emphysema, and a large-bore needle was used to puncture the tissues and vent the gas. However, the subcutaneous emphysema worsened with the use of positive pressure ventilation, developing on both sides of the patient's neck and chest wall. The needle puncture was again performed, but the improvement was minimal. Therefore, a subcutaneous indwelling catheter was placed to relieve the gas accumulation.\nComputed tomography revealed that gas had accumulated on both sides of the neck as well as the skull base, mediastinum, abdominal cavity, scrotum, and beneath the thoracic and abdominal wall (Fig. ). At this point, it was suspected that the subcutaneous emphysema was due to a tracheal injury and possibly an esophageal injury. Fiberoptic bronchoscopy revealed an inward protrusion of the trachea that appeared during expiration and disappeared during inspiration. This protrusion resulted in severe airway obstruction, but no tracheoesophageal fistula was visible (see Video, Supplemental Video, which demonstrates the protrusion of the trachea that appeared during expiration and disappeared during inspiration, resulting in severe airway obstruction). Upper endoscopy indicated no obvious bleeding and no visible esophageal fistula. Fiberoptic bronchoscopy was repeated to adjust the position of the endotracheal tube to relieve the airway obstruction.\nDuring the following weeks, the patient developed a severe productive cough. We adjusted the position of the endotracheal tube multiple times to reduce the airway obstruction. However, after a multidisciplinary consultation, the decision was made to place an 8-cm × 1.8-cm-covered tracheal stent by fiberoptic bronchoscopy (Fig. ). Once the stent was placed and the patient's vital signs had stabilized, the patient was extubated, given oxygen through a nasal cannula, and discharged from the intensive care unit to a regular ward. A sputum culture showed a Staphylococcus aureus infection that was sensitive to rinathiazoleamine and vancomycin, and the patient was started on rinathiazoleamine. The patient ultimately recovered and was discharged on hospital day 26.\nFour weeks later, the patient was rehospitalized with throat pain and hemoptysis. Laryngoscopy was performed at a local hospital, which revealed a metal stent in the hypolarynx that prevented closure of the glottis. A computed tomography showed a small amount of gas around the trachea (Fig. ). The patient was transferred to our hospital, the tracheal stent was removed (Fig. ), and the patient was discharged 2 days later.\nTo date, the patient has been followed up for 10 months since his first admission in our hospital. Recently, he has no hematemesis or melena. Furthermore, no respiratory discomfort has been shown after removing the stent. |
A 58-year-old male developed an ulcer over his chronic scalp scar, which he developed due to bear mauling about 50 years back. The lesion developed following a minor trauma to the scar tissue and went through a cycle of apparent healing and deterioration. The ulcer continued to increase in size, and a cauliflower-like granulomatous mass appeared in the center with repeated episodes of foul smelling serosanguinous discharge and contact bleeding.\nOn examination, he was conscious, with stable vital signs. A fungating growth of size 12×10×5 cm with irregular and indurated margin was found over the scar on his occipital area. The surface was covered with pale granulation tissue with intervening hemorrhage and necrosis []. Scrap cytology revealed squamous cell carcinoma. Fine-needle aspiration cytology of the enlarged right occipital and posterior triangle lymph nodes showed features of inflammation and reactive hyperplasia. Computed tomography scan showed a right occipital extra-calvarial isodense lesion with underlying bone erosion and meningeal thickening [].\nDefinitive surgery was planned based on prior discussion with the plastic surgeons. The patency of scalp vasculature was confirmed and marked over skin by Doppler ultrasound to plan rotational flap. With the patient in prone position, wide excision of the lesion was carried out with a 2 cm margin of normal skin. The underlying bone was found to be eroded with the dura infiltrated and adherent to the brain tissue below it. The unhealthy bone margins were nibbled away. The involved dura and an area of abnormal cortical brain tissue were excised and the dural defect was repaired using a G-dura patch []. The scalp defect was closed with local rotation flap based on left occipital artery in the same sitting. The secondary defect was grafted with split thickness skin graft. Histopathology of the mass revealed squamous cell carcinoma. One hundred percentages flap survival was achieved post-operatively with uneventful wound healing and acceptable cosmetic outcome []. On the 8th day, he was discharged with advice to attend radiotherapy department for possible radiotherapy. |
A 45-year old man was referred to the department of periodontics for periodontal treatment. The chief complaints of the patient were bleeding on brushing teeth and a dull pain in the maxillary left quadrant. Gingival redness, bleeding on probing and pocket depth of 6 mm on palatal surface of molars was found in clinical examination. Pocket depths on buccal, mesial and distal surfaces were 4-5 mm. Besides, there was a generalized gingival inflammation with probing depth of 3-4mm in more than 30% of areas. Vitality test was positive for both of maxillary left molars and there was no percussion sensitivity. There were buccal furcation involvement (grade ΙΙΙ) and mobility (grade II).\nPeriodontal diagnosis was generalized moderate chronic periodontitis. Phase Ι in periodontal treatment, consisting the scaling and root planning, was performed for the patient in two sessions. After 6 weeks, the clinical signs of the gingival inflammation were greatly subsided and the plaque score was less than 10%. The pocket depth changed to 4 mm in the maxillary molars but there was persistent inflammation in the maxillary second molar area. So the conventional flap was elevated and after debridement, a palatal furcation could be seen in the maxillary left second molar from palatal aspect ().\nThere was grade ΙΙΙ palatal furcation involvement and it had no antagonist tooth. So the prognosis of the tooth was assumed hopeless and it was extracted during the periodontal surgery. As it is displayed in the , the tooth had two separate palatal roots with one canal in each root ().\nThe access cavity of the maxillary second molar is usually triangular in shape. The base and the top of this access cavity is the buccal and palatal aspect of the tooth respectively without oblique ridge involvement. In the current case, to obtain a straight line access to the canals, the access cavity was prepared in trapezoidal shape and involved the oblique ridge. The pulp chamber of this tooth was broader in the palatal area and like other teeth, represented the whole crown shape ().\nRoot canal treatment was performed and the working length was determined and the root canals were cleaned and shaped using Gates Glidden drills, stainless steel hand K-files, and Pro Taper nickel-titanium rotary instrumentation (Dentsply Maillefer, Switzerland) under the copious irrigation with 2.5% NaOCl solution. The root canals were dried and were obturated using a cold lateral condensation technique with gutta-percha cones and a resin-based sealer, AH-plus (Dentsply Maillefer, Switzerland). The final radiograph revealed two separate roots with one canal in each root (). |
A 60-year-old woman presented with severe headache and visual loss in the left eye for 2 days. Initially having the headache at the left temporal region and around the left eye, she had developed the visual loss in the left eye after a few hours. The patient denied having pain on eye movement, fever, jaw claudication, or weight loss. She also reported no history of autoimmune diseases or recent trauma.\nThe patient went to her primary care hospital. A computed tomography (CT) scan of the orbit revealed a left orbital-apex mass adhering to the left superior rectus and medial rectus muscles and a right orbital apex mass []. She was diagnosed as having an orbital pseudotumor and was referred to our hospital for further management. Her visual acuity in the right eye was 20/40 and counting fingers in the left eye. An eye examination found a relative afferent pupillary defect as well as a mild limitation of the lateral rectus movement in the left eye. There was no lid swelling or proptosis, and the fundus and disc appeared normal. We observed that the patient also had a blue–green soft nodule on her left cheek []. We reviewed her CT scan and noticed a homogeneous lesion on her left cheek []. Consequently, we thought the cheek lesion might be a hemangioma related to her orbital lesions. We requested magnetic resonance imaging (MRI) of the brain and orbit.\nThe MRI scans revealed an ill-defined intraconal mass at the medial portion of the left orbit causing a lateral pressure effect on the left optic nerve. The mass had an iso-to-low signal intensity (SI) on T1W, a low SI on T2W, and peripheral patchy enhancement. The mass involved part of the left superior oblique and left medial rectus muscles. However, part of the central portion showed a particularly low SI on T2W without enhancement, which was suspicious of a hemorrhagic component. Moreover, there was another small, lobulated, intraconal nodule at the right orbital apex that had a low SI on T1W and a high SI on T2W with homogeneous enhancement. It was located just lateral to the right optic nerve without intraocular muscle involvement [].\nA neurosurgeon was consulted for tissue diagnosis and management of the lesion in the left orbit. The patient underwent left craniotomy and orbitotomy with the aid of CT navigation. The finding was a pink, ill-defined, soft, sticky, and easily bleeding mass at the medial region of the left orbital apex. There were some old blood clots and a few large blood vessels supplying the mass. The mass adhered to the left medial rectus muscle, the left superior oblique muscle, and the optic nerve. Tumor removal was performed. The pathology showed collapsed, thin-walled, vascular channels associated with a dilated area containing organized thrombus, all of which were compatible with a hemangioma with an intralesional hemorrhage []. The patient was diagnosed as having a CVM with an intralesional hemorrhage at the left orbital apex. Two days after the surgery, her vision improved from counting fingers to 20/500 in the left eye. The best-corrected visual acuity of the left eye 20/50 was achieved 1 month postoperatively, and there was no pain nor any limitation of the patient's eye movement. She attended all follow-up sessions. Two years after the procedure, her visual acuity was 20/25 in both the eyes. An MRI scan at that time revealed no change in the CVM in the right eye and no residual tumor in the left eye. |
A 56 year-old female was transported to the emergency department by EMS after physically threatening her husband with a knife. According to the patient, she experienced altered sensorium for one week prior to presentation, primarily resulting in suicidal and homicidal command hallucinations instructing her to overdose on NSAIDs and kill her husband. She denied any headaches, vertigo, fevers, head trauma, urinary symptoms, or use of illicit substances. There was no history of psychosis, schizophrenia, mania, or depression and a review of her medication list for any potential hallucinogenic agents did not indicate a pharmacologic etiology. Her past medical history was comprised of two prior strokes, the most recent being two years ago that involved the right frontal lobe. MRI of the brain at the time also showed evidence of an old right parietal lobe infarct. An echocardiogram during that hospitalization revealed a severely decreased left ventricular function and the patient was initiated on warfarin for anticoagulation. Since the two prior cerebral infarcts, the patient and her husband denied noting any behavioral changes, cognitive impairment, or any focal neurologic deficits. On presentation, she appeared disheveled and exhibited a flat affect with minimal verbalization. Physical examination revealed only a left hemianopia without hemiplegia. All cranial nerves were evaluated as well as gait, cerebellar function, and proprioception, which were all found to be normal. The patient was alert and oriented with intact mentation.\nShe was initially admitted to the psychiatric unit for further evaluation where the patient participated in daily activities and reported no symptoms. Given the acute onset of her symptoms, laboratory studies and brain images were obtained in order to rule out an organic etiology. A complete blood count was normal and a basic metabolic panel revealed normal electrolytes and renal function. Additional labs included liver function tests, lipid panel, cardiolipin antibody, and TSH, which were all normal and RPR was nonreactive. A urine sample was negative for urinary tract infection and 8-panel urine drug screen was negative. An MRI of the brain was obtained, which revealed old ischemic infarcts within the right parietal and frontal lobes along with a new acute right occipital lobe infarct with hemorrhagic transformation (). The patient was subsequently transferred to the medical unit for further workup and management.\nThe patient was placed on telemetry, which showed normal sinus rhythm. Given the involvement of multiple brain territories and circulations, a cardioembolic source of stroke was highly suspected. A cardiologist evaluated the patient and performed a transesophageal echocardiogram that revealed a low ejection fraction of less than 20%. In addition, a bubble study was performed that was positive for a patent foramen ovale. Given her significantly low ejection fraction, the patient underwent placement of an automated implantable cardioverter-defibrillator. The patient's presenting symptom of psychosis, primarily in the form of auditory hallucinations, was self-limited and resolved on day two of hospitalization without requiring the use of antipsychotic medications. |
A 42-year-old female with a known HIV seropositivity for past 6 years reported to our department with a complaint of nonresolving swelling over left side of the face of past 2 months duration. She also gave a history of noticing intraoral growth in the mandibular left posterior region for the past 3 weeks. The swelling was accompanied by progressive decrease in mouth opening, loss of appetite, rapid increase in size of intraoral growth, and significant weight loss of more than 6 kg for the past 2 months. She also complained of fever, night sweats, and easy fatigability. The patient was referred to our institute by a general physician due to nonresolving nature of the swelling. After going through her medical records it came to our notice that patient was diagnosed as HIV positive in the year 2010 and was on art for the same. Her CD4 counts at the time of presentation were 58. On local examination, there was gross facial asymmetry with a single diffuse swelling over left side of the face extending suproinferiorly from the zygomatic arch to about 2 cm below the inferior border of the mandible into the submandibular region. Antero-posteriorly the swelling extended from the angle of the mouth up to the tragus of the ear measuring approximately 8 cm × 5 cm × 3 cm with obliteration of nasolabial fold on the left side. The skin overlying the swelling had a taut and shiny appearance [].\nOn palpation the swelling was firm, tender and nonfluctuant. Lymph node examination revealed single, oval-shaped, mobile node in the left submandibular region.\nIntraorally there was single, diffuse large proliferative growth extending from the mandibular incisor region to the retromolar trigone and crossing over to the lingual side up to the premolar region measuring 8 cm × 4 cm × 4 cm in greatest dimension. The overlying mucosa had a corrugated appearance with areas of hyperpigmentation and slough []. Oral hygiene was poor and carious teeth were present in all four quadrants. A computer tomographic scan was taken to see for the extent of bony involvement which revealed erosion of buccal and lingual cortices. It also revealed an expansile lesion involving buccal and submandibular space [].\nChest X-ray (postero-anterior view) revealed multiple radiopaque foci which were suggestive of old-treated Koch's [].\nThe swelling was subjected to incisional biopsy under local anesthesia. The hematoxylin-eosin stained section showed diffuse sheets of monotonous lymphocytes homogenous in size and shape with intensely basophilic vacuolated cytoplasm. A large number of abnormal mitotic figures were seen. Dilated blood vessels and areas of extravasated erythrocytes were seen between undifferentiated lymphocytes [].\nThe histopathologic diagnosis was suggestive of NHL.\nTo identify the subtype of NHL, immunohistochemistry was performed using CD45, CD20, and CD3 markers. The patient upon definitive diagnosis of NHL was started on palliative chemotherapy. Although partial regression of primary tumor was present, unfortunately the patient was lost to follow-up following 6 months after chemotherapy after being discharged from our unit. |
The patient reported is a 32-year-old man with a past medical history of seizure disorder and a known psychiatric history of bipolar disorder with multiple inpatient hospitalizations for manic episodes during which he exhibited agitated and violent behavior. The patient has a comorbid use of synthetic cannabinoids. He was admitted to the acute inpatient service for a recurrent episode of agitation and threatening behavior in the community in the context of medication nonadherence and continuous use of synthetic cannabinoids. In the course of index hospitalization, the patient self-reported his coprophagic behavior during his initial psychiatric assessment. The patient stated that he believed that the consumption of feces was preventing him from going to jail and facing the death penalty for a murder that he claimed he committed in the past. He was unable to describe any specifics for his murder but felt that he deserved unusually cruel and harsh punishment from law enforcement that could only be prevented by consuming feces. This feeling of guilt and continued belief that he was deserving of cruel and harsh punishment induced his coprophagic behavior. He did not report any associated command auditory hallucinations but expressed depressed mood as he discussed his reasons for feeling guilty. His affect was however incongruent with his stated depressed mood. He was oriented to person, place, and time. Laboratory work-up was within normal limits and a urine toxicology panel (which does not detect synthetic cannabinoids) was also negative for illicit substances. He declined brain imaging for unclear reasons.\nThe patient was started on a course of risperidone 2 mg twice daily, by mouth, and divalproex sodium 750 mg orally twice a day for mood stabilization. He continued to display mood instability with multiple periods of agitation and aggression, as well as coprophagic behavior. His expressed reasons for coprophagia remained the same. He declined any psychotherapeutic interventions to address his excessive guilt and automatic negative cognitions. Over the course of a few days, risperidone was titrated to 6 mg daily in divided doses, with augmentation of his treatment with 200 mg every eight hours orally for mood stabilization/impulsivity in addition to divalproex sodium. The patient's mood symptoms improved after a few days on the current regimen; he became less irritable and easily redirectable, exhibited less impulsivity, and expressed more logical thinking process. His activities of daily living also improved, as he was less malodorous and exhibited improved grooming and hygiene. The patient's coprophagic behavior, however, did not resolve. He continued to express the same guilt and desire of unusually cruel and harsh punishments for his previous transgressions. He was discharged on the twenty-sixth day of admission with resolution of his acute manic episode. His coprophagic behavior and feelings of guilt did not show any resolution. |
Subsets and Splits
No saved queries yet
Save your SQL queries to embed, download, and access them later. Queries will appear here once saved.