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A 74-year-old man with distal bile duct cancer and gastric cancer underwent extended pancreaticoduodenectomy. Thereafter, leakage of pancreatic juice occurred, for which drainage treatment was performed. At 12 days after surgery, a bleeding from the drainage tube and low blood pressure were observed, so an emergency angiography was performed. A bleeding from the celiac artery was observed on angiography (), and a 5 Fr balloon catheter was inflated in the celiac artery for temporary hemostasis, because we needed some time to discuss with surgeons and to prepare a stent graft. Then, a stent graft (Niti-S; Century Medical, Tokyo, Japan) with a diameter of 10 mm and a length of 5 cm was placed at the celiac artery to the common hepatic artery successfully (). Resection of the residual stomach, residual pancreas, and spleen was immediately performed following the stent grafting. After that, wound infection and insufficient anastomosis of the esophagus and jejunum were observed; leukocyte count was 5,400/μL and C-reactive protein level was 5.4 mg/mL. So, drainage treatment was performed. At 40 days after this stent grafting and surgery, melena and reduction of blood pressure were observed. Therefore, emergency angiography was performed, which revealed a bleeding from the celiac artery (). It seemed to be from a distal site apart from the site of the first bleeding, and it was considered not a leakage but a new bleeding. Under fluoroscopy, it was confirmed that the stent graft was not broken. Temporary balloon hemostasis was performed again. Then, we discussed with our surgeon and decided to perform the stent grafting, because it seemed really difficult to reach the celiac artery under laparotomy due to strong adhesion caused by the previous operation. Thereafter, the stent graft (Niti-S) with a diameter of 10 mm and a length of 6 cm was placed at the inside of the initial stent graft to the distal site successfully (). There was no recurrence of bleeding during a 3-month followup period. No antithrombotic therapy was given during follow-up. |
A 41-year-old man with a background of hereditary spastic paraplegia was not tolerating the side effects of oral baclofen and underwent ITB pump placement subcutaneously in the right lower quadrant of the abdomen. He regularly competes as an international power canoeist, and has a muscular build.\nTen months following ITB placement, he attended clinic with a history of pump site discomfort. On examination, the implanted pump had eroded a substantial amount of subcutaneous adipose tissue and the overlying skin was erythematous and tender. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both within normal range. Whilst the overlying skin was intact on presentation, computed tomography demonstrated a fluid collection posterior to the pump. The fluid was aspirated with a needle, and was confirmed sterile on Gram stain microscopy and culture; this fluid was sampled for microbiological analysis and determined to be sterile. Twelve weeks later, the pump was re-sited to the right medial thigh. Intraoperatively, the pump was disconnected and removed from the original site. There was no evidence of infection in the pump cavity. A medial mid-thigh transverse incision was made and a subcutaneous pouch was created, into which the original pump was inserted. A new catheter was connected to the pump. It was first tunnelled out through an intermediate proximal thigh incision, in which the tubing was anchored to the muscle fascia (Fig. ). Subsequently, the same catheter was tunnelled to the original abdominal pouch, where it was connected to the original distal spinal catheter with a straight connector. The pouch was irrigated with gentamicin solution and closed in layers.\nEight months later, the patient presented to his general practitioner complaining of swelling around the revised placement site. For the next 6 months he described intermittent episodes of warmth and erythema at the pump site that worsened during his physical training regime. Towards the end of this period we reviewed the patient in clinic and concluded that this swelling was likely precipitated by exercise. Ten days subsequent to this clinic visit, he was admitted due to increased swelling, pain and ulceration at the pump site. CRP, ESR and white blood cell count (WBC) were all normal. He underwent further surgery: the lateral part of the wound was reopened and thin, inflamed skin edges excised. The wound was washed and closed. Microbiological assessment of the excised skin edges revealed no evidence of infection.\nAt 1-month post-operative follow-up, evidence of dehiscence was still present along with underlying haematoma formation. Thinning of skin and small discharging vesicles were noted lateral to the scar. The patient underwent further surgery under the plastic surgery and neurosurgery team. The wound was debrided and washed out. A new proximal pocket was developed superficial to the deep fascia anterior to the thigh and the pump was re-sited for a second time. At post-operative follow-up, the patient was well and the wound was well healed. Six months later, there was no collection surrounding the pump, the patient was receiving regular ITB pump refills and is able to train without difficulty. |
Presentation
A 60-year-old female with a history of gastrointestinal malignancy had previously undergone a pancreaticoduoduodenectomy after 12 cycles of FOLFOX therapy. Follow-up PET-CT was concerning for a metastatic left pulmonary nodule. This was further evaluated with a chest CT as shown in Figure . She was started on FOLFIRI and SRS of both lung nodules. Despite these therapies, there was progression of the nodule in the left lower lobe of the lung. Additionally, there was new thickening of the distal transverse colon. After discussion at the multidisciplinary tumor board one year after her completion of SRS the decision was made to proceed with staged metastectomy of the abdominal and left pulmonary lesions. The patient noted several months of left-sided chest-wall pain treated with lidocaine patches and no identifiable musculoskeletal abnormalities on preoperative imaging. Seven days after undergoing open left colectomy with lymphadenectomy, she did proceed to the operating room with the thoracic surgery team.
Intervention
The patient was taken to the operating room and placed in the right decubitus position. Thoracoscopic evaluation was begun and there was bulging of the pleura noted adjacent to the lung lesion. Upon incision of the pleura there was a rush of necrotic material with an incidentally noted rib fracture. This was debrided and sent for both cultures and pathology. Frozen sections were performed but negative for evidence of malignancy. The standard wedge resection was then completed with lymphadenectomy. A chest tube was left in place and the patient was taken to the critical care unit for postoperative monitoring.
Hospital Course and Follow Up
The patient was noted to have an air leak postoperatively. The preoperatively placed epidural was removed on postoperative day two due to inadequate analgesia. Final pathology revealed adenocarcinoma, bowel primary, with no evidence of involvement of the lymph nodes or resected rib portion. On postoperative day three she was noted to have feculent drainage from her abdominal incision prompting laparotomy with right colectomy and ileosigmoidostomy for bowel ischemia |
A healthy 14-year-old boy came off his pushbike and fell directly onto his right knee. He immediately experienced pain in his knee that was worsened on weight bearing. This was also associated with significant swelling of his knee. He presented to the emergency department, where examination findings showed a significantly limited range of movement due to pain. A radiograph of his knee showed an isolated fracture of the articular side of the patella with a joint effusion (). He was placed in a Richard splint, and a review in the next paediatric fracture clinic was arranged.\nOn review in fracture clinic three days after the injury, the patient had a significant effusion in his right knee. He was exquisitely tender over his patella and had an intact, though limited, straight leg raise. Range of movement was limited to 30 degrees of flexion, beyond which the pain was intolerable. An MRI was arranged to assess for any associated chondral damage suggesting osteochondritis dissecans, and to look for any other soft tissue derangement of the knee. The patient was treated for one week in a Richard splint and was given instructions to remain nonweight bearing.\nMagnetic resonance imaging (MRI) of the knee (Figures and ) showed an isolated fracture involving the articular surface of the distal part of the patella with surrounding marrow oedema but minimal displacement. The overlying cartilage was intact except along the fracture line with no suggestion of osteochondritis dissecans patellar dislocation, or medial patellofemoral ligament rupture. The quadriceps mechanism was shown to be intact.\nTen days after the injury, the child still had a moderate effusion in his knee and was tender over his patella. Radiographs showed no displacement in the fracture. He was kept in his Richard splint for a further two weeks but allowed to be partial weight bearing.\nAt four weeks after injury, the patient was mobilising using his crutches. On examination, only a small residual effusion was noted and radiographs revealed though no further displacement, and the fracture line was still visible. He was able raise his leg straight but flexion was limited to 15 degrees. The patient was put in a knee brace at this visit, fixed to a range of 0–30 degrees with a plan to gradually increase the range of movement of the knee. He was also referred to physiotherapy.\nAt the fifth week review he had no tenderness over his patella and the effusion had resolved. He was able to flex his knee comfortably to 30 degrees in his brace. The degree of flexion in the brace was sequentially increased to 60 degrees, then 90 degrees and the patient was reviewed two weeks later (seven weeks after injury) at which point he could flex to 100 degrees without any discomfort. Radiographs taken showed that the fracture was healed (). He was therefore allowed to fully mobilise without the brace.\nAt his final appointment, the 14-year-old boy was back to full function with an uncompromised range of movement in his knee and no residual pain. |
A 65-year-old male farmer presented with severe rash on his lower back. One day earlier, he had complained of low backache and treated it with oral diclofenac, oral ranitidine, and topical diclofenac cream. The patient applied diclofenac cream on his lower back and went for his usual work in the field. Initially, the applied area became erythematous and then rapidly developed macular rash with blistering. The eruption was intensely itchy and spread from the lower to the upper back and anteriorly to abdomen []. Although the patient had noted some improvement in the backache, he stopped using the diclofenac cream because of the rash.\nUpon taking detailed history, he reported that he had used the same brand of topical diclofenac cream an year earlier for joint pain but had not developed any rash or erythema on his knee joints even after 1 week of application. As patient has used the same brand before, the reaction cannot be attributed to the excipients of the cream. He had no known allergies. The general examination of the patient revealed no abnormality with normal body temperature.\nLocal examination revealed an extensive, poorly demarcated, erythematous and scaly plaque on the lower back with vesicles and yellow crusting. The affected area extended from the lower back to anterior abdomen and corresponded to the area of application of the diclofenac cream. Only the part exposed to the sun was affected while the part covered with cloth and areas where cream was not applied was completely spared. The expiry date on label of diclofenac gel was checked and it was within its expiry period. Characteristic localization of the lesion to the area of exposure of topical diclofenac supported the diagnosis of diclofenac induced photosensitivity reaction. The causality assessment of the reaction was done by using WHO-UMC scale and Naranjos algorithm and the relation was categorized as probable.\nThe patient was managed by oral amoxicillin-clavulanic acid, antihistaminics, and prednisolone. Oral analgesics were deliberately avoided considering their tendency to exacerbate the reaction. He was advised to avoid sunlight. Patient did not require any intensive treatment or surgical intervention during the follow up and lesions healed without extensive scarring or other complications. |
A 35-year-old Caucasian woman was referred to our outpatient clinic for evaluation of a neoplastic lesion located adjacent to the uterine cervix. She reported not having experienced any pain or discomfort with regard to the lesion and that she had not noticed any changes in bladder or bowel function. The lesion had come to her gynecologist’s attention during a routine pelvic examination 1 week earlier. Her history was remarkable for the excision of a melanoma from her right inner thigh about 4 years earlier. Two inguinal lymph nodes that were excised for sentinel staging at the time were reportedly without metastasis.\nIn her gynecological examination at our clinic, no inguinal lymph node swelling was noted, and her vulva and proximal vagina appeared normal. The vaginal mucosa on the right side of the posterior fornix was bulging inward, displacing the uterine cervix laterally to the left. Underlying the mucosa was a palpable, semimobile mass of about 5cm in diameter that was of plump, elastic consistency. The vaginal mucosa overlying the tumor was smooth but not mobile relative to the tumor. There were no signs of ulceration or retraction by the tumor.\nSonographically, the mass appeared homogeneous with medium echogenicity, few septations, and smooth edges (Fig. ), and it had no papillary projections. Color Doppler imaging revealed several vessels visible within the structure. Subsequently, we took a core biopsy specimen of the tumor while the patient was under general anesthesia. A pathological examination revealed a mesenchymal tumor, most probably benign owing to the absence of any mitotic figures; however, it was not possible to classify the tumor any further. We discussed the findings with the patient and recommended surgical excision of the tumor. Owing to the unusual location of the tumor, we obtained additional magnetic resonance (MR) images of the pelvis (Fig. ). T1- and T2-weighted images showed a homogeneously hypointense lesion that led to deviation of the cervix and the rectum. For excision, we performed a horizontal colpotomy about 1.5cm distant from the cervix, including the biopsy canal. The tumor appeared encapsulated and was dissected from the surrounding tissue. Gross examination of the tumor showed a 9×6×1.5-cm pinkish gray mass weighing 65g. The tumor was covered entirely with a frail, well-vascularized membrane (Fig. ).\nHistologically, the highly cellular lesion represented varying cellularity with vascularization by thin-walled blood vessels surrounded by spindle-shaped epithelioid cells with abundant eosinophilic cytoplasm and positive immunostaining for desmin and estrogen receptor (Fig. ).\nThe mesenchymal cells showed a diffusely positive reaction to CD34, and 70% stained positive for desmin. There was no staining reaction to smooth muscle actin and S100. About 90% of the cells were estrogen receptor–positive. On the basis of these characteristics, a diagnosis of AMFB was made.\nAt her follow-up examination 17 months postoperatively, the patient was doing well and without any evidence of recurrent disease or sexual or urinary dysfunction. |
A 57 -year-old female presented with incidental ultrasonic evidence of left upper pole renal mass in Nov. 2001. Further evaluation with abdominal Magnetic Resonance Imaging revealed a mass in the upper pole of the left kidney with radiologic characteristics of renal cell carcinoma (). Left radical nephrectomy was performed sparing the left adrenal gland. The pathology specimen analysis showed a cystic mass 3 × 3 × 5 cm with yellowish friable tissue. Sections showed malignant epithelial cells, arranged in sheets. The picture was consistent with renal cell carcinoma, Grade II Fuhrman nuclear characteristics, confined to the capsule, neither pelvicalyceal nor vascular invasion was found (pT1bN0M0). Postoperatively she did not receive immunotherapy or chemotherapy. Apart from her hypertension which was well controlled with amlodipine and valsartan, subsequent clinical and radiological follow up showed no local or metastatic recurrence till 5 years after the operation then she stopped her visits. On October 2016 an incidental mass was found in the right adrenal gland during a checkup visit for the status of her right solitary kidney. Abdominal and pelvic computed tomography scan was done, revealing a well-defined mass with a smooth outline in the right adrenal gland measuring 54 × 48 × 39 mm with a central necrosis. The density of the solid component was 38 HU. In dynamic study the solid component showed significant enhancement after intravenous contrast administration (). Thorough hematological, biochemical and hormonal investigations were performed; all were within normal range. The results of laboratory examination showed the adrenal mass to be nonfunctional. The condition was well clarified for the patient and consent was taken to do right adrenalectomy. Under general anesthesia, in left lateral position through right transcostal incision, right adrenalectomy was done (). No any perioperative complications were recorded and she was discharged home on 4th post-operative day. Pathological examination revealed morphological and immunohistochemical findings in line with metastatic renal cell carcinoma, including positive staining for AE1/AE3, cytokeratin 7, vimentin, and CD10, and negative staining for CDX-2, inhibin, and synaptophysin (, ). During the last 2 years she has being on regular follow up. Whole body Positron Emission Tomography-Computed Tomography with fluorodeoxyglucose was performed, neither local nor metastatic recurrence was observed in any system. |
A 65-year-old man with continuous irritable cough over 15 days was admitted to our department for a mass lesion in the right hilum. He presented with no face swelling and superficial varicose veins. He was a former smoker, and medical history included hypertension and diabetes mellitus. At bronchoscopy, the tumor was found occluding the right upper lobar bronchus and infiltrating the bronchus intermedius. It was diagnosed as squamous cell carcinoma by transbronchial tumor biopsy. Chest contrast computed tomography (CT) revealed that the mass of 80 mm in the maximum diameter located in the right upper lobe. The tumor directly invaded the arch of the right PA and a wide range of SVC. It was discovered that the left brachiocephalic vein (BCV) along the left margin of mediastinum walking down the line directly into the coronary sinus (). A venous flow was detected in the anterolateral descending aorta with dilatation of the coronary sinus (diameter of 21 mm) without other heart abnormalities by transthoracic echocardiography. Based on these findings, the diagnosis of PLSVC was made. There were no detectable metastases in other organs through brain magnetic resonance imaging (MRI), upper abdomen CT scan and bone nuclear scan.\nThe right posterolateral thoracotomy was performed on October 31, 2006. As expected, the tumor invaded the wall of SVC and no left brachial cephalic vein bifurcation was observed. The SVC was separated, clamped and resected following intravenous injection of 5, 000 IU of sodium heparin. The ringed PTFE graft of 12 mm in diameter was interpositioned between the right brachial cephalic vein and the origin of SVC by running sutures with 4-0 polypropylene. The tumor resection was completed by double sleeve lobectomy of right upper and middle lobes. The anastomosis between the right main bronchus and the cut end of the lower lobe bronchus was performed by interrupted suture using 3-0 Vicryl (Ethicon, USA). Right PA trunk and right lower PA reconstruction was completed by the running suture with 4-0 polypropylene (). And systematic mediastinal lymph node dissection was performed. All excised margins were tested microscopically negative for malignancy. As anticoagulation treatment, we began with low molecular Heparin on the operative day, then switched and continued to warfarin when thoracic drains removed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 12th postoperative day. Final pathological diagnosis was poorly differentiated squamous cell carcinoma invaded the right SVC, right PA and mediastinal nodes were positive for malignancy.\nAfter 4 cycles of chemotherapy (Gemzar and cisplatin) and 1 cycle of radiotherapy, Chest MRI showed patency of the graft and PLSVC (). He died 21 months after operation because of remote metastasis. |
The author reports a case of 30-year-old male referred to the physiotherapy outpatient department with the chief complaint of difficulty in mouth opening and an inability to eat spicy food for 4 years. He had a positive history of areca nut chewing and smoking tobacco for 10 years. The patient used to chew commercially available areca nut packets with a frequency of 5–6 packets per day and smoke 10 cigarettes in a day. The patient quit the habit completely 1 year ago. The patient had been previously treated with medications for 6 months and was significantly relieved of burning sensation but did not get any significant improvement in mouth opening. The patient gave a history of undergoing treatment with topical application and systemic medication, the nature of the medication is unknown to the patient, for 6 months intermittently. No dietary changes were advised to the patient, but progressively, the intake of solid food was reduced due to increased difficulty in mouth opening, and the patient reported with an ability to have only semi-solid food.\nAn oral physician with specialty in such cases was consulted, and on inspection, reduced mouth opening with the initial inter-incisal distance of approximately 10 mm was recorded. Blanching of bilateral buccal mucosa and soft palate was present. Uvula was normal. Tongue protrusion was mildly restricted. On palpation, thick fibrous bands were present bilaterally in the buccal mucosa near the mandibular trigone area. Panoramic radiological view [] was done to rule out bony abnormality in the maxilla and mandible; however, it revealed generalized horizontal bone loss in the lower arch and impacted 28, 38, and 48. Clinically, the restricted mouth opening was due to the fibrous bands present in the buccal mucosa which may or may not be superimposed by inflammatory changes due to vertical impaction of 48. Based on the features, a clinical grading of severe OSMF (Grade 3) was given.[]\nThrough the global diagnosis of osteopathic findings, it was found that there was restricted mobility at the sacrum, base of the occiput, thoracic outlet, and in the anterior neck region. On palpation, tenderness was present at the gastroesophageal (GE) junction and sphincter of Oddi (SO), supraclavicular region, and also at the temporalis and masseter muscles.[]\nAll the treatment options were explained to the patient, and a written consent of the patient was obtained to treat the patient only with physiotherapy techniques to improve the mouth opening. The osteopathic manipulative treatment techniques were chosen for their effectiveness in addressing muscular dysfunction. The techniques chosen were as follows: all major diaphragms’ release, sacral release, occipito-atlantal release, dural tube rocking, GE junction and SO release, pleurovertebral ligament release, intra-oral techniques such as balancing and distraction of vomer, maxillae suture separation, suprahyoid fascia release, and pterygoid release. In addition, the temporal fascia release, counterstrain to the masseter muscle, was given to reduce the hypertonicity of the muscles.[]\nThe patient was treated with osteopathic manipulative treatment techniques for twice a week for half an hour each session. After 2 weeks of treatment, a temporo-mandibular joint distraction and compression technique were also added which increased the treatment time to 35 min. After 4th week, the home exercise program with the help of wooden spatulas was monitored regularly with feedback from the patient till 3 months.\nThe patient was assessed after 2 weeks initially, and then at 4 weeks and at 3 months and it was found that inter-incisal distance of 10 mm has improved to 22 mm after 3 months []. |
A 51-year-old female with a history of stage 1 hypertension was admitted to the hospital post cardiac arrest. She had a significant family history of premature coronary artery disease. Her father had a coronary artery disease diagnosed in his 40’s, her mother had a pacemaker inserted, and she had two first degree relatives diagnosed with an early cardiac disease. She is a nonsmoker, nonalcoholic drinker and denied recreational drug use. She was in her usual state of health and functionally active until her husband noticed her moaning and eventually unresponsive in the middle of the night. Prior to this, the patient did not complain of any chest pain, dyspnea, dizziness, lightheadedness or any other constitutional symptoms. Her husband started cardiopulmonary resuscitation and was taken over by the emergency medical staff (EMS). She was intubated and defibrillated five times by EMS for ventricular fibrillation then was given a bolus of amiodarone. She eventually had a return of spontaneous circulation and was transported to the hospital in which she was noted to have decorticate posturing with no purposeful movements. Electrocardiogram (ECG) during this time showed sinus rhythm (Figure ). She was admitted to the coronary care unit and was placed on targeted temperature management and was maintained on amiodarone drip. Transthoracic echocardiogram showed no valvular abnormalities, normal left atrium and left ventricular cavity size but with borderline concentric left ventricular hypertrophy with an ejection fraction of 56% and note of subtle regional wall motion abnormalities. About 12 hours after initiating the targeted temperature management, the patient was in severe bradycardia in the mid 30’s and a decision was made to hold the amiodarone at that point. The patient completed the targeted temperature management protocol and eventually had a full neurologic recovery thereafter.\nShe was extubated and subsequently transferred to the floor. She was scheduled for cardiac catheterization; however, she had witnessed ventricular fibrillation arrest on the floor (Figure ). Advanced cardiopulmonary resuscitation was initiated and she was revived immediately after defibrillation. A total of three minutes of resuscitation was performed and she was following commands afterwards. She was also given an amiodarone bolus and transferred back to coronary care unit. ECG did not show any ST elevations at this time. Subsequently, she had 23 more episodes of ventricular fibrillation arrest (Figure ) over a six-hour period which were intervened by timely defibrillation and administration of antiarrhythmic medications and inotropic agents. The antiarrhythmic medications administered were amiodarone and lidocaine boluses and drips. Intravenous magnesium was also given during the resuscitation course. Emergent cardiac catheterization showed minimal coronary artery disease. A transvenous pacemaker wire was placed due to bradycardia during a code in the catheterization laboratory, although the bradycardia did not initiate the arrest. An intra-aortic balloon pump was placed. Subsequently the balloon pump and temporary pacemaker wire were removed after she eventually became more hemodynamically stable. She once again had a full neurologic recovery and underwent an uneventful implantation of a dual-chamber implantable cardiac defibrillator (ICD). She was discharged from the hospital on amiodarone therapy and was closely followed up in the cardiology outpatient clinic. Cardiac magnetic resonance imaging was done which showed mild biventricular enlargement but with normal regional systolic function, no late gadolinium enhancement consistent with the absence of myocardial inflammation, infiltration or infarction and with no imaging features of ARVC. She eventually had a targeted genetic testing for idiopathic ventricular fibrillation and was found to have a mutation in the desmoglein-2 (DSG2) gene (c.338T > C, pVal1113Ala), which is a gene typically involved in ARVC.\nShe had been readmitted several times to the hospital due to palpitations, dizziness, lightheadedness, and defibrillator shocks. Her defibrillator had been interrogated as well as her antiarrhythmic medication had been adjusted which improved her symptoms and reduced defibrillator discharge. Because of intermittent episodes of defibrillator firing due to ventricular fibrillation despite antiarrhythmic medications and intracardiac device, a ventricular fibrillation radiofrequency catheter ablation was performed successfully. Thereafter, she had no repeated episodes of palpitations, dizziness, lightheadedness, and defibrillator shocks. |
A 28-year old white woman presented with distinct deterioration of visual acuity during the last trimester of her first pregnancy. Her vision decreased to 20/40 in the left and 20/400 in the right eye. In the beginning, the visual loss occurred intermittently, but worsened over time. In addition, the patient complained about flickering. During the worst episodes she could only see contours with a vague discrimination of light. Simultaneously, symptoms of a dermatomyositis, which had been diagnosed and successfully treated several years earlier, reappeared. At that time, the diagnosis of dermatomyositis had been confirmed by skin biopsy. An extensive workup to rule out an underlying malignancy had then not revealed any suspicious results. However, a CT scan had not been performed. The patient subsequently had received several immunosuppressive treatments including azathioprine, methotrexate and adalimumab, as well as immunoglobulins and steroids resulting in a long-lasting remission of the dermatomyositis.\nThe decrease in visual acuity occurred isochronal with another exacerbation of skin symptoms and was therefore initially interpreted as a manifestation of the reappearing dermatomyositis and treated with steroids since also initial ophthalmologic workup did not reveal pathological results. After failure of immunosuppressive therapy, repeated ophthalmologic examination revealed an amelanotic choroidal mass at the posterior pole including the peripapillary region and a second choroidal lesion superior to the optic disc in the right eye. Also, in the left eye another amelanotic choroidal tumor situated predominantly nasal superior to the optic disc was detected. In both eyes, an inferior exsudative retinal detachment was seen (Fig. and ). Finally, a large tumor mass in the mediastinum, pleural thickening and pulmonary nodules as well as a mediastinal lymphadenopathy were detected in MRI scans. CT scans were not performed because of the actual pregnancy. After delivery of a healthy boy at the 37th + 2 week of pregnancy through Caesarean section, a lung and pleural biopsy was performed by lateral thoracotomy and the patient was referred to our center for further treatment.\nThe clinical examination showed a 28-year old woman in proper general condition. Her skin was reddish and thickened with distinct flaking. The examination of the heart, lungs and abdomen did not reveal any pathologic results. Decreased visual acuity was noted in both eyes. Additionally, the patient complained about paraesthesia with tickling in both feet. Other neurological symptoms were not detectable.\nLaboratory testing revealed a slightly increased creatine kinase (193 U/l, normal up to 170 U/l), an elevated C-reactive protein (2.77 mg/dl, normal up to 0.5 mg/dl), anemia with haemoglobin of 9.8 g/dl, elevated uric acid levels of 6.5 mg/dl (reference range 2.4 to 5.7 mg/dl) and a significantly increased lactate dehydrogenase of 959 U/l (normal up to 250 U/l) as well as thrombocytosis of 789 G/μl (normal up to 450 G/μl).\nWhole body CT and MRI scans showed metastases to the choroids, pleura and regional lymph nodes (Fig. and ). The lung biopsy revealed a poorly differentiated carcinoma with strong expression of cytokeratins 5/6, CD5 and CD117 and absence of neuroendocrine markers (CD56; chromogranin, synaptophysin), a constellation highly specific for thymic carcinomas (Fig. and ). A lymphoepithelioma-like thymic carcinoma was ruled out by negative EBV in situ hybridization. In addition, a thymic carcinoma with t (15;19) translocation was likewise ruled out by specific real-time polymerase chain reaction (RT-PCR), which failed to demonstrate a BRD4-NUT gene fusion product. Thus a final diagnosis of an undifferentiated thymic carcinoma was established. The tumor at initial diagnosis presented in stage IVb (T4, N2 (hilar lymph nodes), M1b (pleura, lung, choroid)) [, ].\nThymic carcinomas are often moderately differentiated squamous cell carcinomas histologically resembling the appearance of squamous cell carcinomas elsewhere in the body, e.g. the lung [, ]. In our patient, one potential differential diagnosis was the lymphocyte poor EBV-associated lymphoepithelioma-like carcinoma, an aggressive tumor with a poor prognosis [, ]. However, EBV association was ruled out by in situ hybridisation. Another differential diagnosis in young adults with a rapidly progressive carcinoma is the so-called thymic carcinoma with t (15; 19) translocation, which is associated with a fatal prognosis, including rapid local invasion and systemic dissemination [–]. In our case, this diagnosis could also be ruled out, since the BRD4-NUT fusion gene transcript resulting from this chromosomal translocation could not be detected. Hence, a final diagnosis of a high grade, poorly differentiated thymic carcinoma was established by exclusion of other possible subtypes of primary thymic carcinomas.\nClassical metastatic spread patterns of thymic carcinoma comprise regional anterior perithymic, deep intrathoracic and cervical lymph nodes, as well as the pleura, the pericardium and the lung []. Extrathoracic organ metastases mainly affect the liver and the kidney, but may also involve the bones [, –]. Also one case of orbit metastases from a neuroendocrine thymic carcinoma was reported [].\nTo our knowledge, our patient represents the first case of choroidal metastases from thymic carcinoma. Although choroidal metastases are generally rare (e.g. about 5-10 % in breast and lung carcinoma patients, respectively [, ]), the choroid represents the most common ocular site for metastatic disease (up to 88 % of secondary ocular tumors) which is due to hematogenenous dissemination into abundant choroidal vasculature [, , ]. The most common primary tumors presenting with choroidal metastases are breast (40-53 %) [, , –] and lung carcinoma (20-29 %) [, , ] but may also include tumors (2-4 % each) from the gastrointestinal tract, the kidney, the prostate and the skin [, , –], as well as carcinoid tumors of different localisation including one reported case of a thymic carcinoid []. Evidence for choroidal metastases from other tumors has emerged in recents years. These observations are mainly limited to single case reports and comprise metastases from malignancies of the thyroid [, –], the urogenital tract [–], the pancreas [, ], salivary glands [, ], and the chorion [], as well as sarcomas [, ].\nIn our patient, fractioned radiation therapy of the orbits with a cumulative dose of 30 Gy (10 × 3 Gy) using opposite, coplanar and coaxial fields in an isocentric adjustment with 6 MV photons was performed and resulted in regression of the choroidal metastases and an improvement of visual acuity from 20/400 to 20/40 in the right eye and from 20/40 to 20/16 in the left eye resulting in reconstitution of reading ability. Afterwards, chemotherapy with Cisplatin (75 mg/m2) and Paclitaxel (175 mg/m2) was initiated as a t (15; 19)-positive carcinoma was still assumed at that time. Due to the rapid clinical response, this treatment was continued for a total of six cycles after receiving the final pathology report. After four cycles, a good partial response was observed in CT scan. However, progressive disease was evident in the staging after six cycles. The regime was then changed to a modified PAC-scheme (Carboplatin AUC5 instead of cisplatin because of a suspected paclitaxel-induced peripheral polyneuropathy CTC grade 1, Doxorubicin 50 mg/m2 and Cyclophosphamide 500 mg/m2). Nevertheless, the tumor progressed further, and the patient died of progressive disease in respiratory insufficiency eight years after first manifestation of the dermatomyositis and fourteen months after primary diagnosis. The median overall survival of patients with undifferentiated thymic carcinoma has been reported to be about six months [].\nRetrospectively, the pre-existing dermatomyositis might have represented the first symptom of an at that time clinically occult tumor. The association between the epithelial thymic carcinoma and the dermatomyositis in this case could not be totally proven but such an association has been reported in some cases of thymomas [], but appears to be extremely rare in thymic carcinomas with only two reports in the literature [, ]. |
An 8-month-old boy was admitted to our clinic with scalp swelling that developed 21 days after a VP shunt operation. He had no other neurological symptoms except scalp swelling. He was a preterm baby born at 24 weeks of gestational age and was only 520 g at birth. The patient had developed a massive intraventricular hemorrhage associated with hydrocephalus on brain ultrasonography. Furthermore, the QUAD test for preterm screening was positive for Down's syndrome. He had many severe preterm complications, including hematological problems such as anemia and thrombocytopenia that required transfusion; pulmonary problems such as respiratory distress syndrome treated with surfactant and a chest tube was inserted to manage pneumothorax. He also had retinopathy and many cardiac problems such as patent ductusarteriosus (PDA), ventricular septal defect, right ventricular hypertrophy, and a patent foramen ovale. We intended to wait for natural closure for most problems but PDA required ligation surgery. Endocrinological problems such as hyperglycemia, hypothyroidism, and osteopenia were managed with hormones and mineral replacement. Urological complications such as a dilated bladder and ureter and hydronephrosis developed but were mild; thus, we decided to follow-up closely without surgical intervention. He also had a small bowel perforation and bilateral inguinal hernia, which had gone through repair surgery.\nFor only 25 weeks after birth, he had 3 surgeries, brain ultrasonography was conducted and progression of the hydrocephalus and encephalomalacic changes in the right frontal lobe was found (). Spinal tapping for intracranial pressure control was held every day until shunt surgery was capable. At 30 weeks of his gestational age (14 weeks of corrected age) his body weight was 4500 g (<10 percentile) a VP shunt has been inserted using an ultra small, low pressure valve system (Strata®; PS Medical, Gola, CA, USA) and a distal catheter of about 30 cm in length was placed in the peritoneal cavity. No complications occurred except mild redness of the left clavicle area where the catheter passed. The patient was discharged without any complications 12 days after surgery.\nHe visited our outpatient office with prominent swelling of the surgical site 21 days after surgery, and a round coil like mass was palpable under the scalp, but no neurological changes were noticed. Simple chest, abdomen, and skull X-ray images were taken, and no shunt catheter on the trunk was found, but the distal catheter had migrated upward into the subgaleal space (). Brain computed tomography scans indicated decreased ventricle size compared to those taken before surgery (). Shunted cerebrospinal fluid (CSF) was thought to be absorbed in the subgaleal space and shunt function seemed to be maintained.\nThe distal catheter inserted previously for the VP shunt was found coiled freely in the subgaleal space under the primary incision during revision surgery. The shunt was otherwise functioning, but the reservoir was filled with an old hematoma, and the CSF was bloody and turbid (). We placed an extraventricular drainage (EVD) tube rather than a shunt system to wait for the CSF to clear out to prevent shunt system blockage. The VP shunt was reinserted 1 week after the EVD, and the patient was discharged. No further problems were noted during regular follow-ups at the outpatient office. |
A 61 year old Hispanic male with a past medical history of gastroesophageal reflux disease, hepatitis C treated with ribavirin and interferon, and ethanol and tobacco abuse presented to our clinic with a complaint of 2 months of progressing dysphagia starting from solids then liquids, unintentional 15 lb weight loss and occasional nausea and vomiting with noted streaks of blood on vomitus after prolonged retching. Dysphagia was first noted when he started eating mainly cold drinks followed by cold trays. He felt that food was getting stuck in his mid-esophageal region and has constantly pounded his chest with his fist to make the food go down. On physical examination, the patient was noted to have the following: cachectic features of the face and body, a painless and firm 2 cm nodule along the left zygomatic crest and a firm and fixed ∼1 cm nodule of the right base of tongue. On further questioning about the nodules, the patient took notice of only the left cheek nodule which had been present for about 5 months, but did not notice if it progressed in size. The patient was then initially scheduled for an esophagogastroduodenoscopy (EGD) but was lost to follow-up until presentation at the emergency room about 1 month after due to weakness, fatigue and decreased oral intake secondary to progressive dysphagia. The patient was afebrile and his vitals were stable. The complete blood count, metabolic count, liver function tests, coagulation studies were within normal limits.\nThe patient initially underwent fluoroscopy which showed a 3 cm distal esophageal mass followed by computed tomography (CT) soft tissue neck, thorax, abdomen and pelvis with contrast. The CT soft tissue neck revealed a 1.8 cm mass in the left anterior face at the level of the left nare without cystic components or inflammatory fat stranding, a 1.2 × 1.7 × 1.3 cm soft tissue density nodule of the right floor tongue root adjacent to the geniohyoid muscle, a 9 mm hyper dense nodule of the left rectus capitis muscle, a 7 mm hypodense nodule of the left trapezius muscle, a 5 mm enhancing nodule of the right rectus capitis and a more superior 7 mm nodule of the right rectus capitis that is better visualized on delayed images (Fig. ). CT thorax showed an eccentric circumferential thickening of the right distal esophageal wall that is ∼1.8 cm in thickness with a length of 4.6 cm and an 8 mm lymph node adjacent to the distal esophagus (Fig. ). CT abdomen/pelvis showed a liver with a 6.9 cm enhancing dome more likely from a perfusional defect but, over-all, with normal contour, a left adrenal gland that was diffusely enlarged and enhancing, several scattered areas of hyper-enhancement of the right iliopsoas with the largest measuring ∼1.8 cm, multiple left para-spinal musculature nodules about ∼1 cm in size, and several subcutaneous nodules measuring up to 0.6 cm of the left flank (Fig. ). Per initial radiologists' discussions, the chest findings showed an esophageal mass that was highly concerning for malignancy. The face and neck findings raised the possibility of soft tissue metastasis from the esophagus which was unusual; thus, a possible second primary such as melanoma was in the differential. The abdomen/pelvis findings of the left adrenal gland was concerning for metastasis, the multiple nodules were nonspecific but still suspicious for metastasis and once again, a secondary primary such as metastatic melanoma was in the differential along with metastasis from an esophageal primary.\nAn EGD was then done which showed the following: Barrett's-like features in the mid and distal esophagus, a large fungating and ulcerating mass which bleeds on contact in the lower third esophagus that was partially obstructing and circumferential involving two-thirds of the lumen circumference, and a large hiatal hernia (Fig. ). Biopsies of the esophageal mass were then sent for evaluation, and revealed a poorly differentiated adenocarcinoma with squamocolumnar mucosa showing Barrett's and dysplasia. The tissue biopsy was microsatellite stable, p40– and HER2/NEU+ (verified with ERBB2/HER2 FISH). The esophageal brushing also revealed findings consistent with poorly differentiated adenocarcinoma. Oncology was then consulted for further recommendations and requested to for a sample of the left cheek nodule. A fine needle aspiration of the left cheek nodule was then performed which also revealed a poorly differentiated adenocarcinoma favoring metastasis from the esophageal primary per pathologists' consensus after reviewing the esophageal biopsy and reviewing its cytomorphology. Immunostains of the left cheek nodule were noted to be CK7+ and p40–.\nDuring the course of his work-up, within a few weeks' span, the patient started mentioning new sub-centimeter nodules on the left and right forehead and scalp, left shoulder and flank and right thigh which were painful to palpation. A magnetic resonance imaging (MRI) of the head with and without contrast was then done which revealed a well circumscribed homogeneously enhancing 2 × 2 cm lesion of the left pre-maxillary soft tissue, a 1 × 1.7 cm lesion of the left lateral pterygoid muscle, a 7 × 1.4 cm lesion of the right genioglossus muscle adjacent to the root of the tongue which all correlated with past CT findings (Fig. ). Additional findings showed an enhancing 10.9 mm left parietal scalp and 11.8 mm right frontal scalp lesions with possible extension into the right calvarium, an enhancing 0.8 × 1.6 cm lesion of the right spinalis capitis, and an enhancing focus in the left occipital bone which correlated with the fluid attenuated inversion recovery (FLAIR) hyperinstensity suspicious for calvarial metastasis (Fig. ). Per radiologists' consensus, findings were concerning for metastasis that were more likely from an esophageal primary due to prior pathology findings.\nDermatology was also consulted to get a biopsy of the left shoulder and left flank nodules. Per histopathology, a tumor was identified in the deep dermis with no relation to the overlying epidermis. The tumor was composed of atypical epithelial cells, with focal gland formation. Immunohistochemistry showed tissue to be CK7+, diffusely, on all cells, CK20– and p40–. The profile was consistent with metastasis from the esophageal primary, a poorly differentiated adenocarcinoma. HER2 immunostaining was also done and was positive. Due to this, per discussions, the patient's findings such as nodules in the subcutaneous areas of the face, within the base of the tongue, neck muscles, paraspinal and iliopsoas musculature were deemed to be more likely metastasis from the EC primary.\nA tumor board discussion was held, and due to the patient's over-all performance status and social circumstances, it was decided that hospice with palliative radiation therapy was the best course of action. The patient agreed to the plan and was made DNR/DNI. The patient then underwent esophageal stenting and started receiving daily fractions of radiation treatment for his esophageal mass. The patient started experiencing continuous nausea without vomiting and had a mechanical fall without head trauma. During this time, the patient also started refusing his oxygen and requested to be switched to comfort measures. He expired one night from cardiopulmonary arrest. |
A 51 year-old male presented to an outside institution seven years prior with chronic headaches, which began following a motor vehicle accident. He had decreased visual acuity in the left eye from a previous gunshot wound to the face. The patient was diagnosed at initial presentation with a giant, fusiform left PCA aneurysm which was partially thrombosed. It was decided at the time of diagnosis that the risk of morbidity associated with either endovascular or microsurgical treatment of the aneurysm exceeded that of conservative management. Over time, the patient's headaches progressively worsened to an average visual analog scale (VAS) score of 7/10 despite maximal medical management, and the aneurysm gradually enlarged over serial angiographic imaging. The decision was made at this time to treat the lesion via an endovascular approach with the PED (). The aneurysm was successfully treated with two telescoping PEDs, 2.5×20 mm and 3.0×30 mm in size. The patient was discharged on standard oral dual antiplatelet therapy, clopidogrel 75 mg daily and aspirin 325 mg daily, without any change in neurological function. The severity of the patient's headache remained unchanged after PED treatment.\nThe patient presented three months post-PED with progressively worsening headaches to an average VAS score of 9/10, new gait ataxia, and new temporal hemianopsia of the right eye. While the stents remained patent at six weeks, by the follow-up angiography at three months, the diseased segment of the left PCA had progressed to complete occlusion at the origin of the proximal PED (). The patient's new temporal hemianopsia of the right eye was attributed to the left PCA occlusion. However, despite occlusion of the parent vessel, the aneurysm had continued to enlarge, resulting in local mass effect and cerebral edema as well as obstructive hydrocephalus. Therefore, the decision was made to surgically resect the aneurysm. The patient was taken to the operating room for an endoscopic third ventriculostomy, which was performed in a standard fashion through a right frontal burr hole without complications. An external ventricular drain was left in the frontal horn of the right lateral ventricle for subsequent cerebrospinal fluid drainage.\nThe patient was repositioned for aneurysm excision through an infratemporal, post-auricular, presigmoid skull base approach. Electrophysiological monitoring, including motor and somatosensory evoked potentials (motor evoked potential (MEP) and somatosensory evoked potential (SSEP), respectively), was utilized. A standard temporal craniotomy and partial mastoidectomy were performed. During the craniotomy, the sigmoid sinus was breached, requiring hemostatic control with gelfoam tamponade. After dural opening, 50 mL of cerebrospinal fluid was drained from the external ventricular drain to facilitate brain relaxation. After opening the arachnoid of the ambient cistern, the PCA and superior cerebellar artery were identified along with the fundus of the aneurysm dome posteriorly.\nDue to the high degree of thrombosis, the aneurysm was firm and immobile. Therefore the aneurysm dome was opened so that the intrasaccular thrombus could be debulked. Decompression of the fundus facilitated dissection of the aneurysm from the surrounding cortex and brainstem. The proximally placed PED was identified in the lumen of the diseased PCA without evidence of endothelialization and was removed cautiously. After PED extraction from the inflow segment of the parent artery, there was brisk bleeding from the proximal PCA which controlled by clipping the P2 segment. After further debulking of the thrombus, the distal PED placed in the aneurysm outflow was identified and a clip was placed on the outflow portion of the PCA, effectively trapping the aneurysm. The entirety of the aneurysm was then excised from the PCA (). During the final dissection, the right-sided arm and leg SSEPs were lost without change in MEPs. At the end of surgery, there was no recovery of SSEPs in the right arm or leg and MEPs remained stable.\nThe patient's postoperative course was complicated by an extradural hematoma requiring surgical evacuation and thrombosis of the left transverse and sigmoid sinuses, resulting in multiple large territory venous infarcts requiring decompressive craniectomy. The extent of the postoperative infarcts was neurologically devastating, and the patient expired two weeks following the initial surgical intervention. |
A 69-year-old man presented with over 10-year history of a left inguinoscrotal hernia which eventually became incarcerated with increasingly difficult urination. His quality of life had become significantly affected over the past year when he had recurrent episodes of acute urine retention that required long-term catheter. The patient also had significant issues with his mobility. He had no significant co-morbidities or surgical history. Examination revealed a massive left inguinoscrotal hernia that descended to below the level of his knees in the standing position (Fig. ). There was no evidence of inflammation, excoriation or ulceration of the scrotal skin and no focal tenderness over the hernia.\nA contrast-enhanced computed tomography (CT) scan revealed the hernia sac containing most of the colon and small bowel with only the rectum, proximal jejunum and duodenum lying within the abdomen (Fig. ). Preoperative anaesthetic assessment was completed and the patient was admitted to hospital 2 days preoperatively for bowel preparation. After a midline laparotomy, attempts at reduction were not successful even after dividing the inguinal ligament. Reduction in hernia contents was possible only after completely dividing the lower end of the left rectus abdominis muscle. The hernial sac was then dissected and resected. Then, component separation technique was performed laparoscopically using the same balloons used for total extra peritoneal (TEP repair for inguinal hernias). A 2 cm transverse incision located just under the rib cage in the mid-clavicular line was deepened until the area just posterior to the external oblique was entered. The large balloon was inserted in this space in the direction of the pelvis and inflated under laparoscopic guidance to create the space between the external and internal obliques. This was followed by the triangular balloon and insufflation was started at pressure of 11 mmHg under laparoscopic control. A lateral incision to introduce a 5 mm trocar is performed and a pair of laparoscopic scissors introduced to make a longitudinal incision in the external oblique aponeurosis extending along the mid-clavicular line from the rib cage to the inguinal ligament. The same is repeated on the other side. The hernia defect was then repaired extraperitoneally using a large polypropylene mesh extending from the anterior superior iliac spine to the symphysis pubis. Both the inguinal ligament and rectus abdominis muscle were repaired. The procedure ended by mass closure of the laparotomy incision.\nPostoperatively, the patient had continuing respiratory support in high dependency unit, physiotherapy and scrotal support. Recovery was satisfactory with early return of bowel movement and mobilization. He had no significant postoperative complications and was discharged home with an indwelling urinary catheter on postoperative day 13.\nOn follow-up after 8 weeks, the patient was in a very good general condition with intact hernia repair and laparotomy wound. He was found to have a moderate scrotal swelling (Fig. ) which proved by CT scan to be a postoperative seroma (Fig. ) which was managed conservatively. |
A 36-year-old woman, G2P1, with an uneventful pregnancy, presented to Peking Union Medical College Hospital at 22 weeks’ gestation for routine second trimester screening. An ultrasound examination showed the presence of an oral cystic lesion, which measured 18 × 15 × 15 mm. The lesion was posterior to the mandible and attached to the inferior aspect of the tongue in a male fetus (Fig. ). No blood flow signal was observed through the cyst. The lesion appeared to be moving in conjunction with the tongue and did not protrude outside of the oral cavity. The fetal mouth was slightly open for the duration of the ultrasound scan and was shown by 3-dimensional ultrasound in the surface render mode (Fig. ). Color Doppler flow imaging (CDFI) showed fetal deglutition, with clear evidence of transoral amniotic fluid flow around the cyst and in the upper respiratory tract (Fig. ). This indicated patency of the fetal airway. The fetal stomach was visualized and the amniotic fluid volume was in the normal range. This finding indicated normal swallowing function and the cystic mass did not obstruct the esophagus. A sonographic anatomical survey showed no other anomalies of the fetus. Follow-up ultrasound examinations at 24 and 31 weeks of gestation showed a progressive reduction in size of the lesion and absence of polyhydramnios. Tiny internal septation was observed (Fig. ). However, the cyst eventually disappeared in follow-up examinations at 35 and 37 weeks of gestation.\nA male newborn who weighed 3480 g was delivered vaginally, with Apgar scores of 10 and 10 at 1 and 5 minutes, respectively. The neonate had no feeding or breathing difficulty. No major oral cyst was identified in the tongue at a clinical and instrumental examination. We followed the child to 6 years after birth. The child had normal growth and development, with no recurrence of the cyst. The study was approved by the Institute Research Ethic Committee of Peking Union Medical College Hospital. The patient has provided informed consent for publication of the case. |
A 4-year-old girl presented to our hospital with fever and right elbow pain. She had no history of trauma. Her past medical history included the DOOR syndrome, which is characterized by mental retardation, sensorineural deafness, and variable seizures but has no immune abnormality. Physical examination revealed redness, swelling, and local heat around the right elbow. Plain X-rays of the right elbow showed swelling of soft tissues without signs of osteolysis (). Laboratory studies demonstrated elevated inflammatory markers such as C-reactive protein (CRP) of 8.45 mg/dL and a white cell count of 30100/mm3. A total of 3 mL joint aspiration was composed of slightly cloudy synovial fluid. A fat suppressed T2-weighted MRI scan revealed the presence of joint fluid pooling in the elbow joint and swelling of soft tissues (). Based on these findings, a diagnosis of septic arthritis of the right elbow was made and the patient was admitted for treatment. She received intravenous cefazolin sodium for 3 days and the examination of the blood test showed a CRP of 4.57 mg/dL and a white cell count of 17000/mm3. Because the inflammatory markers still remained higher, the patient underwent surgery of arthroscopic debridement of the right elbow. The surgery was conducted in the same way as the adult one. The patient was in a prone position with the upper limb hanging down on an arm board. An anterolateral portal was created to allow assessment of the joint. The medial portal was established using the outside-in technique under visual guidance. The most important point is that the surgery was conducted by use of a 30° wrist arthroscope to visualize the small pediatric elbow joint. There was much proliferation of synovial bursa in the elbow joint, and debridement was performed under 3000 mL of arthroscopic irrigation (). The splint fixation was used for 1 week to protect the elbow joint.\nOn the next day of the surgery, the culture of the first aspiration of the joint revealed Streptococcus pyogenes. The antibiotic was changed to ceftriaxone sodium hydrate for 5 days and discharged with cefditoren pivoxil orally, which continued for 13 days (). The patient is now three years after surgery and has no osteoarthritis without stiffness of the right elbow. |
This 62-year-old British Caucasian man presented to general surgery with a 2 weeks history of non specific right sided abdominal pain and 10 kg of weight loss over the last 6 months. Blood tests including FBC, renal function and electrolytes were normal. Abdominal ultrasound scan did not reveal any intra abdominal pathology. The aorta was measured at 2.6 cm. This pain settled with oral analgesia and he was discharged home with plan for further investigation as an out patient. Six days later the patient was readmitted with right sided abdominal pain and rectal bleeding. Patient has a normal pulse rate, blood pressure and was non febrile. Examination revealed a soft abdomen, palpable aorta and tenderness to the right of the umbilicus. Digital rectal examination revealed small amount of blood on the glove. Blood test showed a haemoglobin level of 12.4 g/dL, elevated WCC of 21 × 109/L and a CRP of 21 mg/L. He has a strong history of ischaemic heart disease with three previous episode of myocardial infarction, the last one being over one year ago. An urgent CT scan of the abdomen and pelvis were organised to rule out a malignant cause of abdominal pain. Patient has no further episode of rectal bleeding and clinically appeared well. The following day, patient collapsed while walking to the toilet. His pulse rate was 110/min with a systolic pressure of 80 mmHg. CT scan early in the day showed a 5 cm infrarenal AAA. (Figure )\nPatient was taken to theatre with a presumed diagnosis of ruptured aneurysm. The on call surgeon who happened to be an upper GI surgeon and an experienced vascular surgeon performed the operation. At laparotomy, patient was found to have an inflamed aorta with a fistula communicating with the 3rd part of the duodenum. The aorta was debrided and repaired using a Dacron tube graft and wrapped in collatamp sheet. This was further covered using an omentum pedicle brought through the transverse mesocolon separating the Dacron graft from the duodenum. The duodenal defect was primarily closed. Patient made good recovery and was discharged on day 8 post surgery with long term antibiotic. Patient remained well at 6 months follow up. |
67 year-old woman with hypertension, coronary artery disease, status post a non-ST segment elevation myocardial infarction and percutaneous coronary intervention to the right coronary artery and heart failure with a preserved ejection fraction with occasional exacerbations (generally when she has atrial fib), also has paroxysmal atrial fibrillation that is poorly tolerated and she is unable to tolerate sufficient doses of AV nodal blockers to achieve rate control when she has atrial fibrillation. She had a significant drop in her DLCO on Amiodarone (which had only been somewhat successful at reducing her episodes of atrial fibrillation), and thought not to be a candidate for other agents because of her other heart disease. She has a friend who had complications during ablation, so declines this treatment and was therefore referred for atrioventricular nodal (AVN) ablation and PM placement.\nAs described in current atrial fibrillation management guidelines, AVN ablation with PM placement is a treatment reserved for patients for whom pharmacologic rate control is unsuccessful or not tolerated, including those with tachycardia medicated cardiomyopathy and/or intolerable symptoms from their arrhythmia or the medications used to control it.[ The procedure appears to be a successful treatment. In a meta-analysis of 21 studies with 1181 patients there were significant improvements in all 19 different clinical outcomes (see ).[\nThe benefits may be due to improved LV function, the slower and more regular ventricular rate or a combination of these.[ There does not, however, appear to be an effect (either positive or negative) on mortality.[\nSince AVN ablation renders patients PM dependent, a device must be placed prior to or at the time of the ablation. If the patient has chronic AF, a single chamber PM is indicated, and it is usually programmed with rate-responsiveness (e.g. VVI-R). If the patient's AF is paroxysmal, then a dual chamber device is usually placed to maintain A-V synchrony during periods when the patient is in sinus rhythm. These devices are usually programmed DDD-R with mode switching, to prevent excessively fast-pacing when patients are in atrial fibrillation. Two trials comparing single and dual chamber pacing with mode switching in patients with paroxysmal AF showed improved symptoms and quality of life compared to either a single chamber PM or a dual chamber device without mode switching.[\nChronic RV pacing causes the RV to be activated before the LV and the intraventricular septum prior to the LV lateral wall resulting in ventricular dyssynchrony. This dyssynchrony can, in turn, lead to systolic dysfunction, decreased exercise capacity and functional status, HFrEF and increase mortality.[ Because of this and data that those with LV dysfunction improve their ejection fractions with upgrading to a CRT, such devices are often implanted prior to AV nodal ablation.[ This can be done with or without an atrial lead depending on whether the AF is chronic or paroxysmal. Such an approach is supported by the results of two randomized trials.\nIn the Post AV Nodal Ablation Evaluation (PAVE) Trial, 184 patients with chronic AF who were refractory to medical rate-controlling therapy were randomized after AVN ablation to standard RV pacing or biventricular pacing (also called cardiac resynchronization therapy (CRT)).[ After 6 months, CRT patients had greater increases in 6-minute walk distance, peak O2 consumption and exercise duration when compared to RV pacing (31% vs. 24% improvement). The improvement in 6-min walk distance was limited to patients who had an LVEF ≤ 45% or were experiencing NYHA Class Ⅱ or Ⅲ symptoms (83% of the patients). CRT patients had higher LVEFs than those who received RV pacing.\nIn the BLOCK HF (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block) trial patients with advanced AV block and an LVEF < 50% had improved outcomes when treated with a biventricular pacemaker compared with those randomized to RV apical pacing.[ The primary outcome was the time to all-cause mortality, an urgent visit for HF requiring Ⅳ therapy, or a 15% or more increase in the LV end-systolic volume index. Of 918 patients enrolled, 691 underwent randomization and were followed for an average of 37 months. The primary outcome occurred in 55.6% of the RV-pacing group, vs. 45.8% of the BiV-pacing group. Patients in the BiV-pacing group had a significantly lower incidence of the primary outcome over time than did those assigned to RV pacing (HR = 0.74; 95% CI: 0.60-0.90); results were similar in both the pacemaker and ICD patients.\nThe usefulness of AV Nodal ablation in patients with HFrEF and atrial fibrillation is also supported by an observational study which suggested that AVN ablation plus CRT may significantly improve survival compared to CRT alone.[ In this study, of the 1285 patients who received CRT, 243 were in AF. Rate control was achieved by medical therapy in 55 patients and in the other 188 AV nodal ablation was required. Patients who received CRT devices achieved Bi-V pacing ≥ 85% of the time. During a median follow-up of 24 months, morality was lower in patients with AV nodal ablation as compared with the medications only group (4.3% vs. 15.2%; adjusted HR 0.26 for all-cause mortality and 0.15 for HF mortality).\nCurrent guidelines support the use of CRT in patients with AF who have an EF ≤ 35% on GDMT if the patient requires ventricular pacing or meets CRT criteria and if AVN ablation or pharmacologic rate control allows near 100% ventricular pacing.[\nAlthough rare, ventricular fibrillation and sudden death rates appear to be increased after AVN ablation. For example, in a review of 334 patients after AVN ablation, 2.7% suffered sudden death. Four took place within 4 days of the procedure, 3 more within 3 months, and 2 were late.[ This increased risk may be due to several factors including comorbid heart disease, post-procedural sympathetic nervous system activation, prolongation of the action potential, and repolarization abnormalities secondary to bradycardia or a combination of these.[ Pacing at a rate of 90 vs. a rate of ≤ 70 beats/min was evaluated in a study of 235 patients. Those whose devices were programmed ≤ 70 beats/min had a 6% rate of ventricular fibrillation, whereas those programmed at 90 beats/min for three months had no VF. This may be because a reduction of sympathetic activity.[ Therefore, most electrophysiologists program the HR higher early after AVN ablation.\nOf note, indications for anticoagulation remain unchanged after an AV nodal ablation with pacemaker placement.\nCase conclusion: AV nodal ablation is performed with/simultaneous placement of a bi-ventricular pacemaker. Initial programming was for a HR 90 bpm, which was reduced on a subsequent visit. |
A 72-year-old, previously well, woman was found to have left ocular uveal melanoma on ophthalmology review (Fig. ). She had previously been noted to have ‘freckles’ on her left retina. At the time of diagnosis the patient was asymptomatic, suffered no visual impairment and declined further investigation, radiotherapy or enucleation. A one-year follow up showed growth of the uveal melanoma with staging undertaken prior to intended radiotherapy. An abdominal CT scan demonstrated a lesion within segments 4 and 7 of her liver (Fig. ). A Further PET scan showed a focal area of FDG avidity within segment 4 but no increased FDG uptake in liver segment 7,\nA diagnostic laparoscopy was performed for the liver lesions of unknown origin. Intraoperatively, no free intraperitoneal fluid was seen but numerous peritoneal nodules were noted on the diaphragmatic and peritoneal surfaces, particularly in the right upper quadrant. There was no obvious omental disease. These peritoneal nodules along with the liver lesion were biopsied. The liver biopsy showed focally necrotic poorly differentiated adenocarcinoma. Immunohistochemical labeling was in keeping with cholangiocarcinoma and in the absence of a primary site in the extrahepatic biliary system or upper gastrointestinal tract the lesion was considered to likely represent a primary intrahepatic cholangiocarcinoma. The lesion did not label for any immunohistochemical markers for melanoma. The peritoneal biopsy showed nodular proliferations of mesothelial cells with infiltration into the submesothelial adipose tissue indicative of malignant mesothelioma of epithelial type. Immunohistochemistry was positive for mesothelial markers and negative for carcinoma markers.\nThe patient’s father and brother had both died of malignant mesothelioma (Fig. ) having had occupational exposure to asbestos. The patient herself had no occupational exposure to asbestos but may have had ongoing household exposure since the 1970s. Her past medical history was unremarkable besides beta thalassemia minor and a previous hysterectomy for benign disease. The patient was of Greek descent. She was a non-smoker and only occasionally drank alcohol. The patient had four children, and two of these had passed away with renal cell carcinoma and acute lymphocytic leukaemia at ages 41 and 17 respectively (Fig. ).\nElective surgical resection was deemed appropriate for the patient’s primary liver mass. A CT prior to resection demonstrated no change in the liver lesion and no evidence of extrahepatic spread. Intraoperatively, a firm porta hepatic node was identified with frozen sectioning confirming metastatic adenocarcinoma. Fine needle aspiration of the segment 7 also showed adenocarcinoma and in view of positive intra- and extrahepatic disease the liver resection was abandoned. A strip of peritoneum was also removed which again demonstrated malignant mesothelioma.\nIn light of her uveal melanoma and malignant mesothelioma, combined with her family history of mesothelioma it was suspected that the patient might have BAP1 hereditary cancer predisposition syndrome. Testing for BAP1 mutations by immunohistochemistry showed loss of nuclear BAP1 labeling in the primary biliary tract adenocarcinoma, but nuclear labeling for BAP1 was retained in the malignant mesothelioma (Fig. ). No biopsies were taken from the uveal melanoma. Germline DNA sequencing was performed and revealed the patient to carry a germline missense mutation in the catalytic domain (g.52441252A > G, p.Tyr173Cys) located in exon 7 of the BAP1 gene (Fig. ). This mutation is predicted to generate a non-functional full-length protein, due to impairment of its ubiquitin hydrolase activity.\nFurther CT surveillance of the patient demonstrated an enlarging liver mass, development of new liver lesions and increasing portacaval lymph nodes. No other distant sites of metastasis where identified on CT. The patient become symptomatic 23 months after the diagnosis of cholangiocarcinoma and mesothelioma and was commenced on palliative chemotherapy. She passed away 31 months after diagnosis of cholangiocarcinoma and mesothelioma due to progression of her intraabdominal malignancies. |
A 35-year old male patient was admitted into hospital owing to a newly discovered tracheal masses, the chronic and repeated dry cough and the shortness of breath after activities. CT revealed a space-occupying lesion in the cervical trachea. The pedicle was in the tracheal membrane and displayed a total length of about 6 cm (Fig. ). Fiber bronchoscope showed that a spherical neoplasm could be seen in the upper part of the trachea and was 1.5 cm below the glottis. Additionally, this neoplasm was characterized by hypervascularity, smooth surface and failure to be moved. The mass protruded to the lumen, resulting in annular narrow of the upper trachea. Its distal end could not be observed (Fig. ). Positron emission tomography computed tomography revealed a remarkably increased levels of glucose metabolism in the upper part of the posterior tracheal wall. Esophagoscope showed that esophagus was not invaded by the mass. Collectively, this lesion was considered as a malignancy. Patient had no other severe diseases and did not undergo any surgery in the past.\nThe patient was scheduled for a primary resection of long-segment tracheal mass and reconstruction by using autologous thyroid-pericardium composite tissue flap. Intraoperatively, the patient was in the supine position. A cervically endotracheal mass with about 6 cm of length was seen following conducting a neck and chest midline incision. The mass extended ranging from the place of 1.5 cm below the glottis to the thoracic inlet level of trachea. Furthermore, the mass was obviously invasive outward and bulged nearly 2 cm outward the tracheal membrane, indicating that it appeared to be closely anatomically associated with the right recurrent laryngeal nerve. It also encroached the part of fibrous membrane and muscular layer of the right wall of cervical segment of esophagus. There was an enlarged cervical lymph node, with moderate hardness and no tendency of invasion.\nInitially, the thymus was resected to expose the trachea above the innominate artery that was near the thoracic inlet level. The bilateral recurrent laryngeal nerves were exposed and the right recurrent laryngeal nerve was in a closely anatomical relationship with the tumor. Thus, it was pivotal to protect right recurrent laryngeal nerve from mechanical injury. Then, the tumor in conjunction with involved trachea (including about 4 tracheal cartilages of the anterior and lateral wall) were resected (Fig. ), and the posterior wall was also resected about 6.5 cm (Fig. ). Two stumps and the inferior margin of tracheal membrane were taken for an urgent pathological examination and there were no remnant tumor cells. The anterior wall of trachea could be closed with low tension. The defective region of trachea posterior wall was approximately 2 × 3 cm2. The right isthmus and isthmus of the thyroid were isolated to be protected. Left thyroid arteries and veins were reserved and the right side of the thyroid was relocated to the anterior of the cervical vertebra. The part of the pericardium was resected and its smooth surface face was toward the inner side of the trachea. Ultimately, the pericardium and thyroid gland were sutured together and were made into a composite flap (Fig. ). The defect of the membrane was repaired with flap by running suture of 3-0 monocryl, and the anterior and lateral walls were reconstructed by 3-0 monocryl (Fig. ). The pericardial defect was repaired by bovine pericardium patch.\nEight days postoperatively, CT scan showed there were no pneumomediastinum and mediastinal abscess (Fig. ). The pathological examination demonstrated that this tumor was derived from epithelial cells and tumor cells were characterized by adenoid or cribriform structures. According to immunohistochemistry, it was considered as highly differentiated adenoid cystic carcinoma with the capacity to invade bronchial wall. The results of immunohistochemistry were the followings: Ki-67(30%), CK5/6(+), P40(+), CK7(+), CAM5.2(+), Syn(–), CgA(–), s100(+), TTF-1(–), P53(20%+), P63(+), CD117(+). Two weeks postoperatively, the patient recovered better and was discharged from hospital. Three weeks postoperatively, fiber bronchoscope showed the flap was in normal color and the tracheal cavity was unobstructed (Fig. ). More media presentation can be seen in supplementary multimedia. |
A 12-year-old male in the permanent dentition was brought to our clinic for orthodontic treatment. The patient presented Class II, Division 2 malocclusion on Class I skeletal base. The overjet was reduced (1 mm) and the overbite increased (5 mm). Medical and familiar histories were unremarkable. The pretreatment radiography showed the presence of all the permanent teeth with also the presence of the wisdom teeth (). Treatment started in 2004 with thermoelastic wires to have a less painful resolution of the crowding []. During the treatment, after two years from the start, a new panoramic radiograph was requested to evaluate the necessity of some brackets rebonding, and ST between 4.5 and 4.6 was detected. The radiography showed a bicuspid crown with a dental follicle ().\nThe treatment objective was to avoid the damage of the surrounded tissues and of the contiguous teeth and the disruption of the occlusion, balancing the risk/benefit ratio between the follow-up of the tooth and the extraction.\nThere are two options when a LDSP is present; the first one is in the radiographic follow-up and the second one is the extraction. In this case the OPG () revealed that the tooth was still developing, only the crown being formed, and that the tooth did not have any contact with the contiguous teeth. Performing an extraction of this tooth implied a germectomy with a deep mandibular access and a great bone loss. Moreover, no further active orthodontic treatment has to be performed in the lower arch. Hence, due to these considerations the best choice was to monitor the tooth during the time.\nThe patient's parents were informed about the LDSP. Clinical and radiographic follow-up were performed to verify the onset of any complication. After 5 years the tooth was still not completely formed but an initial repositioning of the root of 4.5 was present (). In 2013, when the tooth achieved a more accessible position it was extracted upon the request of the patient (). |
A 40-year-old obese lady presented with a severe holocranial headache for 10 days. She had associated nausea, vomiting, and rapid onset of painless loss of vision in both the eyes which progressed over 2 days.\nShe was a known case of schizophrenia on treatment under psychiatry for the past 10 years. She was treated with olanzapine and later with fluphenazine decanoate when she was irregular with medications. This was subsequently changed to risperidone after symptomatic improvement. She was only on 4 mg of risperidone for the past 1-year. She has had associated history of weight gain over the last 4 years which had rapidly worsened after starting risperidone. She did not have any other comorbidity.\nOn examination, she was obese with a body mass index of 32.4 kg/m2. Her general and systemic examinations were normal. On ophthalmological evaluation, the pupils were equal but nonreactive bilaterally. There was the perception of light in the right eye and none at all in the left. Bilateral papilledema with primary optic atrophy in the left eye was noticed on fundus examination. On testing eye movements, she had bilateral restriction of lateral gaze. She was unable to do formal visual field testing due to the poor vision.\nDifferential diagnosis considered included meningitis, cortical venous thrombosis, demyelinating illness with optic neuritis, and idiopathic intracranial hypertension. Magnetic resonance imaging (MRI) of the brain revealed increased diameter of the optic nerve sheath with flattening of the posterior sclera margin with prominent perioptic halo []. There was also a partially empty sella [] and narrowing of the junction of the transverse-sigmoid sinuses [] which were all suggestive of intracranial hypertension. The subsequent CSF study was normal except for the elevated opening pressure of 35 cm of water. A magnetic resonance venogram was also done to rule out cortical venous thrombosis. Visual evoked potential testing showed absent waveform in the left optic nerve.\nA diagnosis of BIH was made based on the modified Dandy's diagnostic criteria. She was then initiated on acetazolamide and mannitol for medical management of BIH. In view of the persistent headache, papilledema, and visual loss a surgical option was considered. As she had developed features of left optic atrophy, it was decided that a thecoperitoneal shunt procedure would be preferable to an optic nerve sheath fenestration. She thus underwent a lumbar thecoperitoneal shunt procedure. Postoperatively, her headache improved, and right eye vision improved from the perception of light positive to finger counting at six feet. Vision in the left eye remained negative for the perception of light.\nRisperidone was stopped from the onset of the present admission. Aripiprazole was started later by psychiatry as part of her maintenance treatment. On review, a month later, she was doing well with no headache or further loss of vision. |
A 23-year-old female patient presented to the Department of Oral and Maxillofacial Surgery with a chief complaint of asymmetry of her face. She gave a history of an abnormally enlarged left half of her face since birth which became more prominent following menarche. The patient had visited multiple plastic surgery units since childhood and had been diagnosed with hemihypertrophy []. However, no genetic studies had been carried out to confirm the diagnosis. She was under a regular follow-up regimen by her GP to look for developing cancers.\nThe patient was born at full term from a nonconsanguineous marriage. The patient was of normal built and intelligence. There was no history of such complaints in the family and serum chemistry revealed no abnormalities. The swelling was diffuse, soft, and extended from the frontal bone to the lower border of the mandible on the left side. The zygomatic root was enlarged on palpation [Figures and ]. Mouth opening and the range of movement was adequate. The left half of the hard palate was enlarged with a normal complement of teeth in the maxillary arch. The molars in the mandibular arch had been extracted at an earlier date due to caries. Three soft growths were present; at the lower labial mucosa, the buccal mucosa, and the retromolar area. An excisional biopsy of the growth at the left buccal mucosa was found to be lipomatous in origin. Body measurements were done from the midline, and no other asymmetry was present.\nPanoramic radiograph showed that the left palate, mandibular body, ramus, condyle, and coronoid were asymmetrically enlarged. No other physical abnormality was noted. The computed tomography showed uniform bony enlargement of the left half of the face including the frontal bone []. The soft tissue window showed an enlarged radiolucency suggestive of a lipomatous enlargement. Based on the clinical and radiographic features, the patient was provisionally diagnosed with true hemifacial hypertrophy of the left face.\nThe patient had been informed of the possible treatment options including extensive surgery for hard and soft tissue debulking and more conservative options for only soft tissue recontouring. She had been informed that irrespective of the treatment done, it would not be possible to achieve complete symmetry. The patient, however, was adamant and wished for treatment only if complete symmetry could be achieved. |
We present a case of a 65-year-old female patient admitted to the Cardiac Surgery Department in Wroclaw in January 2018 with severe mitral regurgitation (MR) and the history of ischemic heart disease, after elective percutaneous coronary intervention of the circumflex branch of left coronary artery with two drug-eluting stents (DES) implantation 4 years earlier. Furthermore, the patient diagnosed with many chronic conditions, such as metabolic syndrome, obesity with BMI 33 and gastroesophageal reflux disease. Currently, with an exercise dyspnoea for about 2 years, intensifying in recent weeks, she was hospitalized in the Cardiology Department for further diagnostics. The transthoracic echocardiography (TTE) revealed non dilated left ventricle with a normal systolic ejection fraction of 60%, and no evidence of segmental wall motion abnormalities, severe MR with the prolapse of the A2 segment and systolic restriction of the posterior leaflet. Colour Doppler showed a highly distinctive eccentric turbulent jet directed towards the lateral wall and the base of the left atrium with ERO 0.6cm2 and regurgitant volume of 60 ml. Additionally, in the performed coronary angiography, hemodynamically significant narrowing was found in the area of the previously implanted DES. The patient was then consulted by the cardiac surgeon and qualified for surgery. After admission to the Cardiac Surgery Department, as part of the pre-operative preparation, TTE was again performed, in which the severe MR was confirmed and no pathological structures in the right atrium were described. Due to the unclear image in the right pulmonary field, described by the radiologist in the chest X-ray (Fig. ), diagnostics was extended by performing a computed tomography of the chest, which excluded the presence of pathological shadow in the lung parenchyma. There was no referral to the atrial septum in the CT report. The patient was scheduled for mitral valve repair surgery and coronary artery bypass grafting (CABG) with the use of saphenous vein graft to the circumflex artery. During the standard procedure of commencing the cardiopulmonary bypass (CPB) and bicaval cannulation, it was found difficult to insert the cannulas from the atrium into both vena cavas. Therefore the cannulation was performed using the smaller cannula sizes, which eventually allowed to go on bypass. On the free wall of the atrial septum, there was a thickening and an excess of adipose tissue with a firm consistency and the size of a walnut, significantly impeding access to the operated mitral valve through the left atrium, and probably completely preventing surgery by the transseptal approach. In the transesophageal echocardiography (TEE), a characteristic image of LHAS was confirmed by the presence of hypertrophy of the septum, up to 2.7 cm, an hourglass shape with a characteristic indentation at the place of the fossa ovalis (Figs. and ). Based on the intra-operative TEE, as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. Due to the asymptomatic course of the LHAS and the complexity of the scheduled operation, the decision was made to leave the change intact. The mitral valve was replaced through the left atrial approach. The surgery was completed in a standard manner and the weaning from the CBP went uneventfully. The patient’s early postoperative period was a routine. |
A 45yr old lady suffered from a road traffic accident and sustained a closed diaphyseal fracture of both the bones forearm on left side. She underwent Open reduction and internal fixation of both the bones after 2 days following trauma with 3.5 Small DCP(6 hole). On subsequent follow up at 6 months with her primary surgeon it was found that there was osteolysis at the radius site while the ulna showed good signs of union. She was complaining of persistent pain (VAS Score-4) and unable to do routine activities with the involved limb. We evaluated her radiographs and did routine haematological tests. The parameters suggested there is some deep tissue infection (Raised Erythrocyte Sedimentation Rate {ESR} and C-reactive protein {CRP}) but the wound was healthy with healthy scar.\nThe patient was planned for staged surgery. First stage for implant removal with debridement, lavage of fracture site with culture sensitivity studies. Second stage for osteosynthesis with FVFG with plate once the acute phase reactants settled down. After a period of 2 months we again admitted the patient and did the routine investigations. As it was expected there was near normalcy of the parameters of infection like ESR, CRP. We diagnosed this as a case of gap non-union of shaft radius as evident from radiological investigation () and described all the treatment alternatives to the patient. After obtaining all the necessary consent we decided to do a free vascularised fibular grafting and fixation with a locking 3.5 small DCP. (12 hole)\nWe approached the radius through the previous incision site and freshened the atrophic ends of radius and finally found the gap to be 8cm (). The ipsilateral fibula was harvested in its middle 2/3rd taken as a pedicle with the peroneal artery, which arises from the posterior tibial artery, 3 to 4 cm distal to its bifurcation into the anterior and posterior tibial arteries (, ). It was fixed in the recipient site with the use of a 3.5 locking Dynamic Compression Plate (). With the aid of a microscope and the use of 8-0 polyamide suture, the feeder artery for the graft was anastomosed to the radial artery in end to end manner. Both the donor and recipient site was closed after thorough wound irrigation and drains in situ.\nPost-operative slabs were given both in upper and lower limb.\nThe patient was followed up monthly with radiographs and serum parameters of infection. She was allowed to do free range of movement exercise for elbow and wrist but non weight lifting. At 6 months there is satisfactory movement in elbow and wrist () and the graft is completely healed (). |
A 41-year-old active woman with no particular history presented with left breast carcinoma tumor in 1987. Biological and radiological clinical assessments had revealed no distant extension.\nThe patient underwent a surgical treatment of Patey technique in the left breast with axillary dissection. The anatomopathological study revealed that it was an invasive galactophoric adenocarcinoma and five to 23 positive nodes were detected. Four cycles of adjuvant chemotherapy with cyclophosphamide, doxorubicin, and 5-fluouracil were administered.\nSeven years following the chemotherapy, a nodule appeared on the intervention scar. The biopsy confirmed a local recurrence of breast cancer. After a staging that was featureless, radiotherapy targeting the chest wall, the collarbone, and armpit with a dose of 45 Gy for five weeks was performed. Hormone therapy with tamoxifen 20 mg per day was administered.\nTwo years after the treatment, the patient developed a significant lymphedema of the left arm, starting from the wrist and reaching the left shoulder, which required regular sessions of lymphatic drainage. 20 years after the appearance of the left mammary neoplasia and the occurrence of chronic lymphedema of the left arm, a burn of second degree appeared on the affected limb. A local treatment was administrated.\nIn September 2007 (one month after healing), the patient began to complain about a small hard erythematous-violet nodule at the rear and upper side of the left arm and reaching the posterior brachial region. They increased and became more painful and had a hard-bloody consistency on contact causing total functional left upper limb impotence (Figures and ).\nThe patient was hospitalized for additional tests following a radiography of the left arm showing significant swelling of the soft tissues. An exam of the biological tumor markers (CA 19-9) indicated that those were in range. An ultrasound of the soft tissue showed a significant subcutaneous edema. A computed tomography scan revealed a member with a fluid collection under fascial muscular near the lower third of the humerus and diffused a thick septa anterosuperior arm (), while an upper limb MRI showed the presence of a nodular formation in fatty tissue of the lower third of the arm ().\nA biopsy of the soft parts of the upper limb and brachial region was performed and the histological analyses confirmed the diagnosis of cutaneous angiosarcoma of chronic lymphedema. Immunohistochemistry indicated the vascular nature of the tumor thus eliminating the diagnosis of cutaneous metastases. Following this diagnosis, a complete staging was performed. The abdominal ultrasound and thoracoabdominal and bone scans revealed no remote extension. A radical decision was made including a dislocation of the left shoulder followed by two cycles of chemotherapy. The evaluation marked alteration of the general condition and dyspnea related to tumor spread in the lungs (pleurisy abundance). The histological tests revealed metastatic character of angiosarcoma. In April 2008, approximately eight months after the start of symptoms, the patient developed multiorgan failure that resulted in her death. |
A 42-year-old female patient presented at a regional hospital complaining of retrosternal pain and shortness of breath on moderate efforts that started 2 weeks before. Pulmonary thromboembolism was initially suspected; however, chest computed tomography angiography ruled out this diagnostic hypothesis.\nThe patient had undergone a hysterectomy 2 years earlier due to leiomyoma. She had been experiencing pelvic pain during the past 6 months. An abdominal ultrasound performed 2 months prior to presentation showed an apparently vascularized left periovarian solid mass with an approximate volume of 90 mL. Surgery for resection of the mass was scheduled but could not be performed because of abrupt onset of the current symptoms suggestive of heart failure.\nThe patient was transferred to our hospital for further evaluation. On admission, her vital signs were within normal limits. On physical examination, we disclosed a regular cardiac rhythm, hypophonic first heart sound, and a regurgitation murmur at the left inferior sternal border associated with an increased v wave venous pulse on internal jugular vein compatible with tricuspid regurgitation. A transthoracic echocardiography performed in the emergency room revealed a mobile and well-defined mass measuring ∼3.0 × 1.6 cm located in the right ventricular cavity, apparently adhered to the interventricular septum, and a probable thickening of the tricuspid subvalvar apparatus and severe tricuspid regurgitation (Figure ). The right ventricle (RV) was enlarged with depressed systolic function. Left ventricle (LV) dimension and systolic function were normal. As it was not clear if the mass was a thrombus or a tumour, the patient underwent cardiac magnetic resonance (CMR) imaging which revealed two large and independent masses in the right ventricular cavity (Figure ). Both lesions were iso-intense to the signal of myocardial tissue on T1 and T2-weighted imaging. The first-pass gadolinium-enhanced perfusion imaging showed heterogeneous nature of flow of contrast suggesting vascularity within the masses and both showed heterogeneous late gadolinium enhancement. These characteristics suggested the tumoural nature of the masses and ruled out the hypothesis of thrombus (Figure ). The largest one, measuring 5.3 × 2.7 cm, was adhered to the anterior face of the right ventricular outflow tract (RVOT) and was responsible for a significant RVOT obstruction. The second tumour presented as a multilobulated, pedunculated, and mobile mass attached to the interventricular septum. Right ventricle enlargement and moderate global systolic deficit (estimated ejection fraction of 39%) were found and both were attributed to the RVOT obstruction. Mild pericardial effusion and bilateral pleural effusion were also observed.\nBecause of the significant obstruction of the RVOT, surgical treatment was mandatory. An operation was performed through median sternotomy with standard bicaval cardiopulmonary bypass. The two masses described in the CMR were carefully resected. A third small neoformation was intraoperatively detected on the tricuspid valve, adhered to the ventricular face of the anterior leaflet and to the chordae (Figure ). A significant segment of the anterior leaflet was resected along with the mass and a valve replacement with bioprosthesis (St. Jude Medical Stented Porcine 31 mm) was performed. The masses were well capsulated without signs of local spread in the surrounding myocardial tissue. At gross examination, they had a nodular, fragmented appearance, elastic consistency, and presented a smooth whitish-yellow capsule. The surgery was performed with no complications and the immediate postoperative course was uneventful.\nHistologic examination revealed a mesenchymal neoplasm consisting of spindle cells with predominantly uniform nuclei and eosinophilic cytoplasm, arranged in long bundles amid collagenized stroma and resembling smooth muscle cells. No mitosis, areas of necrosis, or signs of malignancy were found. A vascular component of varying calibre was observed, sometimes showing thickened walls and permeating the tumour (Figure ). A segment of the cardiac valve accompanied the specimen and had a normal histological appearance.\nImmunohistochemically, the tumour cells expressed desmin and caldesmon (Figure and C), corroborating smooth muscle differentiation. In addition, tumour cells were strongly positive for oestrogen receptors (Figure ) which is supportive of origin in female genital tissues. From both the histologic and immunohistochemistry examination the final diagnosis was cardiac leiomyoma.\nThe gynaecology team started to monitor the case immediately after cardiac surgery due to the knowledge of a previously identified pelvic mass which could be palpated through physical examination. The patient underwent a magnetic resonance imaging of the pelvis. A heterogeneous solid mass was found in the left paramedian situation of the pelvic cavity, measuring about 8.1 × 8.0 × 6.9 cm, in close contact with the left ovary and suggestive of leiomyoma (Figure ).\nDue to the large size of the mass, it was decided to extract it immediately. On the 10th postoperative day of the cardiac procedure, the patient underwent pelvic tumour resection surgery. The tumour’s morphological aspect was suggestive of leiomyoma. The surgical procedure was performed with no complications.\nHistologic analysis of the surgical specimen revealed proliferation of myoid spindle cells without atypia, mitosis, or necrosis (Figure ), compatible with the diagnosis of leiomyoma. The tumour cells expressed desmin and caldesmon (Figure and C), corroborating smooth muscle differentiation.\nPostoperative echocardiography revealed no residual cardiac mass, good function of the tricuspid prosthetic valve, and normal RV size and systolic function. The patient was discharged from hospital in good clinical and haemodynamic conditions with a final diagnosis of BML to the RV, tricuspid valve, and pelvic leiomyoma. Four months after hospital discharge, the patient reported being in good physical condition and denied any complications. |
In October 2012, a 46-year-old woman was referred to our center for the presence of a large mass (50 × 70 mm) in the superior lobe of the left lung with homolateral pleural effusion. The patient was never smoker, without family history of cancer and without comorbidity. The cytological diagnosis was made using a CT-guided fine needle aspiration of the primary tumor and revealed an adenocarcinoma of the lung (TTF1+, CK7+) with the EGFR ex19del mutation. A PET-CT demonstrated the presence of liver and bone metastases and a nodule in the right breast, confirmed as a metastasis by fine needle aspiration. The patient received zoledronic acid 4 mg every 28 days and gefitinib 250 mg daily since November 2012 obtaining a partial response (PR). In August 2013, a disease progression (PD) was documented, with an increase in size of the primary tumor and size and number of liver metastases. A brain MRI revealed the presence of two cortical nodules, which were treated with stereotactic radiotherapy. The patient was enrolled in the IMPRESS trial and received 6 cycles of cisplatin and pemetrexed plus gefitinib obtaining again a PR that lasted until June 2014. Thereafter, a new lung metastasis appeared in the superior lobe of the left lung and the mammary nodule increased in dimensions. From June 2014 to December 2014 the patient received erlotinib 150 mg daily obtaining an initial stabilization of the disease (SD); however, within 6 months, she experienced again a PD with the increase of the mammary nodule and the appearance of a new bone metastasis in the sacrum. In December 2014, EGFR ex19del and T790M mutations were detectable in a new needle biopsy of the primary tumor; only at this time a digital PCR-based method was available for the analysis of circulating tumor DNA (ctDNA). Briefly, the method was optimized in order to recover a suitable amount of ctDNA for molecular analysis from 3 ml of plasma using the QIAmp Circulating Nucleic Acid Kit (Qiagen®, Valencia, CA). ctDNA was examined using the Prime PCR Probe Assay on a QX100™ Droplet Digital™ PCR System (BioRad®, Hercules, CA) for EGFR mutations (ex19del, T790M, and C797S) []. The ctDNA sample was considered as EGFR mutant when at least one droplet was above the fluorescence intensity threshold of 3000 and results were reported as copies/ml. The first plasma specimen was obtained in December 2014 and confirmed the presence of ex19del and T790M mutations (480 and 260 copies/ml, respectively; Fig. ). The patient was treated with atezolizumab from March to May 2015 and received stereotactic radiotherapy on the lung primary tumor and on metastases of the left superior lobe, breast and bone (sacrum and D10). Due to PD, the patient was given afatinib 40 mg daily from June 2015 to September 2015, but she experienced a further PD with an increase in size of the primary tumor and lung nodules, the appearance of new multiple bilateral lung metastases, lymphangitic infiltration and liver metastases. At this time, the presence of ex19del and T790 M was again demonstrated in a biopsy of a liver metastasis. Since osimertinib was available, the patient was enrolled in the ASTRIS trial and given 80 mg daily starting from October 2015 with an immediate clinical benefit. At the first evaluation a PR was documented with disappearance of most of the lung nodules and lymphangitic infiltration, reduction of the primary tumor and of liver metastases as well. A disappearance of ex19del or T790M was demonstrated in ctDNA in a blood sample obtained in October 2016. However, in April 2017, ex19del appeared again (400 copies/ml) and in July 2017 it increased to 1000 copies/ml, while T790M was also detectable (330 copies/ml, Fig. ). Then, ex19del and T790 M continued to increase to, respectively, 1600 and 510 copies/ml in October 2017, 2100 and 550 copies/ml in November 2017, and 6900 and 1900 copies/ml in December 2017.\nA radiological progression was demonstrated with increase in size and number of liver metastases in December 2017. The patient underwent a new liver biopsy that confirmed the PD and the presence of ex19del and T790M, whereas the ctDNA showed also the appearance of C797S mutation (170 copies/ml), in addition to ex19del and T790M. The patient started chemotherapy with carboplatin and pemetrexed and in February 2018 she obtained an SD associated with a drop of ex19del (800 copies/ml), T790 M (380 copies/ml), and C797S (90 copies/ml) and then a PR in May 2018, with disappearance of C797S and reduction of ex19del (760 copies/ml) and T790M (90 copies/ml). In July 2018, however, ex19del strongly increased to 2200 copies/ml, even though T790M and C797S were undetectable. Finally, in October 2018, when a PD was documented, ex19del increased to 5100 copies/ml, while T790M and C797S appeared again in plasma with 600 and 180 copies/ml, respectively (Fig. ). At this time a NextSeq 550 NGS platform (Illumina®, San Diego, CA) was available to analyse ctDNA by the AVENIO ctDNA Expanded Kit (Roche®, Pleasanton, CA). A plasma sample collected in December 2018 and analysed by NGS confirmed the presence of the ex19del, T790M and C797S and found, in addition, EGFR and c-MET amplifications, which were not present in tissue in the last re-biopsy of December 2017. |
A 65-year-old male patient came to our department in August 2013, with varus deformity at the level of middle third and the distal third junction of left forearm. Detailed history revealed that he sustained fracture both bones forearm due to road traffic accident 15 years back, for which he was treated with open reduction and plate osteosynthesis. 6 months after the surgery, the patient fell accidentally and gradually developed deformity of the left forearm, for which the patient did not approach hospital for treatment.\nOur examination () revealed varus deformity of 90° in the middle third and distal third junction of left forearm, shortening of about 10 cm of left forearm, healed surgical scars over radius and ulna. Furthermore, the patient had inability to move wrist and finger joints, probably due to muscle laxity. No neurovascular deficit was encountered. There was 30° fixed flexion deformity at elbow joint with further range of flexion of 80°. Radiological examination () revealed nonunion of fractured both bones forearm with broken dynamic compression plate (DCP) at radius and loosened DCP at ulna, with one screw in the subcutaneous plane. The bones were found to be osteoporotic. Our aim was to correct the deformity, achieve union at the fracture site, restore optimal function of the wrist, hand, and elbow. Our treatment strategy was planned to perform the staged procedure.\nImplants were removed, except a screw, which was adherent to the adjacent vascular tissue. Pennig external fixator was applied on radius (), and universal mini external fixator was applied on ulna in another surgery. The deformity was corrected by gradually stretching (1 mm/day) the contracted soft tissue over a period of 6 weeks (). The neurovascular monitoring done clinically. Then, the external fixator was removed, once full correction was achieved. A long arm slab was applied in fully corrected position for 3 weeks.\nOnce the soft tissue healed and infection was ruled out, definitive fixation was done for nonunion radius (nonunion in ulna was left undisturbed, since simultaneous fixation of ulna in a scarified tissue would lead to increase in compartment pressure and difficulty in skin closure) using dual onlay fibular cortical strut grafting (procedure is explained below) with cancellous bone grafting. The fracture ends were freshened until fresh bleeding was seen from the bone ends, and medullary canal was opened with 2.5 mm drill bit before fixation was done. A gap of 2.5 cm was present. The fibular graft was harvested from left leg (direct lateral approach, middle third) leaving 6 cms of lower end of fibula for ankle stability. Cancellous bone was harvested from the left iliac crest.\nThe fibular graft was predrilled (with 2.5 mm drill bit), tapped and then split longitudinally into two halves using saw. The two halves of the graft were placed over the radius spanning the fracture; drilling was done through the previously drilled holes in the near onlay graft and then into host radius, and then into the opposite onlay graft (). The onlay graft was secured to host radius with 3.5 mm cortical screws, so as to obtain 4 cortical purchases (with each screw). The cancellous graft was placed into the trough lying between fracture ends and between the two onlay grafts. Nonunion in the ulna was left undisturbed ().\nThe patient was immobilized in long arm cast, in mid prone position, for 6 weeks. Immediate post-operative X-ray () shows good deformity correction with graft and implants in situ. After 6 weeks of surgery, the patient underwent protected physiotherapy (with a splint) in the form of active and assisted mobilization of the elbow, wrist, and finger joint. The patient refused another surgery on ulna (because the patient was functionally satisfied and deformity was corrected fully). 1-year follow-up () shows union at the graft site. |
A 70-year-old Sri Lankan Tamil male with a history of well-controlled type 2 diabetes mellitus and a goitre of 30 years presented with a painful enlargement of goitre on the left side for one month. He had progressively worsening difficulty in breathing with intermittent dysphagia for solids. He did not have any symptoms of local infiltration and was clinically euthyroid. Examination revealed a hard mass arising from the left thyroid lobe measuring 8 cm × 7 cm in size with gross tracheal deviation to the right side. In addition, there were two mobile lumps anterior to the mass in the subcutaneous tissue plane (). There was no retrosternal or retroclavicular extension on the left side. The right thyroid lobe was moderately enlarged and had multiple palpable nodules. There was no cervical lymphadenopathy. Ultrasound scan showed a large calcified left thyroid nodule and few superficial nodules. The outer surfaces of the nodules were delineated by an echogenic line suggestive of surface calcification. The internal echotexture of the nodules was not clearly appreciated due to artefacts from the surface calcifications. Right thyroid lobe showed only benign characteristics. Neck X-ray radiography showed a calcified left lobe with significant tracheal deviation to the opposite side (Figures and ). Thyroid stimulating hormone (TSH) and free thyroxine (T4) levels were within normal limits. Ultrasound-guided fine needle aspiration cytology (FNAC) showed scattered cyst macrophages, lymphocytes, and multinucleated giant cells in an eosinophilic background with scanty colloid. The features were compatible with a benign cyst (Thy 2).\nThe patient underwent a total thyroidectomy. Two confluent nodules were noted in the subcutaneous tissue plane extending through the deep fascia between the strap muscles to the calcified left lobe nodule. The deep fascia and strap muscles were thinned out and were adhered to the calcified left lobe (). Division of strap muscles on the left side was required to mobilize and deliver the left lobe containing the calcified nodule.\nMacroscopic assessment of the specimen consisted of the thyroid gland with the right lobe measuring 45 × 25 × 20 mm, the isthmus measuring 65 × 15 × 4 mm, and the enlarged left lobe measuring 80 × 75 × 55 mm. The outer surface of the gland was smooth. There were two confluent nodules over the anterior surface of the left lobe measuring 12 × 8 × 8 mm and 10 × 8 × 6 mm with a smooth outer surface.\nHistology of the thyroid revealed an encapsulated left lobe lesion composed of a thick fibrous wall with foci of calcification. A dense inflammatory reaction comprising lymphocytes, foamy histiocytes, and scattered multinuclear giant cells was present within the capsule. The lumen was filled with amorphous, eosinophilic material with cholesterol clefts. A thin rim of compressed thyroid tissue was noted outside the fibrous wall. Sections from the confluent nodules revealed similar histopathological features and showed encapsulated lesion surrounded by a thin fibrous capsule. They were filled with numerous foreign body type giant cells and foamy histiocytes admixed with amorphous eosinophilic material and cholesterol clefts. No thyroid or lymphoid tissue was seen. The right lobe and isthmus showed features of a colloid storing goitre. There was no evidence of malignancy in the entire specimen. Overall, features of the main calcified nodule of the left lobe and the two smaller confluent nodules were compatible with a colloid cyst with secondary changes including calcification and chronic inflammation. The patient had an uneventful postoperative recovery with the alleviation of the obstructive symptoms. He was discharged on the first postoperative day on thyroxine 100 mg daily and remained healthy without any obstructive symptoms during a three-month routine outpatient clinic review. |
In April 2014, a 90-year-old female presented with left thigh pain after a fall from standing height. She had a previous fixation of a left intertrochanteric hip fracture with a sliding hip screw in 1999 and a 9-year history of bisphosphonate therapy. She noted intermittent left thigh pain over the previous few months. It was unclear whether she fell and then noted pain in the thigh or if the thigh gave way, leading to the fall. She was diagnosed with osteoporosis in 2004 using dual-energy X-ray absorptiometry scan and began treatment on alendronate therapy 70 mg tablet weekly. After 9 years of use, the alendronate therapy was discontinued to give her a drug holiday in 2013; vitamin D3 and calcium supplementation were continued. Her past medical history included a diagnosis of atrial fibrillation treated with rivaroxaban and hypertensive heart disease. Her past surgical history included fixation of a reverse obliquity intertrochanteric hip fracture with a sliding hip screw in 2008. She was asymptomatic on the right side.\nRadiographs obtained in the emergency department revealed a left-sided femoral shaft fracture at the distal aspect of the five-hole lateral plate and screw fixation of the previously applied five-hole side plate. Of note, the periprosthetic fracture demonstrated cortical thickening at the fracture site of the lateral femoral cortex, lack of comminution as well as a transverse appearance (Figs. and ).\nThe patient was taken to the operating room the next day for retrograde placement of an intramedullary nail of the left femur with revision of left intertrochanteric femur fracture fixation. The five bicortical screws were removed from the sliding hip screw side plate so that the intramedullary nail could be inserted across the fracture site. The lag screw and side plate were maintained. The nail was interlocked with two screws distally and proximally. The two proximal interlock screws consisted of one anterior-to-posterior screw and another lateral screw through the side plate and the interlock hole in the nail ().\nPostoperatively, the patient was able to ambulate with a walker and was discharged home with regular follow-up. She used a cane at 6 weeks postoperatively, reaching her pre-operative functional level of ambulation in the community. Healing was noted on her radiographs at 6 weeks postoperatively, particularly at the medial cortex. By 3 months, she had obtained full radiographic union. The patient was also started on denosumab 60 mg single subcutaneous injection once for every 6 months beginning 6 weeks postoperatively in conjunction with her regular vitamin D3 and calcium supplements. No further adverse events were noted. |
A 34-year-old gentleman was first referred to orthopaedic services with a history of persistent knee pain, located over the right femoral condyle near the origin of the lateral collateral ligament. Eleven years prior to presentation, the patient was involved in a road traffic accident where he sustained a fracture of the right femoral neck and ipsilateral shaft. Initial management consisted of open reduction, fixation of the femoral neck fracture with cannulated screws and the ipsilateral shaft fracture with plating. The patient later had a revision of the plate to a femoral nail. Union was subsequently achieved with the femoral shaft fracture; however, a significant external rotation deformity was noted, and discomfort to the knee.\nThe patient was referred on to our tertiary referral orthopaedic centre for femoral de-rotation surgery. An initial CT scan performed revealed an external rotation deformity of 45 degrees. The patient procedure included removal of femoral nail, osteotomy with de-rotation surgery, and subsequent exchange nail. The femoral nail was fixed proximally and locked into place distally, following the corrective 45 degrees of internal rotation achieved to the distal femur during osteotomy, performed under intraoperative radiographic guidance. The post-operative rehabilitation regime consisted of initial touch weight bearing only, with gradual increments in weight bearing status. At six months follow-up, the patient complained of distal lateral femur pain. A repeat CT scan was performed, revealing a delayed femoral union. This was initially thought to be the cause of the patient’s symptoms. The patient was admitted for dynamization of the femoral nail with an injection of bone graft substitute, and iliac crest graft. Despite eventual union, the patient continued to complain of pain at the distal lateral femur, with a cracking sensation on movement now noted.\nRepeat clinical examination revealed a palpable crepitus over the distal iliotibial band with a snapping sensation, as it appeared to catch. A palpable small, solid swelling was noted at the posterolateral right knee. Ultrasound and CT revealed intra-articular loose bodies lying within the lateral para-patellar gutter. The patient subsequently underwent arthroscopy with removal of loose bodies. Despite this, at six-months follow-up to arthroscopy, the patient continued to complain of posterolateral knee pain. MRI showed no evidence of abnormality to the popliteus tendon or muscle, but highlighted the fabella embedded within the lateral head of gastrocnemius at the posterolateral corner of the knee. (Image ). The fabella was also notable on radiographs (Image ) and CT (Image ). Ultrasound scan confirmed the fabella as mobile on movement and associated with tenderness. The diagnosis of Fabella Syndrome was made, and the patient planned for a Fabellectomy procedure.\nAn initial arthroscopy was performed to review the knee joint, and to potentially assist in surgical excision of the fabella. A complete diagnostic arthroscopy was performed, with the fabella unable to be identified through the posterior capsule. After arthroscopy, open fabellectomy was performed. In view of the patient’s extensive scarring from prior orthopaedic procedures, a short 2cm incision was made directly over the palpable fabella (Image ). The common peroneal nerve was identified and spared. Subsequent incision left a cuff of biceps femoris to protect the nerve. Gastrocnemius was split and incised directly over the fabella, which was removed in entirety (Image ). Histopathology confirmed the diagnosis.\nThe patient was followed-up at two and ten months postoperatively. At both follow-ups, he described the complete resolution of his posterolateral knee pain. |
A 72-year-old man was referred to our department with a suspected tumor in the right rib. An abnormal shadow in the right chest was found during screening at 50 years of age. The patient was later followed up intermittently by a general physician ( and ). At 72 years of age, he was referred to our department because of a suspected malignant tumor. There were neither subjective symptoms nor abnormal physical findings. A blood test revealed an elevated level for alkaline phosphatase alone at 706 U/L. A pulmonary function test showed a percent vital capacity (%VC) of 78.8%, indicating a mild restrictive impairment. Plain radiography showed a radiopaque tumor measuring 12 × 9 × 18 cm that was connected to the seventh rib in the right thoracic cavity (). When compared to previous images, the tumor had gradually grown over the preceding 22 years. Computed tomography (CT) showed an extra-osseous tumor-like lesion with calcification, cortical destruction of the right seventh rib and a similar small lesion in the right ninth rib (). Moreover, lesions were also detected in the ninth thoracic vertebral body. Magnetic resonance imaging (MRI) revealed a lower signal intensity inside the lesion compared to the muscle on T1-weighted images and a mixture of low and high intensity on T2-weighted images, while enhancement was observed in the lower intensity area on T2-weighted images ( and ). Bone scintigraphy and positron emission tomography/computed tomography (PET/CT) revealed an increased uptake in the right seventh and ninth ribs and ninth vertebral body, and the right seventh rib showed a high standard uptake value at 7.67 on PET/CT ( and ).\nThe lesion of the right seventh rib was surgically resected due to enlargement and restrictive lung disease. The right ninth rib was also resected. Because we found that the lesion in the seventh rib had adhered to the lung, which was partially resected. The ninth thoracic vertebral body was not resected. The resected sample was a white solid tumor-like lesion measuring 21 × 8 cm (). No malignant findings were observed despite a complete cleaving and thorough evaluation of the sample. The final diagnosis was locally aggressive fibrous dysplasia. The %VC was increased from 78.8% preoperatively to 95.1% postoperatively and restrictive impairment was improved. The patient had no recurrence for 29 months postoperatively and died of gastric cancer.\nBecause differential diagnoses included malignant transformation from fibrous dysplasia based on the clinical course and imaging, a CT-guided biopsy was performed. Tissue was obtained from various areas with differing contrast effect on MRI. Despite no histological evidence of malignancy, signs of fibrous dysplasia such as irregular osseous trabeculae of immature bone with no osteoblastic rimming were observed. Accounting for possibly insufficient samples, incisional biopsies of the right seventh and ninth ribs were performed. The results showed fibrous dysplasia signs similar to those that were shown by the CT-guided biopsy, and the patient was preoperatively diagnosed as fibrous dysplasia (). |
A 68-year-old man with hypertension was admitted to our hospital with a TAAA. He had undergone a nephrectomy for left renal cell cancer 2 years prior and descending thoracic aortic repair for a ruptured Type-B acute aortic dissection at another hospital 8 years ago. At that operation, a reconstruction of the 11th intercostal artery, which was identified as the AKA, was performed. Follow-up computed tomography (CT) was performed annually, which showed gradual enlargement of the thoracoabdominal aorta. Because the maximum diameter of the aneurysm reached 62 mm, we planned to perform a TAAA repair.\nPreoperative CT findings demonstrating a replaced thoracic aorta from the distal aortic arch to just above the celiac artery are shown in\nand\n. Unexpectedly, the reconstructed intercostal artery was occluded. However, the AKA was supplied by a collateral vessel from the left lateral thoracic artery that was clearly visualized by CT. Because the collateral vessel was located in the left lateral thoracic wall, we planned a careful approach to the aorta to avoid injury to this vessel during the incision. A catheter for cerebrospinal fluid drainage was inserted into the lumbar region a day before the surgery.\nDuring the operation, a left-edge skin incision was made 3-cm apart from the inferior angle of the scapula. The chest was then opened through the left eighth intercostal space. We carefully dissected the left lung and the prosthetic graft, as they were severely adhered to the surrounding tissue. Cardiopulmonary bypass was initiated through the left femoral vein to the left femoral artery. A segmental-staged aortic clamp was applied under a partial cardiopulmonary bypass.\nThe aorta was clamped at the prosthetic aortic graft proximal to the previous distal anastomosis and at the native aorta just above the celiac artery. The previous distal anastomosis was transected, and a 20-mm Dacron graft with 8-mm side branches was anastomosed to the previous graft with a 4–0 polypropylene suture. The native aortic clamp was moved to the terminal aorta, and the aorta was incised. The celiac and superior mesenteric arteries were perfused using 8-Fr size balloon tipped catheters via a single roller pump. A cold ringer solution was infused into the bilateral renal artery. Each visceral artery was individually transected and anastomosed to the side branches of the prosthetic graft using a 5–0 polypropylene suture. After reconstruction of the visceral arteries, the prosthetic aortic clamp was moved to the distal end of the prosthetic graft to perfuse the side branches. The right external iliac artery and left common iliac artery were reconstructed with a 16- to 8-mm\nY\n-shaped Dacron graft, and the right internal iliac artery was reconstructed using another 8-mm Dacron graft. No intercostal or lumber arteries were reconstructed. The operation time was 305 minutes.\nAfter the operation, the patient had no neurological deficits including paraplegia. Postoperative CT demonstrated the preserved collateral vessel from the left lateral thoracic artery to the AKA (\n). He was discharged from hospital for rehabilitation on the 18th postoperative day. |
A 27-year-old male patient complained of pain on medial joint space in his right knee after running on the road for few years. He attempted self-treatment, but the pain did not improve. He subsequently consulted a nearby clinic and was diagnosed with medial and lateral discoid meniscus in his right knee with medial meniscus tear on magnetic resonance imaging (MRI). He was referred to our institution for operation.\nPhysical findings for his right knee showed that although the range of motion was not limited, there were swelling and pain on the medial joint space. In addition, the McMurray test revealed pain and clicking on the medial joint line with external rotation.\nRadiographs showed nothing particular in his right knee. T2-weighted coronal and sagittal MRI of his right knee revealed medial and lateral complete discoid meniscus, which was confirmed by arthroscopic examination of his right knee. The medial meniscus had a complete discoid conformation with a horizontal tear, whereas the lateral meniscus had no tear (). Arthroscopic examination of his right knee similarly revealed that the lateral discoid meniscus had no tear, and the medial discoid meniscus had a horizontal tear. In addition, the discoid medial meniscus also had an anomalous insertion to the anterior cruciate ligament, and there was also mild fibrillation of the medial tibial cartilage surface ().\nWe performed arthroscopic partial meniscectomy of the medial discoid meniscus. We performed no surgical procedure for the lateral discoid meniscus because the patient had no clinical symptoms, and the lateral discoid meniscus had no tear. We also checked the stability of the connection between the meniscus and the posterior soft tissue both medially and laterally ().\nWalking was allowed the day following the operation. Three months later, the patient had no pain or symptoms in his right knee and resumed playing sports. At the last follow-up, 18-month post-surgery, he had no limitation of motion, could play sports with full effort, and was satisfied with the result. The medial joint space in his right knee was observed clearly on MRI, and the lateral meniscus had no tear (). |
An 81-year-old gentleman with early stage Alzheimer's dementia who is otherwise well presented with gradual ongoing weight loss as his only symptom. The patient's full blood count and liver function tests were unremarkable. He underwent virtual CT colonography to investigate the weight loss. Whilst no colonic pathology was found, the imaging detected a distended gallbladder with a thickened medial wall of 1 cm and small volume porta hepatis lymphadenopathy ().\nThis raised the suspicion of gallbladder cancer reaffirmed by an ultrasound scan which demonstrated the gallbladder to be markedly distended containing sludge, with a thickened posterior wall of 8 mm but no gallstones ().\nThe decision was made to proceed to urgent laparoscopic cholecystectomy with on-table cholangiogram. Intraoperative laparoscopy revealed a grossly enlarged, thick-walled gallbladder. To aid dissection percutaneous aspiration was carried out draining over 250 ml of pus. Extensive adhesiolysis to free the gallbladder from the duodenum and colon was required prior to identification of Calot's triangle. An intraoperative cholangiogram was performed demonstrating normal ductal anatomy with no obvious obstruction. The cystic duct and artery were then ligated. Dissection of the gallbladder off the liver bed was exceptionally difficult as it was firmly attached, with complete obliteration of the plane. Once the gallbladder was freed, diathermy to the liver bed was carried out in case any posterior wall remained adherent. Thorough washout was performed and a large drain placed on the liver bed before removing the gallbladder via the umbilical port in a bag. Postoperative recovery was uncomplicated and the patient was discharged with analgesia 72 hours later following drain removal.\nUrgent histology revealed replacement of the entire gallbladder by a lymphoid lesion with ulceration of the mucosal surface and transmural infiltration with extension beyond the serosal surface into surrounding adipose tissue. Lymphoid cells were positive for CD 20 and BCL 2 immunostains and negative for CD 3, CD 5, CD 23, CD 10, BCL 6, and cyclin D1 immunostains. CD 21 highlighted expanded follicular dendritic cell MeshWorks. Lymphoid cells showed expression of IgM and were negative for IgD. Overall appearances were those of an extranodal marginal zone lymphoma of the gallbladder ().\nThe patient was referred promptly to haematology, where staging via contrast CT of the neck, chest, abdomen, and pelvis as well as bone marrow studies showed no metastatic disease. The laparoscopic cholecystectomy was considered curative with only routine surveillance required. |
A 70-year-old Sri Lankan Tamil male with a history of well-controlled type 2 diabetes mellitus and a goitre of 30 years presented with a painful enlargement of goitre on the left side for one month. He had progressively worsening difficulty in breathing with intermittent dysphagia for solids. He did not have any symptoms of local infiltration and was clinically euthyroid. Examination revealed a hard mass arising from the left thyroid lobe measuring 8 cm × 7 cm in size with gross tracheal deviation to the right side. In addition, there were two mobile lumps anterior to the mass in the subcutaneous tissue plane (). There was no retrosternal or retroclavicular extension on the left side. The right thyroid lobe was moderately enlarged and had multiple palpable nodules. There was no cervical lymphadenopathy. Ultrasound scan showed a large calcified left thyroid nodule and few superficial nodules. The outer surfaces of the nodules were delineated by an echogenic line suggestive of surface calcification. The internal echotexture of the nodules was not clearly appreciated due to artefacts from the surface calcifications. Right thyroid lobe showed only benign characteristics. Neck X-ray radiography showed a calcified left lobe with significant tracheal deviation to the opposite side (Figures and ). Thyroid stimulating hormone (TSH) and free thyroxine (T4) levels were within normal limits. Ultrasound-guided fine needle aspiration cytology (FNAC) showed scattered cyst macrophages, lymphocytes, and multinucleated giant cells in an eosinophilic background with scanty colloid. The features were compatible with a benign cyst (Thy 2).\nThe patient underwent a total thyroidectomy. Two confluent nodules were noted in the subcutaneous tissue plane extending through the deep fascia between the strap muscles to the calcified left lobe nodule. The deep fascia and strap muscles were thinned out and were adhered to the calcified left lobe (). Division of strap muscles on the left side was required to mobilize and deliver the left lobe containing the calcified nodule.\nMacroscopic assessment of the specimen consisted of the thyroid gland with the right lobe measuring 45 × 25 × 20 mm, the isthmus measuring 65 × 15 × 4 mm, and the enlarged left lobe measuring 80 × 75 × 55 mm. The outer surface of the gland was smooth. There were two confluent nodules over the anterior surface of the left lobe measuring 12 × 8 × 8 mm and 10 × 8 × 6 mm with a smooth outer surface.\nHistology of the thyroid revealed an encapsulated left lobe lesion composed of a thick fibrous wall with foci of calcification. A dense inflammatory reaction comprising lymphocytes, foamy histiocytes, and scattered multinuclear giant cells was present within the capsule. The lumen was filled with amorphous, eosinophilic material with cholesterol clefts. A thin rim of compressed thyroid tissue was noted outside the fibrous wall. Sections from the confluent nodules revealed similar histopathological features and showed encapsulated lesion surrounded by a thin fibrous capsule. They were filled with numerous foreign body type giant cells and foamy histiocytes admixed with amorphous eosinophilic material and cholesterol clefts. No thyroid or lymphoid tissue was seen. The right lobe and isthmus showed features of a colloid storing goitre. There was no evidence of malignancy in the entire specimen. Overall, features of the main calcified nodule of the left lobe and the two smaller confluent nodules were compatible with a colloid cyst with secondary changes including calcification and chronic inflammation. The patient had an uneventful postoperative recovery with the alleviation of the obstructive symptoms. He was discharged on the first postoperative day on thyroxine 100 mg daily and remained healthy without any obstructive symptoms during a three-month routine outpatient clinic review. |
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. |
The patient is a 79-year-old male with a past medical history of hypertension who presented to the emergency department with an ongoing history of weakness, fatigue malaise, and right upper quadrant abdominal pain. Labs showed transaminitis as well as elevated bilirubin concerning biliary obstruction. The patient was also noted to have gram-negative rod bacteremia. Computerized Tomography (CT) scan of the abdomen pelvis revealed significant intra and extrahepatic ductal dilation and intra and extrahepatic pneumobilia (). He underwent an ERCP and found to have thick sludge and stone debris from the ampullary orifice. Due to a concern for a possible filling defect in the distal common bile duct versus possible stricture, distal common bile duct brushings were performed in addition to biopsies and stenting with a 10 French 5 cm biliary stent. Pathology from the brushing and biopsies were negative for dysplasia or malignancy.\nDuring his hospitalization, the patient was found to have elevated troponins and electrocardiogram (EKG) changes consistent with NSTEMI. He underwent a pharmacological stress test followed by coronary angiography. He was found to have chronic occlusion of his Right Coronary Artery (RCA). Given these findings and acute coronary events, surgical intervention for cholecystectomy was delayed. The patient was brought back for robotic cholecystectomy after subsequent follow-up and clearance with his cardiologist and surgery clinic. Intraoperative findings revealed dense adhesions to the gallbladder involving the omentum and colon. A dense adhesion was present between the gallbladder and the transverse colon, and a provisional diagnosis of cholecystocolonic fistula was made on further dissection. The case was continued robotically, and the diagnosis of cholecystocolonic fistula was confirmed with the finding of a fistula between the fundus of the gallbladder and the transverse colon (). The fistula was divided. The gallbladder dissected in dome down method. The cystic artery and ducts identified and ligated, and the gallbladder was removed. The colon fistula site was 5 mm in size and was primarily repaired with two layers using a V-lock suture. |
A 30-year-old male reported to dental O.P. with the complaint of asymmetric appearance of the face. The swelling had been present from childhood and had become evident after puberty. Patient had no history of significant medical problems, trauma or family history of any hereditary disease.\nClinical examination revealed a diffuse enlargement of the lower one-third of the right side of the face. The enlargement was also seen to involve the lower border of the right mandible []. Intra oral examination revealed a swelling involving both the buccal and lingual aspect of the right mandible. The enlargement was more prominent on the buccal side, extending from the distal aspect of 45 to the distal aspect of 47 obliterating the vestibule. On palpation, the enlargement was bony hard in consistency. No sign of inflammation of the overlying mucosa was seen. Intra oral examination revealed an impacted 38 and missing 48 []. Furthermore, observed was that the lesion had not caused any malocclusion [].\nOrthopantamogram (OPG) revealed an increase in vertical height of the body of the right mandible of normal bone density. The ramus and condyle of the affected side were normal. An OPG taken at the age of 25 years (5 years back) and the current OPG showed the lesion was stable [].\nComputed tomography (CT) axial image revealed a solitary well-defined homogenous mass seen on the right body of the mandible measuring around 2 cm × 3 cm with uniform radiopacity. Bony enlargement was seen on both buccal and lingual side, buccal aspect being more prominent than the contralateral side. The bony enlargement can be well-appreciated in three dimensional (3D) CT. Furthermore observed in the radiographs, the enlargement was restricted to the body and did not extend to the condyle, which later aided in the diagnosis [].\nThe histopathology showed compact bone and numerous, small marrow spaces. The compact bone exhibited reversal and resting lines with osteoblastic rimming. Osteocytes could also be seen entrapped within the bone [].\nBased on the clinical, radiographic and histopathologic findings the diagnosis of hyperplasia of the right mandible was given. |
A 50-year-old female patient, who broke her knee joint while skiing. When she arrived at the emergency room, she experienced severe pain in the right knee, which was swollen and had functional limitation. Lateral radiograph and CT better revealed comminuted fracture of the distal posterolateral femoral condyle and rotational dislocation of the knee joint (Fig. ). Physical examination showed the pulse of dorsalis pedis arteria and posterior tibial artery could be detected, with no abnormal sensation over the affected limb. The dorsal and plantar flexion function of the ankle joint was normal. In order to avoid the damage of peripheral vessels and nerves caused by dislocation of the knee joint, we first applied manual reduction on the dislocated knee joint (Fig. ). Furthermore, MRI results clearly reported a complete rupture of bilateral collateral ligaments, anteroposterior cruciate ligaments and avulsion of lateral meniscus (Fig. ). We did not perform the Lachman tests and Bohler sign due to the drastic pain in the right knee. In order to prevent arthrofibrosis of knee joint caused by hematoma in the future, the patient underwent knee joint puncture under ultrasound guidance and had 100 ml of bloody fluid drained. Then, we used elastic bandages to compress the affected knee joint in order to prevent the formation of hematoma. After five days, the swelling subsided and we were able to operate. Initially, the patient was placed in the floating position with the affected limb elevated. Preoperative antibiotics and general anesthetic were administered. Then a posterolateral approach was adopted, we went through the interval space between the biceps and the common peroneal nerve, the popliteus and the lateral head of the gastrocnemius were partial dissected with caution. A horizontal capsulotomy is performed to expose the posterior femoral condyle and allow P-A screw fixation perpendicular to the fracture line. Several kirschner wires were used to temporarily immobilize the fragment fracture after it was reduced by the pointed reduction clamp, then took two 4.5 mm headless compression screws with full thread and placed them perpendicular to fracture line from posterior- anterior orientation. In addition, a locking plate was anatomically contoured and placed it behind the lateral condyle (Fig. ). The anti-slip plate can better resist shear force and provide angular stability, and also prevent the vertical gliding of the fragment. During the operation, we found the lateral meniscus wedged inside the tibiofemoral articular surface, and the lateral collateral ligament was ruptured at the insertion of the femur. Then we released the injured meniscus and immobilized it to the lateral capsule, the anchor suture was used to reconstruct the insertion of the LCL. Thereafter, the patient was placed in the supine position and we took the direct medial approach through the intermuscular plane between the gracilis and semimembranosus. We discovered a complete rapture of the medial collateral ligament (Fig. ) and anchor sutures were used to reestablish both ends of the breakage. After repairing the bilateral collateral ligaments, we checked the stability of the knee joint during intraoperative surgery, and the bohler sign was negative. However, the lachman test was positive. We decided to repair the cruciate ligaments during the second stage of surgery after fracture healing. Rehabilitation training started immediately after surgery and continued for four months. The patient achieved 0–90° range of function of knee after active rehabilitative exercise two weeks after operation. Thereafter, 0–130° range of function was achieved after four months, and the fracture line disappeared on the radiograph results. Moreover, the patient was walking with no limitation and was able to move without using walking aids (Fig. ), the Knee Society Scores (KSS) of the patient was reached 80. After six months, we eventually removed the internal fixations and reconstructed the cruciate ligaments under the arthroscopy. |
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. |
A 73-year-old Chinese man was found a cervical mass for 1 month. He had a history of coronary heart disease for 2 years, but no relevant personal or family history of malignancy. Physical examination showed bilateral neck asymmetry, the trachea was deflected to the left, the carotid pulse was normal, approximately 6 × 5 cm solid masses were felt in the right lobe of the thyroid gland. The tumor mass border was unclear with smooth surface, and the tumor moved up and down with swallowing. The left lobe of the thyroid gland had no palpable mass and the neck had no palpable swollen lymph nodes. Accessory examination of neck color Doppler ultrasound at our hospital showed increase in size of the right lobe of the thyroid gland, which had abnormal shape. The upper right pole of the thyroid gland had an approximately 5.6 × 6.0 × 4.2 cm sized mass, with unclear margin, and multiple cystic nodules in the thyroid. The CT of thyroid showed increase in size of the right lobe of the thyroid gland, and an approximately 5.6 × 6.0 × 4.2 cm sized mass, the trachea was compressed and deflected to the left, the thyroid cartilage was compressed, deformed and reached the right subglottic region. The right thyroid lump had multiple calcifications, indicative of a tumor (Fig. ). Electronic laryngoscope examination showed ventricular bands thickening, the right ventricular bands compartment showed a rice-like projection, arytenoid region movement was poor (Fig. ). Thyroid function test was 5.07 mIU/L. The patient underwent subtotal thyroidectomy and excisional biopsy of neck mass under general anesthesia. Intraoperative findings indicated a hard mass in the thyroid gland area, the lateral border and the lower bound were closely related to the surrounding soft tissues, but there was an extremely close relationship between the medial border, the thyroid cartilage, and cricoid cartilage, with no gap between them. An ENT doctor was invited for intraoperative consultation, who suggested that some of the tumors should be removed and frozen. The rapid pathology of the tumor (thyroid right lateral lobe) indicated chondroma. The ENT doctor suggested laryngeal chondroma resection and tracheotomy under general anesthesia. Intraoperative findings indicated that the right lower half of the thyroid cartilage and the right half of the cricoid cartilage were chondroma, and complete resection of the tumor was performed. Postoperative pathology examination showed (right lobe of thyroid gland and larynx) chondroma (Fig. ). Given the advanced age of the patient, long surgical duration and poor cardiorespiratory function, the patient suffered sudden cardiac death after the operation. |
A 28-year-old G3P2 patient of Native American origin presented to her obstetrician at 7 months pregnant with several months of left breast swelling and redness. At the recommendation of her obstetrician, she underwent diagnostic mammogram and ultrasound showing an ill-defined hypoechoic mass-like area in the left breast 10:00 position, 4 cm from the nipple. Core needle biopsy demonstrated granulomatous mastitis. She also had developed erythema nodosum on her bilateral lower extremities during pregnancy. Tuberculosis was ruled out. Evaluation for autoimmune disease, including serology, was negative. Her obstetrician started a steroid taper at 30 mg per day for a 6 day course, decreasing by 5 mg per day. The patient experienced improvement in pain and swelling during this time. This taper concluded 3 weeks prior to delivery; no further steroids were prescribed in order prevent hematologic or infectious complications at birth.\nThe patient began breastfeeding after delivery and continued to breastfeed from both breasts. She was not able to utilize an electric pump to express milk from her left breast due to discomfort and minimal milk extraction. She did report that the baby latched comfortably with audible swallows from the left breast, but she felt there was less milk production than from the right breast. The patient also felt she produced less milk in comparison to previously breastfeeding her other two children for 1 year without requiring infant formula. Beginning at 2 weeks postpartum, at the recommendation of the pediatrician, the patient initiated infant formula to maintain appropriate weight gain in the current infant. The infant had regained birthweight at two and a half weeks post- partum. Due to her left breast pain and swelling, the patient also restarted prednisone at 20 mg by mouth daily at 2 weeks postpartum.\nShe presented at 4 weeks postpartum to the breast surgeon for evaluation of worsening redness and pain in the left breast despite being compliant with prednisone. She noticed increased difficulty with her infant’s latch on the affected breast due to pain, as well as decreased swallows that she felt corresponded to decreased breastmilk volume. On exam, a large mass-like area with erythema and induration in the left breast was appreciated. This extended from the 9:00 to 4:00 position in the periareolar region, measuring approximately 8.0 × 8.0 × 9.0 cm total size. There was no fistula present.\nThe patient elected to undergo tapered discontinuation of her oral steroid over the course of 1 week and injection of 40 mg/1 mL triamcinolone mixed with 3 mL 2% lidocaine into the affected areas of her left breast. Due to long-acting depot mechanism and high transfer of triamcinolone into breastmilk, the breast surgeon advised her to discontinue breastfeeding from the affected breast; triamcinolone was expected to remain in the breast for 3 weeks until the time of the next injection []. She initiated pumping on the unaffected right breast to stimulate increased production and continued to provide the infant with additional formula supplementation as needed. At the advice of her breast surgeon, she started galactagogues with brewer’s yeast and moringa three times daily. She used ibuprofen and acetaminophen as needed for pain, as well as warm compresses and ice. Her milk production on the left breast was low, and she did not require hand expression to relieve engorgement.\nOn follow up 3 weeks later, the patient had developed right nipple pain. This pain was considered related to increased engorgement in the right breast, as well as, the infant clamping in adjustment to increased flow of unilateral milk. The patient was instructed in lymphatic massage and utilized a laid-back breastfeeding position to reduce velocity of flow in the right breast [, ].\nHer left breast pain had improved, and the mass had decreased in size to 6.0 × 6.0 × 5.0 cm from 11:00–3:00. She had developed a new draining fistula in the 1:00 position. An additional 40 mg/1 mL triamcinolone mixed with 3 mL 2% lidocaine was injected into the affected areas of her left breast.\nAt 10 weeks postpartum (6 weeks after presentation to the breast surgeon), the patient indicated that she would like to attempt to resume breastfeeding from the affected left breast. On examination, the fistula was closed and there was a decreased mass-like area in the left breast to approximately 4.0 × 3.0 × 2.0 cm size. Therefore, no steroid injection was performed. The images showing the difference in volume between her right and left breasts at this time is demonstrated in Fig. . Comparison images demonstrating improvement in her left breast are illustrated in Fig. .\nThree weeks later, the patient presented with increased redness and pain in the previously affected left breast. The patient had attempted breastfeeding from the left breast, but had stopped due to pain and low milk production. A new fistula in the 1:00 position and developed with new erythema and fluctuance in the 7:00 position with an associated new 2.0 × 2.0 × 1.0 cm mass-like area. An injection of 40 mg/1 mL triamcinolone mixed with 3 mL 2% lidocaine was performed into the 1:00 and 7:00 positions of the left breast and she was advised to stop breastfeeding from the left breast after the injection.\nAt three-week follow-up, the patient had developed a new 9:00 position fistula, but there was decreased mass-like effect and erythema in the remainder of the breast. She elected to resume breastfeeding from the left breast and start and oral prednisone taper over 6 days, 30 mg of prednisone per day, tapering to 5 mg per day. She noticed gradual decrease in erythema and fluctuance and no new fistulae. She continued to breastfeed from both breasts until 7 months postpartum. At this point, she stopped breastfeeding due to gradual decrease in milk production over time. |
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 (). |
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 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 26-year-old male was descending stairs when he skipped two steps and jumped to the third. He lost his balance and fell forward, with a twist of his left knee. The patient was brought to the hospital within 30 minutes of the trauma, with severe knee pain and loss of range of motion. He denied any systemic illness or prior trauma to the knee. Upon physical examination, his left knee was in full extension, with tenderness over the lateral and medial aspects of the knee. The patella was palpable and visibly rotated vertically in the intercondylar region of the femur, with tenting of the skin. The articular surface was palpable facing laterally (). There was mild swelling and ecchymosis, and his distal neurovascular status was normal.\nThe radiograph showed vertical dislocation of the patella in the intercondylar groove, with the medial border facing into the groove ().\nClosed reduction without anesthesia was attempted by manipulating the patella and attempting to rotate and translate it superomedially at the same time, with the knee in full extension and the hip in flexion to relax the quadriceps. Since this maneuver is painful and the patient was apprehensive, he was transferred to the emergency surgical theater, where spinal anesthesia was given and another attempt was made at closed reduction using the push up and rotate method, which was successful. Post-reduction knee range of motion was full passively, and patellofemoral tracking was normal. Postoperative radiographs showed normal position of the patella without any osteochondral fracture fragments (). The knee was immobilized in a posterior plaster slab for three weeks, and static quadriceps exercises were started immediately. After three weeks, gradual range of motion was initiated in a hinged knee brace. After six weeks of reduction, the patient achieved pain-free full range of motion of the knee, with minimum discomfort. The patient was a hard laborer and returned to his activities. There were no signs of ligament laxity. At one year of follow-up, the patent was comfortable, with no patellar tenderness, no apprehension, and normal patellar tracking (). |
In June 2002, a 36-year-old woman presented to her primary health care doctor with a history of flushing, diarrhoea, night sweats, and a clinically detectable mass in her left medial supraclavicular fossa. Her past medical history consisted only of essential hypertension for which she did not require prescribed therapy. Her family history included a brother with a diagnosis of sarcoma and two other non-first-degree relatives with primary brain malignancies.\nFine needle aspiration confirmed the diagnosis of medullary thyroid cancer, and in July 2002, she underwent total thyroidectomy with left-sided modified radical neck dissection and central compartment clearance. At this point, concerns were raised regarding optimal cytoreduction as the appearances of the central compartment, level 4 and level 5 nodes, were that of extensive disease. In order to maximise local disease control, she received adjuvant radical radiotherapy delivering 60 Gy to the thyroid bed.\nTwo years after completion of treatment, in February 2004, follow-up repeat imaging reported a recurrent nodule at level 4 of her neck. Subsequent resection confirmed this to be recurrent medullary thyroid cancer with no evidence of distant spread at the time. She continued to be monitored at the oncology clinic and remained disease-free until four years later, in May 2008, when computer tomography (CT) imaging revealed new pulmonary parenchymal metastases. These were closely monitored for the next 2 years with repeat imaging and measurement of calcitonin levels. In May 2010, it was decided that the patient should embark on systemic anticancer treatment.\nShe was offered participation in a phase 2 clinical trial with the agent lenvatinib (E7080) and she commenced treatment with 24 mg once daily in May 2010. One week into therapy, it was noted that she was marginally hypertensive with a blood pressure of 140/100 mmHg. No proteinuria was identified at this point, but she was commenced on 5 mg of amlodipine to manage hypertension. Monitoring of blood pressure and urinalysis continued as per study protocol.\nAfter two completed cycles of lenvatinib, CT imaging reported a reduction in size of all lesions. Further tumour assessment after 4 months confirmed a partial response to treatment with a 50% reduction of the sum of the long diameters of target lesions. She was experiencing various grade 1 toxicities throughout this time but was keen to maintain treatment given the good response. Due to the multiple low-grade toxicities, the dose of lenvatinib was initially reduced to 20 mg and thereafter to 14 mg.\nIn December 2011, 19 months after starting lenvatinib, she developed mild ankle oedema. Urinalysis carried out at the time identified proteinuria. A subsequent 24-hour urine collection identified 3.1 g/litre of proteinuria, equating to a urinary protein creatinine ratio (UPCR) of 625. The patient had not started any other medications and the incidence of proteinuria was felt to be lenvatinib related. Treatment with lenvatinib was ceased; however, due to concerns regarding possible intrinsic renal disease, she underwent screening for glomerulonephritis which was negative.\nA subsequent renal biopsy showed focal segmental glomerulosclerosis (FSGS) in two of twelve viable glomeruli, with tuft-capsule adhesion, hyalinosis, segmental intracapillary hypercellularity, and segmental splitting of capillary walls, predominantly in regions of segmental sclerosis. There was mild tubular atrophy, interstitial fibrosis, mild/moderate arterial intimal fibroelastic thickening, and mild arteriolosclerosis. Immunofluorescence showed no staining in glomeruli. Electron microscopy showed mild patchy reduplication of the basement membrane and effacement of only 20% of podocyte foot processes. There were no widespread electron dense deposits and no endothelial cell tubule-reticular inclusions. The endothelial cells showed no evidence of activation or damage. The appearances were consistent with a diagnosis of focal segmental glomerulosclerosis (FSGS). The lack of widespread podocyte foot process effacement suggests a secondary form of FSGS, which in the context of anti-VEGF treatment, could be mediated by microangiopathy. Whilst there was no histological evidence of acute thrombotic microangiopathy, it is possible that some of the pathological changes seen (splitting of glomerular capillary walls and mild arteriosclerosis) could be related to chronic low-grade endothelial cell damage. Based on histology, it is not possible to be certain whether the FSGS was caused by direct podocyte injury or whether it was related to endothelial cell injury. Histological slides are illustrated below in Figures , , and .\nThroughout this time, excretory function remained stable. Treatment with an ACE-inhibitor (ACEi) was introduced but due to poor tolerance and the quick improvement of the proteinuria after cessation of lenvatinib, the ACEi was stopped and patient's blood pressure was monitored closely.\nWithdrawal of lenvatinib had a marked effect on the levels of proteinuria, as illustrated in .\nThe patient continued follow-up at the renal clinic on a regular basis until July 2013, when she was discharged with no evidence of proteinuria, normotensive and with normal excretory renal function.\nAfter her discharge from the renal clinic and between 2013 and 2017, the patient was treated with vandetanib, nintedanib, and cabozantinib with no evidence of recurrent renal disease.\nE7080, also known as lenvatinib, is a potent inhibitor of the receptor protein kinases VEGFR-2 and VEGFR-3 but also displays inhibitory binding properties against VGFR-1, FGFR-1, and PDGFRα/β, albeit at significantly higher IC50 (half maximal inhibitory concentration, IC50). Its ability to restrain angiogenesis was shown on human umbilical vein endothelial cells (HUVEC) where E7080 inhibited VEGFR-2 phosphorylation and thereby capillary tube formation []. Apart from angiogenesis, E7080 decreased lymphangiogenesis in both the primary tumour of human breast adenocarcinoma cells in xenografts as well as in metastatic nodules in the lymph nodes of nude mice bearing these tumours []. Glen et al. showed in preclinical experiments that abrogation of FGFR and PDGFR signalling by E7080 inhibited invasion and migration of human melanoma cells lines (DX3) and human osteosarcoma epithelial cells (U2OS) []. Its potency against FGFR-1 differentiates E7080 from other currently approved tyrosine kinase inhibitors with antiangiogenesis properties [, ].\nThe preclinical data above were confirmed in several early phase human trials with E7080 in 2011 and 2012 in US, Europe, and Japan. Whilst establishing pharmacokinetic and pharmacodynamic properties of the drug, safety and preliminary efficacy was also well described. Lenvatinib was well tolerated at doses from 10 mg BID to 25 mg OD [–] and was associated with a reduction in disease activity biomarkers [], partial response, and stable disease according to response evaluation criteria in solid tumours []. These findings were further established in phase 2 trials and notably responses were demonstrated in thyroid cancer [–].\nApproval in thyroid cancer was granted in light of significant improvement in progression-free survival (PFS) compared with placebo in patients with radioiodine-refractory differentiated thyroid cancer in a phase 3 study (SELECT study) []. Lenvatinib improved median PFS over placebo by almost 15 months (HR 0.21; p < 0.01) and induced an objective response rate of 64.8%. The median survival results were diluted due to crossover of the patients from the placebo arm to the treatment arm; nevertheless, a subgroup analysis on patients stratified by age showed that older patients (>71 years old) had a survival advantage when treated with lenvatinib compared to placebo (HR, 0.53; p = 0.02), and the younger subgroup achieved a PFS of 20.2 months versus 3.7 m (p < 0.001) [].\nProteinuria and hypertension are the two most commonly reported side-effects of VEGF inhibitors and frequently the cause for therapy discontinuation. Proteinuria is used as a surrogate marker for glomerular damage and hypertension often accompanies and aggravates this.\nThe pathophysiology of proteinuria and glomerular damage in anti-VEGF therapy remains complex and far from well understood. Biopsy-proven cases of glomerular disease in anti-VEGF therapy are few; however, most have demonstrated changes in keeping with glomerular thrombotic microangiopathy (TMA) histology, with predominant endotheliosis and membranoproliferative changes [, ]. Other histological changes documented include cryoglobulinaemic glomerulonephritis, acute interstitial nephritis, collapsing and crescentic glomerulonephropathies, and FSGS plus TMA [–].\nIt has been theorized that hypertension is caused by decreased vascular production of nitrous oxide induced by inhibiting VEGF. This leads to renal haemodynamic compromise and subsequent proteinuria (much akin to exercise-related proteinuria) []. However, a mouse model study showed that glomerular injury preceded hypertension [] and many cases document glomerular injury in the absence of hypertension [], indicating that it cannot be the only trigger for proteinuria in anti-VEGF treated patients.\nInhibition of VEGF in podocytes (by injection of anti-VEGF antibodies or VEGF gene deletion) results in loss of endothelial fenestrations in glomerular capillaries, proliferation of glomerular endothelial cells, loss of podocytes, and proteinuria in mice [, ]. VEGF appears to be a crucial endothelial survival factor and its inhibition often manifests as TMA, a histology strikingly similar to that of severe preeclampsia—as placenta overproduces a soluble VEGF receptor (fms-like tyrosine kinase 1) that acts as a VEGF antagonist.\nIzzedine et al.'s 8-year follow-up study results from 2014 shed great light in anti-VEGF-related renal injury. It showed that in 100 patients who developed renal disease whilst on anti-VEGF treatment, the main histology associated with TKIs was minimal change disease and/or collapsing-like focal segmental glomerulosclerosis (MCN/cFSGS), a FSGC variant which is considered a separate entity to FSGS. In the same analysis, TMA histology was most frequently associated with VEGF-ligand targeted therapy (such as bevacizumab and aflibercept) suggesting two, possibly distinct pathophysiologies [, ] between renal damage caused by targeting the VEGF ligand as opposed to targeting the VEGFR tyrosine kinase domain. This could potentially be explained by considering the associations and signal transduction pathways between podocytes, endothelial cells, and VEGF. Podocytes produce vascular endothelial growth factor (VEGF), whereas VEGF receptor tyrosine kinases (RTKs) are expressed by both podocytes and glomerular endothelial cells.\nOur case demonstrates a secondary form of FSGS pathology which cannot confidently be attributed to TMA but could potentially represent the end result of chronic low-grade endothelial cell damage. The moderate histological findings were in keeping with a less-severe clinical course of the FSGS, with fast resolution of proteinuria and hypertension. More significantly, rechallenging the patient with additional three agents blocking the VEGF axis did not result in recurrence of the renal damage. |
A 51-year-old female with a history of stage 1 hypertension was admitted to the hospital post cardiac arrest. She had a significant family history of premature coronary artery disease. Her father had a coronary artery disease diagnosed in his 40’s, her mother had a pacemaker inserted, and she had two first degree relatives diagnosed with an early cardiac disease. She is a nonsmoker, nonalcoholic drinker and denied recreational drug use. She was in her usual state of health and functionally active until her husband noticed her moaning and eventually unresponsive in the middle of the night. Prior to this, the patient did not complain of any chest pain, dyspnea, dizziness, lightheadedness or any other constitutional symptoms. Her husband started cardiopulmonary resuscitation and was taken over by the emergency medical staff (EMS). She was intubated and defibrillated five times by EMS for ventricular fibrillation then was given a bolus of amiodarone. She eventually had a return of spontaneous circulation and was transported to the hospital in which she was noted to have decorticate posturing with no purposeful movements. Electrocardiogram (ECG) during this time showed sinus rhythm (Figure ). She was admitted to the coronary care unit and was placed on targeted temperature management and was maintained on amiodarone drip. Transthoracic echocardiogram showed no valvular abnormalities, normal left atrium and left ventricular cavity size but with borderline concentric left ventricular hypertrophy with an ejection fraction of 56% and note of subtle regional wall motion abnormalities. About 12 hours after initiating the targeted temperature management, the patient was in severe bradycardia in the mid 30’s and a decision was made to hold the amiodarone at that point. The patient completed the targeted temperature management protocol and eventually had a full neurologic recovery thereafter.\nShe was extubated and subsequently transferred to the floor. She was scheduled for cardiac catheterization; however, she had witnessed ventricular fibrillation arrest on the floor (Figure ). Advanced cardiopulmonary resuscitation was initiated and she was revived immediately after defibrillation. A total of three minutes of resuscitation was performed and she was following commands afterwards. She was also given an amiodarone bolus and transferred back to coronary care unit. ECG did not show any ST elevations at this time. Subsequently, she had 23 more episodes of ventricular fibrillation arrest (Figure ) over a six-hour period which were intervened by timely defibrillation and administration of antiarrhythmic medications and inotropic agents. The antiarrhythmic medications administered were amiodarone and lidocaine boluses and drips. Intravenous magnesium was also given during the resuscitation course. Emergent cardiac catheterization showed minimal coronary artery disease. A transvenous pacemaker wire was placed due to bradycardia during a code in the catheterization laboratory, although the bradycardia did not initiate the arrest. An intra-aortic balloon pump was placed. Subsequently the balloon pump and temporary pacemaker wire were removed after she eventually became more hemodynamically stable. She once again had a full neurologic recovery and underwent an uneventful implantation of a dual-chamber implantable cardiac defibrillator (ICD). She was discharged from the hospital on amiodarone therapy and was closely followed up in the cardiology outpatient clinic. Cardiac magnetic resonance imaging was done which showed mild biventricular enlargement but with normal regional systolic function, no late gadolinium enhancement consistent with the absence of myocardial inflammation, infiltration or infarction and with no imaging features of ARVC. She eventually had a targeted genetic testing for idiopathic ventricular fibrillation and was found to have a mutation in the desmoglein-2 (DSG2) gene (c.338T > C, pVal1113Ala), which is a gene typically involved in ARVC.\nShe had been readmitted several times to the hospital due to palpitations, dizziness, lightheadedness, and defibrillator shocks. Her defibrillator had been interrogated as well as her antiarrhythmic medication had been adjusted which improved her symptoms and reduced defibrillator discharge. Because of intermittent episodes of defibrillator firing due to ventricular fibrillation despite antiarrhythmic medications and intracardiac device, a ventricular fibrillation radiofrequency catheter ablation was performed successfully. Thereafter, she had no repeated episodes of palpitations, dizziness, lightheadedness, and defibrillator shocks. |
Patient I.M.S. (female, 50 years old) checked into ILAPEO (Latin American Institute of Research and Education in Dentistry) to undergo oral rehabilitation treatment. The patient presented with a good state of general health with partial edentulism of the upper and lower jaw () and with removable partial prostheses. In the upper jaw, she had a provisional partial prosthesis and, in the lower jaw, a class III removable partial denture was seated on the third molars in an unfavorable position by distal retainers. The patient's main complaint was the lack of stability, retention of the upper removable partial denture, the positioning of the lower third molars, the sensitivity of element 34 due to little bone support, and the difficulty of using the inferior prosthesis, which frequently injured the adjacent soft tissues. After clinical and radiographic analysis by panoramic radiography (), poor bone availability in the maxilla and posterior mandible was observed and additionally a computed tomography was requested to plan the case in greater detail (). Due to the extreme maxillary atrophy in the right side (including a radiographic image suggesting oral-antral communication), the indication for reconstructive procedures did not have a favorable prognosis as it can be also observed in the 3D reconstruction image (). For this case, an anchoring technique combining conventional and zygomatic implants could be an alternative solution for rehabilitation; extraction of elements 25 and 26 was suggested and was subsequently accepted by the patient. In the lower arch, the extraction of elements 38, 34, and 48 was also indicated together with a combination of screw retained fixed partial dentures (FPDs).\nPrior to the installation of the implants, a prosthetic preparation was performed and included the recording and assembly of the upper teeth performed on a trial basis without anterior vestibular coverage to diagnose the lip support that the FPD would provide. With the patient's approval, this diagnostic assemblage was duplicated, and a multifunctional guide was obtained.\nIn the atrophic maxilla, to install the zygomatic implants, an intravenous general anesthesia was induced along with preparation for surgery using a local anesthetic based on 2% lidocaine hydrochloride with adrenaline at 1 : 100,000. Two zygomatic implants (Neodent Implante Osseointegrável, Curitiba, PR, Brazil) of 45 mm were installed with rotation around 800 rpm and their respective prosthetic abutments of 3.0 mm were installed and tightened using a mechanical torque limiter with 20 N/cm. In addition, to guarantee the Roy Polygon creation orientating the force distribution in the maxilla, four cylindrical implants (Titamax Cone Morse, Neodent Implante Osteointegrável, Curitiba, PR, Brazil) were also installed with diameter of 3.75 mm and a length of 9 mm for elements 11 and 21, 11 mm for element 22, and 13 mm for element 13. The clamping obtained a torque greater than 45 N/cm, showing primary stability that was sufficient for the use of immediate load in the maxilla. Besides, the impression was performed using the multifunctional guide technique, which consists of joining the guide to the impression posts that were previously splinted using self-curing acrylic resin (Pattern Resin, GC America, IL, USA). Afterwards, the interocclusal record was refined by using three points of self-curing acrylic resin after confirming the vertical occlusal dimensions provided by the multifunctional guide record and the material injected between the transferors by a molding syringe. After polymerization of the materials, the screws of the impression posts were loosened, and the multifunctional guide, which had functioned as a molding tray and an interocclusal record, was renewed and taken to the prosthetic laboratory to manufacture a full arch fixed implant-supported prosthesis. Afterwards, the prosthesis was installed with immediate load protocol.\nWithin the lower posterior edentulous spaces on both sides, cylindrical implants were installed (Titamax CM, Neodent Implante Osteointegrável, Curitiba, PR, Brazil) combined with shorter and wider implants (Titamax WS, Neodent Implante Osseointegrável, Curitiba, PR, Brazil) in the distal ends because of mandibular bone atrophy in these areas. In this case, they were installed with the goal of increasing posterior occlusal stability, avoiding the use of distal cantilevers, and favoring a more uniform distribution of occlusal charges during chewing. These short implants with wide diameter platforms for the cortical bone have the advantage that their cervical diameters correspond to the diameter of the implant's body, favoring the uniform distribution of occlusal charges during chewing. Moreover, the high cutting power of their angled tips follows the exact same path as that of the pilot drill tip, providing a perfectly fitted installation at the site of the implant and avoiding empty spaces. Specifically, these implants were maintained around 2 mm under the future gingival margin towards the cement enamel junction.\nThe surgical sequences for perforation to install the conventional implants followed the conventional protocol of progressive diameters with rotation around 1500 rpm and 300 rpm for short implants under abundant irrigation, paying attention to the mesiodistal and buccolingual position of the implant. The conventional cylindrical implants installed had a diameter of 3.75 mm and a width ranging from 7 to 17 mm: 7 mm for elements 36 and 45, 15 mm for element 44, and 17 mm for element 35. Due to a limitation of bone height in the posterior extremity, short implants were installed with a length of 5 mm and a diameter of 5 mm for the region corresponding to element 36 and of 6 mm for the 37 and 47 regions ().\nPrimary stability was also obtained in the mandibular arch and the heights of the mini conical pillars were selected (WS CM, Neodent Implante Osseointegrável, Curitiba, PR, Brazil) and installed () using a torque of 32 N·cm. Afterwards, the impression of the lower arch was made using a perforating tray after installing the square impression posts for mini conical pillars that were splinted using self-curing acrylic resin.\nAfter obtaining the impression (Speedex Light Body, Coltene, Vigodent SA Indústria e Comércio, RJ, Brazil) two provisional partial lower fixed dentures in acrylic resin were constructed. During the installation of the fixed dentures, periapical radiographs were performed in both sides and an occlusal adjustment was performed to establish simultaneous bilateral occlusal contacts in relation to the centric occlusion and the anterior guide. Procedures for the definitive lower prostheses were performed at the same time in both sides after three months and consisted of the following: obtaining a new impression, performing a radiographic test and evaluation of the metallic infrastructures, and registering the interocclusal record. Subsequently, a ceramic trial was performed and partial fixed denture prostheses (FDPs) were installed using a torque of 10 N·cm in the prosthetic screws (Figures and ). The occlusal adjustment also aimed to establish a mutually protected occlusion. The final periapical radiographic preservation () and 2 years of follow-up can be observed in the panoramic radiographic (). |
A 25-year-old woman received five doses of fluconazole (150 mg) once a month for recurrent vaginal candidiasis. She was healthy but had a family history of atopic dermatitis. She noticed a red erythematous macule on the medial side of her right popliteal fossa after taking her second dose of fluconazole. With time, the macule faded, but a violet pigmentation developed. A month later, after taking another dose, she again developed two macules; one developed on exactly the same site and the other in the left popliteal fossa. Both patches were symmetrical and similar in appearance. Again, the patches faded and hyperpigmented areas developed. At this point, she was examined by a dermatologist and misdiagnosed with lichen planus and treated with topical clobetasol that led to the development of striae on both sites. Four hours after taking the fifth dose, the macules reappeared along with a new macule on her right upper lip. She suspected that the symptoms were caused by fluconazole and again visited a dermatologist. An oral challenge test with fluconazole (150 mg) was conducted 4 weeks later and showed similar signs three hours after intake. Local provocation was performed with 10% fluconazole in petrolatum on the left pigmented area and 10% fluconazole in ethanol on the right pigmented area. For comparison, the same compounds were tested on normal skin on the back. After 16 hours, two red patches developed on both sides of her legs and none on her back. A skin biopsy specimen from the left popliteal area revealed a lichenoid infiltrate, a basal cell vacuolization, dermal melanophages and a superficial perivascular lymphocytic infiltrate consistent with FDE. Despite having a family history of atopic dermatitis, she had no major or minor symptoms of atopic dermatitis and she denied having any other reaction to drugs or any allergy history. We recommended that she discontinue using fluconazole.\nTo determine the cause of the recurrent vaginitis, her complete medical history was taken. She had experienced mid cycle spotting while using low-dose oral contraceptives therefore she switched to using high-dose oral contraceptives 2 years before our study. She was also working in a fitness center during that time and she mentioned that she wore a wet swimsuit for long periods of time and used tight synthetic clothes all of which were risk factors for vaginal candidiasis []. At this time, we recommended that she use other contraceptive methods for example, condoms. Furthermore, we asked her to wear cotton underwear and informed her of preventive methods of candidiasis. We followed up with her after 6 months and she mentioned she had not experienced any other episode of candidiasis since then. |
A 45-year-old male presented to our hospital with diaphoresis, chills, and worsening right flank pain. He had a past medical history of cirrhosis due to alcoholism and portal hypertension with esophageal varices managed with prior transjugular intrahepatic portosystemic shunt (TIPS) procedure. He had a history of hepatic encephalopathy, hypertension, and type II diabetes. He had a recent admission to another institution for septic shock secondary to recurrent cholecystitis and had recently had an LC fifty-eight days prior. The patient was admitted to the outside hospital fifty-nine days prior to admission to our institution for subacute cholecystitis, which had initially required a cholecystostomy drain on prior admissions, and then ultimately an LC at that hospital. The gallbladder was not noted to be perforated, but the procedure was complicated by dropped gallstones, some of which were retrieved as stated in the operative report. On the current admission, the patient was hypotensive requiring vasopressors and was anemic and thrombocytopenic, requiring blood and platelet transfusions.\nA CT scan of the abdomen and pelvis with IV contrast was performed on admission demonstrating residual gallstones in the gallbladder fossa and/or cystic duct remnant and multiple small fluid collections and/or forming granulomatous masses surrounding additional retained/dropped gallstones in the surgical tracts and vicinity. A fistula with gallstones was also seen extending through the posterior and inferior wall of the second portion of the duodenum, to the anterior and superior aspect of a right renal cyst, which measured 3.4 cm x 3.0 cm and which contained gas in its superior aspect (Figures and ). A previous CT of the abdomen and pelvis performed with IV contrast sixty-five days prior to admission and seven days prior to the LC demonstrated a simple right renal cyst in the location of the now complex and infected cyst, measuring 2.8 cm x 2.5 cm ().\nDrainage of the infected renal cyst seen on the initial CT was considered; however, the cyst was relatively small and inaccessible. A repeat CT of the abdomen and pelvis with oral and IV contrast was performed four days after admission due to concern for abscess formation as the patient continued to have right flank pain. The CT demonstrated an unchanged superinfected cyst in the right kidney, with the fistula tract still visible, and heterogeneous retention of IV contrast in the right kidney, which was consistent with associated pyelonephritis (Figures and ).\nOn initial presentation, the patient was noted to have a history of Klebsiella pneumoniae and vancomycin-resistant enterococcus (VRE) in the cholecystectomy drain and was treated for the gallstone abscess and fistula accordingly with meropenem as there was no other source of infection. Blood cultures were later positive for K. pneumoniae and VRE. The patient was ultimately treated with linezolid and meropenem was deescalated to ceftriaxone.\nDiscussion between the patient's outside hepatologist, the abdominal radiologist, the interventional radiologist, and the gastroenterologists determined that the most likely etiology of the initial sepsis was an infected renal cyst secondary to an infected dropped gallstone. The patient was ultimately transferred to the outside hospital where he previously had his cholecystectomy for surgical follow-up. |
An 85-yr-old man was admitted to hospital with community-acquired pneumonia on December 21, 2007. He had been suffering from dyspnea due to right fibrothorax associated with pulmonary tuberculosis. His baseline pulmonary function test revealed FEV1/FVC of 89%, FEV1 of 25%, and FVC of 18% predicted values. He was treated with mechanical ventilation for three months and received long-term care at the intensive care unit (ICU) for four months. After removal of the ventilator, the patient was transferred to a general ward for further planning of rehabilitation treatment. However, the patient suffered new-onset atrial fibrillation, after which his oral intake decreased. His general condition deteriorated and he became dehydrated. Therefore, a central venous catheter was placed in the right internal jugular vein for more intensive treatment, including bedside fluid and nutritional therapy, without imaging guidance. Three days after the procedure, he slept all day. When awakened, he answered only briefly with slurred speech. He tended to gaze toward the right. No movement of the extremities on the left side was seen. At this point, he had no circulatory impairment. DWI was performed to evaluate neurological problems and revealed extensive hyperintensity with decreased apparent diffusion coefficient (ADC) value in the right cerebral hemisphere suggesting acute cerebral infarction. There were mottled areas of low signal intensity within the acute infarct area, which were considered to be air bubbles (). With a diagnosis of suspected paradoxical cerebral air embolism, brain and chest CT were performed simultaneously. An extensive area of low attenuation suggesting acute infarction in the right cerebral hemisphere as well as air bubbles mainly in the border zone areas of the right hemisphere were observed on brain CT (), and free air was detected in the right atrium on chest CT (). Transesophageal echocardiography (TEE) revealed microbubbles in the aorta without visible intracardiac shunt after injection of agitated saline ().\nThe patient was suggested to have paradoxical cerebral air embolism associated with central catheterization. We removed the catheter and considered hyperbaric oxygen therapy. However, the patient was too unstable for transfer to a facility with a hyperbaric chamber (); therefore, hyperbaric oxygen therapy could not be applied. The patient's condition deteriorated and he died on day six after central venous catheterization. |
In June 2002, a 36-year-old woman presented to her primary health care doctor with a history of flushing, diarrhoea, night sweats, and a clinically detectable mass in her left medial supraclavicular fossa. Her past medical history consisted only of essential hypertension for which she did not require prescribed therapy. Her family history included a brother with a diagnosis of sarcoma and two other non-first-degree relatives with primary brain malignancies.\nFine needle aspiration confirmed the diagnosis of medullary thyroid cancer, and in July 2002, she underwent total thyroidectomy with left-sided modified radical neck dissection and central compartment clearance. At this point, concerns were raised regarding optimal cytoreduction as the appearances of the central compartment, level 4 and level 5 nodes, were that of extensive disease. In order to maximise local disease control, she received adjuvant radical radiotherapy delivering 60 Gy to the thyroid bed.\nTwo years after completion of treatment, in February 2004, follow-up repeat imaging reported a recurrent nodule at level 4 of her neck. Subsequent resection confirmed this to be recurrent medullary thyroid cancer with no evidence of distant spread at the time. She continued to be monitored at the oncology clinic and remained disease-free until four years later, in May 2008, when computer tomography (CT) imaging revealed new pulmonary parenchymal metastases. These were closely monitored for the next 2 years with repeat imaging and measurement of calcitonin levels. In May 2010, it was decided that the patient should embark on systemic anticancer treatment.\nShe was offered participation in a phase 2 clinical trial with the agent lenvatinib (E7080) and she commenced treatment with 24 mg once daily in May 2010. One week into therapy, it was noted that she was marginally hypertensive with a blood pressure of 140/100 mmHg. No proteinuria was identified at this point, but she was commenced on 5 mg of amlodipine to manage hypertension. Monitoring of blood pressure and urinalysis continued as per study protocol.\nAfter two completed cycles of lenvatinib, CT imaging reported a reduction in size of all lesions. Further tumour assessment after 4 months confirmed a partial response to treatment with a 50% reduction of the sum of the long diameters of target lesions. She was experiencing various grade 1 toxicities throughout this time but was keen to maintain treatment given the good response. Due to the multiple low-grade toxicities, the dose of lenvatinib was initially reduced to 20 mg and thereafter to 14 mg.\nIn December 2011, 19 months after starting lenvatinib, she developed mild ankle oedema. Urinalysis carried out at the time identified proteinuria. A subsequent 24-hour urine collection identified 3.1 g/litre of proteinuria, equating to a urinary protein creatinine ratio (UPCR) of 625. The patient had not started any other medications and the incidence of proteinuria was felt to be lenvatinib related. Treatment with lenvatinib was ceased; however, due to concerns regarding possible intrinsic renal disease, she underwent screening for glomerulonephritis which was negative.\nA subsequent renal biopsy showed focal segmental glomerulosclerosis (FSGS) in two of twelve viable glomeruli, with tuft-capsule adhesion, hyalinosis, segmental intracapillary hypercellularity, and segmental splitting of capillary walls, predominantly in regions of segmental sclerosis. There was mild tubular atrophy, interstitial fibrosis, mild/moderate arterial intimal fibroelastic thickening, and mild arteriolosclerosis. Immunofluorescence showed no staining in glomeruli. Electron microscopy showed mild patchy reduplication of the basement membrane and effacement of only 20% of podocyte foot processes. There were no widespread electron dense deposits and no endothelial cell tubule-reticular inclusions. The endothelial cells showed no evidence of activation or damage. The appearances were consistent with a diagnosis of focal segmental glomerulosclerosis (FSGS). The lack of widespread podocyte foot process effacement suggests a secondary form of FSGS, which in the context of anti-VEGF treatment, could be mediated by microangiopathy. Whilst there was no histological evidence of acute thrombotic microangiopathy, it is possible that some of the pathological changes seen (splitting of glomerular capillary walls and mild arteriosclerosis) could be related to chronic low-grade endothelial cell damage. Based on histology, it is not possible to be certain whether the FSGS was caused by direct podocyte injury or whether it was related to endothelial cell injury. Histological slides are illustrated below in Figures , , and .\nThroughout this time, excretory function remained stable. Treatment with an ACE-inhibitor (ACEi) was introduced but due to poor tolerance and the quick improvement of the proteinuria after cessation of lenvatinib, the ACEi was stopped and patient's blood pressure was monitored closely.\nWithdrawal of lenvatinib had a marked effect on the levels of proteinuria, as illustrated in .\nThe patient continued follow-up at the renal clinic on a regular basis until July 2013, when she was discharged with no evidence of proteinuria, normotensive and with normal excretory renal function.\nAfter her discharge from the renal clinic and between 2013 and 2017, the patient was treated with vandetanib, nintedanib, and cabozantinib with no evidence of recurrent renal disease.\nE7080, also known as lenvatinib, is a potent inhibitor of the receptor protein kinases VEGFR-2 and VEGFR-3 but also displays inhibitory binding properties against VGFR-1, FGFR-1, and PDGFRα/β, albeit at significantly higher IC50 (half maximal inhibitory concentration, IC50). Its ability to restrain angiogenesis was shown on human umbilical vein endothelial cells (HUVEC) where E7080 inhibited VEGFR-2 phosphorylation and thereby capillary tube formation []. Apart from angiogenesis, E7080 decreased lymphangiogenesis in both the primary tumour of human breast adenocarcinoma cells in xenografts as well as in metastatic nodules in the lymph nodes of nude mice bearing these tumours []. Glen et al. showed in preclinical experiments that abrogation of FGFR and PDGFR signalling by E7080 inhibited invasion and migration of human melanoma cells lines (DX3) and human osteosarcoma epithelial cells (U2OS) []. Its potency against FGFR-1 differentiates E7080 from other currently approved tyrosine kinase inhibitors with antiangiogenesis properties [, ].\nThe preclinical data above were confirmed in several early phase human trials with E7080 in 2011 and 2012 in US, Europe, and Japan. Whilst establishing pharmacokinetic and pharmacodynamic properties of the drug, safety and preliminary efficacy was also well described. Lenvatinib was well tolerated at doses from 10 mg BID to 25 mg OD [–] and was associated with a reduction in disease activity biomarkers [], partial response, and stable disease according to response evaluation criteria in solid tumours []. These findings were further established in phase 2 trials and notably responses were demonstrated in thyroid cancer [–].\nApproval in thyroid cancer was granted in light of significant improvement in progression-free survival (PFS) compared with placebo in patients with radioiodine-refractory differentiated thyroid cancer in a phase 3 study (SELECT study) []. Lenvatinib improved median PFS over placebo by almost 15 months (HR 0.21; p < 0.01) and induced an objective response rate of 64.8%. The median survival results were diluted due to crossover of the patients from the placebo arm to the treatment arm; nevertheless, a subgroup analysis on patients stratified by age showed that older patients (>71 years old) had a survival advantage when treated with lenvatinib compared to placebo (HR, 0.53; p = 0.02), and the younger subgroup achieved a PFS of 20.2 months versus 3.7 m (p < 0.001) [].\nProteinuria and hypertension are the two most commonly reported side-effects of VEGF inhibitors and frequently the cause for therapy discontinuation. Proteinuria is used as a surrogate marker for glomerular damage and hypertension often accompanies and aggravates this.\nThe pathophysiology of proteinuria and glomerular damage in anti-VEGF therapy remains complex and far from well understood. Biopsy-proven cases of glomerular disease in anti-VEGF therapy are few; however, most have demonstrated changes in keeping with glomerular thrombotic microangiopathy (TMA) histology, with predominant endotheliosis and membranoproliferative changes [, ]. Other histological changes documented include cryoglobulinaemic glomerulonephritis, acute interstitial nephritis, collapsing and crescentic glomerulonephropathies, and FSGS plus TMA [–].\nIt has been theorized that hypertension is caused by decreased vascular production of nitrous oxide induced by inhibiting VEGF. This leads to renal haemodynamic compromise and subsequent proteinuria (much akin to exercise-related proteinuria) []. However, a mouse model study showed that glomerular injury preceded hypertension [] and many cases document glomerular injury in the absence of hypertension [], indicating that it cannot be the only trigger for proteinuria in anti-VEGF treated patients.\nInhibition of VEGF in podocytes (by injection of anti-VEGF antibodies or VEGF gene deletion) results in loss of endothelial fenestrations in glomerular capillaries, proliferation of glomerular endothelial cells, loss of podocytes, and proteinuria in mice [, ]. VEGF appears to be a crucial endothelial survival factor and its inhibition often manifests as TMA, a histology strikingly similar to that of severe preeclampsia—as placenta overproduces a soluble VEGF receptor (fms-like tyrosine kinase 1) that acts as a VEGF antagonist.\nIzzedine et al.'s 8-year follow-up study results from 2014 shed great light in anti-VEGF-related renal injury. It showed that in 100 patients who developed renal disease whilst on anti-VEGF treatment, the main histology associated with TKIs was minimal change disease and/or collapsing-like focal segmental glomerulosclerosis (MCN/cFSGS), a FSGC variant which is considered a separate entity to FSGS. In the same analysis, TMA histology was most frequently associated with VEGF-ligand targeted therapy (such as bevacizumab and aflibercept) suggesting two, possibly distinct pathophysiologies [, ] between renal damage caused by targeting the VEGF ligand as opposed to targeting the VEGFR tyrosine kinase domain. This could potentially be explained by considering the associations and signal transduction pathways between podocytes, endothelial cells, and VEGF. Podocytes produce vascular endothelial growth factor (VEGF), whereas VEGF receptor tyrosine kinases (RTKs) are expressed by both podocytes and glomerular endothelial cells.\nOur case demonstrates a secondary form of FSGS pathology which cannot confidently be attributed to TMA but could potentially represent the end result of chronic low-grade endothelial cell damage. The moderate histological findings were in keeping with a less-severe clinical course of the FSGS, with fast resolution of proteinuria and hypertension. More significantly, rechallenging the patient with additional three agents blocking the VEGF axis did not result in recurrence of the renal damage. |
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. |
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 ninety-year-old gentleman with underlying dementia and hypertension was presented with a sudden onset of central chest pain while watching television. Upon arrival at the emergency department, he was in severe pain and sweaty. Initial blood pressure was 90/50 mmHg with a heart rate of 110 beats per minute. ECG showed acute inferolateral myocardial infarction. On cardiovascular examination, there was no clinical sign of cardiac tamponade, and the auscultation of the lung was clear. Bedsides, echocardiography was performed showing pericardial effusion with a maximum diameter of 1.3 cm over the apex with no features of cardiac tamponade. The inferior lateral wall was hypokinesia, and the right ventricle wall was akinetic. Given the ECG and echocardiographic findings, and the patient was in severe pain, we decided to proceed with CT aortogram to rule out aortic dissection. The CT scan showed no evidence of aortic dissection; however, there was a presence of hemopericardium (). We decided to proceed with a primary percutaneous coronary angiogram ().\nThe patient was persistently hypotensive and did not respond to fluid resuscitation and inotropic support. We decided to abundant the angioplasty procedure and proceeded with emergency pericardial tapping (). 350 ml of blood was drained from the pericardium. The hypotension resolved after the procedure, and we were able to off the inotropic infusion. The pericardial drainage was in situ for three days and drained haemoserous fluid. After removal of the pericardial drainage, there was a reaccumulation of pericardial effusion. We referred the patient to the cardiothoracic surgeon, but the patient and family opted for conservative treatment and refused for any invasive or surgical intervention. The patient was not given heparin throughout the hospital stay and discharged home with a single antiplatelet. The proximal right coronary artery was stented three months later. He was last seen in our clinic in December 2019 and is currently doing well. The echocardiogram was repeated, and it illustrates mild left ventricular dysfunction with an ejection fraction of 47%. There was no significant residual pericardial effusion. The right ventricular function was normal. |
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 20-year-old Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.\nAt age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.\nSix months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.\nA clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.\nShe was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.\nMagnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partially obliterated the medullary cavity (Fig. ). The surface of the sclerotic bone was uneven. A Tc99-bone scan showed a pathological increase in uptake in most of the right femoral shaft (Fig. ).\nBiochemical bone markers were normal, including normal alkaline phosphatase.\nScreening for the GNAS1 activating mutation R201 was negative in peripheral blood; as was mutation screening of the SQSTM1 gene, which has been reported to be mutated in Paget’s disease of bone.\nA bone biopsy was performed and showed thickened bone springs with preserved lamellar structure and slightly accentuated cement lines. There was no fibrosis, inflammation, or increased alcian positivity, which would be suggestive of active osteomyelitis. There were no signs of malignancy or neoplasia.\nA gynecological examination prior to referral had found a mild degree of polycystic ovaries (PCO) with normal androgen status. There were no endocrinopathies.\nDuring the clinical investigation, four tentative diagnoses were raised: atypical fibrous dysplasia, Paget’s disease of bone, chronic non-infectious osteomyelitis, and melorheostosis. The young age of our patient, normal alkaline phosphatase, and sparing of the metaphysis of the affected bone made Paget’s disease of bone highly unlikely.\nThe cortical thickening is atypical for the diagnosis of fibrous dysplasia. The absence of café au lait spots, the normal age at menarche, the absence of other endocrine disorders, and the negative GNAS1 mutation examination weighed against a diagnosis of fibrous dysplasia. The long bones are a common location for chronic non-infectious osteomyelitis and this can present in childhood; however, the radiological appearance and bone histology did not provide support for this differential diagnosis. With special emphasis on the uneven surface of the affected bone on X-ray (Fig. ), the diagnosis of melorheostosis, which was fully compatible with the relatively unremarkable histology, was found to be the most plausible diagnosis. In addition, the normal bone chemistry is in keeping with melorheostosis [] although in polyostotic cases alkaline phosphatase can be increased [].\nThe timeline for intervention and clinical outcome is presented in Fig. . Initially, zoledronic acid 5 mg was administered intravenously three times with 10-month and 12-month intervals; our patient had pain relief after the first administration, but a poor effect of the second and third injection. Using an analog pain scale she reported average pain of 9 prior to treatment, 6 after treatment with zoledronic acid, and 4 from 2 to 10 months after initiation of treatment with denosumab. Looking at the usage of pain medication, it went from daily dosage before treatment to 23% of days after treatment with zoledronic acid, and to no orally administered analgesics for 8 months following treatment with denosumab.\nIn October 2015, denosumab was chosen as the second line of treatment based on the hypothesis that the pain was caused by increased bone turnover. A dose of 60 mg was injected subcutaneously with some remission of pain that lasted for 6 weeks. At the same time as the pain relapsed, there was an increase in alkaline phosphatase, PINP, CTx, and osteocalcin in blood tests. Biochemistry before and during treatment is listed in Table . Based on these findings it was decided to shorten the interval between administrations to further strengthen control of a hypermetabolic state. The second dose of 60 mg was given after 8 weeks and this interval has been kept up to the present.\nBiochemistry after treatment with both zoledronic acid and denosumab showed suppression of bone-type basic phosphatase, osteocalcin, collagen I, and procollagen I, with a relative increase in parathyroid hormone, and plasma ionized calcium within the normal range. The injections with denosumab were well tolerated with no adverse effects reported. During the whole treatment period, the injections were administered from our out-patient clinic without cancellations.\nAfter the first three doses given 8 weeks apart, there was pain remission for 8 months; in this period our patient did not take any orally administered analgesics. At the latest follow-up in February 2018, she complained of a slight increase in pain and occasional use of paracetamol and nonsteroidal anti-inflammatory drugs.\nThe treatment with denosumab was well tolerated with no side effects observed.\nA Tc99-bone scan and computed tomography (CT) scan were performed in February 2017 and in February 2018, 5 and 17 months after the first injection with denosumab; the pathologically increased activity and cortical thickening were stationary. |
A 68-year-old man was referred to our pain management center from the department of neurology with motor weakness of the left leg following painful herpetic rash on his left lower extremity. Ten days before presentation, a herpetic rash occurred in his left L4 dermatome and 2 days after the onset of vesicular rash his diagnosis of HZ was made by a neurologist. He was managed with famciclovir 250 mg three times daily, tramadol 150 mg once daily, and pregabalin 75 mg twice daily. Even with these medications, his pain was rated as 7 on the visual analogue score (VAS) from 0 (no pain) to 10 (worst pain imaginable). He refused to take opioids due to side effects associated with opioids such as nausea and vomiting. Nine days after the onset of the rash, he noticed progressive motor weakness of his left lower limb. An MRI scan of his brain and lumbar spine was performed to explore the causes of weakness in his left lower extremity by the neurologist. But in the MRI scan there were no abnormalities. The neurological examination showed that the muscle strength of his left knee extension was 3/5 using the Medical Research Council muscle strength grading system [].\nOne year earlier he had been diagnosed with hypertension. Two month previous, he had received a cardiac stent insertion due to myocardial infarction and he was taking warfarin 2 mg and aspirin 100 mg once a day for prevention of thrombosis. His international normalized ratio was 2.2. On physical examination, herpetic rash was localized to his left L4 dermatome (). He suffered from intermittent, spontaneous, sore and throbbing pain over the left L4 dermatome, which was provoked by brushing. PCB was done with 0.5% lidocaine 15 ml and triamcinolone 40 mg under fluoroscopic guidance at the L4 transverse level (). The pain disappeared 3 days after the PCB. In addition, 6 days after the PCB, the motor weakness of his knee extension greatly improved and 12 days after the PCB the motor weakness was completely resolved. He remained symptom free at a 3 month follow-up. |
A 31-year-old woman G4P3+1 presented with a history of continuous vaginal bleeding for six months duration post complete abortion. The patient was diagnosed as a case of incomplete abortion in another hospital, where she was given one dose of misoprostol and passed the tissue (the histopathology was not documented). The patient had a follow-up due to her persistent vaginal bleeding and was found to have a low hemoglobin level, for which she was given a blood transfusion. Ultrasound was done twice before presentation to our hospital. The first ultrasound showed a bulky uterus with an endometrial thickness of 18 mm, no intrauterine tissue, and normal adnexa. The second ultrasound showed a bulky uterus with an endometrial thickness of 15 mm, well defined cystic lesion measuring 5 mm inside the uterine cavity, which appears as a gestational sac of the retained product of conception.\nThe patient presented to our clinic six months later with continuous heavy vaginal bleeding with passage of clot. She denies any passage of tissue or abdominal pain. She had symptoms of anemia but no symptoms of infection. Her examination was unremarkable, apart from mild vaginal bleeding. Her pregnancy human chorionic gonadotropin (hCG) was negative. Endometrial biopsy was done to prove the presence of trophoblastic tissue. The endometrial biopsy showed benign weakly proliferative endometrium with focally embedded necrotic chorionic villi with no hyperplasia or dysplasia identified.\nUltrasound in our hospital showed an endometrial thickness of 0.4 cm. There was an endometrial polyp 1.5x2.0 cm with a large single feeding artery. Minimal free fluids in the pouch of Douglas were noted. Ultrasound images for this case were not available as they were not uploaded to our hospital system.\nThe patient underwent hysteroscopy resulted in a normal endometrial cavity, and in the right corner, there was irregular fungating firm necrotic chorionic villi, typical old white trophoblastic projection, which was resected, and the patient started to bleed. The bleeding was difficult to control by cauterization with a resectoscope. So, Foley’s catheter size 12F was inserted in the cavity, and 15mls of saline was used to inflate the balloon. Six hours later, the balloon was deflated and removed after confirming that there was no active bleeding. The patient was discharged on the next day in stable condition with no bleeding.\nTwo weeks later, the patient was seen in the outpatient clinic - there was no bleeding, and the histopathology finding was prominent necrotic retained products of conception (chorionic villi), background benign proliferative endometrium, no hyperplasia, and no dysplasia. |
This case is of a 55-year-old female who initially presented with a palpable left neck mass. The mass had been noted by the patient 8 years ago and had progressively grown in size. A computed tomography (CT) of the neck was obtained, which demonstrated a 3.5 × 2.3 × 4.6 cm lesion deep to the left sternocleidomastoid (SCM) muscle in addition to a smaller 1 × 1 × 1.8 cm left posterior neck-enhancing mass. A fine needle aspiration (FNA) had been performed 2 years prior at an outside hospital with pathology indicating a low-grade spindle cell proliferation. She was thus referred to our institution for further evaluation. At the time of initial presentation to our group, the patient had noted dysphagia, left ear ache and tinnitus, and neck pain localized to the two masses. A positron emission tomography (PET) CT was performed, which demonstrated increased fluoro-2-deoxy-\nd\n-glucose uptake in the high cervical mass and, to a lesser degree, in the mass located within the posterior triangle of the neck (\n). The outside tissue blocks were reviewed at our institution and felt to be consistent with a peripheral nerve sheath tumor compatible with schwannoma from both lesions. Because of the patient's ongoing symptoms and because malignancy could not be completely excluded based on the results of the prior FNA, the decision was made to proceed with surgical excision of both lesions. Prior to proceeding, a magnetic resonance neurogram was obtained (\n). Tractography demonstrated that the two lesions appeared to originate from the spinal accessory nerve and that apparent diffusion coefficient values were elevated in both masses, supporting the diagnosis of a less aggressive tumor (\n).\nThe patient was taken to the operating room for surgical resection. The patient was positioned with her head turned slightly to the right with the neck extended (\n). The smaller lesion was approached first through the posterior triangle of the neck. Stimulation mapping of the tumor was conducted. The tumor was found to be located on the distal spinal accessory (cranial nerve XI) nerve, with evidence of trapezius activation with nerve stimulation (\n). After identifying no overlying nerve fibers, the tumor was removed en bloc. A separate incision was made in the upper cervical region to approach the larger second mass located lateral and deep to the SCM muscle, which was reflected medially (\n). During dissection of the tumor away from the nerve, motor evoked potentials (MEPs) to the trapezius were lost. As the tumor was of significant size, view of the proximal aspect of the afferent nerve was initially obstructed. Distally, the tumor was mapped, and the fascicle of origin was identified, which appeared to activate the SCM. After significant debulking of the mass, the proximal fascicle of origin was identified but did not provide any muscle activation after stimulation. The tumor was therefore removed in its entirety. All parameters for brachial plexus monitoring remained stable.\nPathology for both lesions was consistent with schwannoma without malignant features. Next-generation sequencing analyzing the coding regions of 479 cancer genes as well as select introns of 47 genes using the UCSF 500 Cancer Gene Test revealed a small in-frame insertion at codon p.R177 of the Sox 10 gene. There were no identifiable alterations in NF1, NF2, LZTR1, SMARCB1, and TRAF7 genes. Despite the change in MEPs, the patient was noted to be full strength in all muscle groups in the left upper extremity including shoulder shrug and head turning immediately postoperatively. At follow-up, her neck pain and prior dysphagia had improved significantly. |
A 47-year-old male patient with palliated pulmonary atresia with ventricular septal defect (VSD) presented with progressive fatigue and hypoxaemia to our outpatient clinic. He was no more able to perform his daily activities, such as washing himself and his walking distance was limited to 25 m. His peripheral oxygen saturation was only 69% (haematocrit 71%). As to his history, a modified BT shunt was performed between the left subclavian artery and the left pulmonary artery at the age of 7 years. At the age of 27 years, a WC anastomosis was performed to increase blood flow through the pulmonary circuit, because the still patent BT shunt was not sufficient for pulmonary blood supply. Surgical correction was not a preferred option because of the technical difficulties.\nSince 1997, the patient did not need any further cardiac surgery or intervention and was able to carry out his daily routine activities until 3 months prior to hospital admission. In the preceding months, the patient received treatment for left basal pneumonia and pneumosepsis at another hospital. Presenting with atrial fibrillation and atrial flutter, the patient needed cardioversion twice to convert his heart rhythm to sinus rhythm. There was no history of dizziness or syncope at any time. In the presence of intermittent left thoracic pain, coronary angiography was performed to rule out any relevant coronary artery stenosis. Oxygen therapy was initiated 2 weeks prior to admission to our hospital, but did not significantly ameliorate the progressive desaturation.\nOn physical examination, distinctive cyanosis was notable (SpO2 69%). There were neither peripheral oedema nor heart murmurs or pulmonary crackles on auscultation present. Blood pressure was 140/100 mmHg, and heart rate was 90 b.p.m.\nOn admission, electrocardiogram showed a sinus rhythm and complete right bundle branch block. Echocardiography revealed the ventricular septal defect, occluded right ventricular outflow tract with hypertrophic right ventricle and dilation of both atria. Systolic function of the ventricles was preserved, and the aortic root was known to be ectatic. Computed tomography scans showed the occluded BT shunt and a reduced perfusion of the WC anastomosis (Figure ); besides that, many major aortopulmonary collateral arteries (MAPCAs) were detected.\nBecause of the limited pulmonary blood flow oxygen therapy did not elevate saturation. Therefore, possible therapeutic approaches such as an interventional re-opening of the BT shunt or the WC anastomosis as well as a new surgical aortopulmonary shunt or correction were discussed in our interdisciplinary Heart Team meeting. Surgery was ruled out due to the excessive risk. The WC anastomosis showed a small lumen and unfavourable angle for access and intervention. In this respect, the occluded BT shunt was addressed as an interventional target. Prior to intervention, we carried out a pulmonary function test. A restrictive lung function with a reduced forced vital capacity (FVC) of 2.75 L (= 51%) was documented. Lowest oxygen level of pO2 40.9 mmHg under room air and pO2 48 mmHg under 4 L oxygen were measured.\nFor re-opening the BT shunt, the left radial artery was punctured. The occluded BT shunt could be wired with a Radifocus®-wire with a flexible tapered tip and a Glide-Cath® (both Terumo). Then, we performed a rotational thrombectomy using a 6 Fr-Rotarex®-system (AB Medica, Duesseldorf, Germany). Afterwards, the shunt was dilated with a standard balloon. Due to significant recoil of both the proximal and the distal anastomosis, then two Genesis® Stents (6 × 25 and 7 × 25 mm) were deployed in the proximal and distal anastomoses of the shunt (Figure ).\nFinally, the shunt was patent with a rapid perfusion of the left lung. Immediately, the peripheral oxygen saturation increased from 69% to 82% under room air.\nThe day after, the patient noticed significant improvement of his physical abilities. Vascular access site showed no complications. The patient was discharged in a stable general condition.\nAt his 5-month and 1-year follow-up appointments in our outpatient clinic, the patient reported on an improved exercise tolerance. There was a reduction in peripheral cyanosis with improvement in oxygenation (79%) and haematocrit (66%).\nEchocardiography demonstrated patent BT shunt. Clopidogrel treatment was stopped 1 month after bare-metal stent implantation. Anticoagulant treatment with rivaroxaban was continued for thrombo-embolic prophylaxis due to atrial fibrillation. |
A 64-year-old male was referred to the Gunma University Hospital with complaints of a progressive oppressive feeling in the left thoracic region. His past medical history was unremarkable. At admission, general conditions were satisfactory, and a physical examination of the thorax was normal. Routine laboratory tests were within normal values, but a chest roentgenogram revealed an oval-shaped anterior mediastinal mass in the left hemithorax. An enhanced computed tomography (CT) scan of the chest revealed the presence of an ovoid mass about 9-cm at its greatest dimension in the left anterior mediastinal region. Its border, adjacent to the left lung parenchyma, was poorly demarcated. The mass showed a heterogeneous densitometric characteristic accompanied with areas of necrosis after contrast enhancement (Figure ). From the graphical specifications and laboratory studies, an invasive thymoma was strongly suggested, and we decided to perform a radical resection of the tumor.\nWritten informed consent concerning the operation was obtained from the patient before surgery, and the patient was admitted to the Gunma University Hospital for surgical resection of the tumor. The patient underwent tumor excision and thymectomy through sternotomy with continuous anterior thoracotomy of the third intercostal space. During the operation, the tumor, as seen on the CT scan, was 9-cm wide, elastic, and off-white in color. It was found to have infiltrated the upper lobe of the left lung. Based on this surgical finding, partial resection of the lung together with the tumor was performed with a sufficient surgical margin. On the basis of its morphologic and immunohistochemical features, the tumor was diagnosed as a mediastinal atypical meningioma. The patient had an uneventful recovery and was discharged on postoperative day 6. An ectopic pulmonary site of origin, such as the mediastinum in this case, should be accepted only after the possibility of spread or metastasis from primary intracranial or intraspinal origin has been excluded. One month after operation, the patient had an enhanced magnetic resonance imaging (MRI) of the head and spine, and no abnormal findings were observed, which eliminated the possibility of an intracranial or intraspinal origin. He has been monitored for 12 months as an outpatient without any symptoms of recurrence or metastasis.\nThe surgical specimens were routinely fixed with 10% formaldehyde and embedded in paraffin. Tissue sections (6-μm thick) were stained with hematoxylin and eosin (H-E), and periodic acid-Schiff (PAS) with and without diastase digestion. For immunohistochemical studies, tissue sections were incubated using the standard avidin-biotin peroxidase complex (ABC) method with the following antibodies: epithelial membrane antigen (EMA), vimentin, S-100, MIB-1, CD34, D2-40, αSMA, desmin, synaptophysin, and neurofilament. Macroscopically, the resected tumor measured 9-cm in its greatest dimension and adhered to a parenchyma of the left lung. The oval-shaped tumor had a smooth surface, and its cut surface was homogenously solid and yellow-white in color (Figure ).\nMicroscopically, the tumor was partially encapsulated and composed of bundles of spindle-shaped cells with elongated nuclei and syncytial nets of tumor cells with oval nuclei. A few tumor cells had an intracellular cytoplasmic inclusion. In some areas, many typical whorl formations for fibrous meningioma were observed (Figure ). There were several foci of small cells with a high nuclear/cytoplasmic ratio (Figure ). Spontaneous and zonal necroses were occasionally seen (Figure ). In addition, the tumor involved adjacent pulmonary parenchyma (Figure ). The mitotic index was four per 10 high-power fields (hpf) at the areas where the mitotic figures were most frequently observed, and the Ki-67/MIB-1 labeling index was approximately 7% in relatively higher positive-rate fields (Figure ). Immunohistochemical examinations showed positivity to EMA (Figure ) and vimentin, focal positivity to S-100, CD34, and D2-40, and negativity to αSMA and desmin. Some oval tumor cells containing large cell bodies were stained for synaptophysin and neurofilament. |
A 70-year-old Sri Lankan Tamil male with a history of well-controlled type 2 diabetes mellitus and a goitre of 30 years presented with a painful enlargement of goitre on the left side for one month. He had progressively worsening difficulty in breathing with intermittent dysphagia for solids. He did not have any symptoms of local infiltration and was clinically euthyroid. Examination revealed a hard mass arising from the left thyroid lobe measuring 8 cm × 7 cm in size with gross tracheal deviation to the right side. In addition, there were two mobile lumps anterior to the mass in the subcutaneous tissue plane (). There was no retrosternal or retroclavicular extension on the left side. The right thyroid lobe was moderately enlarged and had multiple palpable nodules. There was no cervical lymphadenopathy. Ultrasound scan showed a large calcified left thyroid nodule and few superficial nodules. The outer surfaces of the nodules were delineated by an echogenic line suggestive of surface calcification. The internal echotexture of the nodules was not clearly appreciated due to artefacts from the surface calcifications. Right thyroid lobe showed only benign characteristics. Neck X-ray radiography showed a calcified left lobe with significant tracheal deviation to the opposite side (Figures and ). Thyroid stimulating hormone (TSH) and free thyroxine (T4) levels were within normal limits. Ultrasound-guided fine needle aspiration cytology (FNAC) showed scattered cyst macrophages, lymphocytes, and multinucleated giant cells in an eosinophilic background with scanty colloid. The features were compatible with a benign cyst (Thy 2).\nThe patient underwent a total thyroidectomy. Two confluent nodules were noted in the subcutaneous tissue plane extending through the deep fascia between the strap muscles to the calcified left lobe nodule. The deep fascia and strap muscles were thinned out and were adhered to the calcified left lobe (). Division of strap muscles on the left side was required to mobilize and deliver the left lobe containing the calcified nodule.\nMacroscopic assessment of the specimen consisted of the thyroid gland with the right lobe measuring 45 × 25 × 20 mm, the isthmus measuring 65 × 15 × 4 mm, and the enlarged left lobe measuring 80 × 75 × 55 mm. The outer surface of the gland was smooth. There were two confluent nodules over the anterior surface of the left lobe measuring 12 × 8 × 8 mm and 10 × 8 × 6 mm with a smooth outer surface.\nHistology of the thyroid revealed an encapsulated left lobe lesion composed of a thick fibrous wall with foci of calcification. A dense inflammatory reaction comprising lymphocytes, foamy histiocytes, and scattered multinuclear giant cells was present within the capsule. The lumen was filled with amorphous, eosinophilic material with cholesterol clefts. A thin rim of compressed thyroid tissue was noted outside the fibrous wall. Sections from the confluent nodules revealed similar histopathological features and showed encapsulated lesion surrounded by a thin fibrous capsule. They were filled with numerous foreign body type giant cells and foamy histiocytes admixed with amorphous eosinophilic material and cholesterol clefts. No thyroid or lymphoid tissue was seen. The right lobe and isthmus showed features of a colloid storing goitre. There was no evidence of malignancy in the entire specimen. Overall, features of the main calcified nodule of the left lobe and the two smaller confluent nodules were compatible with a colloid cyst with secondary changes including calcification and chronic inflammation. The patient had an uneventful postoperative recovery with the alleviation of the obstructive symptoms. He was discharged on the first postoperative day on thyroxine 100 mg daily and remained healthy without any obstructive symptoms during a three-month routine outpatient clinic review. |
A previously fit and well 38-year-old man was presented to the emergency department with immediate extreme pain in the left arm after twisting it at home that day. Plain radiographs of the left upper limb showed a fracture of the left proximal humerus associated with a lytic lesion (Fig. ).\nAn urgent staging magnetic resonance imaging (MRI) of the left humerus demonstrated a fairly well-defined destructive lesion of proximal left humerus, which measured ~6 cm craniocaudally (Fig. ). Both the cortex and the marrow were diffusely infiltrated and there was a small extra-osseous tumour mass anteriorly. Computed tomography (CT) scan of thorax/abdomen/pelvis with contrast could not identify a clear primary source of malignancy but it showed an enlarged right lobe thyroid gland with retrosternal extension (Fig. ).\nThe thyroid lobe was investigated 6 years before where a multi-nodular goitre (MNG) with a dominant solitary nodule on the right thyroid lobe was discovered. Ultrasound did not show any suspicious characteristics. A fine needle aspiration cytology (FNAC) specimen of the solitary nodule was reported as a Thy2 with features consistent with a simple nodule. The investigations were arranged by the patient's general medical practitioner who reassured the patient without the input of secondary services.\nFollowing the finding of the CT scan, the patient was referred to the local ENT department, where ultrasound of the neck and core biopsy of the thyroid nodule was conducted. The image confirmed a MNG with largest nodule in the right lobe. And the core biopsy showed a follicular pattern with thyroid follicles of varying sizes set in a mixture of fibrous tissue.\nA CT guided biopsy of the left humerus after the initial presentation confirmed a metastatic thyroid cancer.\nThe patient underwent urgent excision of tumour and replacement of left proximal humerus. Histologically, the mass from the left proximal humerus demonstrated features consistent with metastatic thyroid carcinoma. Six weeks later, he underwent total thyroidectomy and neck dissection. A large thyroid lobe was found with no local invasion and four large Level VI lymph nodes were excised. The pathologic findings confirmed complete excision of a 70 mm widely invasive follicular carcinoma with evidence of vascular invasion and metastasis of three out of the four central neck nodes.\nAfter thyroidectomy, the patient was seen by clinical oncology and radioiodine therapy was administered. He continues to be followed up by the local orthopaedic and ENT teams. |
A 62 year old male patient presented to our hospital with a 9 year history of swelling in the neck. The swelling was situated in front of the neck in the thyroid region which gradually increased and 6 years later further swellings appeared in the left side of the neck. There were no other associated symptoms including those of hypo or hyperthyroidism. There was no difficulty in swallowing or breathing. Six months prior to presentation at our hospital, patient noticed a small ulceration in the skin over the tumor in the supra-sterna notch which did not heal (Figure ). A small quantity of discharge from this sinus has persisted since then.\nExamination revealed a swelling in the thyroid region, more prominent on the left side with multiple palpable nodes in the left neck. The skin surrounding the sinus was inflamed and thickened. Investigations revealed euthyroid status. There was neither infiltration of trachea nor retro-sternal extension on CT scan of the neck and upper chest. No contrast was used as it could interfere with post operative radio-iodine scans. There was no vocal cord palsy.\nWith a pre-operative diagnosis of papillary carcinoma of thyroid, patient underwent en-bloc total thyroidectomy including excision the sinus skin (2 cm margin) with strap muscles. In addition patient underwent a left modified radical neck dissection. It was possible to obtain primary closure of the skin incision. Post operative histopathology showed tall cell papillary carcinoma thyroid with infiltration of strap muscles and subcutaneous soft tissue mainly in the isthmus – left lobe junction. While the sinus showed malignancy, the skin was free of tumor (T4a, N1b, M0, Stage IVa). No metastases were detected on post operative radio-iodine scan. Patient underwent an ablative radioactive iodine scan post operatively and is on suppressive dose of thyroxine since then. In view of extensive extra-thyroidal spread, patient was administered 50 Gy of radiation over 25 fractions. Patient is on regular follow-up and is disease free for the last 2 years. |
A 73-year-old man was admitted to our emergency department with complaining of repeated syncope in two days. Prodromal symptoms of light headache and diaphoresis prior to the episodes were told. He regained consciousness spontaneously followed by brief conscious loss without mental impairment. The events occurred on his toilet in the fist episode. The second event developed on the following day when he was sitting and watching television. With similar warming symptoms as light headache and diaphoresis, the brief loss of consciousness was followed by full recovery. He was otherwise well, and had no chest pain, shortness of breath, or palpitation before the episodes. He also experienced a recent unproductive cough, but not concomitant with syncope. He had neither systemic disease as hypertension nor medical history before and without medication used. He had a history of smoking for decades and quit for many years without drinking. His blood pressure (BP) was 118/72 mmHg and pulse rate was 64 beats/minute on arrival. No significant abnormalities were discovered at the time of physical examination of heart and lung. There was no abnormal finding in neurologic examination. Brain computed tomography (CT) was checked and the results showed normal study without vascular atherosclerosis change. His electrocardiogram (ECG) revealed sinus rhythm and unremarkable. Biochemical analysis demonstrated normal cardiac enzyme (troponin I, total creatine kinase and CK-myocardial isoenzyme) level. Chest radiography was checked and showed a soft tissue density mass at left upper lobe. There was prominent soft tissue density at left apex and left lower neck (). He was advised to be admitted to our hospital under the suspicion of pulmonary tumor. On the following day after admission, chest CT was arranged and performed. The results showed a 4.5 cm soft tissue density mass with heterogenous enhancement at left lower lobe near hilum with extensive lymphadenopathy at left hilum, left paraaortic, anterior mediastinum with left paratracheal extending to left lower neck. The lymph nodes caused obstruction of left upper lobe bronchus with right side displacement of trachea, thyroid gland, and left internal jugular vein was compressed (). Pulmonary neoplasm with lymphadenopathy was suspected and the patient was discharged for the secondary opinion after we explained the probability with his family. |
A 45-year-old male presented to our hospital with diaphoresis, chills, and worsening right flank pain. He had a past medical history of cirrhosis due to alcoholism and portal hypertension with esophageal varices managed with prior transjugular intrahepatic portosystemic shunt (TIPS) procedure. He had a history of hepatic encephalopathy, hypertension, and type II diabetes. He had a recent admission to another institution for septic shock secondary to recurrent cholecystitis and had recently had an LC fifty-eight days prior. The patient was admitted to the outside hospital fifty-nine days prior to admission to our institution for subacute cholecystitis, which had initially required a cholecystostomy drain on prior admissions, and then ultimately an LC at that hospital. The gallbladder was not noted to be perforated, but the procedure was complicated by dropped gallstones, some of which were retrieved as stated in the operative report. On the current admission, the patient was hypotensive requiring vasopressors and was anemic and thrombocytopenic, requiring blood and platelet transfusions.\nA CT scan of the abdomen and pelvis with IV contrast was performed on admission demonstrating residual gallstones in the gallbladder fossa and/or cystic duct remnant and multiple small fluid collections and/or forming granulomatous masses surrounding additional retained/dropped gallstones in the surgical tracts and vicinity. A fistula with gallstones was also seen extending through the posterior and inferior wall of the second portion of the duodenum, to the anterior and superior aspect of a right renal cyst, which measured 3.4 cm x 3.0 cm and which contained gas in its superior aspect (Figures and ). A previous CT of the abdomen and pelvis performed with IV contrast sixty-five days prior to admission and seven days prior to the LC demonstrated a simple right renal cyst in the location of the now complex and infected cyst, measuring 2.8 cm x 2.5 cm ().\nDrainage of the infected renal cyst seen on the initial CT was considered; however, the cyst was relatively small and inaccessible. A repeat CT of the abdomen and pelvis with oral and IV contrast was performed four days after admission due to concern for abscess formation as the patient continued to have right flank pain. The CT demonstrated an unchanged superinfected cyst in the right kidney, with the fistula tract still visible, and heterogeneous retention of IV contrast in the right kidney, which was consistent with associated pyelonephritis (Figures and ).\nOn initial presentation, the patient was noted to have a history of Klebsiella pneumoniae and vancomycin-resistant enterococcus (VRE) in the cholecystectomy drain and was treated for the gallstone abscess and fistula accordingly with meropenem as there was no other source of infection. Blood cultures were later positive for K. pneumoniae and VRE. The patient was ultimately treated with linezolid and meropenem was deescalated to ceftriaxone.\nDiscussion between the patient's outside hepatologist, the abdominal radiologist, the interventional radiologist, and the gastroenterologists determined that the most likely etiology of the initial sepsis was an infected renal cyst secondary to an infected dropped gallstone. The patient was ultimately transferred to the outside hospital where he previously had his cholecystectomy for surgical follow-up. |
A 65-year-old man with continuous irritable cough over 15 days was admitted to our department for a mass lesion in the right hilum. He presented with no face swelling and superficial varicose veins. He was a former smoker, and medical history included hypertension and diabetes mellitus. At bronchoscopy, the tumor was found occluding the right upper lobar bronchus and infiltrating the bronchus intermedius. It was diagnosed as squamous cell carcinoma by transbronchial tumor biopsy. Chest contrast computed tomography (CT) revealed that the mass of 80 mm in the maximum diameter located in the right upper lobe. The tumor directly invaded the arch of the right PA and a wide range of SVC. It was discovered that the left brachiocephalic vein (BCV) along the left margin of mediastinum walking down the line directly into the coronary sinus (). A venous flow was detected in the anterolateral descending aorta with dilatation of the coronary sinus (diameter of 21 mm) without other heart abnormalities by transthoracic echocardiography. Based on these findings, the diagnosis of PLSVC was made. There were no detectable metastases in other organs through brain magnetic resonance imaging (MRI), upper abdomen CT scan and bone nuclear scan.\nThe right posterolateral thoracotomy was performed on October 31, 2006. As expected, the tumor invaded the wall of SVC and no left brachial cephalic vein bifurcation was observed. The SVC was separated, clamped and resected following intravenous injection of 5, 000 IU of sodium heparin. The ringed PTFE graft of 12 mm in diameter was interpositioned between the right brachial cephalic vein and the origin of SVC by running sutures with 4-0 polypropylene. The tumor resection was completed by double sleeve lobectomy of right upper and middle lobes. The anastomosis between the right main bronchus and the cut end of the lower lobe bronchus was performed by interrupted suture using 3-0 Vicryl (Ethicon, USA). Right PA trunk and right lower PA reconstruction was completed by the running suture with 4-0 polypropylene (). And systematic mediastinal lymph node dissection was performed. All excised margins were tested microscopically negative for malignancy. As anticoagulation treatment, we began with low molecular Heparin on the operative day, then switched and continued to warfarin when thoracic drains removed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 12th postoperative day. Final pathological diagnosis was poorly differentiated squamous cell carcinoma invaded the right SVC, right PA and mediastinal nodes were positive for malignancy.\nAfter 4 cycles of chemotherapy (Gemzar and cisplatin) and 1 cycle of radiotherapy, Chest MRI showed patency of the graft and PLSVC (). He died 21 months after operation because of remote metastasis. |
A 4-month-old female baby was brought to our clinic with the complaint of mass in the upper lip which existed since birth []. The mass filled midline and left upper lip totally and extended to the right upper lip in a small area. The mass deformed columella and caused superior deviation of the left alar. With palpation, the mass was mobile, had medium consistency, smooth borders, and a size of approximately 2 cm × 2 cm. There was no history of respiratory problems. The lesion did not transilluminate and there was no change in size when the child cried. There were no other pathologies in the head, neck and systemic examination of the child. Ultrasonography and echo–Doppler scanning revealed solid mass with no proliferation of vessels. We planned magnetic resonance imaging (MRI) to make the differential diagnosis from other congenital midline lesions and to evaluate the cranial connection of the mass. The MRI of the brain was normal. However, the MRI of the face showed a mass of 21 mm × 17 mm, which occupied midline and left upper lip, with no erosion of the bony walls and had an intracranial extension with a fibrotic band []. The patient was operated under general anaesthesia. The inner mucosa of the upper lip was incised and the mass was explored. It was seen that the mass continued as fibrotic band in the posterior and the fibrotic band was excised through nasopharynx []. After the removal of the mass, the excess skin in the lip area was excised with an incision from midline to the left alar rim. There was no destruction of the bony structures. The patient had no problems in the post-operative period. The definite pathological result of the mass was glial heterotopia.\nIn the early post-operative period, the elevation of the alar rim was obvious, but this elevation was indefinite in the post-operative 3rd year. There was no recurrence in the follow-up period of 3 years []. |
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. |
Case 1. A 67-year-old man presented with pain and swelling in the right shoulder. He was diagnosed to have metastatic thyroid carcinoma at another facility four years ago and was treated with radioactive iodine.\nAt initial presentation, he also underwent open reduction and internal fixation of the right proximal humerus for a pathological fracture with the T2 Humeral Nail (Stryker, Kalamazoo, Milwaukee, USA), followed by radiation therapy to the right humerus. He presented to our institution with plain radiographs of his right shoulder showing an osteolytic lesion of the head of the right humerus along with soft tissue swelling of the proximal arm. A computed tomography (CT) scan showed the disappearance of the proximal humeral cortex (). Magnetic resonance imaging (MRI) showed the lesion to have mild high signal changes on both T1 and T2 weighted imaging, extending to the surrounding muscles (). Needle biopsy confirmed recurrent metastatic thyroid carcinoma. After counseling the patient, a surgical resection and reconstruction were planned. Preoperative embolization of tumor feeding vessels was carried out by interventional radiologists. The surgical incision extended from the medial side of the right clavicle, across the coracoid process, extending to the distal end of the right humerus and included the needle biopsy tract. The tumor and surrounding muscles were carefully resected en bloc with a humeral intramedullary rod. The axillary nerve and posterior humeral circumflex vessels were sacrificed. The right clavicle was mobilized by freeing its medial attachments but leaving its attachments to the acromion intact. The floating clavicle was rotated by 90 degrees clockwise and was fixed to the distal humerus with an AO small fragment locking plate.\nNo postoperative complications were observed after the surgery. Radiographs taken 9 months after the operation showed callus formation between the clavicle and the distal humerus. The postoperative length of the reconstructed upper limb was 28 cm, 1 cm shorter than the preoperative length (). The patient had good arm function based on the Musculoskeletal Tumor Society (MSTS) score for limb salvage evaluation with scores of 5 for pain, 3 for function, 3 for emotional acceptance, 2 for positioning of the hand, 5 for manual dexterity, and 2 for lifting ability. The total score was 20 points (67%). |
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 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. |
A 31-yr-old female visited our department in October 2002. She had a history of endotracheal intubation for a week to maintain her airway after an inhalation burn, and she then developed dyspnea after the treatment. Prior to the inhalation injury, she had no family history of disease or any notable medical conditions. On physical examination, the mobility of both vocal folds was found to be intact; however, we observed upper tracheal stenosis. The patient's airway was severely compromised with less than 30% of the normal function due to the stenosis. A neck computed tomography (CT) scan showed a tracheal stenosis lesion around the 6th cervical spinal level. The narrowest diameter of the lesional trachea was about 0.7 cm and the lesion length was about 3cm. Slight enhancement was also visible on the stenotic lesion, which most likely due to granulation tissue. We performed bronchoscopy and balloon dilatation procedures. The 10 mm balloon dilatation was initially successful, but further procedures could not be performed because of the patient's unstable vital signs. We decided to perform a resection with end-to-end anastomosis in November 2002. We performed a hyoid release and resection of a 2 cm segment of the trachea (from the 2nd to 5th tracheal rings) 2 months after the burn injury. Two months later, the dyspnea symptoms reappeared and the tracheal stenosis was found. Tracheal ballooning and stent insertion were then performed, but the stent was removed after 1 month due to displacement. Granulation tissue was observed a few months later at the previous operative site. LMS was performed next to remove the granulation tissue and mitomycin C was applied. In 2006, upper tracheal stenosis due to a fibrous stricture of the tracheal mucosa was found. A neck CT scan revealed a narrowed airway with hour-glass-shaped tracheal rings on the 6th cervical spinal level (). The narrowest diameter of the trachea was about 0.6-0.7 cm and LMS then was performed two more times. Five years after the inhalation injury, we performed slide tracheoplasty to treat the stenotic tracheal lesion.\nThe procedure was performed under general anesthesia and the airway was secured using an endotracheal tube. A transverse midline neck incision along with a thyroid split was performed. Additional dissection was performed 4 to 5 cm distal to the site of the stenosis. The dissection was meticulously performed to avoid damage to the recurrent laryngeal nerves. Three circumferential narrowed tracheal rings were observed, and transection of the stenotic trachea was performed at the narrowest midpoint; thick fibrous mucosal changes were observed. The proximal half of the trachea was split along its anterior wall, while the distal segment was split along its posterior wall. The right angle corners, where the vertical incisions met the transverse incision, were trimmed. Both ends of the trachea were then anastomosed (). The endotracheal tube was advanced to the distal area of the reconstruction. Extubation was done on postoperative day 2. On postoperative day 7, we confirmed that the anastomosis site was healing and that the upper tracheal lumen was maintained with about 70% patency by a telescopy-guided examination. Three months after the operation, the tracheal anastomosis area was visually healthy and the upper trachea was enlarged. A follow-up neck CT scan revealed a more widened tracheal lumen. Objective improvement of the airway was confirmed on the CT image with using a 3D volume rendering technique at the levels 15 mm above and below the stenosis area. The preoperative selected airway volume of 1,082.6 mm3 had increased to 1,767.8 mm3 postoperatively (). The patient has been followed up for 18 months and there has been no tracheal narrowing or symptoms of dyspnea. |
A 15-year-old female with a past medical history of only autism spectrum disorder presented to the ED with complaints of a laceration to her right fourth digit and an abrasion to her right third digit, which were sustained approximately 22 hours prior to ED arrival. Before presenting to the ED, the patient’s mother attempted wound care at home; however, secondary to persistent bleeding, the patient was brought to a referral urgent care center that then subsequently sent the patient for evaluation at our ED.\nOn evaluation in the ED, the patient was at her baseline mental status as per her parents. Physical examination revealed a weight of 53 kg, a temporal temperature of 37 degrees Celsius, a heart rate of 71 beats per minutes, a respiratory rate of 18 breaths per minute, a blood pressure of 114/86 millimeters of mercury, and a room air oxygen saturation of 99%. She was noted to have a small abrasion to the medial aspect of the distal phalanx of the right third finger and a one-centimeter, elliptical-shaped laceration to the medial aspect of the distal right fourth finger that was actively bleeding. She had full range of motion of all 10 of her digits with a capillary refill of less than two seconds on each digit. Of note, her neurologic exam revealed the patient to be at her baseline status as per her parents, awake and alert, and she was symmetrically moving all of her extremities equally. The remainder of her examination was normal.\nDue to continued bleeding of the laceration despite other attempts at hemostasis, and after a discussion with the patient’s parents regarding increased risk of infection because the wound had been open for 22 hours, they consented to have the laceration repaired with sutures in the ED. Because of the patient’s baseline mental status, secondary to her autism spectrum disorder, the decision was made to perform the laceration closure under procedural sedation.\nFor the procedural sedation, there was no IV access available; thus, the medication was administered intramuscularly. It had been greater than four hours since her last meal, she was able to fully flex and extend her neck, and she was able to fully open her mouth. We chose ketamine as the sedating agent for the procedure at a dose of 3–5 mg/kg, which is in the accepted intramuscular dosage range. Consent for the sedation was obtained from her parents after a full discussion regarding the risks and benefits of sedation and the known adverse effects of ketamine.\nKetamine was administered via a one-time dose intramuscularly at the start of the procedure; the total dose given was 150 mg, which was less than the recommended intramuscular dose. The patient was on a cardiac monitor with pulse oximetry and end-tidal carbon dioxide monitoring throughout the procedure and remained normoxic. The laceration on the right fourth digit was repaired using an aseptic technique after cleansing of the site, with four 4-0 chromic gut sutures. No local anesthetic was administered. As the last stitch was tied and nine minutes after ketamine was administered to the patient, she was observed to have generalized tonic-clonic seizure of one-minute duration that self-resolved without any administration of further medications. Medical toxicology was consulted and advised to evaluate the patient for a new onset seizure, as ketamine was not known to induce seizure activity.\nThe patient remained postictal in the ED, IV access was established, and a complete blood count, basic metabolic panel, and a computed tomography (CT) without contrast of the head were ordered. Blood analysis was noted to be within normal limits for our institution’s normal value range. The head CT was read by radiology to show mild colpocephaly of the ventricles with uncertain significance as there was a present corpus callosum and no evidence of transependymal resorption or other white matter findings.\nPediatric neurology was consulted, and the case, laboratory findings, and imaging findings were discussed. Pediatric neurology recommended inpatient admission if the patient maintained altered mental status and to otherwise follow up with them for an electroencephalography (EEG) due to new onset seizure. The patient continued to be hemodynamically stable in the ED and maintain her airway, but did not return to her baseline and had one episode of vomiting despite observation for four hours after the observed seizure activity. At that time, she was admitted to the pediatric step-down unit for further evaluation and monitoring.\nWhile in the pediatric step-down unit, the patient gradually returned to her baseline mental status; she had no further seizure activity throughout her stay and required no administration of any medications. She was evaluated by neurology and underwent a one-hour EEG, which showed no areas of focal slowing, epileptiform discharges, or electrographic seizures. The patient was discharged in stable condition after undergoing the EEG to outpatient follow-up on a course of cephalexin for empiric antibiotic coverage of her repaired finger laceration. The patient was then lost to follow-up. |
A 45-year-old male presented to our hospital with diaphoresis, chills, and worsening right flank pain. He had a past medical history of cirrhosis due to alcoholism and portal hypertension with esophageal varices managed with prior transjugular intrahepatic portosystemic shunt (TIPS) procedure. He had a history of hepatic encephalopathy, hypertension, and type II diabetes. He had a recent admission to another institution for septic shock secondary to recurrent cholecystitis and had recently had an LC fifty-eight days prior. The patient was admitted to the outside hospital fifty-nine days prior to admission to our institution for subacute cholecystitis, which had initially required a cholecystostomy drain on prior admissions, and then ultimately an LC at that hospital. The gallbladder was not noted to be perforated, but the procedure was complicated by dropped gallstones, some of which were retrieved as stated in the operative report. On the current admission, the patient was hypotensive requiring vasopressors and was anemic and thrombocytopenic, requiring blood and platelet transfusions.\nA CT scan of the abdomen and pelvis with IV contrast was performed on admission demonstrating residual gallstones in the gallbladder fossa and/or cystic duct remnant and multiple small fluid collections and/or forming granulomatous masses surrounding additional retained/dropped gallstones in the surgical tracts and vicinity. A fistula with gallstones was also seen extending through the posterior and inferior wall of the second portion of the duodenum, to the anterior and superior aspect of a right renal cyst, which measured 3.4 cm x 3.0 cm and which contained gas in its superior aspect (Figures and ). A previous CT of the abdomen and pelvis performed with IV contrast sixty-five days prior to admission and seven days prior to the LC demonstrated a simple right renal cyst in the location of the now complex and infected cyst, measuring 2.8 cm x 2.5 cm ().\nDrainage of the infected renal cyst seen on the initial CT was considered; however, the cyst was relatively small and inaccessible. A repeat CT of the abdomen and pelvis with oral and IV contrast was performed four days after admission due to concern for abscess formation as the patient continued to have right flank pain. The CT demonstrated an unchanged superinfected cyst in the right kidney, with the fistula tract still visible, and heterogeneous retention of IV contrast in the right kidney, which was consistent with associated pyelonephritis (Figures and ).\nOn initial presentation, the patient was noted to have a history of Klebsiella pneumoniae and vancomycin-resistant enterococcus (VRE) in the cholecystectomy drain and was treated for the gallstone abscess and fistula accordingly with meropenem as there was no other source of infection. Blood cultures were later positive for K. pneumoniae and VRE. The patient was ultimately treated with linezolid and meropenem was deescalated to ceftriaxone.\nDiscussion between the patient's outside hepatologist, the abdominal radiologist, the interventional radiologist, and the gastroenterologists determined that the most likely etiology of the initial sepsis was an infected renal cyst secondary to an infected dropped gallstone. The patient was ultimately transferred to the outside hospital where he previously had his cholecystectomy for surgical follow-up. |
A 63-year-old male farmer of Chinese Han ethnicity presented pain in his left neck, right chest wall and back for 10 months, along with swelling under the right nipple for 1 month. He was admitted to the hospital on November 26, 2014. The left neck pain with no particular predisposing factors was dull and intermittent in the beginning. It gradually progressed and extended to the left upper extremity, where the pain was more serious and accompanied by numbness at night. The pain eventually spread to the chest and back. The patient has no history of exposure to TB or any recent weight loss, cough, low-grade fever, decreased appetite or night sweats.\nDuring the previous 10 months, the patient had been hospitalized first in the department of orthopedics and then in the department of interventional radiology. Enhanced chest computed tomography (CT) studies did not show any parenchymal lung lesions or lympho-adenopathy. Then, CT and magnetic resonance imaging (MRI) both showed multiple osteolytic bone lesions at C4, C5, C6, T10 and T11 vertebrae, which were noted along with similar lesions on the ribs of these vertebrae. The dural sac was pressed at the corresponding surface. A bone marrow biopsy revealed granulocytosis in the bone marrow. A fine needle aspiration biopsy of the 9th rib lesion showed that both bones and cartilages had a small amount of fibrous tissue attached to them. Accordingly, multiple bone metastases were suspected (Fig. ). Final confirmation of the diagnosis was not performed, and the patient was discharged from the hospital with a prescription of morphine sustained-release tablets to relieve the pain. The diagnosis of the patient could not be confirmed by several hospitals for the following 8 months and no additional biopsies were performed.\nThe patient was re-admitted on November 26, 2014 as the conditions worsened with the development of numbness in both legs. A red swollen area appeared on the right side of the chest without obvious predisposing factors 1 month before re-admission. The swelling with obscure boundary and poor mobility grew gradually from the initial size to about 1 cm × 1 cm at the time of re-admission.\nThe vital signs of the patient were stable at the time of re-admission. No obvious abnormal signs were observed in neurologic examination. Laboratory results were as follows: Routine blood test: WBC 11.7 × 109/L, N 75.8 %, RBC 3.06 × 1012/L, HGB 89 g/L, PLT 232 × 109/L, and serum albumin 38 g/L. Serum protein electrophoresis and immune fixation electrophoresis were normal. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were 60.08 mm/hr (normal value 0–15 mm/hr) and 37.55 mg/L (normal value 0–8 mg/L), respectively. Serum tumor markers including AFP, CEA, CA199, CA724 and PSA, were all within normal ranges. Interferon gamma by T-SPOT was negative. Hepatitis B surface antigen (HBsAg) and HIV were negative.\nA smear test for acid-fast bacilli of pleural effusion was negative on November 27, 2014 (CT didn’t show pleural effusion in April, 2014). A routine pleural effusion test showed: yellow, turbid, WBC: 1500/μl (neutrophils 55 %, lymphocytes 45 %), and RBC: 1550/μl. Rivalta’s test was positive. Pleural effusion biochemical examination showed: total protein 48.3 g/L, lactate dehydrogenase 188 U/L, adenosine deaminase 12.7 U/L, and glucose 7.08 mmol/L. Malignant cells were not detected in the pleural effusion. 18 F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)/computed tomography (CT) revealed that there were multiple metastases in the bilateral pleural effusion, whole bone, bilateral hilar lymph nodes, mediastinal lymph node and chest wall (Fig. ). But a primary tumor location was not detected.\nOn December 2, 2014, the swelling soft tissue under the right nipple ulcerated. Both a smear test of acid-fast bacilli and a polymerase chain reaction (PCR) of TB-DNA of the pus were positive. As a result, the diagnosis was corrected to multiple musculoskeletal tuberculosis. After 1 month of anti-tuberculosis combination therapy (rifampicin, isoniazid, pyrazinamide and ethambutol), the swelling significantly decreased and the back pain was reduced. After 3 months of treatment, the numbness in the arms resolved. |
A 48-year-old woman, gravida 1, para 1, visited the internal medicine department at another hospital with a complaint of abdominal fullness and weight loss of 10kg during the last year. A huge abdominal mass was palpated, and she was referred to the gynecology department to search for a tumor of uterine origin. She was premenopausal and had no significant past medical history. Physical findings revealed a large elastic hard mass extending from the xiphoid to the pubic bone. The magnetic resonance imaging (MRI) examination revealed a huge tumor on the uterine corpus, and a number of dilated vessels were observed between the tumor and the myometrium. Therefore, the tumor was suspected to derive from the uterus. The tumor showed an uneven signal on T2-weighted sagittal section (), and the enhanced MRI study showed that the tumor edge but not the center was enhanced (). As such, necrosis was suspected to have occurred in the center of the tumor. Uterine sarcoma was primarily suspected due to the large size, degeneration, and necrosis on MRI imaging. Computed tomography (CT) examination showed no lymph node swelling or distant metastasis. Preoperative laboratory testing revealed anemia (hemoglobin level, 5.6g/dl). We transfused 18 units of RCC before surgery. CT examination and ultrasonography on lower extremities indicated an absence of thrombosis. Preoperative serum levels of CEA, CA 19-9, CA 125, and LDH were within normal limits. A biopsy of the endometrium was not collected as the sounding examination of the endometrium was unsuccessful due to a deviated uterine cervix. At this point, preoperatively, we suspected the tumor was a leiomyosarcoma or leiomyoma with degeneration.\nThe patient underwent laparotomy, where we identified a huge tumor occupying a space from the pelvis to the diaphragm. The tumor surface was smooth and hard with many dilated veins (). A massive tumor with a diameter of 30 cm was observed arising from the posterior uterine wall with a smooth contour and invaded the retroperitoneal cavity under the mesentery. The tumor was firmly adhered to both the mesentery and right ovary. There were no findings of extra-uterine dissemination. The intraoperative frozen section report for the uterine tumor was of degenerated myoma with no findings indicating malignancy. A total abdominal hysterectomy (TAH) and right salpingo-oophorectomy (RSO) were performed. The operation duration and blood loss were approximately 216 minutes and 1000 ml, respectively. The excised specimen weighed 7600 g.\nMacroscopic findings of the tumor revealed a well-circumscribed tumor showing extensive continuity with the posterior wall of the uterus, measuring 28 × 23 cm (). On the sliced surface of the tumor, an obvious heterogeneous pattern was recognized within the mixture of a whitish homogeneous area, suggesting benign uterine fibroids, and a vulnerable area, due to bleeding and necrosis ().\nFor the intraoperative frozen section, we examined three areas, namely, a white homogenous part, a necrotic part, and a cystic part, of which all were findings of a leiomyoma. In the permanent histological examination, 10 additional sections were collected from the tumor. The basic histological findings of all the sections were the same. The tumor was comprised of spindle-shaped cells, homologous to smooth muscle cells, which were arranged in bundles with areas of hyalinization, consistent with a degenerated leiomyoma. The tumor was mostly comprised of degenerated uterine leiomyoma. However, enlarged blood vessels were observed within an area of approximately 2 cm × several mm, and proliferation of atypical cells showing a fine meshwork microvascular structure was observed in the blood vessel cavity (). These atypical cells consisted of various contours, such as cubic, polygonal, and short spindle shape. The nucleus was circular with a high degree of vacuolar enlargement and pleomorphism. Abnormal mitotic figures were also interspersed (). A tumor derived from a blood vessel was thus considered, and malignancy was suggested by the presence of nuclear atypia and abnormal mitosis.\nImmunohistochemical analysis revealed the atypical tumor cells to be positive for ERG, CD31, and AE1/3 (Figures and ), partially positive for Factor VIII, and negative for α-SMA, desmin, H-caldesmon, EMA, CD34, and D2-40. From the above, the atypical tumor cells were of epithelial origin and the final diagnosis was epithelioid angiosarcoma arising in a degenerated uterine leiomyoma.\nThe efficacy of postoperative adjuvant therapy for angiosarcoma has not been demonstrated and there is currently no established chemotherapy regimen. In this case, because the atypical tumor was observed in the blood vessel cavity, we thought it could have been spread hematogenously throughout the body. Hence, we selected adjuvant chemotherapy rather than adjuvant radiotherapy. Six courses of combination adjuvant chemotherapy with paclitaxel (150mg/m2), epirubicin (50mg/m2), and carboplatin (area under the curve = 4) were administered in the present case, following referral to previous reported cases. No recurrence has been observed 10 months after the primary surgery. |
Patient n. 2 was a 60-year old female, diagnosed with suffering from POAG for ten years, under treatment with hypotensive drugs and regularly controlled IOP twice a year which appeared maintained within normal ranges. During a control visit in January 2016, the patient had reported irritating symptoms of eye discomfort, described as burning, itchiness, and feeling sand, mainly in her right eye (RE), over the last six months. The situation had been managed with the use of several types of tear substitutes, none of them successful in symptom relief. Symptoms were scored in the RE as OSDI of 74 out of 100 and a VAS score of pain of 85 mm out of 100. In the left eye (LE) the symptoms were defined by the patients as light and acceptable: OSDI score was 22 out of 100 and VAS 21 mm out of 100. Slit lamp evaluation had not shown epithelial damage, and there were no signs of inflammation, but only a reduced Tear Film Break-Up Time (TFBUT) of 4 seconds in RE and 8 seconds in LE had been recorded. A therapy with hyaluronic acid (HA) based tear substitute to be administered 4 times/day in both eyes was prescribed.\nIn March 2016, the patient was proposed to receive in her RE a treatment with topical CBS, as a compassionate unconventional therapy, with the aim to reduce the pain symptoms for which the previous therapeutic attempts had turned to be unsuccessful. The therapy for the contralateral LE was maintained with HA based tear substitutes.\nThe patient signed the specifically designed informed consent and started administration of the CBS eye drops in April 2016, with the posology of 0.4 ml (8 drops) in RE, each day for a total of two months. In the GF dosages determined for the two CBS lots were administered during the first and second month.\nOn September 2016, the patient reported a significant relief from subjective symptoms of discomfort; in RE the OSDI was 28 out of 100, with VAS: 32 mm out of 100. Also in LE a reduction was observed, with OSDI score determined as 16 out of 100 and VAS 15 mm out of 100. During this visit, also the IOP was measured, which resulted in the normal range in both eyes and the analyses of the visual field tests performed since 2006.\nIn the mean deviation (MD) values recorded over several visits performed from December 2006 through September 2016 were graphed. A significant progressive lowering in MD values was observed which was followed by an important amelioration in correspondence with the period of treatment with CBS, in the figure highlighted with the arrow. It has to be noted that the increase in MD values was recorded either in the treated right eye or in the untreated left eye. Moreover, the MD values recorded in September 2016, four months after the end of the CBS eye drop administration, showed in both eyes a further amelioration.\nThe improvement is also demonstrated by the analysis of the PSD shown in . A progressive worsening in PSD values had been observed over ten years, whereas a rapid change was recorded in correspondence with the CBS eye drop treatment, either in the treated right eye or in the untreated left eye.\nIn the central 30-2 visual field tests before ((a): right eye RE; (b): left eye LE), at the end (c, d) and after four months (e, f) from the end of the CBS eye drop treatment were shown. An amelioration of the defect was observed in all the four quadrants in both the treated RE and the untreated LE.\nTaking together these observations, a positive effect also in the left untreated eye could be recorded, which suggests a neural cross-talk mechanism between the eyes. |
A 35-year-old left-handed man who works as a mechanic and firefighter presented to our institution with hand pain and cold intolerance for 3 months. He was referred by a local vascular surgeon who had made the diagnosis of hypothenar hammer syndrome (HHS) following an angiogram of the right upper extremity showing complete occlusion of the ulnar artery (). On initial examination, Doppler signals of the ulnar artery, superficial palmar arch, and ring/small digital arteries were absent in the right hand. Subsequently, the patient developed an ulcer on his right long fingertip after minor trauma that had not healed over a 4-week period. He suffered ischemic hand pain and severe cold intolerance. After conservative management failed, the decision was made for operative intervention. We proposed using an arterial graft versus a venous graft in order to improve long-term patency. Our plan was to utilize the descending branch of the lateral circumflex femoral artery (DLCFA) as an arterial graft.\nIntraoperatively, Doppler ultrasound revealed a segmental thrombotic defect extending from the superficial palmar arch, across the Guyon canal, extending 10 cm proximally in the forearm. The ulnar artery was resected back to healthy bleeding pulsatile flow, resulting in a segmental defect of 12 cm. Final pathology of the submitted ulnar artery segment revealed organizing thromboembolus in the lumen, which at the time of resection was adherent to the lumen.\nThe DLCFA was harvested, with care taken to prevent injury to the lateral femoral cutaneous nerve. A 12-cm segment of the artery was circumferentially dissected, as well as approximately 2 cm of 2 branching vessels at the distal end of the segment that would be used to reconstruct the superficial palmar arch and common digital arteries with one graft. With the arterial graft completely dissected, it was ligated both distally and proximally.\nThe arterial graft and recipient vessels were examined under the operative microscope. The proximal anastomosis was preformed first. The two branches at the distal end of the arterial graft were anastomosed to the superficial palmar arch stump, and common digital artery to the ring and small finger, respectively. A bolus of 5000 units of heparin was given intravenously before release of the microvascular clamps. Adequate pulsatile flow was achieved though the graft and confirmed with Doppler ultrasound to each finger ( and , Video 1). The hand was then irrigated, and the ulnar nerve was explored to ensure that no injury had taken place. The skin was closed, and the patient's hand was placed into a dorsal splint.\nThe patient remained in the hospital overnight for monitoring and was discharged the following morning on oral aspirin as the only anticoagulant. On follow-up examination 2 days later, strong Doppler signals were elicited at the ulnar artery, palmar arch, and radial and ulnar aspect of each digit. At 1 month, Doppler signals remained strong and the ulcer previously present on the right long fingertip had completely resolved (, Video 2). During this visit he reported to be asymptomatic and has had complete resolution of the cold intolerance and burning pain of his right hand. |
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 74-year-old female presented for a complete skin examination in May 2016. She had a history of actinic keratoses and five basal cell carcinomas. There were several new skin lesions since her last visit six months earlier.\nShe also had a previous mantle cell lymphoma. In February 2015, she had achieved a clinical remission after receiving three cycles of Rituxan and Treanda that was followed by an autologous stem cell transplant in April 2015. She also has a past medical history of diabetes mellitus (controlled with diet), obstructive sleep apnea (treated with continuous positive airway pressure therapy) and a recent deep vein thrombosis (that is currently being treated with Coumadin).\nThe cutaneous examination was remarkable for four erythematous scaling plaques on her arms and back, consistent clinically with actinic keratoses. She had three red plaques, each approximately 6 x 4 mm, on her right upper central back, right upper mid back and right hip (Figure ). In addition, she had a 2 x 2 mm red dot within a 7 x 9 mm area of erythema on her left mid back (Figures -); the lesion blanched when pressed with a glass microscope slide (Figure ).\nThe actinic keratoses were treated with liquid nitrogen cryotherapy. The back lesions were each biopsied using a shave technique. The red dot on the left mid back showed superficial buds and nodular aggregates of basaloid tumor cells extending from the epidermis into the dermis; there were also telangiectatic blood vessels in the papillary dermis (Figures -). The other back lesions and right hip lesion also showed similar appearing tumor cells along the basal layer of the epidermis and in the superficial dermis.\nCorrelation of the clinical presentation and pathologic findings of the left mid back lesion was a red dot basal cell carcinoma (with superficial and nodular tumor aggregates). The tumor was excised using the Mohs technique. Only one stage was required for cancer removal; the size of the defect was 15 x 11 mm. A complex layered closure was used to repair the surgical wound.\nThe three superficial and nodular basal cell carcinomas on the right back and right hip were also subsequently excised using the Mohs technique; the surgical wounds were closed with complex layered closures. Follow-up examination six months later showed excellent healing of the four surgical sites and no evidence of recurrence. |
A 40-year-old female presented with progressive weakness of all four limbs of four months duration, bowel and bladder disturbances of two days duration. She was also complaining of pain and paresthesias in all four limbs. The patient was presently bedridden. There was decreased sensation to pain, touch, temperature and posterior column sensations below neck. There was no history of trauma and fever. On physical examination there was no dermal sinus or other stigmata. Higher mental functions and cranial nerve examination was normal. Motor examination revealed increased tone in all four limbs, muscle bulk was normal in all groups. Power was grade 4/5 in all groups. Deep tendon reflexes were exaggerated in both upper and lower limbs with bilateral Hoffmann and Babinski signs. Sensory examination revealed decreased sensation to all modalities below C5 level. Magnetic resonance imaging (MRI) revealed a well defined intramedullary lesion extending from C2-C3 level with widening of the cord. The lesion was hypointense on T1W images, hyperintense on T2W and fluid attenuation and inversion recovery images with thin rim of enhancement after contrast administration ( and ). The patient underwent laminectomy from C1 to C4. During surgery after opening the dura, pale and widened cord could be seen. A midline myelotomy was performed and a thin walled cyst with pale yellow clear contents was recognized. There was ill defined capsule, difficult to separate from the surrounding cord; only small fragment for biopsy could be taken (). Histopathological examination of the excised specimen revealed features of an epidermoid cyst (). Immediately after surgery in post-operative period the patient deteriorated in motor power but recovered to the pre-operative period over a period of one week. At the 6 month follow up she reported improvement in motor power with reduction in the spasticity, complete control in bowel and bladder functions and able to carry her activities of daily living. Follow up MRI showed complete excision of the lesion and thinning of the cord at that level (). |
A 19-year-old man was referred from general surgery. He was a soccer player and had been playing for several years. He had experienced insidious dull and diffuse pain in his left groin area, which was aggravated during sports activity for a month. The subject assumed his pain originated from an inguinal hernia and went to a surgeon first. However, his abdomen and pelvis CT showed normal posterior inguinal wall contours without any other abnormalities (). A professional radiologist performed an ultrasonography; however, no significant findings were detected. Thinking it was unrelated to hernia, the surgeon referred him to the rehabilitation center.\nWe carried out a detailed physical examination. The insidious onset, gradual worsening with activity and diffuse nature of the groin pain proposed non-traumatic pathology. We asked the patient to identify the areas of pain by shading them on a pain diagram (). On inspection of both groins, there was no definite swelling or sign of injury on either side. Scrotum was normal in size and looked symmetrical. With the patient lying supine, we let him raise his both legs gradually to make an eccentric contraction of the lower abdominal muscles. This action produced unbearable pain to the subject.\nFor further evaluation, we performed an ultrasonography examination. Having the patient lying in supine position, we used a 5-MHz high-frequency transducer and explored both sides of groin and scrotal region. During the initial investigation with the patient in a recumbent position, we failed to find any evidence of pathology; however, we found significant clues through dynamic investigation. We detected an incipient direct bulge of the posterior inguinal wall after the patient contracted his abdominal muscles by raising both his legs to about 30° and fully inhaling (). Incipient direct bulges of the posterior inguinal wall were detected on both sides of the groin, more prominently on the left.\nTo rule out other possible lesions, we prescribed an MRI of the pelvic region. It identified a bilateral bone marrow edema and enhancement of both symphysis pubes, favoring osteitis pubis rather than a simple sports hernia ().\nBased on the dynamic ultrasonographic findings, we referred the subject to a general surgeon for a posterior inguinal wall deficiency reconstruction operation. Preoperatively both groins did show the presence of an inguinal hernia; a direct type on left side and both a direct and indirect form on right without a prominent fascia tear. Using the totally extraperitoneal (TEP) repair technique, a reduction of both hernias followed by Prolene mesh placement on each side to seal the hernia from outside the peritoneum was performed.\nThe postoperative outcome was uneventful and the patient was discharged four days after surgery. Before discharge, he was educated in exercises including curl-ups, side-bridge, bird-dog, and more to perform on his own at home to prevent possible related diseases like rectus abdominis or adductor longus tendinopathy. At the one week follow-up visit, he expressed mild persistent pain on both groins during the resisted straight leg raise (SLR) test, however, it did not bother him as much as before. He returned to field one month after the operation with substantial symptom improvement. Three months after surgery the subject was completely symptom-free, even when engaged in sports activities with no residual pain noted during the resisted SLR test. |
A 77-year-old Caucasian woman with chronic kidney disease, diabetes mellitus type 2, heart failure, previous nephrectomy due to clear cell renal cell carcinoma, and previous upper right lobectomy of the lung due to adenocarcinoma was admitted to the hospital because of acute hypercapnic respiratory insufficiency. She needed respiratory support with non-invasive ventilation. She was also hemodynamically unstable.\nCT angiography of the pulmonary arteries was performed. The CT scan revealed left-sided subsegmental pulmonary thromboembolism and a suspicious mass in the left atrium. She was treated for pulmonary embolism. The previous CT scan of her thorax, which she had undergone a couple of months before for her pulmonary carcinoma follow-up, had shown a normal image of the heart, proving the mass in the left atrium grew de novo. The transthoracic and transesophageal echocardiography discovered a massively enlarged left atrium, fibrous changes of the mitral valve and a mobile tumor formation measuring 2.8 × 3.6 cm that arose from the posterior annulus (shown in Fig. ).\nThe stem of the discovered formation was broad but did not reach the leaflet of the mitral valve. The tumor prolapsed through the mitral valve and caused severe mitral stenosis with minimal regurgitation. The tumor seemed to have caused postcapillary pulmonary hypertension as well. Cardiologists suspected it was myxoma and referred the patient to cardiac surgeons. A preoperative PET scan showed high metabolic activity in the left atrium that pointed to the possibility of the tumor's more aggressive origin, such as metastasis or a primary malignant tumor of the heart rather than myxoma. The patient underwent an open mitral valve replacement and extirpation of the tumor of the left atrium. At the time of open-heart inspection, the tumor was not encapsulated, but grew inside the atrial wall with root-like extensions. It hung on a stem that masked its appearance as myxoma on echocardiography. It did not overgrow the mitral valve (shown in Fig. ). Surgeons reconstructed the left atrial wall and replaced the diseased mitral valve with an artificial biological valve.\nA histopathological examination (shown in Fig. ) revealed a pleomorphic spindle-cell malignant tumor with high mitotic activity and focal necrosis. Immunohistochemically, the tumor cells were diffusely positive for S100 protein, SOX10, PRAME and focally positive for melan A and melanoma cocktail, negative for HMB45, CD31, CD34, ERG, desmin, GMA, Myf4, h-Caldesmon, calponin, CK18, CKAE1AE3, DOG1, EMA, STAT6, PAX8, MITF, GFAP, consistent with diagnosis of metastatic melanoma.\nMolecular genetic analysis of the tumor did not confirm the presence of common genetic mutations in melanoma BRAF, NRAS or KIT, or the presence of NTRK genes fusions, but confirmed the presence of ERBB2 (HER2) gene amplification.\nThe patient experienced several anticipated postoperative complications, including atrial fibrillation, pulmonary edema with respiratory failure and deterioration of a preexisting kidney disease. Following a full recovery, she was discharged from the hospital and referred to designated cancer center for further oncological treatment. Sadly, she passed away before systemic treatment initiation. The primary source of melanoma was not identified. |
We describe the case of a 77-year-old female, who for the last 12 months, had been presenting progressive dyspnoea and orthopnoea associated with asthenia. The patient denied the presence of angina-like chest pain or other symptoms. Her past medical history was relevant for hypertension and atrial fibrillation, she was treated with Rivaroxaban 20 mg once daily and with angiotensin converting enzyme (ACE) inhibitors (Enalapril 5 mg once daily). On physical examination, she presented a grade II systolic murmur, rales at the lung bases and grade II oedema of the lower limbs. The patient had been diagnosed in 2009 with a CAF and a CAA, but she never had surgical treatment until she was referred to our institution.\nAt her arrival, a coronary computed tomography (CT) angiogram was performed that showed the presence of an arteriovenous fistula from the distal RCA and LAD artery to a dilatated coronary sinus (). She also had a giant sacular aneurysm arising from the proximal coronary artery, right after the coronary ostium that was 9 cm in diameter. The remaining portion of the right artery was tortuous and dilatated with a diameter of 12 mm (). A coronary angiography was performed and showed the same results as the CT scan and showed no evidence for coronary obstructive arterial disease (). A transthoracic echocardiogram showed normal left ventricle ejection fraction, severe tricuspid regurgitation (TR), a patent foramen ovale and a 10 mm ASD.\nDue to the fact that the patient had symptoms of heart failure because the fistula generated a volume overload of the right cavities and the aneurysm represented a high risk for rupture and/or thrombosis, we considered the patient should be treated. The case was discussed by the Heart Team, medical and endovascular options were considered, but according to the anatomy of the lesions we decided that the best option was to perform an open procedure. The patient was taken to the operating theatre, standard invasive monitoring with transoesophageal echocardiogram was used. We considered there was a high risk for rupture during opening, so the right axillary artery and right femoral vein were cannulated, and the chest was opened through a standard median sternotomy. The right superior vena cava was also cannulated, the patient went into cardiopulmonary bypass and the heart was arrested with Del Nido cardioplegia. A giant sacular aneurysm, 9 cm × 9 cm × 8 cm in diameter, was found emerging from the right coronary ostium and was located between the aortic root and right atrium. A coronary arteriovenous fistula located between the distal portion of the RCA and LAD artery to three large veins draining into a severely enlarged coronary sinus was also found. The aneurism was open and resected, the RCA was ligated at the distal end of the aneurysm and a saphenous vein bypass graft was performed (). The fistula and the atrial septal defect (11 cm × 13 cm) were corrected with an autologous pericardial patch () and a ring annuloplasty was performed to correct the severe TR. The procedure was finished, the patient was taken out of bypass and taken to the intensive care unit (ICU). She had an uneventful post-operative course and recovered completely. The patient has been monitored at 6, 12, and 18 months, at the moment she is asymptomatic and under medical management with enalapril, metoprolol, and acetylsalicylic acid (ASA). |
A 65-year-old man with a history of squamous cell carcinoma of the anal canal presented in February 2011 with newly formed nodules on his scrotum. The patient had been diagnosed with cancer of the anal canal in September 2010 and was treated with chemotherapy (5-fluorouracil and cisplatin) and concurrent radiation. His radiation therapy was delivered in 29 2 Gy fractions over 38 days for a total of 58 Gy. His treatment was completed on November 4, 2010. During his therapy, he developed severe radiodermatitis which subsequently resolved completely.\nIn January 2011, he discovered several new skin lesions on his scrotum [Figures and ]. Cutaneous examination revealed eight painless nodules on his right scrotum, and two additional nodules on his right inguinal fold. All of the new lesions were restricted to the area within his radiation port. They were mildly pruritic; one had ruptured and extruded foul-smelling white material. Biopsies from both sites showed metastatic squamous cell carcinoma, indicating loco-regional failure of his chemoradiation therapy.\nRestaging chest roentgenogram and computerized axial tomography scan also discovered lung metastases. The patient was sequentially treated with several different antineoplastic agents either as single or combination drug therapy. However, there was not only increased size of previous scrotal nodules but also continued appearance of new cutaneous metastases. He was referred to the Phase 1 department to be considered for a trial of an investigational drug treatment.\nCase 2\nA 52-year-old woman was diagnosed in February 2009 with invasive ductal carcinoma in her left breast and poorly differentiated carcinoma in her right breast. She was subsequently treated with neoadjuvant chemotherapy consisting of four cycles of doxorubicin and cyclophosphamide. Following her initial chemotherapy, she received weekly paclitaxel for 12 weeks and trastuzumab every 3 weeks for 1 year.\nIn October 2009, the patient underwent modified radical mastectomy of the left breast and right lumpectomy with axillary lymph node dissection. She began radiation therapy in December 2009. This included bilateral radiation of the chest wall, internal mammary nodes, supraclavicular fossa, and axillary apex totaling 50 Gy in 25 fractions. In addition, her left infraclavicular fossa received 10 Gray in 5 fractions, and her mastectomy and lumpectomy scars were boosted with an additional 14 Gray in 7 fractions. In February 2010, she was restaged and considered to be free of cancer.\nCutaneous examination in August 2011 revealed macular erythema with pruritic, erythematous macules, superficial plaques, and small papules within the radiation port on the left chest wall [Figures and ]. She also had a nonpruritic, hyperpigmented superficial plaque with surrounding areas of erythema within the radiation port on the right breast [Figures and ]. The skin lesions had appeared 1 month earlier and had not improved with over-the-counter topical preparations applied by the patient. Biopsy of both areas revealed metastatic breast carcinoma. |
A 55-year old male presented to an academic medical center in February 2020 with a six-week history of increasing midline back pain. He had a history of chronic mid- and lower back pain as the result of degenerative disc disease, however his pain had abruptly worsened in the 6 weeks prior to presentation. Pain was worsened with trying to sit up straight or walk. Pain was partially relieved with acetaminophen, ibuprofen, and oxycodone 5 mg tablets taken as needed. He reported no associated fevers, chills, or night sweats. He did not recall a febrile illness prior to the onset of symptoms. He did report anorexia and 15-pound weight loss in the last 6 weeks. His medical history included chronic obstructive pulmonary disease, chronic hepatitis C infection, hyperlipidemia, generalized anxiety disorder, and lumbar degenerative disc disease. His surgical history was notable for cervical spine laminectomy in the remote past. His social history was notable for heavy and ongoing tobacco use with a 60 pack-year smoking history. He denied alcohol or illicit drug use including intravenous drug use.\nHe was afebrile and hemodynamically stable on presentation. Physical exam revealed a gaunt Caucasian male in moderate distress due to pain. Poor dentition was noted. His cardiopulmonary examination was unremarkable. On spinal examination, no bony tenderness was elicited upon palpation of the thoracic and lumbar spine, however paraspinal tenderness was noted in the lumbar spine. Neurologic examination including strength and sensation of the lower extremities was intact. Babinski reflex was downward bilaterally.\nMRI with and without gadolinium contrast revealed abnormal enhancement of the lower endplate of the L2 vertebral body as well as diffuse enhancement of the L3 vertebral body with irregularity of the upper endplate. This abnormal enhancement extended to the intervertebral disc. Findings were suggestive of discitis with osteomyelitis not excluded. Additionally, there was enhancement and thickening in the anterior epidural space measuring 2 mm × 4 mm which may represent epidural abscess or hematoma (Fig. ). Laboratory evaluation including CBC with differential and comprehensive metabolic panel was unremarkable. Sedimentation rate was 36 mm/hr. and C-reactive protein was 30.1 mg/L. Blood cultures were sterile.\nBased on initial results of clinical, laboratory, and radiographic evaluation, antibiotic therapy was withheld. CT-guided aspiration of the L2-L3 disc was performed for culture and histopathology. Gram stain revealed Gram variable rods. Histopathology revealed fibrocartilage with degenerative changes and acute inflammation suggestive of discitis (Fig. ). He was seen in Infectious Diseases outpatient consultation, initially offered intravenous antibiotic therapy however patient requested oral antibiotic therapy for empiric treatment of discitis. He was started on treatment with cephalexin 1 g by mouth three times a day as well as linezolid 600 mg by mouth twice a day. (Initially, prior to the revelation of RBF infection, linezolid was chosen (in addition to cephalexin) because Gram stain revealed Gram-positive rods. The intention was to cover Corynebacterium spp. and coagulase-negative staphylococci, skin flora which tend to have resistance to beta-lactams but susceptibility to vancomycin or linezolid.) Cultures were sent to a reference laboratory, with growth noted on Mueller-Hinton media with 5% sheep blood. The organism was identified as Streptobacillus moniliformis by matrix-assisted laser desorption ionization time-of-flight mass spectroscopy (MALDI-TOF). On further history, it was revealed that patient had two pet rats and had sustained numerous bites in the last 1 year prior to symptom onset. In vitro susceptibility testing using broth microdilution revealed low MIC for penicillin (< 0.06 μg/ml), ampicillin (< 0.12 μg/ml), and ceftriaxone (< 0.06 μg/ml), with elevated MIC > 4 μg/mL for gentamicin. The patient’s symptoms dramatically improved with cephalexin so a decision was made not to switch to oral or IV penicillin. Linezolid was discontinued after 2 weeks once culture results were available. He completed 6 weeks of oral cephalexin therapy with dramatic improvement of back pain. The patient was offered TEE to evaluate for endocarditis. However, he declined to have the test done as this coincided with the onset of CoVID-19 pandemic. |
A 7-year-old girl presented with a history of breathlessness on exertion and mild exercise intolerance over a period of 2 years. On clinical examination, she was normotensive with normal heart rate. She had a hyperdynamic right ventricular impulse, normal heart sounds, and a soft ejection systolic murmur over the pulmonary area. Echocardiography (ECG) showed sinus rhythm with right axis deviation. Chest radiograph showed a prominent right descending pulmonary artery. Laboratory data were normal. Preoperative ECG evidenced a coronary sinus type of interatrial communication measuring 10 mm × 16 mm with left to right shunting []. The subcostal view was most useful in defining the interatrial shunting characteristic of this defect. The right-sided heart chambers and the pulmonary artery were marginally dilated. The absence of a left superior vena cava was documented. Intraoperatively, we encountered a pure coronary sinus type of interatrial communication measuring 1.5 cm in size and a normal coronary sinus ostium []. She underwent successful pericardial patch closure of the defect. To avoid atrioventricular block, sutures were placed close to the rims of the defect. The postoperative course was uneventful, and at 1-month follow-up, the patient remained asymptomatic.\nUnroofed coronary sinus, an unusual form of interatrial communication, is a rare cardiac anomaly accounting for <1% of lesions associated with interatrial shunting. It is not a true defect of the atrial septum and is an uncommon variety of interatrial communication through the mouth of the coronary sinus.[] Such defects are often difficult to diagnose and may even be overlooked during surgery for complex congenital heart disease.[] In this defect, the coronary sinus forms initially within the left atrioventricular groove. Depending on the extent of dissolution of its wall adjacent to the left atrium, along with the corresponding left atrial wall, a communication between the atriums through the persisting mouth of the sinus is produced. Shunting of blood occurs through the defect in the roof of the coronary sinus from the left atrial side to the right atrium through the coronary sinus ostium. It is in the majority of cases, associated with a persistent left superior vena cava and is often a part of a more complex cardiac malformation.[] Several anatomic variations of this defect have been described, including partial fenestrations between the walls of the coronary sinus and left atrium to a “pure form” of this defect. An isolated coronary sinus-left atrial fenestration is extremely unusual.[] Furthermore, the surgical treatment of such an isolated defect is complicated by its proximity to the atrioventricular node.\nWe are aware of only one such case of an isolated form of this defect in childhood[] although we did find a handful of such cases in adults.[]\nWe report an uncommon presentation of an unroofed coronary sinus without the association of a persistent left superior vena cava. In this case, the defect was diagnosed preoperatively using transthoracic two-dimensional ECG followed by successful patch closure.\nThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nNil.\nThere are no conflicts of interest. |
A 61-year-old female was admitted to the Second Affiliated Hospital of Zhejiang University College of Medicine (Hangzhou, China) on December 11, 2010, complaining of lower abdominal pain with nausea, vomiting and constipation. The patient had a medical history of hypertension, coronary heart disease, hepatitis B, cirrhosis and hepatic RFA for hepatocellular cancer in segment VIII of the liver 12 months prior to admission (). During the intervening 12 months, there was no history of trauma or surgery. An abdominal X-ray showed an elevation of the right hemidiaphragm and an air-fluid level in the subphrenic intestine. The patient was initially diagnosed with an ileus of unknown cause and was managed conservatively.\nTen days later, the patient developed respiratory failure and shock with an onset of acute chest pain and high fever. The patient was transferred to the ICU for mechanical ventilation and life support. An emergency chest X-ray revealed a right pleural effusion and enlarged bowel in the chest cavity (). Diaphragmatic defect was visualized by coronal thoracic computed tomography (CT) imaging (). Closed drainage of the pleural cavity and antibiotic treatment were administered. Feculent fluid was drained through a chest tube, indicating that the patient suffered from a diaphragmatic hernia with incarcerated colon perforation and pyothorax. Emergency laparotomy was performed and showed a section of necrotic transverse colon with perforation and a large quantity of pus in the pleural cavity. It is likely that infarction and perforation occurred following colon herniation into the pleural cavity. Following the return of the herniated colon to the abdomen, a defect in the diaphragm measuring 4 cm in diameter was found abutting the liver. A spot of thermal focal damage was located beneath the defect, at the position of the previous RFA treatment for hepatocellular carcinoma. The perforated diaphragm was not adherent to the liver, so direct tumor invasion may be excluded.\nIn addition, intestinal necrosis was identified 70 cm from the ileocecal valve and the proximal small intestine was enlarged with gas accumulation. A transverse colectomy with proximal colostomy, ileum resection with side-to-side anastomosis, thoracic irrigation and simple suture of the diaphragmatic defect were completed. The patient recovered well and was discharged from hospital two months following surgery. Written informed consent was obtained from the patient for publication of this case report and the accompanying images. |
A 2-year-old girl was admitted through accident and emergency room with a short history of abdominal pain. The initial clinical and laboratory assessment of patient was unremarkable and a plain X-ray of abdomen showed 26 pieces of rare-earth magnets joined to each other in linear fashion in the left upper quadrant (). Further exploration from parents revealed that prior to this she was playing with a box of rare-earth magnets with her 5-year-old brother. The patient was kept under close observation and a repeat abdominal X-ray after 6 hours showed that all pieces of rare-earth magnets still joined together and are present in the left upper part of abdomen. After 12 hours, the patient developed vomiting and showed tachycardia, mild dehydration, and guarding in the midabdomen. Another X-ray of abdomen showed 26 magnetic pieces forming a ring in the left upper abdomen with no pneumoperitoneum and/or obstructive bowel pattern (). After discussion with parents, the child was taken to operating room for laparoscopy and proceeds to remove the magnets. Laparoscopy showed multiple small bowel loops adherent to each other forming a mass in the left upper quadrant. The procedure was converted to open through umbilical port site. On careful examination, it was observed that loops of jejunum are entrapped in between multiple magnetic pieces inside the jejunum resulting in pressure necrosis and perforation of jejunum at two sites (). Through this enterotomy site, 14 pieces of magnets were retrieved and the remaining 12 pieces were not palpable in the small and large bowel. A table X-ray showed these missing pieces of magnets in the stomach, which were palpated and retrieved through a gastrostomy. Her postoperative course was unremarkable and she was reviewed in clinic after 2 weeks. Six months after initial surgery, the patient was brought back to accident and emergency room with symptoms of bowel obstruction, which was confirmed by the radiology images. After adequate resuscitation and a period of observation, the patient was taken to operating room for emergency reexploration of abdomen, which showed multiple adhesions resulting in bowel obstruction requiring adhesiolysis. The patient's postoperative recovery was slow and was discharged after full recovery. She has been reviewed in our follow-up clinic and has remained stable. |
A Saudi Arabian girl weighing 520 g was born at 25 weeks gestational age to a 35-year-old, gravida 4, para 3 mother. There was no family or medical history of a thrombophilic disorder. The infant was a vaginal delivery with Apgar scores of 3 at 1 minute and 8 at 5 minutes. The birth weight was appropriate for gestational age with no dysmorphic features. The infant was immediately intubated, received surfactant, and was mechanically ventilated. The initial chest X-ray was compatible with respiratory distress syndrome. Shortly after birth, the baby developed hypotension. Umbilical venous and arterial lines were inserted, and a dopamine drip was started at 10 mcg/kg/minute with subsequent stability. A partial sepsis workup was performed, and the baby was started on ampicillin and gentamicin. Hyperglycemia on day 2 was managed with an insulin infusion. Cerebral ultrasound on day 3 of life was normal. The umbilical venous and arterial lines were removed on day 7 of life.\nOn day 14, the baby developed acute renal failure secondary to sepsis with poor urine output, hypotension, metabolic acidosis, hyperkalemia, and a raised creatinine. Numerous attempts were made to insert a peripheral arterial line for frequent blood sampling and blood pressure monitoring without success. Due to the severity of illness and need for arterial access, a decision was made to insert a right brachial artery catheter, but after 8 hours the middle, ring, and index fingers of the right hand were noted to be cold, and cyanosed, and the arterial line was immediately removed (). The hand was elevated, and warm compresses were applied to the contralateral limb. Ischemic changes soon became evident and 4 hours later progressed to involve the distal part of the fingers which started showing signs of probable early necrosis (). The international normalized ratio (INR) and partial thromboplastin time were normal. A complete prothrombotic screen was not performed because the event was not spontaneous, there was no family history of thrombophilia, and there was a causal relationship of the ischemia with the brachial cannulation procedure []. A Doppler ultrasound indicated a sluggish flow through the brachial artery without definite visualization of a thrombus which suggested that the underlying etiology was more likely vasospasm rather than thrombosis. Anticoagulation was considered as one possible strategy to preserve perfusion and prevent digital loss, but the risks of heparinization and potential bleeding were considered significant. A ribbon of 2% nitroglycerin ointment (less than 4 mm/kg) was initially sparingly applied to the fingers, approximately 2 cm proximal to the line of pallor. Slight improvement in color and perfusion was noted in the fingers over the next 8 hours. Topical nitroglycerin was subsequently applied every 8 hours, 1 cm proximal to the ischemic site, following the anatomic course of the brachial artery. Methemoglobin levels were monitored daily and stayed in the normal range (metHgb < 1%).\nThere was a gradual improvement in color and capillary refill over the next several days. By day 12, the area of ischemia was limited to the tips of the fingers, and treatment was discontinued on day 21 (Figures and ). The nail beds were intact with full restorative function of the fingers (). The baby made an uneventful recovery from her renal failure, was extubated at 1 month of age, and was eventually discharged home at 34 weeks corrected gestational age, weighing 1.85 kg. |
A 66-year-old male presented to the clinic with an 11-month history of a painless enlarging mass on the left side of his chest wall. The patient noticed the mass after being discharged after a weeklong hospitalization for bilateral pneumonia. During that week the patient was continuously coughing and developed a pain in the left side of chest wall. Chest X-ray and computed tomography of the abdomen imaging showed no rib fracture or other type of injury to the chest wall, diaphragm, or abdominal wall. Discharge diagnosis included pneumonia and back pain. A few months later the patient found the mass on the left side of chest wall enlarging and decided to seek medical reevaluation by his primary care physician. He was later referred for another CT of his abdomen with intravenous contrast. This study report stated: “Patient developed a fracture with some displacement in the left posterior lateral eighth rib. The ribs more cephalad could be fractured as well. Associated with this finding there is some distortion of the ribs caudal to this left eighth rib fracture. Those ribs are displaced medially and there is bulging of the fat of the peritoneal cavity laterally without evidence of an actual hernia” []. The images were not conclusive for an intercostal hernia. A few more months past and the patient returned to the primary care physician with the same complaint of the chest wall mass. Additional CT of the abdomen was performed, and it showed the eighth rib fracture, the torn intercostal muscles, and no diaphragmatic defect [].\nPhysical examination revealed an obese patient who had a soft, nontender, reducible mass on the lateral aspect (midclavicular line to the midaxillary line) of the left-sided chest wall between eighth and 11th ribs. The mass measured 12 cm in diameter. Sensation over the mass was decreased slightly when compared to the right side.\nHis past medical history was significant for hyperlipidemia, hypertension, and benign prostatic hyperplasia. The patient had no history of any external trauma, no history of any rib fractures, and no lung disease other than the recent pneumonia. Patient denied any current tobacco use (quit 25 years earlier), patient occasionally used alcohol, and denied any illicit drug use.\nAfter reviewing the CT scans and examining the patient, a diagnosis of a chest wall hernia induced by severe coughing was established. The patient was referred to a cardiothoracic surgeon to repair the hernia. |
A 48-year-old female patient had been followed up for 5 years for both polycystic liver and kidney diseases at other institution. She was referred to us for identification of effective treatment. At the first visit, she complained of progressive distension of the abdomen and abdominal fullness leading to gradual decrease in body weight without shortness of breath. Her liver function was quite normal; hence, we decided to observe the patient regularly without considering palliative surgery or liver transplantation. Medical treatment with somatostatin analogue was not considered primarily due to the high medical cost as well as the undetermined therapeutic efficacy.\nDuring the outpatient clinic follow-up for 1 year, we recognized that she had barely maintained her ability of function in daily activities due to progressive worsening of fatigue and dyspnea on exertion. Finally, she complained of shortness of breath even in a resting state. Eastern Cooperative Oncology Group (ECOG) performance status worsened from 2 to 3 during observation for 1 year. Gastrointestinal Quality of Life Index (GIQLI) score also deteriorated from 75 to 44 during observation for 1 year. Physical examination revealed that the liver was prominently bulged out of the abdomen, but leg edema was absent. Liver and kidney functions were still quite normal. Abdominal computed tomography (CT) showed progressive enlargement of multiple liver cysts with smooth and regular walls (), which was regarded as type III according to Gigot's classification (), grade 4 according to Qian's classification (), and type C according to Schnelldorfer's classification (). Magnetic resonance imaging study revealed water-filled multiple liver and kidney cysts ().\nAfter obtaining consent of the patient on the uncertain effect of fenestration treatment as well as high risk of disease recurrence, the patient underwent surgical fenestration treatment. Multiple cysts in the enlarged liver were opened and the cyst walls were excised with electrocautery (). To avoid bleeding and bile leakage, the thin membranous portions were meticulously fenestrated and none of the viable normal liver parenchyma was resected. The majority of accessible liver cysts were opened. At the end of the fenestration procedure, the liver appeared to be markedly shrunken. Three Jackson-Pratt type drains were inserted to evacuate the ascitic fluid: the abdominal drainage output was about 500 ml/day at postoperative day 1 and then it gradually decreased to less than 150 ml/day after 5 days. After performing follow-up CT at 1 week, the drains were removed. No surgical complication occurred and the patient was discharged 10 days after the open fenestration surgery. The total liver volume by using CT volumetry was 3,870 ml before surgery and 3,125 ml at 1 week after surgery, showing a volume reduction of 19.3%.\nAt 1 month after surgery, ECOG performance status improved to 1 and the GIQLI score was significantly increased to 122. During regular follow-up at an interval of 6 months, follow-up CT showed no progression in cyst size and flat abdomen was observed (). After 1 year, ECOG performance status improved to 0 but the GIQLI score was slightly decreased to 114. The patient is doing well and she is performing her normal activities at 18 months after surgery with no evidence of disease recurrence. |
A 28-year-old male experienced fever and increasing unilateral calf pain after a football game and presented himself to the emergency department the following day. The physical examination showed typical signs of a peripheral arterial occlusion, as well as splinter hemorrhages of the fingernails (). The rest of the physical examination was inconspicuous and there were no signs of infection in the otherwise normal blood tests. The patient had no relevant personal medical history, nor family medical history. He had no history of drug or alcohol consumption. The patient’s written consent for use of his data and tissue for research purposes and the subsequent publication were obtained.\nUltrasound scan diagnosed an acute embolic closure of the left popliteal artery and the patient underwent immediate embolectomy. Histological examination of the embolus showed thrombotic material without any sign of microorganisms. Further diagnostic workup during hospitalization displayed a visible vegetation with a cross diameter of 6 mm on the bicuspid aortic valve in transthoracic echocardiography and was subsequently confirmed in transesophageal echocardiography (TEE) along with a small patent foramen ovale (PFO). A TEE was seen as a supplemental test for evaluation for cardiovascular source of embolus with no identified noncardiac source []. Phenprocoumon was started in therapeutic dose. All blood cultures came up negative and the patient had no neurological symptoms. Empiric antibiotic treatment was initiated.\nSix weeks later, TEE demonstrated a sudden progressive growth of the vegetation to 12 × 12 × 10 mm3 and new moderate aortic insufficiency (; ). Due to the lack of regression, a more complex bleeding disorder seemed unlikely.\nThe indication for urgent aortic valve reconstruction was given by the interdisciplinary heart team. Intraoperatively, the valve was tricuspid with a large vegetation fusing and destructing two leaflets, creating a functionally bicuspid valve (). Therefore, a mechanical aortic valve (Medtronic Open Pivot™ AP 360®, 28 mm) was implanted. The histopathological analysis of the vegetation, also using PCR analysis, showed no identification of common or rare pathogens, or organisms. Light microscopy revealed a destructive, ulceropolyposis of the native valve combined with a florid inflammation composed predominantly of leucocytes and fibrin and again no signs of bacterial infection (). The patient recovered well and was discharged after a short hospitalization under phenprocoumon therapy with target international normalized ratio (INR) values of 2.0–3.0. Subsequent genetic testing as an outpatient revealed a hereditary heterozygous prothrombin-mutation (G20210A-Mutation).\nSeven months later, the patient presented himself again to the emergency ward with chest pain after cycling. High-sensitivity Troponin T was increased to a maximum value of 1521 ng/L (0–14 ng/L) and creatine kinase myocardial band (CK-MB) to 76 µg/L (0–5 µg/L). The coronary angiogram showed multiple, distal coronary embolisms with no signs of atherosclerosis (). In echocardiography a well-functioning mechanical valve prosthesis without any signs of adhering material was observed and there was no change in the left ventricular ejection fraction (LVEF) (60%). No intervention was performed, and the patient was monitored in the intensive care unit. Repeat blood tests including a full coagulation factor panel showed a Factor VII deficiency leading to false high INR values. Anticoagulation monitoring was subsequently changed from INR monitoring to Factor II analysis with target values of 20–25%.\nThe patient was discharged after a short hospitalization and at the time of writing (May 2020), had fully recuperated at the 18-month cardiological follow-up. Factor VII deficiency is an indication for family screening [], however the patient and his family were unable to attend hematologic follow-ups. |
A 22-year-old female with a distant history of a resected posterior fossa pilocytic astrocytoma and a right occipital VP shunt presented to our hospital with new onset of headaches, nausea, vomiting, and 6th nerve palsy. On both computed tomography (CT) and magnetic resonance (MR) imaging, she had isolated dilatation of her fourth ventricle likely due to adhesions from her prior surgery []. Her history included a prior attempt several years ago of a suboccipital craniotomy for lysis of adhesions when she presented with similar symptoms at another hospital, which did resolve her symptoms for sometime. After a multidisciplinary discussion, it was believed that a repeat lysis of adhesions this time would not be sufficient for definitive management due to the present recurrence both of her symptoms and the robust adhesions around her brainstem. Therefore, in addition to adhesiolysis, a fourth VPL shunt was placed from a single-stage prone approach given her symptoms and the magnitude of brainstem compression.\nShe was positioned prone with her head fixated a Mayfield three-pronged head clamp in a chin-tucked flexed position. Her neck and upper back were prepped widely from the inion down to the inferior angle of the scapula.\nFor the cranial portion of the case, a linear incision was made down her prior scar from the inion to the C2 spinous process. The tissues were dissected in usual fashion down through her prior scar past her craniotomy site until her dura was identified and opened. The arachnoid adhesions from her prior tumor resection were carefully released and fenestrated widely for access into her fourth ventricle, under which clear CSF came out under moderate pressure.\nFor the posterior chest portion of the case, the 5th rib was estimated anatomically through both palpations and as being under the medial border of the scapular spine. A transverse incision was made on its superior border 4.5 cm off the midline to be lateral to the thoracic spine transverse process and rib tubercle. Monopolar electrocautery was used to carry the muscle dissection down to the posterior superior surface of the rib. The intercostal muscles were then atraumatically spread over the superior surface of the rib until the posterior parietal pleura was identified.\nA shunt passer was tunneled subcutaneously from the cranial suboccipital incision to the posterior chest incision, and a shortened distal catheter was passed upward and secured to a Delta 0.5 valve (Medtronic Sofamor Danek, TN, USA). This was subsequently secured to a premeasured 5 cm proximal catheter that was laid inside the fourth ventricle. Catheter depth was planned to anticipate that once the posterior fossa contents collapse on decompression of the ventricular system, the catheter would not protrude into brainstem parenchyma. A posterior neck musculature pocket was then bluntly created to secure the valve so that closure of the suboccipital wound would not move the proximal catheter further intracranially as well.\nAt the posterior chest wound, a small hemostat was used to bluntly enter the intrapleural space, and the distal catheter was inserted inside. A pursestring stitch was placed around the catheter, the wound was filled with antibiotic irrigation and on a Valsalva maneuver to 40 mmHg; the suture was tightened to reduce the likelihood of a postoperative pneumothorax. Both cranial and posterior chest incisions were then closed in usual standard fashion.\nPostoperatively, the patient experienced immediate relief of her headaches and mild improvement with her 6th nerve palsy as well. Postoperative shunt series X-rays and CT imaging demonstrated good positioning of her shunt hardware without intracranial complications or pneumothorax [Figures and ]. She was discharged on postoperative day 2 without issues. At 1-year follow-up, she was clinically doing well with complete resolution of her 6th nerve palsy and routine shunt series, and MR imaging showed appropriate positioning of her hardware, continued decompression of her fourth ventricle, and no signs of hydrothorax or pleural effusion [Figures and ]. She did not experience any neurologic or pulmonary complications during this follow-up period. |
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