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A 16-year-old male patient reported to our department with a chief complaint of swelling in the right posterior region in the mandible for the previous two months. The patient reported a history of a huge swelling in the same region associated with fever and pain of a pricking intermittent type around two months earlier. The patient had consulted his doctor, who had prescribed him antibiotic and analgesic medication and an incision and drainage procedure had been performed emergently. Subsequently, the patient had been recalled for extraction of the offending tooth, however he did not continue with any more treatment.\nThe patient had swelling without any fever and occasional pain just from touching the region. He did not take any medication, and had no functional difficulties or paresthesia associated with the swelling. On extraoral examination, a diffuse swelling was present on the right side of his face, measuring approximately 2 cm×2 cm, and the skin over the swelling appeared normal with no secondary changes. On palpation, there was mild local heat and swelling, which was bony hard, non-tender with expansion of the buccal cortical plate bilaterally (). Intraorally, a small well-defined swelling was present on the alveolar mucosa corresponding to the periapical region of the right mandibular first molar measuring 1 cm×1 cm, with pus discharge (). The swelling was tender and soft in consistency. Based on the clinical history and examinations, the provisional diagnosis was chronic periapical abscess in relation to the root stump of the mandibular first molar. Adjacent teeth were found to be vital on electric pulp testing.\nAn intraoral periapical radiograph revealed a large well-defined radiolucency whose entire extent was not visible on the radiograph, therefore a panoramic radiograph was taken subsequently, which revealed a large unilocular radiolucency bilaterally in relation to the mandibular first molar and the retained root of the left mandibular first molar. Both the radiolucencies were well corticated and showed no internal trabeculae. There was displacement of the adjacent teeth and the involved teeth showed slight root resorption (). A mandibular cross sectional occlusal radiograph revealed buccal cortical expansion bilaterally along with trabeculation present at the periphery of the lesion ().\nBased on the radiographic findings, the differential diagnoses of radicular cyst, multiple odontogenic keratocyst associated with nevoid basal cell carcinoma syndrome, bilateral central giant cell granuloma, brown's tumor associated with hyperparathyroidism, and unicystic ameloblastoma were considered.\nOn surgical enucleation and extraction of the tooth, the specimen was subjected to histopathological examination, which revealed non-keratinizing epithelium of variable thickness exhibiting an arcading pattern and connective tissue wall consisting of moderately collagenous with dense inflammatory infiltrate predominantly plasma cells and lymphocytes. These findings were suggestive of radicular cyst (). |
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. |
This is the case of a 37-year-old, primigravid woman who underwent spontaneous vaginal delivery. She was deemed to be well before labour with an uncomplicated pregnancy having walked to the delivery unit that morning. She had a normal blood pressure throughout pregnancy as well as in the postpartum period.\nDuring labour, it was noticed that the patient was becoming increasingly confused but hours later she underwent normal vaginal delivery. She was however noted to be still confused by her husband. Twenty-five minutes after delivery, her first generalised tonic-clonic seizure occurred, lasting about 5 minutes before spontaneously resolving. Despite being given magnesium sulphate for possible eclampsia at that time, she remained confused and had a further seizure within 3 hours. A further infusion of magnesium was administered unsuccessfully, thus the patient was given intravenous anti-convulsants causing a decrease in consciousness requiring subsequent intubation for airway protection. She had a one-off elevated blood pressure of 160/102 during fitting, and at all other times she was normotensive. Her urinalysis showed a trace of protein after delivery. Eclampsia was subsequently thought to be unlikely. At the time of the mother's second fit, the newborn baby also had a seizure. Further information from the partner suggested that the couple normally drank a lot of water between them, with the mother drinking up to 4 litres of water a day. The mother had recently been drinking more than this because of the recent hot weather. She also continued to drink increasing amounts of water in the run-up to labour due to a feeling of thirst, after being taught to avoid dehydration in antenatal classes. Liberal fluid intake is encouraged to counter the fluid losses and energy expenditure during childbirth []. There was no other medical or drug use history. The patient had an otherwise normal healthy diet.\nHer immediate blood tests showed a metabolic acidosis, likely to have been caused by the two fits, as well as low serum sodium of 111 mmol/litre, low urea of 0.8 mmol/litre along with low chloride and potassium levels. Urinalysis revealed a urine osmolality of 67 mosmol/kg and urinary sodium of 10 mmol/litre. A paired serum osmolality of 228 mosmol/kg was consistent with a dilute serum and urine, suggesting water overload. Neurological examination before intubation showed normal fundi and no focal neurological abnormality other than the marked confusion. The newborn baby also had low serum sodium of 108 mmol/litre, urine osmolality of 46 mosmol/kg, urinary sodium <10 mmol/litre and serum osmolality of 225 mosmol/kg. The mother was subsequently managed on the intensive care unit and the baby on the special care baby unit. A maternal lumbar puncture was normal as was subsequent cranial magnetic resonance imaging (MRI) showing no venous sinus thrombosis or evidence of central pontine myelinolysis.\nThe maternal sodium was initially corrected at a rate of 1 to 2 mmol/l/hour with hypertonic saline. This rapid correction was done due to her ongoing seizure risk and stopped when the serum sodium reached 125 to 130 mmol/litre (Table ) or the patient deemed to be no longer at risk of life-threatening manifestations of severe hyponatraemia with cessation of seizure activity. Too rapid a correction of serum sodium can trigger demyelination of pontine and extrapontine neurons to occur after one or up to several days after the correction. This causes neurological dysfunction, including quadriplegia, pseudobulbar palsy, seizures and death. Most reported cases of osmotic demyelination have occurred after rates of correction exceeding 12 mmol/litre per day []. A correction rate of up to 8 to 10 mmol/litre per day is recommended to reduce the risk of osmotic demyelination but can be cautiously exceeded if severe symptoms do not respond [,]. Due to the acute and life-threatening nature of her illness, hypertonic saline was chosen to raise the serum sodium rather than fluid restriction which may be more appropriate in more chronic conditions. The amount of hypertonic saline needed is estimated by calculating the sodium deficit using the following equation:\nTotal body water is estimated as lean body weight times 0.5 for women or 0.6 for men.\nThis gave us an estimate in mmol/litre of sodium required, thus allowing a suitable volume of hypertonic saline to be infused to achieve the above rate of correction []. Another equation can also be used to see the effect of 1 litre of any intravenous solution on serum sodium.\nFrequent sodium measurements are still required to assess the efficacy of treatment. Blood tests in both mother and baby subsequently slowly normalised. This improvement allowed the mother to be extubated the next morning. It was noted that the mother had fractured her left neck of femur as well as having a right shoulder fracture dislocation, both of which were subsequently repaired without incident. Bone densitometry and biopsy showed osteoporosis. A short synacthen test was normal ruling out primary adrenal failure as a possible cause for the hyponatraemia and osteoporosis. Parathormone and thyroid function testing was also normal. The osteoporosis could be associated with the pregnancy, as no other cause was identified in this young primigravid woman. The mother subsequently made a full neurological recovery with no further episodes of confusion or fitting. |
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. |
A 61-year-old man with a history of hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, chronic kidney disease stage III, and diastolic heart failure (ejection fraction 40%) with bioprosthetic aortic valve presented to the hospital with lightheadedness and dark stools. The patient was noted to have anemia with a working diagnosis of gastrointestinal bleeding and was transfused two units of packed red blood cells, which clinically resolved. On hospital day 2, the patient had sudden left hemiplegia and dysmetria which resolved within 4 h from onset. Vitals on admission were notable for a blood pressure of 147/70 mm Hg and a heart rate of 88 beats/min. On neurologic examination after the ischemic incident, the patient did not have any residual neurologic deficits. Initial head computed tomography (CT) showed old bilateral infarcts and no acute abnormalities. CT angiogram of head revealed 99% stenosis of right ICA (), foci of probable ischemia in the right inferior temporal and posterior parietal lobes, and an incidental aneurysm of the tip of basilar artery measuring 3 × 5 × 4 mm (). Brain magnetic resonance imaging (MRI) showed no acute infarct. Carotid duplex showed at least 99% stenosis of right ICA, and about 50% stenosis of left ICA.\nThe patient underwent an uncomplicated right CEA with bovine patch angioplasty. Systolic blood pressure (SBP) for majority of case was in the range of 140 - 160 mm Hg, with one episode of 200 mm Hg requiring single push of 5 mg intravenous (IV) metoprolol. Post-operatively, the patient was transferred to surgical intensive care unit, and was started on aspirin and clopidogrel. SBP was initially high and a nicardipine drip was used to maintain a systolic blood of less than 140 for 24 h. The patient remained without neurologic deficits and was discharged home on post-operative day 1. Six days later while at home, the patient had sudden onset of severe headache with loss of consciousness requiring endotracheal intubation. On readmission, the patient was noted to have a blood pressure of 180/80, unequal non-reactive pupils and demonstrated flexion withdrawal of the right arm. Head CT showed diffuse SAH (), and CT angiogram of head again demonstrated an aneurysm at the tip of basilar artery measuring 3 × 5 × 4 mm, presumably the source of SAH (). Bilateral common, internal and external carotid arteries were without significant stenosis. The patient had an extra-ventricular drain placed and was taken emergently for pipeline embolization of the basilar tip and a right superior cerebellar artery aneurysm. He remained intubated post procedure and never regained any neurologic function, developed multi-organ system failure and was terminally extubated on post-operative day 11. |
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. |
We present a case of a 44-year-old man with end-stage kidney disease from ADPKD due to a frameshift truncating mutation in the PKD1 gene. After being on hemodialysis for less than a year, he received a directed related deceased donor kidney transplant from a 21-year-old male first cousin known to have ADPKD and who died from a motor vehicle accident. The donor/recipient human leukocyte antigen mismatch was reported as 3/6. The recipient received induction immunosuppression with corticosteroids (only induction agent available at that time). Ten years later, the recipient underwent a right native nephrectomy followed by a left nephrectomy for significantly enlarged and symptomatic kidneys as well as a significantly enlarged polycystic liver. Over the course of 20 years, the recipient was maintained on cyclosporine and prednisone and enjoyed a stable renal allograft function with a serum creatinine of 1.5 to 1.7 mg/dl without any episodes of rejections or urinary tract infections. His renal allograft function declined rapidly with several episodes of acute kidney injury in the setting of new-onset severe ischemic cardiomyopathy with a reduced left ventricular ejection fraction of 36% and severe mitral valve regurgitation. He also developed significant hypervolemia and ascites. At that time, his serum creatinine was as high as 3.2 to 4.1 mg/dl in the setting of aggressive use of a combination of thiazide and loop diuretics along with aquapheresis. He was quite symptomatic due to the enlarged cystic liver. In addition, he had significant abdominal fullness and ascites contributed partially by the cardiac failure. The distribution of the cysts in the liver was such that he was not a candidate for aspiration foam sclerotherapy, cyst fenestration, or surgical resection. He was treated conservatively for his heart failure due to the underlying comorbidities, including severe polycystic liver disease. To improve his kidney allograft function, the cyclosporine was switched to sirolimus without improvement of his kidney allograft function. He subsequently died at the age of 64 years from complications related to decompensated heart failure. A computed tomographic scan of the abdomen without intravenous contrast () shows severe polycystic liver disease (arrowheads) and a polycystic kidney transplant in the left lower quadrant (arrow). The cystic allograft kidney volume was 1244 ml with a growth rate of 19% per year over the preceding 6 years. The trend of the kidney allograft volume along with the estimated glomerular filtration rate over the preceding 6 years is depicted in . |
The patient was a 41-year-old female with past medical history of appendectomy and dysmenorrhea. She presented to the emergency department with nausea, severe vomiting, and acute pain in the lower abdomen. She reported having experienced asthenia and weight loss for one month. On clinical examination, abdominal distension and tenderness were discovered. Blood tests revealed leukocytosis with neutrophilia, and a contrast-enhanced abdominal computed tomography (CT) showed a 7 × 7 × 4 cm hyperenhanced mass in the cecum that caused complete bowel obstruction (). Also, a 5 × 3 × 3 cm right adnexal mass that compromised the ovary with intimate contact with the uterus was found (). Furthermore, the CT showed dilated loops in the small bowel (>4 cm), some of which had an enlarged wall thickness and presence of intraluminal fluid stasis ().\nWith these findings, particularly the observation of a mass through the CT scan, and due to the evident weight loss that the patient had undergone, neoplasia could not be ruled out. Surgery was decided, and at laparotomy, a volume of 200 ml of inflammatory fluid was found in the cavity. Most of the loops of the distal ileum were dilated, and a 7 × 7 × 3 cm cecum mass was discovered, which compromised the ileocecal valve and caused complete bowel obstruction. Surgical decision was straightforward, the cecum mass was completely resected, and a right hemicolectomy was executed. An ileocolic anastomosis was also performed during the procedure. Furthermore, the right adnexal mass that was previously identified through the CT scan (measuring 4 × 3 × 2 cm) was observed to be firmly attached to the ovary and the fimbriae and displayed a pale external capsule surrounded by a cystic component. Gynecology consultation was required, and due to the size of the mass and its characteristics, surgical removal of the right adnexal mass was performed. After completion, closure of the abdominal wall was performed, and the remainder of the procedure continued without any complications.\nPathology revealed a 4 × 3 × 2.5 cm blueish heterogenic mass that occluded 90% of the lumen of the cecum and the ileocecal valve. Microscopy revealed that the colon wall was invaded by glands and endometrial stroma. The colonic epithelium showed inflammatory changes and was negative for malignancy (Figures and ). In the ovarian parenchyma, an endometrial cyst was discovered, covered with siderophages. Glands and endometrial stroma were observed in the fallopian tube as well ().\nThe postoperative course of the patient was uneventful. She initiated clear liquids a day after surgery and was discharged once full diet was resumed. On follow-up controls, the patient was completely asymptomatic, without any pain or complications. |
A 24-year-old female patient was referred to the Department of Periodontics, K.S.R Institute of Dental Sciences with the chief complaint of growth in the gums of right upper front teeth for the past 2 months. She was 10 days old of post-partum phase when she visited the Department of Periodontics. Past dental history revealed of similar growth in the same region which was excised in a private clinic during the 7th month of pregnancy. No history of radiographs taken in the same region. Within a week, same type of growth reappeared and gradually started increasing in size. As the lesion re-appeared, patient was apprehensive that it could be a carcinogenic tumor which was interfering with speech and mastication. She wanted immediate attention toward the lesion and treatment for the same.\nOn extra oral examination, no gross abnormalities were detected. On intra oral examination, diffused gingival growth was noticed between the 12 and 13 region. On the labial aspect, it measures l cm × 2 cm in diameter, red, sessile, smooth and shiny, soft in consistency and bled on slight provocation []. On the palatal aspect, the lesion was similar, but the size is somewhat more pronounced when compared with labial aspect [] Due to the increase in size of the tumor, subgingival local irritants were found more around the involved teeth due to the improper plaque control measures. On periodontal examination, periodontal pocket depths of 7 mm, clinical attachment loss of 5 mm, with Millers Class I gingival recession was associated with the involved 12 and 13 teeth region. Based on the clinical findings, the lesion was provisionally diagnosed as a pregnancy tumor with localized periodontitis and the differential diagnosis was made as peripheral giant cell granuloma, peripheral ossifying fibroma with localized periodontitis.\nRoutine blood investigation was advised and values were found to be within normal limits. Full mouth intraoral radiographic investigations revealed horizontal type of bone loss extending up to the middle third of 12 and 13 teeth region only [].\nPatient was reassured with proper periodontal treatment plan. Scaling and root planning was carried out under phase I therapy and was treated accordingly with plaque control measures. Although plaque control measures improved the periodontal status dramatically, the lesion appeared static. A complete surgical excision was planned.\nUnder local anesthesia, excisional biopsy procedure was performed using electrocautery thereby minimizing the pre-operative bleeding for proper manipulation of the tissues in elevating the flap []. Full thickness mucoperiosteal flap reflected involving 11-13 regions. Root planning and flap curettage was done and irrigated with saline. Flap repositioned with figure of eight sutures and non-eugenol periodontal dressings placed. Post-operative instructions with medications were given. Excised specimen was sent for histological examination.\nHistopathologic examination of the excised specimen confirmed our clinical diagnosis; the specimen stained with hematoxylin and eosin showed partial covering by parakeratotic stratified squamous epithelium of variable thickness which showed areas of ulceration and fibrinopurulent membrane. Under fibrous connective tissue stroma, numerous small and larger endothelium lined channels are formed that are engorged with red blood cells. A mixed population of inflammatory cell infiltrates comprising of neutrophils, plasma cells and lymphocyte is evident. The microscopic appearance was compatible with clinical picture and final diagnosis of pregnancy tumor was made [].\nOne week post-operative healing showed some marginal inflammation with receded gingival margin. The patient was comfortable and the healing was uneventful. Sutures were removed and proper maintenance program was initiated. During recall visits of 3 and 6 months, the surgical site appeared normal without recurrence of the lesion []. |
A 66-year-old, systemically healthy female patient presented with a complaint of pain and swelling on the right side of the face since 5–6 months. The patient reported a rapid increase in size of the lesion over the past 2 months.\nPast dental history revealed that the patient had got her maxillary right first molar(16) extracted from some local dentist about 3 months ago.\nExtraoral examination of the patient revealed an ill-defined swelling on the right side of the face in the superficial part of the parotid, with an intact surface, measuring approximately 3-4 cm in size, that caused an unilateral bulging of the canine fossa and zygomatic process with no facial nerve palsy []. The lesion was not fixed to the underlying bone and was entirely within the soft tissues of the right buccal mucosa.\nThe nasolabial fold on the right side of the face was unobliterated. Right submandibular lymph node, less than 2 cm in size and oval in shape, was enlarged, palpable and minimally tender.\nOn intraoral clinical examination, an ovoid, firm, sessile nodule, measuring approximately 3 × 4 cm, in relation to 16 within the soft tissues of the right buccal mucosa was observed. The overlying mucosa was intact and normal in color with no signs of inflammation, ulceration or pus discharge.\nHematological investigations revealed a normal complete blood count, erythrocyte sedimentation rate, and blood chemistry.\nBased on the patient's history and clinical examination associated with a rapid growth of the observed lesion, diagnosis of a malignant neoplasm was hypothesized and further investigations were carried out.\nPlain and contrast-enhanced scans with axial and coronal sections revealed a heterogeneous enhancing soft tissue mass, measuring approximately 4 × 3 × 3 cm in size, seen in the parotid region on the right side of the face []. Erosion of the adjacent alveolar margin of the maxilla was noted. The mass was extending inferiorly in the buccal region adjacent to the mandible. No fat plane was seen separating the mass from the masseter muscle. There was no extension in the oral cavity. Minimal mucosal thickening was seen along the floor of the right maxillary sinus. The overall features were suggestive of a neoplastic lesion.\nIncisional biopsy was carried out and histopathologic analysis demonstrated a neoplastic proliferation of dark-staining epithelial cells with basophilic nuclei and scant cytoplasm enclosing circular spaces, arranged in a cribriform pattern. The lumina of few ductal structures contained a mucinous substance that was faintly eosinophilic. The hyalinized eosinophilic product was also seen surrounding these cribriform islands []. At the periphery, epithelial cells were arranged as single ductal structures formed by layers of isomorphic cells []. However, the cribriform pattern appeared to dominate, giving the entire structure a typical “swiss-cheese” appearance. The histopathologic impression was that of an ACC of cribriform pattern.\nSubsequently, the patient was referred to the Department of Oral and Maxillofacial Surgery, where she underwent a radical parotidectomy. Infraorbital nerve and masseter muscle were sacrificed and modified radical neck dissection was performed under general anesthesia after metastatic work up. 60 Gy adjuvant external beam radiotherapy with 2 Gy fractions was administered postoperatively to the parotid area and the neck.\nNo local recurrence of the lesion was observed 6 months after the treatment, during which time X-ray chest was repeated which revealed no pleural or parenchymal abnormalities. |
A 63-year-old Caucasian man initially presented with painless jaundice against the background of no significant past medical history. He underwent a Whipple procedure for carcinoma of the head of the pancreas. Histology showed a pT3 tumour with the involvement of 8 lymph nodes. He commenced on adjuvant gemcitabine (1,000 mg/m2 to the nearest 38 mg as 2,100 mg given on day 1, 8, 15 on a 28-day cycle, planned for 6 cycles).\nJust prior to his 3rd cycle, he gradually developed bilateral pedal oedema, with no other signs or symptoms. He was started on furosemide and chemotherapy continued. During his 4th cycle he received 2 units of blood. At the start of his 5th cycle he developed occasional shortness of breath, but by day 15 he was found to be anaemic and thrombocytopenic with acute kidney failure. Investigations ruled out urinary obstruction. He was treated with intravenous fluids and blood products. Patient was discharged home after renal team review. After a week at home, peripheral oedema and breathlessness increased and he was readmitted to hospital. Chest X-ray showed a mixed picture of fluid overload and right upper lobe consolidation. An echocardiogram demonstrated impaired systolic function with LVEF of 38%, mildly dilated left atrium, and mild mitral and tricuspid regurgitation. The patient was admitted to the coronary care unit by the cardiology team and was treated with antibiotics and diuretics, initially intravenously and later orally as he improved. It was decided to terminate adjuvant chemotherapy at the 5th cycle.\nThe CT scan at this stage was clear and the patient was placed on surveillance and continued outpatient follow-up by the cardiology and nephrology teams. A further cardiac MRI arranged by the cardiology team 2 months later demonstrated stable cardiac function, with an improvement in the EF to 67%, but demonstrated a suspicious retrocrural lymph node. To rule out recurrence a repeat CT staging scan was performed, additionally confirming that the retrocrural lymph nodes also showed multiple peritoneal metastases.\nHe was subsequently commenced on 2nd line FOLFOX (FOLFIRINOX modified due to renal and cardiac impairment) at a 75% reduced dose; treatment was well tolerated with only grade 1 peripheral neuropathy affecting fingertips and fatigue. The CT scan after 6 cycles and on completion of the 12th cycle showed stable disease. A surveillance scan after 3 months demonstrated disease progression again with worsening peritoneal and omental disease. He was re-challenged with FOLFOX. He continued to tolerate chemotherapy with minimal toxicity. Unfortunately he quickly deteriorated after cycle 5 of re-challenge FOLFOX chemotherapy, with severe cachexia and anorexia. A repeat CT confirmed significant progressive disease in the peritoneum and omentum with an enlarged metastatic node in the right groin. He passed away a few days later in February 2017. |
A 50-year-old female reported to the dental hospital with the complaint of swelling in the left lower jaw and the right side of the face for the past 3 months [Figure –].\nHistory revealed that the swelling in the left mandible was present since 3 months and swelling in the right side of the face was present since 1 month. Both the swellings were rapidly increasing in size. Patient was asymptomatic initially but experienced pain 10 days back with the rapid increase in size of the swellings. The patient took analgesics, but there was no relief. Further, the patient also developed a growth in the gingiva 1 month back which was also rapidly increasing in size causing a gradual reduction in mouth opening. Patient was on treatment for gastritis and abdominal pain since 1 year.\nOn clinical examination, a diffuse swelling was seen in the left side of the body of the mandible, ovoid in shape and another diffuse swelling present in the right side of the face. Depressions were seen in the superior part of the swelling in the zygomatic region. On palpation, both the swellings were firm with mild tenderness on palpation. Mouth opening was limited to 20 mm. Intra-oral examination revealed a localized growth present on gingiva and alveolar mucosa extending both buccally and lingually from 33 to 37 region. The growth was irregular in shape; surface was irregular covered by slough. Margins were everted with the obliteration of buccal sulcus, and the growth was firm in consistency, fixed to the underlying bone []. Another swelling was seen in the right buccal mucosa that was spherical in shape, slightly ulcerated in the centre, firm in consistency and nontender on palpation.\nSince the swellings and growth were sudden in onset, irregular in shape, rapidly increasing in size and destroying the surrounding structures, a provisional diagnosis of malignant growth was made.\nSquamous cell carcinoma, primary intra-osseous carcinoma and metastatic carcinoma were considered in the differential diagnosis. |
We present a case of a 69-year-old female with a past medical history of multiple myeloma followed by autologous peripheral stem cell transplant who was hospitalized after presenting with worsening dyspnea. Prior to her stem cell transplantation, she was found to have pulmonary Cryptococcus neoformans infection and was placed on oral flucytosine and intravenous liposomal amphotericin B. Subsequent studies revealed no central nervous system (CNS) involvement, and flucytosine was discontinued. She was discharged from the hospital to complete two weeks of intravenous liposomal amphotericin B and a year of oral fluconazole. She was readmitted after two weeks due to constitutional symptoms of fever, loss of appetite, and fatigue in addition to dry cough. Cryptococcus serum titers were 1 : 640 during this time as compared to 1 : 2560 at diagnosis. Bacterial and fungal cultures taken from peripheral and central access sites revealed no growth and Aspergillus serum antigen was negative. Chest CT revealed worsening pulmonary infiltrates in both the lingula and right upper lobe with a strong suggestion of fungal source (). In this setting, a bronchoscopy with bronchoalveolar lavage was recommended. Concurrently, due to the expected low likelihood of dual infection with Cryptococcus and Aspergillus, empiric treatment of immune reconstitution syndrome was considered but held until invasive fungal infection was definitively ruled out. Subsequently, bronchoalveolar lavage was performed which showed an Aspergillus galactomannan antigen level of 3.258, confirming pulmonary aspergillosis, while cultures revealed no growth. Oral fluconazole was switched to oral voriconazole to provide additional coverage. Upon initiation of oral voriconazole, the patient defervesced and remained afebrile for the remainder of her nine-day hospital stay. She was subsequently discharged from the hospital after experiencing improvement in her condition and was diagnosed with pulmonary aspergillosis coinfection in the setting of pulmonary Cryptococcus neoformans. Repeat chest CT at three months () and six months () from hospitalization shows significant interval improvement of both infiltrate and effusion and outpatient Cryptococcus serum antigen titers showed a continual decrease from discharge (). The patient was continued on oral voriconazole treatment for the duration of a year and tolerated the treatment well. |
A 26-year-old male had recurrent attacks of proximal and distal muscle weakness for the last 5 years. Since the age of 21 he has multiple episodes of weakness frequently following strenuous exercise. He came to the emergency room on December 15, 2012, with sudden onset paralysis following participating in a cricket match. There was bilateral weakness of both proximal and distal muscles. He had no neck or facial muscle weakness and had no difficulty with swallowing. He denied any history of recent diarrhea, chest pain, or shortness of breath. He had been suffering from seizures since the age of 19 and had been on regular antiepileptic drugs. The last witnessed seizure was eleven months ago after which his local physician had increased the dose of his AEDs. He did not have any other significant past medical history and denies use of alcohol and drugs.\nOn physical examination, he was moderately built and otherwise normal in overall appearance. There was no jugular venous distension, goiter, or lymphadenopathy. There was hypotonia, flaccid paralysis of all extremities, and depressed deep tendon jerks. Cardiovascular examination revealed a regular pulse with no murmurs. Other system examinations were unremarkable.\nRoutine hemogram, biochemistry, and liver enzymes were within normal limits except for a serum potassium level of 1.9 mmol/L. In search of an etiology of hypokalemia, urine sodium and potassium were measured and found to be normal. Serum renin and aldosterone and thyroid function tests were also measured to rule out adrenal and coexistent thyrotoxic periodic paralysis, respectively. A routine electrocardiogram revealed the presence of a prolonged PR interval with U waves. EMG revealed total electric silence. Following intravenous potassium supplementation he made a complete recovery within 48 hours with dramatic improvement of muscle power and deep tendon reflexes.\nOn the fifth day of admission, he developed a convulsion with clonic movement of both arms and legs with tonic spasms of the neck muscles. The patient was afebrile and had no neck stiffness. A complete haemogram and biochemistry revealed a normal serum potassium, sodium, and blood sugar. A lumbar puncture showed normal findings. A postictal electroencephalogram study revealed synchronous generalized polyspike-and-wave discharges with normal background. Fosphenytoin and valproic acid were used to control the epileptiform discharges. |
The patient is a 72-year-old man with a history of bladder cancer diagnosed two years ago now status post two rounds of intravesicular BCG. His most recent treatment was given 8 months prior to his ultimate diagnosis with BCG-positive mycotic aneurysms. The indication for treatment was a recurrence in carcinoma in situ that was picked up on routine screening. There was no trauma or concern for infection noted at that time.\nHe initially presented to an outside emergency room one month after this second round of BCG with recurrent fevers and rigors. Urine cultures grew coagulase-negative Staphylococcus aureus and he was sent home on Macrobid. He then presented shortly thereafter with increasing lethargy and was transferred to our facility where he was found to have an acute kidney injury and pancytopenia of unclear etiology. His AKI resolved with hydration and work-up for his pancytopenia was notable for a thyroid nodule that was biopsied but ultimately found to be benign. Imaging at that time was notable for a normal abdominal aorta. The patient declined a bone marrow biopsy. He would then present once more a few months later to an outside facility with worsening rigors, chills, and fevers. A chest X-ray was concerning for pneumonia which was treated with cefuroxime.\nIn the midst of these recurrent hospitalizations, the patient transferred his care to a urologist with our group. He was found to have positive urine cytology which was concerning for a recurrence of his cancer and a CT urogram was ordered as follow-up (). This CT, now 8 months from his most recent BCG treatment, was notable for two abdominal aortic aneurysms, both infrarenal. Given that these aneurysms were not present on his imaging 7 months earlier, there was a concern for a mycotic process. He was admitted and underwent open resection of his aneurysms with inline reconstruction utilizing a rifampin-soaked Gelsoft 16 × 8 mm bifurcated graft. Mycobacterium complex DNA was isolated from fluid around his aortic wall for which he was started on rifampin, ethambutol, and isoniazid (). His postoperative course was complicated by chylothorax and GI bleed requiring transfer to an ICU and multiple transfusions. He was discharged after a month in good condition with a follow-up and a plan for 6 months of therapy with rifampin, ethambutol, and isoniazid. |
A 13-year-old Caucasian boy presented with acute appendicitis, characterized by right lower quadrant pain. He underwent a laparoscopic appendectomy, and a pathology report confirmed the diagnosis of focal acute appendicitis. No intra-abdominal masses were noted at the time of surgery. However, after the operation, the patient experienced persistent drainage of serosanginous fluid from a trochar site. Once this drainage ceased, the patient was discharged home ten days after admission.\nDuring the next six months he continued to experience intermittent abdominal pain, which led to representation to the emergency room. Additionally, the patient experienced an increase in abdominal girth, abdominal pain, and weight loss. No constipation, diarrhea, nausea, vomiting or jaundice was reported. A CT scan of the abdomen and pelvis demonstrated a 23 by 12.5 cm fatty soft tissue mass surrounded by mesenteric fat (Figure ). The tumor encased branches of the superior mesenteric artery and displaced the small bowel. Multiple fluid collections were also seen in the right lower quadrant. A subsequent CT-guided biopsy suggested a benign fatty tumor; the differential diagnosis included lymphangioma, lipoma and fibrolipoma. The patient was then transferred to our institution for definitive care.\nA physical examination of the patient revealed that his vital signs were within normal limits and that his abdomen was distended with a large palpable mass extending from the left flank to the right semilunar line. A large part of the bowel appeared to be displaced in the right abdomen, and the presence of shifting dullness suggested ascites.\nThe patient was taken to the operating room where a diagnostic laparoscopy confirmed a large intra-abdominal tumor arising from the mesentery and a significant amount of free chylous fluid. The tumor adhered to the duodenum and the superior mesenteric artery (SMA) and vein (SMV). A frozen biopsy performed during the operation suggested that the mass was a lymphatic vascular malformation with a fibrous stroma and fibrous capsule consistent with a benign tumor. The operation was converted to a midline laparotomy for tumor resection. As mentioned earlier, the tumor was largely entangled with the mesentery. However, a circumferential dissection was performed through the creation of a plane between the tumor and mesentery. The SMA, the third and fourth portions of the duodenum, and the proximal small bowel were each affixed to the tumor but were successfully dissected off. The tumor was excised along with 50 cm of small bowel, and a primary anastamosis was performed (Figure ). The final pathology demonstrated a 27.5-cm lymphatic malformation with no evidence of malignancy (Figure ); the ascitic fluid aspiration was deemed to be chylous ascites. The patient recovered well and was discharged home eight days after the operation. At a follow-up visit six months after the operation, the patient is doing well and tolerating full oral feeding, with complete resolution of his abdominal complaints. |
A 25-year-old healthy right hand dominant male who works as a seaman presented to our multidisciplinary hand clinic with persistent radial sided wrist pain. He reports sustaining an injury to his wrist one month prior to presentation from a fall on an outstretched hand. He had been placed in a short arm cast by an outside hospital for immobilization of his left scaphoid waist fracture and was referred to our hand clinic for definitive management. On examination, he had persistent anatomic snuffbox tenderness. Radiographs confirmed a displaced and malrotated fracture pattern (Figures –) with suspicion of acute on chronic injury.\nUnder general anesthetic, a volar approach to the scaphoid was used to expose the fracture. Direct intraoperative visualization of the fracture site demonstrated central comminution with no signs of healing. There were significant cystic and fibrous changes at the fracture site with sclerotic changes at the proximal pole consistent with fracture nonunion. The nonunion site constituted the central 1/3 of the length of the scaphoid. The fracture nonunion site was debrided until punctuate bleeding was visualized in both proximal and distal poles. This debridement was performed using a combination of curette and burr with copious saline irrigation to minimize the chance of thermal necrosis. Upon completion of debridement it was noted that there were longitudinal fracture lines in the proximal scaphoid pole, as well as a significant bony void secondary to the significant fibrous and sclerotic tissue. Ultimately this was concerning for the potential for propagation of these fracture lines if a headless compression screw was used for fixation.\nAfter debridement of the proximal and distal ends, a corticocancellous iliac crest autograft bone graft strut was harvested using a standard anterior approach to the pelvic brim with the incision centered 2 cm inferior and 2 cm posterior to the anterior superior iliac spine. Additional cancellous bone was harvested from the iliac crest to further fill the scaphoid nonunion defect. The corticocancellous bone graft strut was contoured and wedged centrally into the proximal and distal poles of the scaphoid to recreate the appropriate anatomic length of the scaphoid as well as reduce the humpback deformity. Although the bone graft strut was contoured as best as possible, there was still toggle of the proximal and distal poles and the bone graft demonstrated a propensity to extrude out and cause malalignment. The additional cancellous iliac crest bone graft was densely packed around the cortical strut for further stability. A well contoured corticocancellous strut is the best option for scaphoid nonunion. However, this fracture pattern created a unique situation secondary to the longitudinal fracture fragment as well as the large gap of bone which destabilized the proximal and distal segments of the scaphoid. It was determined that plate fixation would best serve to further stabilize the nonunion and buttress of the bone graft to minimize graft extrusion and malalignment. A precontoured Medartis® TriLock 1.5 mm 6-hole scaphoid plate was selected and temporized in position using 0.028 Kirschner wires. Utilizing the variable angle locking system, three screws could be secured into the proximal pole and three screws were secured into the distal pole. Fluoroscopy confirmed appropriate reduction and hardware placement (). Gentle wrist range of motion demonstrated excellent stability of the construct with no signs of impingement at the radiocarpal joint ().\nThe patient was placed into a Muenster cast for 4 weeks. At that time X-rays were performed out of cast. He was subsequently placed back into a Muenster cast for an additional 4 weeks. At 8 weeks post-op immobilization was discontinued and a radiographic imaging was performed to evaluate bridging trabeculae at the fracture site. The X-rays demonstrated partial uniting of the fracture and we continued the patient immobilization again in a Muenster cast for 4 more weeks (Figures –). Repeat imaging at 12 weeks post-op displayed evidence of bony consolidation with small bridging callus and bony incorporation along the fracture with incomplete graft incorporation (Figures –). He demonstrated excellent mobility, achieving 85% of his contralateral range of motion, with discomfort only at extremes of flexion and extension. |
An 85-year-old man with severe heart failure due to dystelectasis was followed up and cared for by a cardiologist. The patient also had advanced chronic kidney disease (CKD) secondary to hypertension. The patient was admitted to hospital due to severe dyspnea. Initially, the cardiologist administered diuretic therapy; however, this treatment was not effective because of CKD. The cardiologist then consulted us as nephrologists and dialysis nurses to inquire whether dialysis was a better treatment for controlling CKD. The patient was provisionally diagnosed with advanced dementia, and we therefore concluded it was too difficult to initiate hemodialysis (HD) due to the patient being unable to keep still during therapy. We had frequent opportunities to obtain informed consent from his family, and as a result of these discussions it was decided that peritoneal dialysis (PD) managed mainly by the family would be a suitable therapy for the patient. The physical state of the patient was improved by PD, and he was able in be discharged from hospital. However, as expected, he had difficulty to accepting the procedure of PD, so he sometimes tried to draw or twist a PD tube. Hence, we supposed that even PD would be quite burdensome for his family as a caregiver.\nAfter discharge, the patient was briefly readmitted suffering from a swollen scrotum, diagnosed as a communicating hydrocele from a hypogastric hernia complicated by PD. Although we recommended surgical treatment to continue PD, the family did not want further treatment due to further pain and physical burden for the patient and the risks associated with the operation. In that situation, as conservative care, we observed the hydrocele with discontinuation of PD. After one week, he had successfully recovered and he was able to stay without annoying pain. We were afraid that the of recurrence of communicating hydrocele as a result of restart of PD. Both we and his family were in the very difficult situation of the care for him. What kind of treatment should we prepare? Judging by his urinary volume, we considered that his residual renal function would be maintained for several weeks. We concluded that he had a right to live a peaceful and painless moment for the last period. We therefore proposed withdrawal from dialysis (WD) and palliative care as an optional treatment. We also assured the family of nonabandonment and continued careful follow-up. Despite this care, we could not obtain the patient's preference for end-of-life care. However the patient's family agreed with our choice of conservative care, and the patient was allocated to home care with follow-up and close contact being provided by our hospital.\nFortunately, the patient's respiratory distress caused by overhydration was controllable by prescribing diuretic drugs, and he was therefore able to live peacefully with his family for 147 days after WD. During this terminal phase, he was readmitted to hospital, and after the family's agreement on the risks of opioid therapy, he was administered morphine to reduce dyspnea. Palliativists played a major role in this treatment which lasted 7 days. The patient subsequently passed away peacefully, with dignity surrounded by his family. |
The first patient, a 52-year-old woman, presented with persistent chronic pain and loss of function after sustaining a proximal humerus fracture treated with open reduction internal fixation 12 years before the index surgery. There was no major deformity of the proximal humerus but partial humeral collapse with secondary OA. According to the glenoid bone loss classification system of Walch et al. [], the patient had a type A2 glenoid. After HA with osteochondral glenoid allograft initial pain relief and improved function were noted, but the patient worsened rapidly thereafter. The erosion of the glenoid allograft bone was 0.5 cm at latest FU 24 months postoperatively. Infection was ruled out and a revision to TSA was performed 2.5 years after the index procedure but did not alleviate symptoms. A revision to an RTSA was performed 9 months after the TSA and the patient was satisfied because of pain relief at latest FU with an SSV 35% of and CSr of 43 points 5 years postoperatively. The second patient was a 37-year-old man who had had two stabilization procedures, including open and arthroscopic Bankart repair and subsequently developed OA (type B1 glenoid). Nine months after HA and glenoid allograft procedure the patient remained unacceptably painful with an SSV of 15% and a CSr of 7 points. CT showed a median erosion of the allograft of 0.3 cm. Consecutively, conversion to an RTSA was performed 9 months after the initial procedure. At last FU, 1 year after revision surgery, the pain had clinically resolved. This patient was lost to follow-up thereafter. The third patient was a 51-year-old man who presented with primary OA (type B2 glenoid) with pain and loss of function. After HA with osteochondral glenoid allograft the pain persisted with an SSV of 20% and a CSr of 46 points. The median abrasion of the glenoid bone was 0.2 cm at last FU. Consecutively revision to a TSA was performed 1 year after the index procedure. Two years after glenoid conversion radiographic loosening was diagnosed. Conversion to an RTSA was offered but refused and the patient was lost to follow-up. |
A 46-year-old female presented to the emergency department (ED) with a complaint of the sudden onset of low back pain. The symptoms began shortly prior to arrival when the patient experienced sudden onset of severe pain upon standing from a seated position. The pain was rated 10/10 and was localized across the low lumbar area with radiation to both legs. The patient took no analgesics and self-transported to the ED.\nOn ED presentation, the patient was noted to be unable to ambulate secondary to pain. Her initial vital signs were as follows: blood pressure of 177/99; heart rate of 88 beats per minute and regular; respiratory rate of 18 breaths per minute with an oxygenation saturation of 99% on room air; and an oral temperature of 99°F. The patient was an obese female with a history of untreated pernicious anemia and significant smoking history. The patient had not seen a physician in more than three years and had no recent illness or injuries. Examination revealed diffuse lumbar tenderness with normal lower extremity strength and gross sensation. Detailed sensory examination could not be undertaken due to patient distress at the time of evaluation. Posterior tibial and dorsalis pedis pulses were noted to be present bilaterally. Reflexes were found to be 2+ symmetrically with no evidence of saddle anesthesia. Shortly after presentation, the patient was noted to have urinated on herself because of a sense of “urgency.” Given this new finding, it was decided to immediately perform a noncontrast lumbar CT which showed no evidence of acute abnormalities. The patient was provided analgesics and a decision was made to monitor pain response.\nForty-five minutes after the analgesics were given, the patient experienced new onset of right lower extremity weakness. An emergent lumbar MRI was performed which showed no acute abnormalities. The patient continued to complain of severe back pain and progressively worsening lower extremity weakness which now included both lower extremities with the new onset of paraesthesias. Reexamination revealed pallor to the lower extremities, nonpalpable distal pulses, and decreased temperature to touch with near complete paraplegia. Concern for a vascular etiology prompted the performance of a chest and abdominal CT with contrast which revealed the near complete occlusion of the distal aorta with a saddle embolism which extended to the level of the third lumbar vertebra (Figures and ). A focal area of prominent plaque projecting into the aortic lumen at the level of the aortic arch was considered to be the potential source of the occlusive embolus. The patient was immediately taken to the operating room and underwent bilateral transfemoral arthrotomies with satisfactory retrieval of clots from the aorta and iliacs. Postprocedural bilateral angiograms showed superficial femoral, popliteal, and distal vessels with good runoff to the feet. Postprocedural transesophageal echocardiography revealed no clear cardiac source of the embolus. The patient's hospital course including a workup for a hypercoagulable state revealed no clear etiology for embolus formation. The patient experienced rapid improvement in clinical symptoms with mild residual right lower weakness, was provided aspirin and Plavix, and was ambulatory at discharge with the assistance of a walker. |
An 18-year-old boy presented with a history of progressively increasing growth on his right ring finger. He had undergone excisional biopsy of the lesion 1 ½ years ago, which was performed at another hospital. The biopsy reported the lesion to be a schwannoma. He had associated pain and numbness of the affected finger, which was progressively increasing over the past six months.\nOn examination, there was a globular, lobulated swelling of size 6 x 3 cm encircling the proximal phalanx of the right ring finger extending over the mid axial lines on both sides (Figure ).\nIt was tender on palpation and firm in consistency, and the skin over the swelling was not pinchable. The sensation was decreased over both radial and ulnar sides of the affected fingertip.\nX-ray of the right ring finger showed only soft tissue swelling with no bony involvement (Figure ).\nMRI showed an irregular moderately enhancing soft tissue mass at the volar aspect of the right fourth (ring) finger at the level of the proximal phalanx, extending to both ulnar and radial surfaces, likely representing a benign soft tissue neoplasm or a peripheral nerve sheath tumor arising from the digital nerve on the ulnar side of the ring finger (Figure ).\nThe pre-operative diagnosis was a peripheral nerve sheath tumor arising from the digital nerve. The patient then underwent surgery. The intra-operative findings were nerve tumor of size 5 x 4 cm over the proximal and middle phalanx region of the right ring finger (Figure ), the tumor was encasing the radial neurovascular pedicle, the ulnar branch of the digital nerve was found to be transected previously (in the first surgery), and the proximal end was found to be merged with the tumor and the distal end of the previously cut ulnar digital nerve was found just distal to dip joint with a stump neuroma (Figure ). Hence, a nerve tumor excision, distal digital nerve stump neuroma excision, neurolysis, and nerve reconstruction with lateral antebrachial cutaneous nerve graft were performed (Figures , ).\nThe post-operative biopsy reported it to be an ES and suggested immunohistochemical (IHC) studies to confirm this finding. IHC studies confirmed ES and it was found to be pan-CK (cytokeratin) positive, EMA (epithelial membrane antigen) positive, vimentin positive, and CD34 positive. The post-operative period was uneventful (Figure ), but unfortunately, the patient failed to comply with the radiotherapy regimen as suggested by the oncologist. He subsequently developed a recurrence after six months and was advised ray amputation, which he refused and failed to show up for further follow-up. |
A 57-year-old woman presented to the rheumatology clinic with recurrent fever and painful ulcers on her legs since two months. Eight months prior to current presentation, she developed vertigo and decreased hearing in her left ear which she felt was “full of air” all the time. She was found to have sensorineural deafness in her left ear. Two weeks later, she developed fever with chills. A chest radiograph revealed infiltrates in her right lung and an elevated ESR. She was treated with oral antibiotics which relieved her symptoms. Then she developed gingival hypertrophy and a CT scan of the paranasal sinuses revealed subcutaneous soft tissue thickening of the right buccal area suggestive of an inflammatory process. She was treated with ibuprofen and felt better. Her past medical history was notable for hypothyroidism for 20 years and she as well was maintained on 50 mcg of thyroxin daily. She had undergone hysterectomy for uterine fibroids 15 years ago. She reported no recent travel history. Of note, she revealed contact with sick animals. She nursed her paralyzed pet dog and also had cats. She was treated with antibiotics yet continued to spike fever and came to our center for comprehensive evaluation. On examination, she appeared weak and ill. The temperature was 37.5°C, the blood pressure 139/69 mm Hg, the pulse 78 beats per minute, and the respiratory rate 16 breaths per minute, with 99% oxygen saturation at room air. Erythematous tender nodules were noticed on bilateral lower extremities ().\nThe remainder of the examination was unremarkable. Her complete blood count revealed normocytic, normochromic anemia with normal white cell and platelet count. Her biochemistry showed normal kidney and liver function. No active sediment was present on urinalysis. Her three sets of blood cultures and one urine culture reported no growth. The test for latent tuberculosis by interferon gamma release assay (IGRA) was also negative. Serology for Brucella abortus and melitensis also came negative. Tests for chronic viral hepatitis B and C were also normal. Serological tests for connective tissue disease were negative as was the serum angiotensin converting enzyme level. Other relevant investigations are outlined in . An upper abdominal ultrasound showed hypoechoic, cystic lesions scattered across both lobes of the liver (). A subsequent CT scan of the abdomen with contrast showed multiple oval hypoattenuating lesions in both lobes of the liver ().\nOn liver biopsy there was evidence of cholestasis and multiple large irregular areas of necrosis, palisaded by epitheloid cells with associated granulomatous inflammation with a number of plasma cells ().\nAcid-fast bacilli culture of liver biopsy specimen after six weeks came out negative. Meanwhile, the patient continued to spike fever with maximum temperature of 101°F. Leg lesions were becoming worse with central necrosis and purulent discharge (Figures and ).\nPus cultures were negative for bacterial, fungal, and mycobacterial growth. A biopsy of the skin was performed. Pathological examination of frozen sections revealed surface ulceration with fibrinoid necrosis and vasculitis involving superficial and deep dermal vessels along with granuloma formation, neutrophilic infiltration, and debris ().\nImmunohistochemical testing was performed on biopsy specimen using immune-alkaline phosphatase technique which came negative for mycobacterial species. Real-time PCR for mycobacterial species also turned out to be negative. It was concluded from the skin biopsy that the patient had cutaneous granulomatous vasculitis. Treatment was commenced with prednisone 1 mg/kg/day and the patient was offered induction with cyclophosphamide which she refused due to associated toxicities. Meanwhile, azathioprine 2 mg/kg/day was added to prednisone. After seven weeks on prednisone and six weeks of azathioprine her lesions had healed almost completely (). She was maintained on prednisone 5 mg bid and azathioprine 50 mg bid with healing lesions. A repeat CT scan of the abdomen revealed normal architecture of hepatic parenchyma.\nTherefore, considering a chronic inflammatory process characterized by hearing loss, gingival hypertrophy, granulomatous hepatic lesions, and cutaneous ulcers with necrotizing granulomatous inflammation on skin biopsy, a unifying diagnosis of granulomatosis with polyangiitis (GPA) was made. |
A 69-year-old female with a history of right-sided breast cancer in 1991 (reportedly Stage I, but details of her pathology at that time are unavailable) was treated at an outside institution with lumpectomy and axillary lymph node dissection at the time of her initial diagnosis. She received adjuvant treatment with chemotherapy, followed by whole breast radiation therapy, and took two years of tamoxifen, which was discontinued due to uterine polyps. In January 2021, she presented to our institution with extensive changes to the skin of her right breast and a recent skin punch biopsy of the right breast showing Paget’s disease with a focus suspicious for microinvasion. The patient reported an intermittent rash to her right breast for two and a half years with an occasional stinging sensation but without regions of palpable concern bilaterally. She reported the rash to be pruritic and scaly and with intermitted bleeding. A diagnostic mammogram performed at an outside institution showed no significant interval mammographic change over multiple years (Figure ).\nNo suspicious radiologic findings were present in the right breast to suggest disease underlying the skin. Static ultrasound imaging of the right subareolar breast demonstrated no suspicious mass (Figure ). Breast MRI performed at an outside institution was of suboptimal quality, but demonstrated no gross suspicious findings with minimal background parenchymal enhancement (Figure ). Her past medical history was significant for hypertension, osteoporosis, and hyperparathyroidism status post parathyroidectomy. The patient had a family history significant for liver cancer in her paternal uncle and grandmother but no reported family history of breast or ovarian cancer. Patient is of Ashkenazi Jewish ancestry but elected not to undergo genetic testing.\nOn presentation to the surgical oncologist, the review of systems was positive for tenderness in the right breast and was negative for hematologic or lymphatic complaints. Clinical breast examination showed that the right breast was slightly smaller in size than her left breast, status post lumpectomy. There was an extensive area of right breast skin excoriation and erythema spanning 9 x 5.5 cm, which encompassed a majority of the skin of the breast. The right breast nipple-areolar complex was obscured by the skin changes (Figure ). There were no dominant masses in either breast, no nipple discharge, and no palpable axillary lymphadenopathy bilaterally.\nSkin punch biopsy performed at an outside institution and reviewed by our pathology department showed two separate areas of the skin consistent with apocrine cancer/Paget’s disease and a focus suspicious for microinvasion. Given the extent of skin involvement, the surgeon recommended right breast mastectomy without immediate reconstruction to remove all of the affected skin. Given that the patient had prior complete axillary lymph node dissection, a negative clinical axillary exam, and negative imaging, additional staging of the axilla was not performed to limit her risk of lymphedema.\nFinal pathology of the right breast mastectomy specimen showed irregular nests of poorly differentiated tumor cells infiltrating the superficial dermis in the background with epidermal Paget disease and dermal scar (Figure ). Paget cells and invasive nests were positive for cytokeratin 7 (CK7) with equivocal staining for human epidermal growth factor receptor 2 (HER2) (2+/3). The diagnosis of invasion was confirmed by negative staining for myoepithelial cells on p63/AE1/3, calponin, and smooth muscle myosin heavy chain (SMMHC)/AE1/3 and p40. As no primary breast tumor (in-situ or invasive mammary carcinoma) was seen in the underlying breast and due to the presence of invasive Paget nests in the dermis immediately underneath the epidermal Paget, the tumor was classified as “invasive Paget disease.” Final surgical pathology revealed free margins.\nOn follow-up, the patient healed well and had no specific complaints. The patient was seen by medical oncology to discuss the role of adjuvant anti-HER2 directed therapy, and she decided not to pursue any additional treatment. The patient remains clinically free of disease at six months following surgery. |
A healthy 27-year-old male patient was admitted to the first author’s institution with left hip pain for 10 months of duration without a history of a distinct trauma. He had severe pain in the left groin on weight bearing, with variable degree of pain at rest. He also expressed some mechanical symptoms of the affected hip, including catching and locking related to work and daily living activities. He did not have any systematic disease nor any congenital or developmental hip diseases. He did weekly jumping and running activities including basketball and soccer. On clinical examination, he had an antalgic gait and ambulated with a cane. Although the range of motion (ROM) of the hip joint was not restricted, his hip was painful with each of the extremes of passive flexion, internal rotation, and abduction. There was no compensatory external rotation with hip flexion. On the first evaluation, the Harris hip score of his left hip was 62 points. He did not receive any conservative treatment before the admission.\nThe anteroposterior radiograph of the pelvis showed a focal osteochondral defect on the weight-bearing surface of the femoral head (). The subchondral lesion was clearly seen separate and isolated from the remainder of the femoral head by a radiolucent line. Lateral center edge, sharp, femoral neck shaft, alpha angles, and acetabular inclination were 38°, 40°, 131°, 44.9°, and 44.3°, respectively. All these radiological parameters were within normal limits. Magnetic resonance imaging (MRI) scans showed an osteochondral separation without any displacement and evidence of collapse of the major fragment ( and ).\nHip joint arthroscopy was recommended to the patient. Under general anesthesia, a left hip arthroscopy was performed in a usual manner while the patient lay in a supine position on a fracture table. The standard anterolateral portal was used to visualize the hip joint with a 70° arthroscope and the anterior portal was used for instrumentation. The anterior hip joint capsule was released via the anterior portal and the joint space was identified clearly. There was no acetabular labral tear or distinct femoroacetabular impingement. A round osteochondral defect of 10 mm diameter was identified at the superior dome of the femoral head ( and ). The chondral lesion was excised and the defect was curetted and shaved. Under fluoroscopic control, a K wire with a 1.5 mm diameter was passed from the lateral border of the femur below the trochanter major and the tip of the K wire was visualized with an arthroscope (). Then overdrilling was performed over the K wire with a 10 mm diameter drill to prepare the host defect (). The osteochondral cylindrical plug with a 10 mm diameter and 15 mm in length was harvested from the non-weight-bearing area of the proximal lateral femoral condyle of the ipsilateral knee through a small lateral parapatellar arthrotomy using the Osteochondral Autograft Transfer System (OATS) (Arthrex, Naples, Florida, USA). The harvested osteochondral plug was transferred to the femoral head in a retrograde fashion and positioned within the spherical surface of the femoral head cartilage using fluoroscopic and arthroscopic control until the plug and intact chondral articulation were level ( and ). Afterward, the femoral tunnel was filled with a 60 mL spongious allograft. The arthroscopic portals and the incision on the knee joint were closed in a standard fashion.\nThere were no peri- and postoperative complications related to the procedure. Active and passive hip ROM exercises were started on the second day postoperatively and he was discharged home the day after surgery. He was mobilized non-weight bearing with two crutches for six weeks. At the end of the sixth week, he gradually started weight bearing and at the end of the 10th week, he was allowed to walk with full weight bearing. At the final follow-up (26 months postoperatively), he had a full range of movement without any complaints of rest pain or pain related to activities. The Harris hip score of his left hip was 96 points. Postoperative radiographs at the final follow-up showed near complete incorporation of the graft with preservation of the native joint space (). MRI scans confirmed the stability of the osteochondral plug and ongoing healing (). Informed consent for publication was obtained from the patient. |
The patient was a 39-year-old woman, gravida 2, para 1 with a normal term male infant delivered by a previous cesarean section 8 years ago. From 2 years ago they had an infertility problem due to azospermia of the second husband. The hormonal profile was normal. The present pregnancy was achieved following ICSI/PESA (intracytoplasmic sperm injection/percutaneous epididymis sperm aspiration). Successive ultrasound examination at 13-week gestation demonstrated a live fetus with a marginal placenta previa. The patient reported spotting from the first weeks of pregnancy until the end of pregnancy. At 15 weeks of pregnancy, a normal placenta and a live fetus was observed. Meanwhile, multiple small vesicles were reported by the sonologist at the anterior side of the uterus which were separated from the normal placenta (). In the next sonographic evaluation (18-20 weeks), a live fetus with a normal placenta was reported again in which a separated area of multiple small vesicles was seen. First, it could be diagnosed as dizygotic twin pregnancy consisting of a normal fetus and a mole ().\nAt this time, the diagnosis of dizygotic twin molar pregnancy was confirmed and the patient was offered the termination of pregnancy due to future problems. However, she refused to accept and desired to continue her pregnancy. So every week control was recommended.\nThe next control ultrasound examination showed the normal fetus and the hydatidiform mole clearly ( and ).\nSuccessive prenatal examination manifested the patient in good condition without any serious problems for the mother and the fetus.\nAt 39 weeks gestation, cesarean section was performed because of repeat surgery. A 3150 g normal male infant, with an Apgar score of nine and ten at 1 and 5 minutes, respectively, was delivered. The placenta was extracted completely from the inner uterine wall.\nAccording to the gross examination report, the specimen consisted of a placenta 20 × 15 × 12 cm in diameter and 315 g weight consisting of two parts. One portion with a pink to dark reddish color and spongy consistency resembling a normal placenta and the other part consisted of multiple small vesicles resembling a hydatidiform mole. It seems that the normal placenta and the hydatidiform mole were attached subsequently increasing the gestational age.\nMicroscopic examination revealed some fragments of the placental tissue. Most of the chorionic villi showed a nearly normal appearance. Foci of villi necrosis and intervillous fibrin deposition were evident. Sections of molar vesicles revealed edematous villi with marked stromal hydropic changes and cistern formation. Foci of trophoblastic proliferation were observed.\nCytogenic analysis of the molar part of the placenta revealed a diploid 46, XX karyotype. After cesarean section, the β-hCG was followed for 1 year finally, returning to the normal level. So, complete remission was diagnosed and the patient has remained clinically well eversince. |
A 70-year-old postmenopausal woman was referred to our gynecologic emergency unit with an impression of endometrial cancer after she presented with profuse vaginal bleeding of 3 hours associated with lower abdominal pain and protruding mass per vagina of 20 hours. She noticed the mass after experiencing urinary retention and was straining to void her bladder.\nThe history revealed intermittent vaginal bleeding and progressively worsening voiding difficulties for the past 3 months. Four weeks earlier, she visited a local health facility where transabdominal ultrasonography was done and showed intrauterine echocomplex mass consistent with leiomyoma. A cervical punch biopsy was found to be negative for malignancy. She had two uncomplicated term vaginal deliveries. She is a known diabetic patient taking insulin for the past 8 years.\nOn examination, she had tachycardia (118 bpm) and blood pressure of 90/60 mmHg. The patient looked pale. Gynecologic examination revealed an irregular beefy red mass measuring about 15 × 10 cm protruding through the vaginal introitus. The mass was noted to have two distinct parts with a clear demarcation (). The lower part was a solitary globular mass with a firm consistency and smooth surface. The upper part had an irregular sloughing surface with areas of necrosis and contact bleeding. The cervix could neither be seen nor palpated. It was difficult to appreciate the uterus on bimanual examination due to tenderness.\nThe patient had a hemoglobin of 10.3 g/dl. Renal function test, blood sugar, and ketone levels were within the normal range.\nTransabdominal ultrasonography could not identify the uterus in the pelvic cavity. The patient was consented for surgery with a tentative diagnosis of nonpuerperal uterine inversion due to leiomyoma. However, due to the age of the patient and the features of the mass, the possibility of malignancy could not be excluded. A combined vaginal and abdominal approach was planned.\nIn the operating room, examination under anesthesia was done and a hard and tight cervical ring was identified behind the mass ().\nDuring laparotomy, the diagnosis of uterine inversion was confirmed. The uterus was absent, and the bilateral infundibulopelvic, uteroovarian, and round ligaments and fallopian tubes were pulled medially into a central constriction ring. Only the fimbrial end of the fallopian tubes and the ovaries were visible at the edge of the constriction ring. The liver, omentum, and bowel loops appeared normal.\nThe surgeon first removed the tumor to reduce the volume of the mass protruding from the vagina. Then, an initial attempt to reposition the uterus abdominally by applying tension on both round ligaments (Huntington procedure) failed. Afterward, a linear incision was made on the constriction ring and advanced on the posterior wall of the uterus while applying gentle upward pressure vaginally (Haultain procedure). The uterus was subsequently reinverted to its normal anatomy by placing a finger abdominally through the myometrial incision and exerting pressure on the fundus (). Finally, a total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The estimated blood loss was 400 ml.\nThe hemoglobin level determined 6 hours after the surgery was found to be 7.0 g/dl, and the patient was transfused with 3 units of blood. She recovered well and was discharged on postoperative day 7. Histopathological examination of the specimen showed leiomyoma with adenomyosis. There was no evidence of malignancy (). The patient had follow-up visits at 2 and 6 weeks. She has no constipation, urinary frequency, urgency, retention, or involuntary loss. An abdominal exam showed a clean and healed surgical incision. On pelvic examination, the vaginal cuff appeared healthy and well suspended at the level of the ischial spines. There was no anterior or posterior vaginal wall defect. The patient was reassured and was linked to the diabetic clinic to continue her follow-up. |
A 67-year-old Caucasian woman was seen at our clinic for possible prosthetic infection following a total left hip replacement. Her medical history was negative until three years before, when she began to complain of left hip pain during walking, movement limitation, and pain at rest. After one year of unsuccessful prior rehabilitative and analgesic treatment, she underwent total left hip replacement. The results of a pre-operative chest X-ray and blood tests were normal; however, erythrocyte sedimentation rate (ESR) was elevated (94 mm/hour). The post-operative period was uneventful, and the patient was discharged five days after surgery. She remained in good clinical condition until about 16 months after surgery, when she began to feel pain and movement limitation at the prosthetic site. Two months later, a hip computed tomography (CT) scan showed a suspect iliopsoas abscess, which was confirmed by peripheral blood mononuclear cells marked with 99 mTc. Her clinical conditions worsened because of increasing local pain and an irregular mild fever. She was admitted to an orthopedic unit for needle aspiration of the abscess (102 × 53 mm) under ultrasound guidance. Culture of the needle aspiration and blood cultures for aerobic and anaerobic bacteria were performed, and empiric antibiotic therapy was started with intravenous linezolid (600 mg twice a day). Her fever increased, and all cultures were negative. After one week of unsuccessful medical treatment, the surgeon decided to perform surgery to inspect and clean the infected site.\nA pseudocyst containing dense material was found just near the prosthesis. A complete aspiration with culture of dense and cloudy liquid, including biopsies of the wall of the cyst and the surrounding tissue, was performed. Intravenous antibiotic therapy with 400 mg of teicoplanin, 160 mg of gentamicin, and 800 mg of ciprofloxacin was started. After four days, the fever disappeared and the patient was discharged without antibiotic therapy. Repeat cultures were negative. A histopathological examination disclosed a fibrous tissue with acute and chronic inflammation, partly with an aspecific granulomatous aspect.\nTwenty days later, the patient complained of mild fever and a painful, fluctuant nodule located at the superior internal surface of the left thigh along the surgical scar. The nodule was then surgically drained. A large quantity of cloudy liquid was collected from the site. Cultures were again negative. At the site of the cut, there appeared to be a deep fistula of about 5 cm in diameter with discrete, greenish, and odorless secretion. There was no evidence of inflammation to the surrounding tissues. The patient was then admitted to our unit. Her vital signs were normal. During a physical examination, she showed bad general health conditions and evident brownish coloration of the skin to the extremities (hands, feet, palmar, and plantar plicae), nipples, linea alba, and oral mucosa. The cutaneous fistula appeared unchanged. Laboratory studies showed the following: red blood cell count of 4.53 × 109/L, hemoglobin of 12.9 g/dL, platelet count of 336 × 109/L, white blood cell count of 8.2 × 109/L (60.9% neutrophilis and 24.2% lymphocytes), ESR of 89 mm/hour, and C-reactive protein (CRP) of 75 mg/L (normal value is less than 0.5 mg/L). The result of a tuberculin skin test (5 IU purified protein derivative) was positive, QuantiFERON-TB Gold was 3.08 IU/mL (cutoff value is 0.35 IU/mL), serum cortisol at 8 a.m. was 9.5 μg/dL (normal value is 4.3 to 22.4), adrenocorticotropic hormone (ACTH) was 2300 pg/mL (normal value is 10 to 60), and anti-cortex antibodies were negative. The second controls of serum cortisol and ACTH were 5.5 μg/dL and 1490 pg/mL, respectively. Major causes of adrenal insufficiency are autoimmune disorders and MTB infection. Anamnesis, CT scan of adrenal glands, and the absence of anti-cortex antibodies suggested exclusion diagnosis of Addison disease secondary to MTB infection. The result of an experimental whole blood test based on interferon-gamma (IFNγ) response to RD1-selected peptides, which tends to be related to active tuberculosis, was also positive []. The active IFNγ response was 2.6 IU/mL (cutoff is 0.7 IU/mL). The remaining biochemical parameters were normal. The amount of secretion was discrete; thus, fistula microbiological cultures could not be done. A single specimen was collected to perform Gram and Ziehl-Neelsen staining. Only polymerase chain reaction (PCR) for MTB complex was positive.\nHip, abdominal, and chest CT scans revealed a periprosthetic abscess with diffusion to the left psoas muscle (Figure ), a slight bilateral adrenal enlargement with calcifications, and a mild fibrosis of both upper lobes of the lungs. Our patient's condition was diagnosed on the basis of the laboratory and clinical findings as tuberculosis and secondary Addison disease. So that Pott disease could be excluded, our patient underwent a backbone X-ray, which was negative. She was put on treatment with anti-tuberculosis agents: rifampicin (RFP), ethambutol, isoniazid (INH), pyrazinamide, and pyridoxine without removal of the prosthesis. Hydrocortisone and fludrocortisone were prescribed for Addison disease. After three months, the anti-tuberculosis treatment was continued with RFP and INH only. The fistula continued to slowly discharge discrete amounts of secretion and appeared to be completely healed after six months. Our patient was totally asymptomatic and without pain upon hip movements after 15 months. The iliopsoas abscess was no longer evident on a CT scan performed about one year later. |
A Finnish male patient in his sixties with hepatitis C and osteoarthrosis of both knees was admitted to the emergency department because of acute right-sided hemiparesis that had started a day before the admission. Prior to the onset of hemiparesis, the patient's friend had injected a dose of α-PVP into the patient's neck. The intended injection site was the left external jugular vein, since the peripheral veins were damaged due to numerous injections. Before the injection, the drug had been mixed with tap water and injected using a clean needle and a microfilter provided by a nonprofit organization aimed at diminishing health complications from drug use.\nThe clinical neurological evaluation at the emergency department showed right-sided hemiparesis, no visual deficits, and no aphasia or dysarthria. A head CT demonstrated infarctions along the left sulcus centralis. Only a small puncture wound without surrounding hematoma was found on the patient's neck.\nCT angiography of the head and neck arteries showed no dissection or other signs of trauma of the carotid or vertebral arteries, and no critical stenosis. Only minor atherosclerotic plaques were found. In the distal part of the basilar artery, either vasospasm or stenosis due to atherosclerosis was suspected. Thrombosis of the left jugular vein was also suspected.\nAspirin 250 mg p.o. and enoxaparin 40 mg s.c. as a prophylactic dose against deep vein thrombosis were administered, and the patient was admitted to the neurology ward. Further investigations included a neck ultrasound, which ruled out thrombosis of the jugular vein. Head MRI showed multiple new ischemic lesions in the left cerebral hemisphere (Fig. ). The lesions were mainly located in the deep watershed area of the centrum semiovale. MRA of the carotid and cerebral arteries did not show vasospasm or clinically relevant atherosclerotic stenosis. There was no indication of puncture of the left internal carotid artery in these studies.\nAtrial fibrillation was not found on 48-h ECG monitoring. Transthoracic and transesophageal echocardiography showed no evidence of endocarditis or intracardial thrombi. Clinically irrelevant, small patent foramen ovale was found. A urine drug screen was positive for benzodiazepines, and the patient reported occasional use of benzodiazepines. A full thrombophilia workup was negative and along with a normal complete blood count ruled out most common thrombophilias and hematological disorders. LDL cholesterol was 2.2 mmol/L, and HbA1c was normal.\nThe patient was evaluated, and rehabilitation was initiated by an occupational therapist. However, the patient left the hospital on the fifth day of his own will before a complete physiotherapy evaluation. At discharge, the patient had a mild right-sided hemiparesis but could walk with the aid of forearm crutches he had already been using because of osteoarthrosis. Prescriptions of aspirin 100 mg and atorvastatin 10 mg once per day were given, and the patient was advised to continue occupational therapy at the local healthcare center to rehabilitate right arm functions. |
In February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pulmonary anomalies were identified either. Our patient responded well to antitubercular antibiotic therapy and his clinicians, together with his family, decided to keep him under control with clinical follow-up, avoiding surgery for the moment. |
An 18-year-old male genetically diagnosed HED came to our clinic for implant rehabilitation of his edentulous maxilla and mandible. He was the only affected member in the family and his chief complaints were loose fitting denture and an unaesthetic appearance. Severe hypodontia (only one existing permanent tooth in the maxilla), dry mucosa, loss of vertical dimension, underdeveloped alveolar ridges and class III jaw relation were detected in the oral cavity ( and ). Clinical and radiographic examination showed that only right maxillary second molar was present in the oral cavity. Both mandibular canines and the left mandibular first premolar were impacted. Severe maxillary and mandibular hypoplasia and mandibular prognathia were present, in addition to a loss of the vertical dimension. A CT Scan was ordered to evaluate the presence of sufficient cancellous bone volume at each potential implant position site and for site specific selection of the implants according to the surgical and prosthetic treatment plan. The residual bone height (RBH), was 8 mm at the former position of the maxillary central and lateral incisors, 7 - 8 mm of the second premolar, and 6 - 7 mm of the first molar ().\nThe patient was treated in the oral and maxillofacial center of Dey General Hospital under general anesthesia with nasotracheal intubation. The initial radiographs (panoramic and computed tomograms) and patient profile revealed severe maxillary and mandibular hypoplasia, mandibular prognathia, minimal vertical projection and bilateral large sinus cavities. Furthermore, diagnostic casts confirmed class III inter-arch relation in both sagittal and frontal planes. After mounting the diagnostic casts, anterior movements of the maxilla were evaluated in accordance with the estimated intermaxillary relation, desired occlusal plane, estimated position of the implants, and facial esthetic improvement. A written informed consent form was signed by the patient.\nA Le Fort I maxillary osteotomy was performed with simultaneous sinus floor augmentation using the mixture of cortical autogenous bone graft harvested from iliac crest and organic Bio-Oss (Geistlich, Osteohealth Biomaterials, Bern, Switzerland) in a 1:1 ratio by M.B. Anterior and inferior repositioning of the maxilla was successfully attained with rigid fixation using 4 bone plate (). With the exception of the only emerged teeth in the oral cavity, extraction of the remaining impacted teeth was sequentially performed to prepare for future implant placement.\nRadiographic evaluation revealed an appropriate healing with the stable bone height (22 mm) in posterior maxillary area. The bone quality at other sites was poor; therefore, ridge augmentation with onlay graft was done to construct adequate bone volume allowing proper implant placement, using tissue harvested from the iliac bone. Six month after surgery, bone plate and screw removal and dental implants insertion were performed under local anesthesia with intravenous sedation. The two-stage method was used for implant placement, providing a 12-week period between two stages. After 2 weeks, a temporary removable denture was fabricated for the patient. Seven implants (BIOMET 3i, OSSEOTITE®Implant Co., USA) were placed in the maxilla and 7 implants were inserted in the mandible, using a surgical template to assist appropriate implant placement (). All of the implants were placed with their neck leveled with the crestal bone. The implant insertion torque value was approximately 30 N/cm for all fixtures. The implant diameters and length were summarized in .\nDiagnostic wax-up and digital imaging, were used to demonstrate the proposed functional and esthetic results that could be achieved. A diagnostic mounting and tooth-arrangement were completed for definitive evaluation of occlusal vertical dimension, interarch distance, centric relation, and the evaluation of the patient's esthetic anticipation. The patient returned to the prosthodontist immediately after completion of the surgery for delivery of temporary removable dentures, which were carefully relieved over the implant healing abutments while maintaining support for the surrounding soft tissues. Twelve weeks after insertion, implant stability was verified and final impressions were taken. Right side posterior mandibular implant was failed and removed. Definitive impression of the implants was made with a regular-viscosity polyether (Impregum F; Espe Dental, Seefeld, Germany) in a custom impression tray. Master casts (Die keen, Heraeus Kulzer Inc. Lafayette Blvd., USA) were fabricated. Despite the failure of right side posterior mandibular implant, a full maxillary bridge was fabricated, maintaining sufficient space for antagonistic implant. Ultimately, the failed implant was replaced. Abutment selection was performed on the master cast, and superstructures were fabricated according to the diagnostic set-up. On account of the poor bone quality a conventional loading protocol was applied, allowing 12 weeks before delivery of the final implant-retained restorations. During this period, provisional removable prosthesis was installed over the implants. Screw-retained metal ceramic FPDs were fabricated with an occlusal scheme that provided simultaneous contact in maximal intercuspation and group function articulation. At delivery, abutment screws and superstructure screws were tightened with controlled torque (35 and 15 N/cm2, respectively), and a clinical remount was done to refine the occlusion. The access holes were filled with a light-cured composite resin (Filtek Z250 -3M ESPE, St Paul, MN, USA). Oral hygiene instructions were provided to the patient. After tightening the retaining screws with the recommended torque, periapical radiographs were taken for the examination. One week later, the occlusion was re-adjusted and screw access holes were filled with the flowable resin.\nFollow up clinical and radiographic examination performed 24 month after delivery of the final restoration. All implants were clinically stable and a successful functional implant assisted dental reconstruction was achieved according to criteria of Smith and Zarb. Relapse after orthognathic surgery was undetectable, and the intermaxillary relationship and facial profile were enhanced. Crestal bone resorption values were within normal ranges and no implant was lost during observation period. There was no clinical or radiographic sign of inflammation (pain, mobility, infection with suppuration, radiographic continuous peri-implant radiolucency) (). Periodontal and peri-implant soft tissues revealed no variations and were healthy, showing normal probing depth values. There was no sign of biting on cheeks and all of the relevant masticatory and facial muscles were relaxed and had normal tone. The implants were functionally active and competent in chewing and phonetic, as well as satisfying aesthetic concerns. The patient was fully satisfied with the functional and esthetic results and also his new found smile (). |
A female patient aged 3 years and 10 months was referred to our outpatient clinic with a preliminary diagnosis of neurodegenerative metabolic disease due to complaints of hand tremor, impaired walking, and irritability. Clinical findings were evaluated by questioning the disease history and detailed personal and family history.\nHer complaints began when a stray cat scratched her. We found out that the hospital to which she was admitted provided only local wound care due to her history of contact with a cat and that she was vaccinated against rabies. After 1 month, her body temperature rose, her neck lymph nodes were swollen, and otitis and mastoiditis developed. After being readmitted to the hospital, the patient received 1 week of oral amoxicillin-clavulanic acid treatment, reducing her fever and regressing the defined infection findings. However, the patient presented to the pediatric neurology unit 6 weeks later due to a deterioration in her walking and tremor in her hands. The patient was referred to our department with metabolic screening tests performed in this last referral center.\nHer medical history revealed that she was born by normal spontaneous delivery at term with a weight of 3380 g and had postnatal 40-day jaundice. Her umbilical cord dropped in 15 days. Additionally, we learned that the patient began walking at the age of 11 months, spoke normally, and experienced no complications during vaccinations. When she was 12 months old, she developed an inner ear infection called mastoiditis. The patient’s father had a family history of acute lymphoblastic leukemia treatment.\nSince the basal metabolic tests (tandem screening and organic acid in the urine) performed before the patient’s admission to our department were found to be normal, the patient’s clinical finding was considered as a preliminary diagnosis of cat-scratch disease, with a history of onset. The patient was referred to the infectious diseases unit. However, it was learned that cat-scratch disease was thought to be a self-limiting disease, and tests were requested for the differential diagnosis of additional metabolic and infectious diseases before treatment. Even after positive immunological tests and initiation of cat-scratch disease treatment with rifampicin, additional testing was ordered (see ). Changes in disease clinical manifestations are shown in on a timeline.\nConsent was received from the patient’s family for publication. |
A 79-year-old male with a history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, and persistent atrial fibrillation was brought to hospital after being successfully resuscitated following a brief pulseless electrical activity (PEA) cardiac arrest. During his convalescence, he had a second PEA arrest, from which he was again successfully resuscitated. Telemetry revealed atrial flutter with atrioventricular conduction that slowed markedly to ventricular rates as low as 34 beats per minute. A balloon-tipped temporary pacing catheter was floated in via left internal jugular vein until adequate ventricular capture was observed. Fluoroscopy was not used during insertion. A follow-up chest X-ray confirmed appropriate placement of the lead, which revealed the lead in the right ventricle with redundant lead slack forming a loop ().\nThe patient subsequently had a PPM implanted. The PPM was implanted without complication using a standard left cephalic vein access. The lead was advanced under fluoroscopic guidance. Implantation of the PPM lead was carried out without difficulty with active fixation to the right ventricular septal wall. The lead pin was attached to a pacemaker pulse generator which was then placed in a pocket located in the prepectoral plane below the left subclavicular fossa.\nThe TVP was then removed under fluoroscopic guidance. The large loop of redundant wire was noted, but it exited the cardiac silhouette without any resistance or interaction with the newly implanted PPM lead. However, significant resistance was noted when attempting to pull the tip of the TVP lead out through the introducer sheath. This resistance was only encountered when the TVP lead tip was at the level of the skin; fluoroscopy was not performed at this stage to determine the cause of resistance. The resistance was overcome and the TVP lead was successfully removed. It quickly became evident that the reason for the resistance was that the TVP lead had looped and formed a knot around the RV PPM lead at the junction of the left subclavian and left internal jugular vein. Continued traction had thus dislodged the RV lead tip from the endocardium, resulting in inadvertent removal of the RV lead through the left internal jugular vein (). No dislodgement of the PPM lead had been apparent fluorocopically during removal of the TVP wire from the cardiac silhouette as the ensnarement occurred at the level of the thoracic inlet when fluoroscopy was no longer being employed, and no loss of capture was noted as the patient was in their intrinsic rhythm. The patient remained hemodynamically stable.\nIn order to place a new RV PPM lead, left axillary venous access was obtained and a new lead was successfully placed, which was connected to the original pulse generator. The ensnared RV lead was cut within the pocket, and the lead pin was removed from the pulse generator directly. The external portion of the RV lead () was then removed without complication from the left internal jugular vein. The new PPM assembly functioned well, and the procedure was completed without any further complication. |
The patient was an 89-year-old woman with a recent history of urothelial carcinoma who presented with worsening headaches and left-eye vision loss over the previous four weeks. While her headaches had been present for several months, the vision loss began a couple of weeks following an intravitreal injection for macular degeneration. She had been following with her outside ophthalmologist who suspected temporal arteritis; however, temporal artery biopsy was negative, and steroids failed to improve her symptoms. A CT head obtained at an outside facility was reportedly negative though unavailable for our review, and because of an incompatible pacemaker, she was unable to have an MRI. She was admitted initially to the Neurology service for workup of stroke versus malignancy, with lumbar puncture returning with a normal CSF profile and cytology negative for malignant cells. Ophthalmology evaluation revealed essentially complete left eye ophthalmoplegia with an unreactive left pupil. CT angiography performed on their recommendation revealed a hyperdensity within the left sphenoid sinus, as well as erosion of the supralateral wall, extension into the optic canal, and enhancement of the left cavernous sinus, concerning initially for an infectious process (Figure ). At this time, Otolaryngology and Neurosurgery were both consulted, and a CT sinus was then performed (Figure ). Otolaryngology performed a bedside flexible endoscopic evaluation of the nasal sinuses, which did not reveal any sign of infection or malignancy; therefore, in order to obtain a tissue diagnosis, the patient was taken to the operating room with Neurosurgery for a microscopic sublabial approach to the sphenoid sinus. Upon entering the sinus, a hemorrhagic lesion resembling clotted blood was encountered which was collected for a specimen. The mucosa was stripped and sent for a specimen as well. No obvious bony defect was visualized under microscopic evaluation, but the surface of the superio-lateral sphenoid sinus was irregular. The frozen section in the operating room reported acute and chronic sinusitis. The patient remained clinically stable but unfortunately did not have any improvement in her vision or extraocular movements post-operatively.\nThe surgical pathology specimen was examined by our neuropathology team and independently reviewed by an outside pathologist specializing in otolaryngic pathology. The left sphenoid lesion was fixed in formalin, embedded in paraffin, and examined on four-micron sections stained with H&E. Immunoperoxidase studies with appropriate controls were performed with the following antibodies: CK7, CK20, CK5/6, CDX2, b-catenin, TTF1, p63, p16, p53, SOX-10, GATA3, S100, synaptophysin, chromogranin, estrogen receptors (ER), AMACR, and Ki67. Microscopically, the tumor was located growing beneath non-ulcerated mucosa, and the complexity of the growth pattern and local invasive growth supported the diagnosis of malignancy. The morphological features were consistent with sinonasal non-salivary gland non-intestinal type adenocarcinoma, although the immunophenotype supported this diagnosis only partially. There was no evidence of SOX10 and S100 expression that is characteristic of this entity. At the same time, the absence of CDX2 and CK20 immunoreactivity helped to rule out sinonasal non-salivary gland intestinal-type adenocarcinoma, and the lack of TTF1 expression ruled out a metastatic lung and thyroid carcinoma. Figures - describe the surgical pathology findings in further detail.\nAlthough no definitive fungal elements were identified on the nasal biopsy, there were features consistent with this additional diagnosis including the presence of eosinophilic mucus, eosinophils, and Charcot-Leyden crystals. Culture results eventually returned positive for methicillin-sensitive Staphylococcus aureus; therefore, she was treated with two weeks of augmentin and posconazole. After a multidisciplinary discussion with our Hematology and Radiation Oncology teams, she received outpatient palliative radiation of 2000cGy in five fractions to the left sphenoid sinus and cavernous sinus. She was not felt to be a good candidate for chemotherapy given her age and evidence of renal and spinal metastases on positron emission tomography (PET) imaging. At the last follow-up, three weeks after surgery, the patient’s neurologic deficits were stable. She chose to transition to hospice shortly after that appointment in order to avoid lengthy travel to our institution and further diagnostic studies, which she did not feel would improve her outcome. The patient died 3.5 months after surgery. |
A 14-year-old boy, was brought to us by his mother for complaints of behavioral change for the past one month. She reported that he has not been working properly. He would demand for money and would go out frequently to watch movies. He would remain outside house for most time and talked a lot. He would look more cheerful then before and would not obey family members, and easily became irritable and angry. His hygiene and grooming also was increased and he would take bath 3-4 times a day. At home, he would keep pacing here and there. His sleep was markedly decreased from 7-8 h before to 3-4 h and the patient would not report any fatigability. There was no past or family history of any psychiatric illness. Mental status examination revealed a restless boy, with increased psychomotor activity, with eye to eye contact established but not maintained. His speech was increased in pitch, tone, and volume. His affect was elated. Flow of thought was increased and revealed ideas of grandiosity. He had no insight into the illness. His higher mental functions were, however, normal. Detailed neurological examination including fundus examination was normal. A diagnosis of first episode mania was made. Routine hematological investigations including chest X ray and ECG were normal. He was started on olanzapine 5 mg per day increased to 10 mg after 5 days. The patient followed up after about 10 days and her mother reported that he was not able to tolerate the medication. He was unduly sedated and would at times pass urine in clothes. Also, now she reported that the patient would have spontaneous jerky movements for a very short period of time repeatedly. On examination at this time, the patient had myoclonic jerks and his gait was unsteady. His affect was inappropriate. Olanzapine was stopped. He was further investigated. Magnetic resonance imaging of the brain revealed multiple areas of hyper intensities in bilateral brain parenchyma on T2W image which were more in posterior part of cortex. Patient was subsequently referred to neurologist. Blood tests for toxoplasma, cytomegalovirus, and herpes Simplex virus IgG and IgM were negative. Venereal disease research laboratories (VDRL) slide test was negative. EEG revealed typical picture of generalized periodic spike and wave formation with periodicity at every 7 seconds. Cerebrospinal fluid (CSF) was grossly clear with normal opening pressure and showed 5 lymphocytes/cumm, protein 20 mg/dl and sugar 70 mg/dl against a blood sugar of 100 mg/ dl. There were elevated anti measles IgG and IgM anti bodies. A diagnosis of SSPE was made. His condition deteriorated with increase in frequency of myoclonic jerks with urinary and fecal incontinence over next 4 weeks. He could not take care of himself and had to be assisted by family members for his daily routine. His gait became progressively unsteady with frequent falls as well. He was started on sodium valporate 400 mg per day along with clonazepam 1 mg per day. Subsequently, the patient was lost on follow-up. |
The patient was an 18-year-old, primiparous woman who was admitted to hospital by the gynecology and obstetrics service for removal of an SCI that had been implanted 1 month previously. The implant had been placed in the medial arm, but after the procedure the patient had suffered from pain, localized swelling, and ecchymosis. At an outpatients follow-up consultation to review the case, the patient exhibited paresthesia, progressive loss of finger flexion strength, and hypoesthesia in the field of the left median nerve. The gynecology team therefore decided to remove the device prematurely during the postoperative outpatients follow-up visit.\nThe gynecology team reported that during initial surgical manipulation they found removal of the device to be extremely difficult, using a surgical approach via the medial aspect of the arm at the proximal extremity of the implant, and decided to abort the procedure. Afterwards, the patient experienced significant localized pain and was unable to fully extend her arm, which was swollen. A pulsating mass was observed, and distal paresthesia was detected. At this point, on the same day as the attempted removal, the vascular surgery team was called in, because of a suspected brachial pseudoaneurysm (). Physical examination revealed a pulsating mass in the medial aspect of the distal third of the patient’s arm. The SCI could not be located by palpation, probably because of the volume of local hematoma. Color Doppler ultrasound showed a pseudoaneurysm in the medial aspect of the brachial artery, with thrombi in the wall, diameters of 4.2 cm x 3.5 cm, a 6 mm neck, and turbulent flow ().\nImmediate open surgical intervention was initiated to repair the injury, in view of the neurological involvement. The procedure was performed under local anesthesia and mild sedation, via a medial incision in the arm. The injury to the brachial artery was identified and local compression of the nerve was observed. The arterial orifice was sutured and the local hematoma was evacuated. In immediate postoperative recovery, the patient presented strong and symmetrical distal pulses, adequate perfusion, and unimpaired distal motricity and sensitivity.\nDuring follow-up, the patient recovered within 14 days with total remission of pain and recovery of motor capacity, full extension of the forearm, and no flexion deficit, paresthesia, or hypoesthesia of the fingers. Distal pulses remained strong and symmetrical bilaterally. |
A 34-year-old man was referred to our clinic. His symptoms were left nasal obstruction, foul-smelling discharge, and occasional nasal bleeding. His symptoms had been lasting for three months. During physical examination, the foul-smelling discharge in the left nasal cavity was aspirated. On the left side of the nasal cavity, a hard, immobile, white colored mass was observed between the deviated nasal septum and nasal sill extending to the inferior surface of the inferior turbinate. The tip of the mass was covered with nasal mucosa. It looked like a tooth. Onn the right side of nasal cavity, we observed mucosal bulging on the nasal sill and right turbinate hypertrophy. The patient was asymptomatic on the right nasal cavity. A coronal section of a paranasal CT scan of the patient was observed and a mass of bone density arising from the left nasal cavity floor was seen ().\nThe mass in the left nasal cavity had the same appearance and density of the tooth. This structure was evaluated as an ectopic tooth. In addition, another ectopic tooth was observed in the right nasal cavity. The axial section of the paranasal CT scan of this patient was observed and an ectopic tooth along the base of the nasal cavity was seen ().\nExtension of the right nasal cavity was minimal. The patient was operated under general anesthesia. After removing the left sided deviation of the cartilage septum, we observed a hard white colored bone, which looked like a tooth and was vertical to the direction of the nasal sill. The left ectopic tooth was excised using punch forceps. It was 2cm in length. The root of the tooth was 1cm in length ().\nThe tip of tooth was covered with mucosa. Nasal packing was administered in the nasal cavity to prevent bleeding after surgery and was removed after two days. The right ectopic tooth was just followed, because it was asymptomatic. There were no complications (bleeding, synechiae, or repeated complaints). There were no complaints after the operation or during the one-year follow up. |
A 50-year-old woman with a past medical history of kidney stones underwent uretroscopy for removal of a proximal right ureteral stone. During the operation, she had a ureteral avulsion and subsequently underwent a laparoscopic right ureteral re-implant with the removal of the kidney stone. She presented three months post-operatively with right flank pain and fever and was found to have hydronephrosis and a perinephric fluid collection of the right kidney on ultrasonography. A percutaneous nephrostomy tube was placed after the patient underwent failed attempts at retrograde ureteral stent placement and open ureteral stent placement.\nAn antegrade nephrostogram (), computed tomography (CT) abdomen and pelvis with intravenous contrast (), and cystoscopy were performed revealing an extensive ureteral loss of the right side. Initial imaging suggested preserved function of the kidney function; therefore, the surgeon was elected to perform a renal autotransplantation. A retroperitoneal nephrectomy was performed through a flank incision. The right kidney was then placed into the left iliac fossa through a Gibson incision (). The kidney was revascularized by performing an anastomosis of the two renal veins to the left external iliac vein and the two renal arteries to the left external iliac artery. A neoureter was constructed using the Boari technique due to an absent ureter and renal pelvis. Prior to closure, a double J ureteral stent and two surgical drains were left in place. Surgical drains were removed on postoperative day five and the patient was discharged after all necessary criteria were met.\nThe ureteral stent was removed cystoscopically at the one-month post-operative mark. The patient then returned to the clinic two months post-operatively for follow-up. Her incisions were well healed, and she had appropriate urine output. The transplanted kidney showed normal arterial and venous flow on Color Doppler ultrasonography. The mean parenchymal arterial vascular resistance of the transplanted kidney was 0.86. The height, anteroposterior diameter, and transverse diameter of the transplanted kidney were 80 mm, 39 mm, and 42 mm, respectively.\nThe abdomen and pelvis CT scan 2 months () and 6 months () after the surgery showed that although the transplanted kidney was smaller than that before the surgery, its morphology and function were still in an acceptable general range. |
A 65-year-old postmenopausal primigravida who conceived after donor embryo transfer was referred to our center at 29 weeks of pregnancy with antepartum hemorrhage. Her previous antenatal monitoring was at the private hospital where she had undergone in vitro fertilization (embryo donation). At the time of admission, her blood pressure was 160/108 mmHg for which she received intravenous labetalol. Other vitals were within the normal range. Cardiovascular system examination revealed a Grade 3 diastolic murmur, but there were no signs of congestive heart failure. Obstetric examination showed uterine height corresponding to the period of gestation with a transverse lie; uterus was relaxed and regular fetal heart rate. On local examination, there was no active bleeding.\nPatient was hospitalized. For control of blood pressure, she was started on oral methyldopa 250 mg thrice a day and labetalol 100 mg thrice a day. She was kept on conservative management and was evaluated further for heart disease and diabetes. Echocardiography showed trace tricuspid regurgitation with moderate pulmonary artery hypertension with normal left ventricular function. No active intervention was advised by the cardiologist. She was also diagnosed as gestational diabetes mellitus controlled on diabetic diet and insulin therapy. Ultrasonography complete placenta previa. She also received steroid cover for fetal lung maturity. At 32 weeks period of gestation by date of embryo transfer, she had another bout of bleeding; therefore, emergency lower segment cesarean section was performed. A male child with birth weight 1650 g was born with an APGAR score of 9, 9, 9. Most of the placenta was adherent with no plane of cleavage and hence cesarean hysterectomy was performed. She received two units of packed cells blood intraoperatively. Postoperatively, the patient was monitored in the Intensive Care Unit (ICU) for 24 h. Baby was shifted to neonatal ICU for observation. In ICU, her systolic blood pressure ranged 190–220 mm Hg and diastolic blood pressure ranged 110–130 mmHg. Nitroglycerin drip was required for blood pressure control on postoperative day 1. On the 2nd postoperative day, she was started on tablet amlodipine 10 mg per orally once daily. Mother started lactating from the 3rd postpartum day. Both healthy mother and baby were discharged on the 15th postoperative day. |
The patient was a 70-year-old man with a history of a solitary pulmonary nodule in the right lower lobe. He underwent a minimally invasive right lower lobectomy for lung adenocarcinoma (pT2aN1M0) and chemotherapy 2 years ago. He exhibited no specific symptoms until he was admitted to hospital due to progression of a severe cough with fever, 12 months after lung resection. Although his fever was relieved by antibiotic administration and insertion of closed thoracic drainage, his cough continued and a large volume of air leaked into the chest tube. A physical examination revealed a uniportal incision and a chest tube in the right thorax (Fig. A). Chest computed tomography (CT) scan showed a simple empyema cavity containing a pleural effusion and a tube in the right lower thorax (Fig. B). Based on his clinical symptoms and these imaging findings, we diagnosed the patient with right lower bronchial stump fistula with empyema after lobectomy. Bronchoscopy confirmed a fistula of approximately 5 mm in diameter between the right lower bronchial stump and pleural cavity, and endoscopic placement of covered bronchial stent (Boston Scientific Corporation, Natick, MA) was performed. After that, air leakage was lessened but discharge of purulent fluid from the tube continued at about 60 mL/day. Due to the inadequate outcome, rib resection thoracostomy was recommended. After the sixth and seventh posterior ribs were partially resected, purulent pleural effusion was observed in the thoracic cavity, which was cleaned to remove debris and necrotic tissue by debridement and washing. Two drainage tubes were inserted into the cavity and the wound was closed. The pathogen identified via pus culturing was Klebsiella pneumoniae. After irrigation of the right intrathoracic space with antibiotic solution for 14 days, his condition improved. When cultures confirmed there was no infection in the thoracic cavity, he underwent surgical intervention. During operation, a 15 cm × 11 cm latissimus dorsi muscle flap was harvested, the tip of the pedicled muscle flap was sutured and fixed to the anterior lower mediastinum, and the rest was transposed to completely obliterate the empyema cavity (Fig. C). His postoperative course was uneventful, and he was discharged on postoperative day (POD) 21(Fig. A). The chest magnetic resonance imaging (MRI) revealed successful obliteration of the empyema cavity and BPF after surgery (Fig. D). The patient remained healthy, and no recurrence of the fistula with empyema was evident during the 22 months of follow-up. |
A 14-month-old female presented with repeated emesis since 3 months of age. The vomitus was mainly milk with occasional bilious fluid. The vomiting often occurred at night, 2 to 3 times a week. When she was 8 months old the vomiting increased to 2 to 3 times a day, with larger portion of the vomitus containing bile. No evidence of blood in the vomitus or abdominal distension was noted. GI radiography was performed at a local hospital, and obstructions were seen at the third and forth portion of the duodenum. Three surgeries were performed at the local hospital including a Ladd operation and duodeno-duodenostomy; however, her symptoms were not alleviated after these procedures. Hence, she underwent a further exploratory operation at the local hospital, and an obstruction which has the appearance of a diaphragm at the third portion of the duodenum was noted, along with severe adhesions. A proximal duodenostomy, resection of the septum, and enterolysis was performed, and a jejunal nutrition tube was placed. Unfortunately, her symptoms worsened after surgery. She was then admitted to our institution, and reexamination of the GI radiographic studies indicated that there was still an obstruction at the duodenum.Surgical exploration at our hospital revealed significant dilation of the second portion of the duodenum, while the distal intestines were saggy and flat. The third portion of the duodenum was adhered in a U-shape. After releasing the adhesions, a diverticulum was visible at the lateral margin of the mesentery. We removed the duodenum drainage catheter to inject air and extrude the air towards the distal end, and air was noted to pass through. A further attempt was made to place a rubber tube in the third portion of the duodenum, but the placement was inhibited at the junction of the second and third portions of the duodenum. The diverticulum was removed by wedge resection (Figure ), and the obstructed duodenum was explored. After opening the intestinal lumen, a diaphragm-like area of tissue with a perforation in the center was found at the second and third portion of the duodenum. The diameter of the perforation was 0.3 cm. The segment of the duodenum was incised longitudinally, and the diaphragm-like tissue was completely resected. The duodenal incision was then sutured transversely, and passage of a rubber tube was successful.\nHer postoperative course was uneventful, and the symptoms did not recur. At 1 year postoperatively, her growth and development were within the normal range. |
A 70-year-old female patient consulted medical doctor for recurrent moderate abdominal pain in the last few months. She had had a cholecystectomy 30 years ago; later on, without significant illness in medical history, she was a teetotaler and she smoked 2 cigarettes per day during 10 years but stopped completely during the 6 last months. Routine blood tests were in the normal range. Abdominal ultrasound did not visualize the pancreas well due to bloating. A CAT scan was performed, finding multiple calcifications and irregularly dilated main pancreatic duct, predominantly in the pancreatic head (Figures and ), where the dilatation had some cystic aspect and was disproportionally more pronounced than in the pancreatic body and tail. The same alterations were confirmed by MRI (Figures and ), without intramural nodules in the dilated main duct. Based on the two imaging methods, we could not distinguish between chronic calcifying pancreatitis and mucin-producing neoplasia, that is, main duct IPMN. ERCP was performed, and contrast injection revealed a cystic dilation of main pancreatic duct in the head (). The duct of Wirsung was less dilated in the body. Through pancreatic papillotomy, typical whitish pancreatic stone passed into the duodenal lumen (). However, after having continued the contrast injection, mucin passage was seen producing the typical fish eye appearance in the major and also the minor papilla (Figures and ). Simultaneous existence of CP with pancreatic stones and main duct IPMN was our final diagnosis. Given the high probability of malignancy in the dominant cystic lesion, surgery was decided and performed. Surgery revealed a cystic tumor that was found in a fibrotic pancreas. Pancreatoduodenectomy was performed with preservation of pylorus and pancreaticogastrostomy. Some whitish pancreatic stones were extracted. No lymph node metastasis was seen. Histological () findings confirmed the existence of a mucinous tumor emerging from the main pancreatic duct, with multiple foci of high grade dysplasia and even with evident transformation into an infiltrative malignant lesion (). No lymph node metastasis or vascular involvement was found. Fibrosis, acinar cell degeneration, and tubular complexes [] were seen in the surrounding tumor-free pancreatic tissue. The patient is still doing well 4 years after the intervention, without suspicion of any tumor recurrence. |
A 40-year-old female patient presented with bilateral paraplegia, decreased vision in right eye and urinary incontinence since 1-month. She was delirious since 2 weeks. The patient was on oral amlodipine 5 mg once daily for hypertension and on thyroxine 100 μg once daily for hypothyroidism. She also had associated hypocortisolism and hypogonadism. Magnetic resonance imaging scan of the brain showed a homogenous contrast enhancing mass measuring 7.0 × 5.0 × 6.0 cm arising in the sellar area with extension up to lateral and third ventricle []. Computed tomographic (CT) angiogram revealed a large lobulated sellar mass with suprasellar extension causing mass effect on adjacent structures and displacement of bilateral cavernosal and supraclinoidal internal carotid artery. Rests of the preoperative investigations were unremarkable. The craniotomy was carried out under general anesthesia with invasive blood pressure and central venous pressure monitoring. During tumor resection, the patient had continuous bleeding, and the hemodynamics kept fluctuating. Intravascular volume was maintained with crystalloid, colloid and packed red cells transfusion. After 3 h of surgery and following loss of almost 2½ L of blood, the surgeons decided to quit. However, it appeared difficult to achieve hemostasis. The bleeding continued from the tumor bed despite repeated attempts to control it. There prevailed a situation of uncertainty. Based on our previous experience, it was decided to administer tranexamic acid at a dose of 10 mg/kg.[] Within 5 min of administration of tranexamic acid, there was a significant decrease in the bleeding from the tumor bed and in the next 10 min the surgeons reported satisfactory hemostasis. This also coincided with the improvement in hemodynamic profile of the patient and reduction of fluid to the maintenance dose. Postoperatively the patient was shifted for elective ventilatory support and gradual reversal of neuromuscular blockade. The postoperative noncontrast CT scan showed no major collections of blood in the operated field []. Subsequently the patient was weaned off the ventilatory support and was discharged on the 10th postoperative day. |
A 44-year-old Turkish woman admitted to the department of vascular surgery for her leg varices. She was on treatment with pentoxifylline and etodolac and her coagulation status was normal (prothrombin time=11 s, partial thromboplastin time = 25 s). The patient placed on the table in sitting position and her back was prepared and draped in the operating room. The patient instructed for full cervical and lumbar flexion, lumbar 4-5 intervertebral space was infiltrated with 1% lidocaine and a midline epidural catheter was easily placed into the L4-5 interspace using loss of resistance technique. No blood or cerebrospinal fluid was aspirated from the epidural space. An anesthetic test dose 5 ml of 2% lidocaine was injected and then continued 18 ml of lidocaine 2%. An anesthetic level to T11 was obtained. No adverse reaction was noted. During the operation, the patient felt motor loss in her legs. Epidural anesthesia was stopped and the procedure was continued and completed under general anesthesia. During the 4-h course in post-anesthesia care unit and 6-h course in the neurology intensive care unit, the patient’s sensory block decreased from T11 to L1 level, but motor block persisted. There was symmetrical loss of reflexes and flaccid paraplegia in the legs. Lower extremity sensation to light touch and pain returned, and the patient complained of pain at the dorsolumbar region. The patient urgently underwent magnetic resonance imaging (MRI), with suspicious epidural hematoma or spinal cord compression or ischemia. Thoracic and lumbar MRI images revealed intervertebral disc protrusion at T11-T12 level and an outstanding spinal cord compression ( and ). There was no evidence of hematoma and the spinal cord intensity was normal throughout the thoracic spine which ruled out spinal cord ischemia. There were osteophytes of the vertebral endplates in different levels of thoracic and lumbar spine. The patient was given methylprednisolone and transferred to the rehabilitation unit. Her sphincter control and anal reflex was intact, and tonus of the anal sphincter was normal. Over ten days of rehabilitation including range of motion and strengthening exercises, electrotherapy to the dorsal region and superficial heat, the patient’s dorsolumbar pain reduced, motor recovery was achieved with a weakness of 3/5 of the lower extremities. The patient was discharged after 20 days of rehabilitation with minimal weakness of the lower extremities and independent in daily living activities. |
A 29-year-old woman (gravida 3, para 2, live 2), with a history of two previous cesarean sections (both were lower segment CS), was admitted to Ghaem University Teaching Hospital (Mashhad, Iran) in November 2017. She complained of moderate abdominal pain and vaginal bleeding during the previous 10 days. Her last menstruation was about 15 weeks prior to admission. Due to the history of an irregular menstrual cycle and lack of financial means, the patient was unable to seek proper medical consultation. She only took a urine pregnancy test. Two days prior to admission, she underwent a sonogram and the report revealed a 24 mm endometrial lining and an 82×37 mm heterogeneous mass in the left adnexa, probably associated with a perforated gestational sac. An 8 cm long dead fetus corresponding to 14 weeks of gestational age, laterally positioned at the side of the heterogeneous mass was reported. The previous two pregnancies were uneventful. There was no history of either curettage or intrauterine device insertion. In addition, she had no history of drug use, abdominal trauma, or smoking.\nOn general examination, the patient was in good condition and was not pale. Physical examination revealed moderate tenderness in the lower abdomen, especially in the left lower quadrant. There was no rebound tenderness. Her vital signs (blood pressure and pulse rate) were normal. On speculum examination, mild vaginal bleeding was observed. Her primary hemoglobin level was 11.8 gr/dl. A second ultrasound assessment revealed a 96×52 mm heterogeneous mass and a fetus without a heartbeat, 13 weeks of gestational age, positioned in the left lateral paracolic gutter of the abdominal cavity (). With an initial impression of abdominal ectopic pregnancy, laparotomy was performed. After opening the fascia, about 100 cc of hemoperitoneum was suctioned. The patient was about 12 weeks pregnant and placental tissue was present with multiple organized blood clots surrounding the lower segment of the anterior wall of the uterus and bladder. After removal of the placental tissue and clots, a tear of approximately 3 cm in length at the site of the previous cesarean scar was exposed; no active bleeding was noted (). The uterus was examined for residual placental tissue and the remaining tissue was removed. A macerated fetus was found in the left lateral paracolic gutter of the abdominal cavity (). Both salpinx and ovary were normal. The presence of a rupture at the site of the previous cesarean scar and almost empty uterus led to a change of diagnosis from abdominal ectopic pregnancy to uterine rupture. There was no abnormal placental adhesion or bleeding, which ruled out the diagnosis of cesarean scar pregnancy. The uterus was closed in two layers of 1-0 vicryl sutures. Subsequently, the abdominal cavity was washed with 2-liter warm saline and the walls were closed in the anatomical plane. There was no medical indication for a blood transfusion nor post-operative complications. Hematinic was prescribed and the patient was discharged 2 days after the surgery. At 6-month follow-up, no specific problems were noted. Written informed consent was obtained from the patient for the publication of this case report. |
A 70-year-old man presented to his primary physician with dysphagia that progressed to upper chest and back-pressure. The patient underwent imaging, and a large anterior mediastinal mass was detected on computed tomography (CT). The mass was biopsied, and the patient was subsequently referred for further work-up. Pathology of the tumor was reviewed and confirmed to be poorly differentiated squamous cell carcinoma. The tumor histology was most consistent with thymic origin; however, metastasis of other sources, such as lung, could not be ruled out. A repeat CT scan (Figure ) showed a necrotic mediastinal mass with local sternal invasion. An initial positron emission tomography (PET) scan (Figure ) showed a hypermetabolic anterior mediastinal mass without evidence of regional or distant metastases. The anterior mediastinal location made the mass most likely of thymic source. Upon presentation, the patient denied any hemoptysis, voice changes, fatigue, weakness, vision changes, headaches, nausea, or vomiting. The patient underwent surgery for removal of the tumor. During the operation, the tumor was found to invade the sternum and bilaterally encase both the phrenic nerves. In attempts to see if the phrenic nerves could be freed without injury, the pericardial sac was opened and the right phrenic nerve was followed. Based on the extent of tumor invasion of the right phrenic nerve, the surgeon concluded that there was no safe way to free both the phrenic nerves without injury, and the tumor was concluded to be unresectable.\nThe patient was referred to oncology and radiation oncology for other definitive therapy options. The patient was not considered a candidate for cisplatin therapy due to a rising protein–creatinine ratio at the time of presentation. A biopsy obtained for further work-up of his poor kidney function showed lambda light chain deposits consistent with multiple myeloma. After consultation with radiation oncology, intensity-modulated radiation therapy (IMRT) was recommended for definitive management of his thymic carcinoma. The plan was designed to deliver volumes based on the image data seen in Figure . A dose of 45 Gy in 25 fractions (red line) was prescribed to cover the thoracotomy operative bed, mediastinum, and level VI lymph node region of the low neck. A boost plan of 21.6 Gy in 12 fractions was designed to cover the gross tumor (blue color wash), bringing the total dose to the gross tumor to 66.6 Gy (yellow line). IMRT resulted in a lower dose to the spinal cord and heart while maintaining target coverage compared to a 3D-conformal technique. In addition, the patient was started on a regimen of bortezomib and dexamethasone for treatment of multiple myeloma during this time.\nOverall, the patient tolerated the treatment well and did not experience any significant side effects other than skin irritation. The patient did notice gradual improvement in his dysphagia throughout treatment. A CT performed 1 month following the completion of his treatment showed a decrease in the size of his mediastinal mass (6.8 cm × 3.0 cm × 4.2 cm) when compared to the mass initial size prior to radiation (8.4 cm × 5.7 cm × 7.8 cm). The CT also showed no enlarged lymph nodes of the axilla or mediastinum and was negative for pulmonary metastases. Imaging revealed a new right pericardial thickening that was later determined to be radiation-induced inflammation. The patient had significant improvement in kidney function after completing 22 cycles of bortezomib and dexamethasone for his multiple myeloma. His protein–creatinine ratio normalized within 6 months of this treatment. A bone marrow biopsy prior to treatment showed 30% plasma cells and 1% plasma cells following treatment. He continues to stay on a maintenance dose of dexamethasone.\nThe patient was last seen in radiation oncology 4 years following the completion of his radiation regimen. He reports that he is doing well and is symptom free. To date, the patient’s CT scan continues to show a stable small soft tissue mass in the anterior mediastinum with surrounding fat stranding consistent with radiation change. |
We present the case of a 75-year-old male whom initially presented to our service with a mass on his right upper back. The patient's medical history included coronary artery disease and hyperlipidemia. Further history revealed he had received (2) stents in the past and undergone multiple heart catheterizations (up to seven) approximately seven years prior at an outside facility. During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (). During the following years, the burn was closely followed at an outside facility, and the area developed a chronic nonhealing ulcer which continued to evolve over time eventually growing outward from his back and developing a foul odor on his presentation to our facility in 2017. He reported increasing pain at the periphery of the tumor margin. Up to a year prior to presentation, the area was flat and biopsies revealed no evidence of malignancy. Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 × 9 cm with central purulent necrosis and induration surrounding the periphery (Figures –). No additional nodularity or adenopathy was found on physical exam initially. At this time, punch biopsies demonstrated undifferentiated pleomorphic sarcoma along with frankly necrotic debris.\nInitial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures and ). Approximately one month following diagnosis, the patient underwent a radical excision with a 20 × 9 cm elliptical excision of the site. In this case, the patient chose human dermal matrix reconstruction, as primary closure was not possible due to the size of the site. Our patient did not want an additional wound of autologous skin procurement.\nPathology of histologic sections revealed a highly cellular spindle cell neoplasm. Focal areas of necrosis comprised less than 50% of sampled tissue. Mitotic figures were readily evident (17 per 10 high-power microscopic fields), including atypical forms. Marked pleomorphism was present with vesicular nuclei, irregular nuclear contours, and scattered prominent nucleoli (Figures and ). The immunohistochemical staining pattern was supportive of sarcoma. The neoplastic cells are positive for CD68 and vimentin (). The neoplastic cells were negative for markers of melanocytic origin (S100 protein, sox10, and melan A), epithelial origin (pancytokeratin AE1/AE3), vascular origin (CD31), neural origin (S100 protein), and muscle origin (smooth muscle actin, myoD1, and desmin). MDM2 gene amplification by FISH testing was negative. Overall histologic and immunohistochemical staining features were those of undifferentiated pleomorphic sarcoma (pleomorphic malignant fibrous histiocytoma). The final pathology of the mass demonstrated a grade 3 undifferentiated pleomorphic sarcoma-staged pT2a. All margins were negative for malignancy obtaining an R0 resection. Furthermore, there was no evidence of angiolymphatic invasion. After discussion by our institutional multidisciplinary tumor board, adjuvant therapy was not recommended. The patient's postsurgical course was essentially benign with the exception of not unexpected wound healing issues. The patient is under continued observation with clinical follow-up in accordance with NCCN guidelines. Follow-up CT in October 2018 demonstrated pulmonary metastases, and he passed away from disease in June 2018. |
Case 4 is a 42-year-old woman (weight = 59 Kg). She was admitted with an acute manic episode with psychosis. She had been previously diagnosed with major depressive disorder with psychosis and had been stable on escitalopram 20 mg for about a year. This was the first manic episode precipitated by work related stressors. The escitalopram was discontinued and the patient was initiated on divalproex sodium EC, the dose of which was increased to 1000 mg over 5 days. In addition she was also started on risperidone 0.5 mg and the dose increased to 1.5 mg at bedtime over one week. The serum level of valproate reported after one week was 1032 mmol/L and so the dose was reduced from 1000 mg to 750 mg at bedtime. The serum valproate level after one week was 877 mmol/lit. The dose was further reduced to 500 mg and serum level after one week was 644 mmol/L. The complete blood count and liver function tests were normal.\nThe serum prolactin level after one week of risperidone 1.5 mg dose was found at 146 μgm/L. She started expressing delusion of pregnancy. A decision was made to cross-taper risperidone with olanzapine 10 mg hs. Serum prolactin came down to 36 μgm/L in two weeks.\nHer manic and psychotic symptoms resolved by week 3 of admission; however, she reported feeling depressed, being tearful and guilty, and having difficulty in making decisions by week 2. As the dose and serum levels of valproate went down, her mood started improving and she was eventually discharged after 5 weeks of admission. She was on valproate 500 mg at bedtime and olanzapine 10 mg at bedtime at discharge. At outpatient follow-up in two weeks, she continued to experience some residual depressive symptoms and so valproate was reduced further down to 375 mg and olanzapine continued at 10 mg at bedtime. The dose of olanzapine was gradually reduced to 5 mg due to complaints of excessive sedation. She remains euthymic for 12 months at the time of reporting this case; current medications include valproate 375 mg and olanzapine 5 mg daily. |
A 54-year-old man with a past medical history significant only for hypertension presented to our clinic with a large soft tissue growth on hislower back which had been present for the past 20 years. Over the past three years it had been rapidly enlarging, nearly doubling in size over that time frame. He had recently re-established medical care after having not seen a physician since childhood. At the time of presentation, he denied any pain or tenderness over the mass and denied any systemic symptoms such as fever, night sweats, and weight loss. The patient had an unremarkable physical exam except for the large soft tissue mass over the lower back, with the maxiumum dimension measured to be 38cm () .\nAfter evaluation by the surgical oncology and radiation oncology services, an abdominal CT scan was obtained and thisdemonstrated a large (35 cm, x 38 cm x 17 cm), heterogeneous soft tissue mass. A differential diagnosis consisting of teratoma versus liposarcoma was established based on the radiologic imaging. Subsequently, several core biopsies of the mass were performed, all of which revealed fat necrosis with calcifications.Surprisingly, given the size and rapid growth of the mass, a diagnosis of benign giant lipoma was made.\nFour weeks after presentation, several surrgical teams performed a six hour operation to remove the 14 kilogram mass. After the patient was widely prepped and draped, the skin overlying the central portion of the tumor was shaved and harvested as multiple split thickess skin grafts (). Subsequently, an incision was made in the skin overlying the tumor in an area outside the skin graft donor sites, preserving significant flaps in all dimensions to permit primary closure (). Numerous, large variceal vessels feeding the tumor were ligated as the tumor was dissected off of the paraspinous muscles, which constituted the deep margin.\nThe specimen was sent for frozen section analysis,which was consistent with a lipoma, and was confirmed on final the pathology. The defect was able to be closed primarily with the preserved skin flaps, which measured greater than 200 cm × 40 cm (). The skin flaps were de-epithelialized and imbricated to achieve a multi-layered closure of the entire back wound, obliterating as much of the deadspace as possible. Two subcutaneous closed-suction drains were placed prior to the final closure. Postoperatively, the patient did well without complication (). After a brief and uneventful hospital stay postoperatively, he was discharged home in good condition. On follow-up, his drains were sequentially removed and the incision line has healed without problems. He has not had any evidence of recurrence or infection at six months postoperatively. |
A 46-year-old man was referred to our neurosurgical unit complaining of progressive right hemiparesis. At admission, he was alert and fully oriented. Neurological examination revealed right hemiparesis (grade 3/5). In the past medical history, he had undergone a craniotomy in the left fronto-parietal region for brain tumor 10 years ago in another hospital. Although we could not obtain pathological and medical records, he informed that his brain tumor had been diagnosed as low grade glioma, and he had received radiation therapy following craniotomy. Magnetic resonance images (MRI) and computed tomography (CT) scan on admission demonstrated a poorly defined heterogenously enhancing mass with extensive peritumoral edema in the left frontal motor cortex (). Since the mass was located near the previous craniotomy site, we suggested that this tumor might be related with previously diagnosed glioma. Under the presumptive diagnosis of secondary tumor, malignant transformation of a low grade glioma or radiation induced glioblastoma, we performed the surgical resection of the tumor. The histopathological diagnosis was compatible with GBM (). After the operation, the patient made uneventful recovery and showed improvement of his right motor function. The MRI scans taken 2 weeks later showed a remnant mass in the left frontal lobe (). Considering his previous history of radiation therapy, we performed gamma knife radiosurgery for the remnant mass, with a marginal dose of 20 Gy to the 50% isodose line, followed by 6 cycles of adjuvant chemotherapy with the PCV regimen (i.e. procarbazine, lomustine, and vincristine). After the gamma knife radiosurgery, the patient was not followed up. Three years later, he presented with progressive weakness of the right extremities and dysarthria. The MRI showed a recurrent tumor in the left cerebral hemisphere (). Surgical resection was done for the mass lesion and the histopathological findings revealed recurrence of the GBM. He remained in a stable condition during the 6 cycles of adjuvant chemotherapy with temozolomide. Since then, he underwent craniotomy two more times and shunt procedure for the recurrence of the tumor and hydrocephalus for 30 months. Five years after the initial diagnosis, a palpable mass lesion was observed on his left side of the neck. The mass was firm, tender and associated with enlarged palpable cervical lymph node. The neck CT with contrast enhancement revealed a 3×4 cm sized round mass, with peripheral rim enhancement in the left side of the neck (). Mass was biopsied and the histopathology indicated a metastatic deposit of the GBM. At that time, his condition, including consciousness and motor function, worsened, and the brain MRI noted the progression of the GBM. We performed the surgical resection of the brain tumor and of the neck mass, simultaneously. The pathological specimens were shown with increased cellularity, with blood vessel proliferation and necrosis (30%). The Ki-67 proliferation index was about 50%. All pathological specimens, from both the brain tumor and the neck mass, were confirmed as GBM (). Despite the aggressive treatment for the GBM, the patient was aggravated and died 6 months later. |
A 22-year-old man was involved in a motorcycle crash. At the scene of the accident, he had a severe neck pain. The man was placed in a soft cervical collar and transferred to the local emergency center. No neurologic complication was noted upon admission. The cervical spine radiograph and computed tomographic scan demonstrated a type II odontoid fracture that was displaced 2 mm anteriorly. The skull traction with 3 kg was applied immediately for cervical reduction. Once the displacement was reduced, a percutaneous anterior odontoid screw fixation was made in local hospital after he signed the informed consent form. The postoperative radiograph and CT were taken immediately, and both of them demonstrated an iatrogenic distraction of the odontoid fracture with a gap of 6 mm (Fig. ). The patient was fitted with a soft collar for 6 weeks, and the follow-up radiograph did not show any sign of bone union. After the distraction and no sign of bone union, the patient was referred to our spinal unit where the decision was made to attempt the anterior endoscopically assisted bone grafting for the distraction of the odontoid.\nThe anterior endoscopic approach to C1 to C2 was similar to the approach we previously reported in the microendoscopic anterior approach for irreducible atlantoaxial dislocation.[ The patient was placed in supine position on a radiolucent table, and a nasal intubation was performed under local anesthesia when the patient was still awake. Then the general anesthesia was given. To facilitate the open-mouth view, a radiolucent circular plastic tube was placed in the patient's mouth. After the surgical field was prepared and draped, the incision was made which the previous surgery had made for percutaneous odontoid screw fixation. Along the medial border of sternocleidomastoid blunt dissection was used to reach the anterior border of the cervical vertebra. Thereafter, a guide wire was placed through the space aiming the C1 to C2 space with the guidance of fluoroscopy. First, an initial cannulated dilator (Medtronic Sofamor Danek, Memphis, TN) was inserted over the guide wire, and then the next bigger size dilators were sequentially placed over the initial dilator down to the anterior space of the C1 to C2. Finally, a tubular reactor was placed. All procedures were carried out under the real-time fluoroscopic images. Using the endoscope we could view the anterior space of C1 to C2, and we found that there was a 5-mm gap filled with scar tissues in the fractured odontoid. A curette was used to remove the scar tissues between the fracture site; thereafter, a high speed burr was used to remove some anterior cortical bone of the odontoid. Finally, morselized autograft from the anterior iliac crest was packed into the fracture site (anterior and bilateral of the screw) under the endoscope (Fig. ).\nPostoperatively, prophylactic antibiotics was given for 3 days, the patient was encouraged to sit out of bed immediately after the surgery with the protection of a soft cervical collar. Radiographic and clinical evaluation was obtained at 1 week, and 1, 3, 12, and 24 months postoperatively.\nThe operation was successfully performed with the aid of endoscope. The operation time was 90 min and the estimated blood loss was 70 mL. The patient had slightly sore throat while swallowing after the surgery. The symptom disappeared 3 days postoperatively. No complications such as neural structures or vascular injuries were found. Postoperative CT scans demonstrated some autografts in the distraction site. The 1-year follow-up, bone union has achieved based on CT scans (Fig. ). Physical examination showed a full range of motion in the neck (Fig. ). |
A 79-year-old male with a history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, and persistent atrial fibrillation was brought to hospital after being successfully resuscitated following a brief pulseless electrical activity (PEA) cardiac arrest. During his convalescence, he had a second PEA arrest, from which he was again successfully resuscitated. Telemetry revealed atrial flutter with atrioventricular conduction that slowed markedly to ventricular rates as low as 34 beats per minute. A balloon-tipped temporary pacing catheter was floated in via left internal jugular vein until adequate ventricular capture was observed. Fluoroscopy was not used during insertion. A follow-up chest X-ray confirmed appropriate placement of the lead, which revealed the lead in the right ventricle with redundant lead slack forming a loop ().\nThe patient subsequently had a PPM implanted. The PPM was implanted without complication using a standard left cephalic vein access. The lead was advanced under fluoroscopic guidance. Implantation of the PPM lead was carried out without difficulty with active fixation to the right ventricular septal wall. The lead pin was attached to a pacemaker pulse generator which was then placed in a pocket located in the prepectoral plane below the left subclavicular fossa.\nThe TVP was then removed under fluoroscopic guidance. The large loop of redundant wire was noted, but it exited the cardiac silhouette without any resistance or interaction with the newly implanted PPM lead. However, significant resistance was noted when attempting to pull the tip of the TVP lead out through the introducer sheath. This resistance was only encountered when the TVP lead tip was at the level of the skin; fluoroscopy was not performed at this stage to determine the cause of resistance. The resistance was overcome and the TVP lead was successfully removed. It quickly became evident that the reason for the resistance was that the TVP lead had looped and formed a knot around the RV PPM lead at the junction of the left subclavian and left internal jugular vein. Continued traction had thus dislodged the RV lead tip from the endocardium, resulting in inadvertent removal of the RV lead through the left internal jugular vein (). No dislodgement of the PPM lead had been apparent fluorocopically during removal of the TVP wire from the cardiac silhouette as the ensnarement occurred at the level of the thoracic inlet when fluoroscopy was no longer being employed, and no loss of capture was noted as the patient was in their intrinsic rhythm. The patient remained hemodynamically stable.\nIn order to place a new RV PPM lead, left axillary venous access was obtained and a new lead was successfully placed, which was connected to the original pulse generator. The ensnared RV lead was cut within the pocket, and the lead pin was removed from the pulse generator directly. The external portion of the RV lead () was then removed without complication from the left internal jugular vein. The new PPM assembly functioned well, and the procedure was completed without any further complication. |
A 7-year-old, female neutered cross-breed dog, was referred to our centre with a 2 week history of hindlimb weakness, which then progressed to paraplegia. No concurrent systemic signs were reported. Prior to referral to this centre, an MRI scan of the thoracic and lumbar spine was performed. The spinal cord and meninges were grossly abnormal from the level of L1 caudally, with extensive swelling of the cord. The lesion in the spinal cord was hyper intense on T2W images. The meninges were thickened surrounding the spinal cord from L2-L7 causing circumferential compression of the spinal cord. The abnormal meninges were homogenous in appearance and intermediate in signal on T2W images. T1W post contrast images revealed a dense, homogenous enhancement of the abnormal meninges at the level of L4 (). Within the abdomen, a lesion consistent with enlargement of the right lumbar aortic lymph node was identified (). Due to the clinical suspicion of lymphoma, the case was referred to our institution for further investigations. At presentation, the dog was alert and in good body condition (BCS 5/9); her body weight was 28.6 kg. Physical examination revealed no significant abnormalities except for a bilateral muscle atrophy affecting both pelvic limbs. Neurological examination revealed a normal mentation. The dog was paraplegic with deep pain sensation intact in the right pelvic limb but absent in the left pelvic limb. The segmental spinal reflexes were absent in the pelvic limbs and deep pain sensation was absent in the left and present in the right. The perineal reflex was reduced. The cutaneous trunci reflex was intact. Neurological examination of the thoracic limbs revealed normal voluntary movement, proprioception to be present and segmental spinal reflexes to be intact. Cranial nerve examination revealed no abnormalities. Spinal pain was evident on palpation of the lower lumbar spine. The neurological examination indicated a lesion affecting the L4-S3 segment of the spinal cord. The peripheral lymph nodes were normally palpable and rectal examination revealed no remarkable findings. The MRI scan was reviewed confirming the suspicion of lymphoma, with a lesion consistent with neoplastic infiltration at the level of L4 and extension to the right lumbar aortic lymph node. Abdominal ultrasonography was performed under sedation and identified splenomegaly with increased echogenicity and nodular lesions, with confirmed enlargement of the right lumbar aortic lymph node. The liver and the remainder of the internal lymph nodes and other organs were within normal limits. Aspirates of the right lumbar aortic lymph node, spleen and liver were collected, together with additional samples for flow cytometry collected from the splenic aspirates. Cytology was consistent with a high grade lymphoma with a large granular lymphocyte (LGL) morphology identified on samples of the lymph node (, ) and spleen (); flow cytometry was not diagnostic due to the poor cell preservation, whilst PCR for antigen receptor gene rearrangements (PARR) was positive for a clonal T-cell receptor rearrangement, confirming a T- cell lymphoma.\nGiven the evidence of multicentric disease and the abnormal changes at the level of the spinal cord and meninges visible on MRI, which were compatible with lymphoma, systemic chemotherapy was recommended. A haematology with a manual differential count and a biochemistry profile were performed, showing no presence of abnormal circulating lymphoid cells nor other major abnormalities. A multidrug chemotherapy protocol was discussed with the owners (). The patient initially received 10,000 IU/m2 of L-asparaginase intramuscularly (IM), followed by dexamethasone 0.3 mg/kg intravenously (IV). After 24 hours, the dog regained deep pain sensation in the left pelvic limb, and treatment was continued with cytarabine 150 mg/m2 q 12 hours subcutaneously (SC) for the following 48 hours. The dog’s neurological condition continued to improve and the patient regained good voluntary movement after 5 days of therapy and intact segmental spinal reflexes in the pelvic limbs. Additional chemotherapy was administered at that stage prior to discharge, consisting of vincristine as an IV bolus at 0.5 mg/m2. A reduced dose was used due to an asymptomatic non-febrile neutropenia (Veterinary Cooperative Oncology group- VCOG grade I) and earlier administration than planned, due to logistical reasons. The dog was discharged on oral prednisolone and omeprazole and a dose reduction of corticosteroids was applied as per protocol (). She represented a week later to continue chemotherapy with oral lomustine at 60 mg/m2. At that stage, the dog’s gait was ambulatory paraparetic. The dose-limiting side effect was an afebrile VCOG grade III neutropenia, one-week post lomustine administration; a 5 days course of a broad-spectrum, oral antibiotic (potentiated amoxicillin) was prescribed and the patient recovered uneventfully. Due to the documented neutropenic events, dose reductions were applied for the remainder of the protocol: vincristine was administered at a reduced dose of 0.5 mg/m2 IV and lomustine at 50 mg/m2 PO. Cytarabine was continued at 150 mg/m2 SC q 12 hours for 48 hours. The dog experienced neurological deterioration 152 days after treatment was started, formally at week 19 of the protocol. Neurological examination revealed ambulatory paraparesis with mild proprioceptive deficits in the pelvic limbs and reduced segmental spinal reflexes; an L4-S3 neurolocalisation was suspected. At that stage, she received L-asparaginase SC to try and consolidate the response together with the planned cytarabine treatment. She represented 2 weeks later at which point the gait had deteriorated and, although still ambulatory, the dog had marked proprioceptive deficits in both pelvic limbs. An anthracycline-based rescue protocol was offered at that stage but, due to a VCOG grade III thrombocytopenia, inappetance and diarrhoea, it was elected to start prednisolone at 40 mg/m2 SID PO only. A haematology with a manual differential count was reassessed 7 days later and the thrombocytopenia found to have resolved; the dog’s appetite was back to normal and her demeanour had also improved. Epirubicin as single agent was started at that stage; this was administered as a slow IV infusion over 20 minutes at a standard dose of 30 mg/m2 diluted with 0.9% NaCl, following administration of maropitant at 1 mg/kg IV. Additional oral maropitant was prescribed for use at home for an extra 4 days at a standard dose of 2 mg/kg PO q 24 hours.\nThe dog experienced a partial clinical response (PR) and no adverse events a week after chemotherapy. However, 14 days since epirubicin was administered, the neurological signs recurred in the form of progressive weakness on the hind limbs and, although further chemotherapy was offered and discussed at that time, the owner elected to discontinue treatment and administer prednisolone only at a dose of 40 mg/m2 PO q 24 hours. The patient eventually developed paraplegia 7 days later and she was euthanased due to severe clinical deterioration. The overall survival was 195 days since chemotherapy treatment was started. |
A 22-year-old right-handed paratrooper was presented to the orthopedic emergency department because he fell on his outstretched right hand after having attempted a wrong landing technique. The accident took place in the island of Rodos where he received first aids and was then transported to our hospital for further treatment.\nOn physical examination, there was swelling and pain over the dorsum of the hand. Despite the swelling, it was feasible to notice deformity and to palpate the characteristic step-off created by the bases of the metacarpals. Active movement of the wrist and the fingers was limited while the patient was unwilling to cooperate due to pain. Neurovascular assessment revealed both a strong palpable radial pulse and a lively capillary refill while sensation of the hand was normal.\nPlain radiographs (a dorsopalmar and an oblique view) of the right hand showed complete dorsal dislocation of the three ulnar CMC joints (). In order to achieve a better assessment of the injured joint surfaces, an additional CT scan of the right hand was conducted. The latter not only confirmed the diagnosis but also revealed a bony fragment at the base of the fifth metacarpal that originated from the hamate (Figures and ).\nAt the emergency department, closed reduction was attempted by applying longitudinal traction to the involved digits with pressure over the bases of the dislocated metacarpals. After that, the wrist was immobilized with a plaster. Three days later, the patient was operated under general anaesthesia in supine position. The surgical treatment chosen was open reduction and internal fixation (ORIF). Two longitudinal incisions were made over the second and fourth web spaces addressing adjacent respective joints. At this point, it is of note that when the subcutaneous hematoma was evacuated and the extensor tendons were retraced with the surrounding loose connective tissues, we noticed that our initial closed reduction which took place in the emergency room has been lost. Therefore, a new one was achieved under image intensifier guidance, and then, internal fixation was accomplished with K-wires 1.6. In detail, the third and fourth metacarpals were transfixed on the trapezoid and on the capitate, respectively. The fifth metacarpal was pinned similarly on the hamate (). Regarding the fracture of the hamate, it was extra-articular and its reduction was secured by an interosseous suture vicryl 2-0. After the fracture alignment and joint reduction were evaluated under image intensifier, all wounds were meticulously irrigated and then closed in layers. Lastly, a sterile dressing and volar splint were applied for six weeks.\nBoth the splint and the K-wires were removed in six weeks' time (Figures –). At this point, active ROM exercises were started. The DASH score one week after the splint removal was 62.5. At 8 weeks, physiotherapy was begun emphasizing on both strengthening exercises and earning full range of motion. In total, 10 sessions were done and the patient was reevaluated after one month. The DASH score was then 12.5. The patient was able to fully return to former activities in six months' time. The DASH score was 0.0. The last follow-up that took place 6 months after the injury revealed great functional results with full return of strength as well as satisfactory cosmetics results. The patient did not mention any difficulties in his labor and everyday life activities. |
A five-month-old boy of Caucasian ethnicity presented at our pediatric emergency unit. He had suffered acute paroxysmal abdominal pain and bilious vomiting for nine hours. His general condition and vital signs were normal.\nDuring physical examination, an abdominal mass was noted in the upper right quadrant - there was no blood in stools in the rectum. Biological examinations did not yield significant results, but an ultrasound scan revealed a target sign in the form of an opaque mass under the liver. An air enema reduction was performed and identified a loop in the transverse colon that was refluxing under air pressure. This procedure did not result in a complete reduction of the assumed intussusception even after two attempts under midazolam infusion. An ileocolic intussusception of 2 cm was diagnosed during the laparoscopic exploration and a reduction was carried out by applying gentle traction. The adjacent small intestine and the ascending colon had a normal color and the child had normal peristalsis. The procedure was finished on these reassuring signs. During the night, the boy suffered repeated episodes of vomiting and had blood in his stools. An ultrasound scan performed in the morning revealed an intussusception, a swelling of the distal small intestine and the presence of a mass in the pouch of Douglas. It was difficult to determine with confidence whether the intussusception was ileocolic or ileoileal.\nA second laparoscopic procedure determined that the intussusception was not ileocolic. The cecum was in its usual location, and there was no inflammation of the appendix. The small intestine was examined more closely and an intussusception was found, located 40 cm above the ileocolic junction. A reduction attempt failed even with the help of a third forceps. A right hemitransverse abdominal incision was performed but the reduction attempt failed. Palpating the ascending colon revealed a diffuse induration with no signs of wall necrosis. The small intestine appeared normal. A transverse enterotomy was performed 5 cm before the ileocolic junction. An intussusception of a bowel segment was identified but it could not be reduced. After full exploration, a tumor of less than 15 mm was identified at the top of the first intussusception. 40 cm of ileum was resected and an end-to-end anastomosis (A-B) was performed. The postoperative course was uneventful.\nHistologic examination indicated the presence of 12 mm of heterotopic pancreatic tissue (Figure ). The first intussusception was 60 cm away from the ileocolic junction with ileal heterotopic pancreatic tissue as the lead point. The second intussusception, which formed an additional loop on the first one, was located 40 cm away from the ileocolic junction. The third intussusception completed the telescoping in the ascending colon (Figure ). |
A twenty-year-old male patient presented to our clinic with pain of the right wrist and the long finger MP joint. Two years earlier, the patient slipped on his hand. After injury, he did not received any evaluation or treatment, but he felt a snapping of the ulnar side of the wrist in forearm rotation and dorsal side of the long finger MP joint in MP flexion. At that time, the symptoms improved spontaneously after several weeks without specific treatment, three months earlier, after heavy lifting, he had persistent symptoms despite the conservative treatment including short arm splint for 4 weeks. A physical examination revealed painful ECU dislocation in forearm rotation and painful extensor tendon subluxation at the long finger MP joint in MP flexion. He showed generalized ligament laxity according to the Beighton and Horan criteria but did not have any symptoms in the contralateral hand.\nPlane radiography did not reveal any fracture or abnormality. Ultrasonography and magnetic resonance imaging (MRI) were performed to confirm the subluxation and identification of the associated pathology. In dynamic ultrasonography, the sagittal band (SB) was subluxated ulnarly as the long finger MP joint was flexed more than 70°. In addition, the ECU was subluxated volarly in forearm supination with tendon attrition at the level of the ulnar styloid process where the ECU groove exists. MRI revealed longitudinal splitting approximately 5 cm at the level of the ulnocarpal joint and dislocation of volar half slip of the ECU tendon on T2 axial plane image ().\nThe patient had been in military service. He required surgical treatment for rapid return to his previous work. Therefore, surgical treatment was performed.\nWith the patient under general anesthesia, the long finger MP dorsum was approached longitudinally. The radial SB did not reveal any definitive rupture but diffuse thinning was observed. The extensor tendon slipped off the metacarpal head ulnarly as the joint flexed intraoperatively. The redundant radial SB was augmented using a cross-stitch with a 6-0 prolene suture (). This effectively prevented any additional slippage of the extensor tendon of the long finger.\nWith an approximately 4 cm longitudinal incision in the ulnar styloid area, the ECU sheath on the ECU groove was approached protecting the dorsal ulnar nerve sensory branch. Neither the ECU sheath nor extensor retinaculum was ruptured but the space within the ECU tendon compartment was dilated because of its redundancy at the ulnar styloid process. An ECU tendon dislocation in an ulnar and palmar direction was confirmed with the forearm in supination and the wrist in palmar flexion. The fibro-osseous sheath of the ECU groove was incised at the ulnar border and elevated radially. The ECU tendon surface showed no longitudinal tear unlike the MRI finding. The ECU groove was deepened approximately 2 mm using a curette. Two small FASTak (Arthrex Inc., Naple, FL, USA) suture anchors were inserted at the ulnar border of the ECU groove just proximal to ulnar styloid and 1 cm apart proximally. The overlying ECU sheath was advanced to the underlying periosteum reducing the enlarged sheath volume with a horizontal mattress tie (). A long arm splint with MP extension at neutral forearm rotation was applied for 4 weeks and the wrist motion was allowed thereafter. A removable splint was applied for an additional 2 weeks. Vigorous activities were restricted for an additional three months. At the 1-year follow-up, the long finger MP joint, wrist and forearm showed normal motion with no pain (). He returned to his previous activities without a recurrent dislocation of the ECU tendon and long finger extensor tendon. |
Patient A, a 70-year-old woman (weight: 67 kg; BMI: 24.2) had experienced dizzy spells and collapse for 2 years. She did not possess any of the features of the metabolic syndrome [, ]. A blood glucose concentration of 2.4 mmol/L had been detected while symptomatic in primary care, and she was referred to the metabolic clinic. There was no family history of diabetes. Direct questioning suggested an association with meals, especially those containing high amounts of carbohydrate.\nIt was decided to carry out an eGTT. The results of the relevant biochemistry are presented in and . During the test, she became symptomatic (neuroglycopenic symptoms; light headedness, but without clinical evidence of sympathetic counter-regulation; blood pressure and heart rate remained at 117/74 mmHg and 65 bpm, resp.) between 100 and 120 minutes with no evidence of clinical improvement. There did not appear to be any improvement after 130 minutes and the test was abandoned after discussion with the patient. She was given fast acting glucose energy tablets and recovered rapidly while under close medical supervision.\nThe results were discussed and an association between insulin levels and blood sugar was noted. The pattern observed appeared to fit a reactive pattern, albeit hypoglycaemia occurring early. It was considered that the raised insulin levels prevented the physiological counter-regulation; hence, the patient recovery was compromised. At this point, we decided to repeat the eGTT, but using half the glucose content to establish whether a different clinical, biochemical pattern and recovery took place. Although this modified eGTT was unconventional and may not be useful in determining the diagnosis, it was decided that it might yield important information when compared to the original eGTT. Further, it could be useful to see if smaller glucose load would lead to less severe symptoms. The results of the modified eGTT are presented in . Although the patient once again became symptomatic after 120 minutes she began to recover without medical intervention with the blood sugar increasing to 3.8 mmol/L after 150 minutes. The FFA levels increased in line with the blood sugars suggesting a physiological response to hypoglycaemia. |
A 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy with bilateral salpingectomy 3 months earlier. She is a housewife with no history of routine drug use and no prior history of hypertension, diabetes, allergies, or other chronic disease. She does not smoke tobacco and does not consume alcohol.\nA physical examination revealed that her general condition was good and her vital signs were: blood pressure 112/74 mmHg, heart rate 89 beats per minute, respiratory rate 18 times per minute, and temperature 36.6 °C. There were no abnormalities in her chest and abdomen, or in musculoskeletal and neurological examinations. In a genitalia examination using a speculum, we identified fistulae above her vagina wall that were 1 cm in size. All laboratory findings (that is, complete blood count, liver functions, renal functions, and urine analysis) were within normal limits.\nAfter discussion with our patient regarding the risks and benefits of an open abdominal procedure and laparoscopic approach, we discussed the similarities and differences between the two procedures were her. We chose surgical management using laparoscopic approach with the considerations that it could facilitate precise dissection, offer good visualization, and be minimally invasive, thereby enabling faster recovery.\nOur patient was placed in the lithotomy position and received general anesthesia. A cystoscopy was performed to confirm the fistulae orifice and a stent was inserted into the fistulae tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina and prevent loss of pneumoperitoneum. A transperitoneal approach was performed with trocars distributed as follows: The camera was placed through a 12 mm port with 30° down lens located superior to the umbilicus. Two ports for the surgeon were placed on the right side (Fig. ).\nShe had adhesions; therefore, adhesiolysis was performed, using a combination of sharp and blunt dissection to expose the vaginal stump and the superior aspect of her bladder (Fig. ). A simple cystotomy was performed and extended to include the fistulae site, and the fistula tract was excised until viable fresh tissue was exposed. Later the defect was repaired by using a running stitch of 3–0 Vicryl. Knots were tied intracorporeally. A second layer of closure was performed in an imbricating fashion with the same suture. The vagina defect was not closed separately but covered with an omental flap (Fig. ). A vascularized omental flap was made using a scalpel, which was placed in the plane of dissection between her bladder and her vagina, and it was secured with two attachment points.\nThe ureteral stents were removed without difficulty. A urethral catheter was placed for adequate postoperative urinary drainage. This procedure takes approximately 2.5 hours; the estimated blood loss for our case was minimal and there were no intraoperative complications.\nOur patient was given intravenously administered ceftriaxone 1 gram per 12 hours postoperatively for prophylaxis and orally administered diclofenac for pain control on an as-needed basis from the following day. At postoperative day 1, she was able to eat as usual and complained of minimal abdominal pain during mobilization. The surgical wound was good and there was no urine leakage from her vagina. After that, she was discharged while still using urethral catheter for adequate postoperative urine drainage for 2 weeks.\nShe returned for a follow-up 2 weeks after surgery and reported that she experienced no recurrent incontinence and urination was normal. She continued to do well at 1-month, 3-month, and 6-month postoperatively. |
A 62-year-old woman presented to our hospital with a 1-year history of persistent pain in the right lower abdomen. No abnormalities were observed during the physical examination, and no palpable abdominal mass was identified. Abdominal enhanced CT (Fig. ) and gastric reconstruction imaging (Fig. ) revealed a gastric filling well, a low-density shadow on the lesser curvature of the gastric cardia with nodular calcifications on the edge, and a mass of approximately 6.4 × 4.9 cm with uniform density. No obvious enhancement, thickening of the gastric wall, or strengthening of the gastric mucosa was observed. No abnormalities were found by electronic gastroscopy. We considered the mass to be a GIST, although we did not exclude the possibility of other diagnoses. Exploratory surgery was performed for diagnosis and treatment.\nThe patient agreed to undergo laparoscopic surgery. After careful exploration, we found that the mass was located on the side of the lesser curvature, near the cardia. It was prominent on the stomach wall, and its diameter was approximately 6 cm. The mass was soft and mainly consisted of cystic components, which did not conform to the characteristics of a GIST. Therefore, we exposed the visual field of the cardia and endoscopically resected the muscular layer and mass. The mass was not significantly adhered to the surrounding tissues, and the separation was smooth; neither removal of the surrounding tissues nor lymph node dissection was needed. The specimen (Figs. and ) was sent out for pathological examination. We performed seromuscular suture of the gastric wall after the resection. The patient recovered well and her cardiac function was normal after operation. She was discharged 6 days postoperatively. A follow-up consultation 3 months after the operation indicated that the patient was in good condition and had no abdominal pain or other complaints or complications.\nThe postoperative pathological examination findings (Fig. ) revealed that the specimen was a single nodule of 7.0 × 4.5 × 1.5 cm and had a cystic surface. The contents under the capsule were dark brown, soft, and brittle; the capsule wall was smooth and 0.1 to 0.2 cm thick. A partially mucosal, slightly gray area of 2 × 1 cm was also present The pathological results indicated that the mass was a bronchogenic cyst. The patient underwent regular postoperative follow-up in our hospital for 1 year, during which time she experienced no discomfort or recurrence of the tumor on CT. |
A 47-year-old female presented to an outside institution with chronic low back pain and right L5 radiculopathy, and an MRI of the lumbar spine was performed (not shown). It showed a mass-like lesion at the right L5–S1 foramen and a diagnosis of hernia or tumour was considered. Over a 1-month period, the patient was managed clinically with analgesics with partial resolution of symptoms.\nThe patient then presented to the emergency department of our hospital owing to her persistent symptoms and an MRI of the lumbar spine (T1 and T2 weighted sequences) was obtained (). At this point, no contrast injection was performed as it is not included in the low back pain/radiculopathy investigation protocol in the emergency department. It showed the previously described lesion at the right L5–S1 foramen, as well as other ipsilateral lesions in the posterior paraspinal muscles and the anterior epidural space. Most of the lesions had a mass-like appearance and low signal intensity in all MR sequences. Interestingly, one lesion in the posterior paravertebral muscle showed mixed signal intensity on T2 weighted sequence, defining a fluid–fluid level. All the lesions were unchanged compared with the outside scan. The radiology team suspected that the lesions were calcified and suggested a contrast-enhanced CT scan of the lumbar spine ( and ) to confirm their initial suspicion and rule out possible soft tissue components associated with the lesions. The CT scan confirmed the calcified nature of the lesions and also showed no contrast enhancement. It also contributed to an additional finding of interstitial lung disease, as seen in a few images at the base of the lungs in the thoracolumbar region. A CT scan of the chest was suggested () and showed signs of pulmonary fibrosis and oesophageal dilatation. At this time, the hypothesis of paraspinal tumoral calcinosis secondary to SSc was suggested.\nAdditional clinical investigation showed that the patient had a history of dyspnoea, generalized weakness, arthralgia and gastro-oesophageal reflux disease. On physical examination, Raynaud’s phenomenon with a distal phalanx skin ulcer of the left third digit, sclerodactyly and multiple facial telangiectasias were also observed. Laboratory analysis indicated that creatinine, calcium and phosphorus levels were normal. In fact, the patient had an established diagnosis of lcSSc over a period of 15 years. However, this information was not provided to the radiology department, making the diagnosis of lumbar paraspinal tumoral calcinosis secondary to lcSSc challenging.\nAfter a multidisciplinary team meeting, it was initially decided that the patient’s radiculopathy should be managed clinically with non-steroidal and steroidal anti-inflammatory drugs and follow-up MRI of the spine should be performed within 6 months. In case of non-resolution or worsening of the symptoms during the follow-up interval, it was decided that surgical decompression could be considered depending on the patient’s general clinical status. |
An 18-year-old male with a medical history of right inguinal hernia repair during childhood, presented with a history of left groin swelling for three months. There was a progressive increase in its size. Initially, he had been able to reduce the mass, but now it had become irreducible. His history revealed no symptoms of bowel obstruction.\nOn examination, he looked comfortable with normal vital signs and no signs of distress. On palpation, a large mass was found in the left inguinal region extending to the left scrotum, about 10 cm in diameter. Cough impulse was present; the transillumination test was negative; and the mass could not be reduced.\nAs the presentation was not typical for an incarcerated hernia, further investigations were done. An ultrasound examination of the area revealed normal testes with no hydrocele; it also showed that the mass had increased vascularity most likely representing omentum.\nThe patient was prepared for surgery and taken to the operating room where the left inguinal canal was explored. The content of the hernia could not be reduced, so the hernia sac was opened and a piece of omentum was seen extending from the internal ring to the scrotum. The incision was then extended into the scrotum and a large encapsulated mass was encountered attached to the omentum []. The mass was easily delivered out of the scrotum as it was not attached to the scrotum or the testes and it was completely excised along with a small piece of omentum to get a clear margin. The hernia was then repaired using a prolene mesh. The patient's postoperative course was uneventful and he was discharged from hospital after one day with no complications.\nGrossly, the mass measured 19 × 9 × 7 cm and was well encapsulated. The cut surface had a yellowish myxoid appearance [].\nThe histopathological examination revealed that the tumor consisted of bland spindle-shaped and satellite cells evenly distributed in a collagenized and myxoid stroma []. A Keloid type collagen was also present. Occasional mitotic figures were seen. The tumor tested positive for Vimentin, but negative for CD117 and CD34 []. All were consistent with mesenteric fibromatosis. The patient was called back to perform endoscopy and CT scan of the abdomen to rule out polyposis syndromes or other abdominal lesions, but he did not return for follow-up. |
We report a 12-year-old male child, post balloon dilatation of CoA at 3 years of age and followed by surgical intervention i.e. PTFE patch repair of CoA, ligation of ductus arteriosus and reimplantation of left subclavian artery to left carotid artery seven years later i.e. in 2014. The child was doing well till April 2016 when he had pain in the left hypochondrium and right leg followed by mild fever. There was no history of loss of appetite, weight loss, edema or any urinary complaint. The child was evaluated by a local physician. Work-up showed high leucocyte counts, high C-reactive protein and microscopic hematuria. Blood and urine cultures were sterile. He was treated as case of urinary tract infection with intravenous antibiotics (ceftriaxone and amikacin) for 14 days. One week after stopping the antibiotics, the child had recurrence of fever and was reevaluated. Repeat septic workup showed high inflammatory markers, numerous RBCs in urine while all cultures remained sterile. Chest X-ray frontal view showed a homogenous opacity of the left upper mediastinum at the site of aortic knuckle ().\nEchocardiography showed no evidence of intracardiac vegetation, no pericardial effusion and normal ventricular function. The suprasternal long axis view showed a well opened aortic arch, with no significant gradient but there was suggestion of aneurysmal dilatation of aorta. There were multiple echogenic flagellar masses at the site of the repair ().\nCT angiography of the aorta () showed multiple aneurysms at the site of surgical repair starting 5 mm distal to the left carotid artery and involving a length of 60 mm, mediastinal edema, enlarged mediastinal lymphnodes and multiple infarcts in the spleen. The child was treated as a case of mycotic aneurysm with intravenous antibiotics for 6 weeks.\nHe was planned for surgical intervention after completion of the antibiotic course. Repeat echocardiography, after completion of antibiotics showed no vegetations in the arch. Repeat CT angiography aorta showed no increase in number and size of aneurysms, the mediastinal edema had subsided but the mediastinal lymphnodes were still enlarged. In addition there was an aneurysm of the right profunda femoris artery. To rule out any active infection, positron emission tomography (PET) scan was also done.\nWith the diagnosis of MA, he was planned for intervention. Both options, surgical and nonsurgical i.e. endovascular aneurysm repair (EVAR) were discussed with the family and the parents agreed for endovascular stenting. After high risk consent the child was taken for EVAR.\nThe procedure was done under general anesthesia with antibiotic cover. The right femoral artery lumen was small (5 mm) for a large sheath to be used for stenting. In addition there was small aneurysm involving the right profunda femoris artery. For these reasons, the procedure was planned from the right iliac artery. After profiling the aortic arch anatomy with from the left femoral artery (), the right iliac artery was exposed by incision in the iliac fossa. The aortic arch was crossed with the help of Multipurpose II catheter and an Amplatzer extrastiff wire (0.035”) was stabilized in the ascending aorta. Endurant Medtronic Limb Extension (16-20-93) was chosen to cover the length of diseased aortic segment and to exclude the aneurysms. Stent graft was deployed uneventfully under fluoroscopic guidance (). Post deployment angiography showed no restriction of flow to left carotid artery and to left subclavian artery, complete exclusion of aneurysms, and no dissection (). The pigtail catheter which was placed from the left femoral artery was removed over a Terumo wire as a precautionary measure.\nThe post procedure antibiotic course was planned for 6 weeks and the family completed that under local pediatrician care. There was no recurrence of fever and inflammatory markers remained negative. CT angiography aorta 6 weeks and 6 months post procedure showed stent in situ, completely excluded aneurysms and no new lesion in the aorta. |
A 4-year-old girl was previously diagnosed with asplenia, single right ventricle, and supracardiac TAPVC. She underwent pulmonary artery banding at the age of 1 month, followed by a bidirectional Glenn procedure and TAPVC repair at the age of 5 months. She did not demonstrate symptoms of PVO, and there was no evidence of delay in the excretion of contrast media in cardiac catheter examination before Fontan procedure. Extracardiac Fontan palliation was subsequently performed at the age of 19 months. At the age of 3 years, although right lower PVO occurred because of the compression of the vertebra, she did not demonstrate symptoms of PVO (). At the age of 4 years, she underwent a cardiac catheterization to evaluate her hemodynamic parameters after Fontan procedure (). She was taking oral aspirin, warfarin, and enalapril. After a routine hemodynamic assessment, NO and oxygen tests were performed. A pigtail catheter was placed in the single ventricle, and a wedge catheter was positioned in the pulmonary artery. We performed the pulmonary vasodilator examination in the same way as when doing the examination in patients with pulmonary hypertension []. Subsequently, 20 ppm NO was administered via face mask. After 5 minutes of NO administration, her hemodynamic parameters were measured. Following a washout period of 5 minutes, 100% oxygen was administered, and after 5 minutes of oxygen administration, her hemodynamic parameters were again measured. To measure the pulmonary arterial wedge pressure and pulmonary arterial pressure accurately, the waveform was monitored carefully (Figures and ). After the administration of NO, the single-ventricle end-diastolic pressure, bilateral mean pulmonary arterial pressure, and cardiac index did not change. Oxygen saturation did not change at 95%, and pulmonary resistance index decreased from 2.1 to 1.0 Um2. However, the right lower pulmonary arterial wedge pressure increased from 8 to 12 mmHg, and the left lower pulmonary arterial wedge pressure increased from 7 to 9 mmHg. The cardiac index remained almost the same. Similarly, following the administration of oxygen, the single-ventricle end-diastolic pressure did not change; however, the right lower pulmonary arterial wedge pressure increased from 8 to 14 mmHg and the left lower pulmonary arterial wedge pressure increased from 7 to 12 mmHg. The bilateral mean pulmonary arterial pressure increased from 13 to 15 mmHg. Although angiography was performed after the inhalation of NO and oxygen, there was no evidence of left pulmonary venous obstruction or delay in the excretion of contrast media (Figures and ). A systemic-to-pulmonary shunt was also nonexistent. On echocardiography, there was no acceleration of blood flow at the left pulmonary vein or surgical anastomosis between the pulmonary venous confluence and the atrium. There was also no stenosis of the atrioventricular valve. Despite the inhalation of NO and oxygen, there was no acceleration of blood flow, and stenosis was not identified at the surgical anastomosis between the pulmonary venous confluence and the atrium (). |
A 79-year-old male with a history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, and persistent atrial fibrillation was brought to hospital after being successfully resuscitated following a brief pulseless electrical activity (PEA) cardiac arrest. During his convalescence, he had a second PEA arrest, from which he was again successfully resuscitated. Telemetry revealed atrial flutter with atrioventricular conduction that slowed markedly to ventricular rates as low as 34 beats per minute. A balloon-tipped temporary pacing catheter was floated in via left internal jugular vein until adequate ventricular capture was observed. Fluoroscopy was not used during insertion. A follow-up chest X-ray confirmed appropriate placement of the lead, which revealed the lead in the right ventricle with redundant lead slack forming a loop ().\nThe patient subsequently had a PPM implanted. The PPM was implanted without complication using a standard left cephalic vein access. The lead was advanced under fluoroscopic guidance. Implantation of the PPM lead was carried out without difficulty with active fixation to the right ventricular septal wall. The lead pin was attached to a pacemaker pulse generator which was then placed in a pocket located in the prepectoral plane below the left subclavicular fossa.\nThe TVP was then removed under fluoroscopic guidance. The large loop of redundant wire was noted, but it exited the cardiac silhouette without any resistance or interaction with the newly implanted PPM lead. However, significant resistance was noted when attempting to pull the tip of the TVP lead out through the introducer sheath. This resistance was only encountered when the TVP lead tip was at the level of the skin; fluoroscopy was not performed at this stage to determine the cause of resistance. The resistance was overcome and the TVP lead was successfully removed. It quickly became evident that the reason for the resistance was that the TVP lead had looped and formed a knot around the RV PPM lead at the junction of the left subclavian and left internal jugular vein. Continued traction had thus dislodged the RV lead tip from the endocardium, resulting in inadvertent removal of the RV lead through the left internal jugular vein (). No dislodgement of the PPM lead had been apparent fluorocopically during removal of the TVP wire from the cardiac silhouette as the ensnarement occurred at the level of the thoracic inlet when fluoroscopy was no longer being employed, and no loss of capture was noted as the patient was in their intrinsic rhythm. The patient remained hemodynamically stable.\nIn order to place a new RV PPM lead, left axillary venous access was obtained and a new lead was successfully placed, which was connected to the original pulse generator. The ensnared RV lead was cut within the pocket, and the lead pin was removed from the pulse generator directly. The external portion of the RV lead () was then removed without complication from the left internal jugular vein. The new PPM assembly functioned well, and the procedure was completed without any further complication. |
A 72-year-old male, a case of malignant mesenchymal tumor of upper one-third of right tibia, evaluated first 13 years ago by the surgical oncology unit, was found to have localized disease with PET negative for any distant metastasis. He underwent right above knee amputation under combined spinal epidural anesthesia. For postoperative pain, epidural morphine 3 mg twice per day was administered for the next five days and he was totally pain-free. He was discharged on oral morphine 5 mg four hourly, paracetamol 1000 mg six hourly and Bisacodyl 10 mg at bedtime. After one week, the patient complained of severe pain, squeezing in nature with occasional pins and needle sensation in the amputated limb starting from palmar aspect of the right foot radiating to dorsal aspect and subsequently to the entire right leg associated with heaviness in the limb suggestive of PLP. His pain score was 8 on a visual analog scale (VAS). He was started on oral morphine 10 mg four hourly, which needed progressive upward titration to 120 mg four hourly over a period of four weeks. Once pain control was optimal (VAS of 1-2), he was maintained on monthly follow up for the next one year with a stable oral morphine dose, conferring pain relief of 80-90% with VAS of 1-3. Thereafter, he started complaining of increased pain, which required an increase in morphine dose gradually to 300 mg four hourly to achieve a VAS <4. During subsequent follow up, his pain was inadequately controlled, which warranted epidural analgesia with 0.125% bupivacaine infusion for pain relief. This provided adequate pain relief with no phantom limb sensations. However, any attempt to wean dose of oral morphine caused rebound pain and features of opioid withdrawal. Hence chemical lumbar sympathectomy was planned under fluoroscopic guidance at the level of L2 with 4 ml of phenol. Following this procedure, patient had partial pain relief (VAS: 4/10). Dose of oral morphine was gradually decreased to 240 mg four hourly. In view of persistent pain, other modalities of interventional chronic pain management techniques like the placement of spinal cord stimulator, neuromodulator, and nerve blocks like lumber plexus block (right), sciatic nerve block (right) were also attempted over the next few years. However, pain relief was inadequate and VAS score remained >4. Dose of morphine was gradually titrated to 540 mg every four hourly. With this dose of morphine, there were concerns regarding opioid dependence/addiction. These concerns were addressed by gradual withdrawal of morphine under in-patient supervision. Withdrawal of morphine only caused rebound pain and patient did not manifest any features to suggest addiction. A formal psychiatry opinion was sought to confirm the findings administered following tests for assessment such as verbal adult intelligence scale (VAIS), Bender-Gestalt test; Draw a person test and Rorschach inkblot test. The results of these tests revealed that the patient has average intelligence with cluster B and C traits, and ruled out possible drug-seeking behavior. Presently, the patient is under follow up in our pain clinic and taking 540 mg of oral morphine every four hourly without any signs of toxicity or features of opioid dependence. Patient is actively involved in his routine daily activities. He enjoys good family support and his depression is well controlled with medications. |
We present a case report and a surgical video of a 42-year-old woman with perineal hernia. The manuscript has been written according to CARE guidelines. This patient presented with stage IIA squamous cell carcinoma of the cervix, initially treated by radiotherapy, chemotherapy and brachytherapy in December 2013. Surgery consisted of laparoscopic total hysterectomy and ovariectomy, together with pelvic and para-aortic lymphadenectomy. Early left paravaginal recurrence occurred in 2015 and was treated by resection of the left Bartholin gland. Another course of radiotherapy and chemotherapy was administered due to positive surgical margins (R1) of this resection. The patient presented another recurrence of her cervical carcinoma in February 2017 confirmed by pelvic CT scan and MRI. Due to the presence of a suspicious rectovaginal node, abdominoperineal resection with terminal colostomy was performed via a laparoscopic and perineal approach. We performed laparoscopic dissection of the left and right pararectal space to prepare an extralevator abdominoperineal excision and partial posterior colpectomy. We then performed radical posterior vulvectomy and a perianal incision at the lateral margin of the external anal sphincter and continued the dissection into the ischioanal fossa as far as the insertion of the pelvic floor muscles. We repaired the perineal defect and performed reconstruction of the posterior part of the vagina with an omental flap to preserve sexual function. After another course of chemotherapy and cycles of bevacizumab, the patient presented with her third recurrence two years later. Anterior pelvectomy was initially indicated due to a malignant mass infiltrating the right ischiopubic ramus and the right obturator internus muscle responsible for urethral retraction. This patient's case was discussed at a multidisciplinary consultation meeting and it was decided to treat her with chemotherapy. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia (Fig. ). The perineal hernia was causing pain and discomfort with a sensation of perineal heaviness. On physical examination, a reducible posterior perineal mass was palpated, which increased in volume during Valsalva manoeuvre.\nThe patient was placed in the supine position. We performed open laparoscopy with the introduction of three 5-mm trocars under direct vision: suprapubic, right and left iliac fossa. Exploration did not reveal any signs of carcinoma. The patient was placed in the Trendelenburg position. No postoperative peritoneal adhesions were observed and the content of the sac was easily removed to visualize the omental flap that constituted most of the hernia sac. We pediculized the omental flap, that was vascularized by the left gastroepiploic artery and the Barkow’s arcade. The perineal hernia sac was not resected because of its extremely fibrous structure and the need to preserve the vaginal reconstruction. We introduced Symbotex prosthetic mesh, composed of two layers: one layer of 3D monofilament polyester for the abdominal wall, and the other hydrophilic collagen layer for the visceral side. We simply applied the mesh inside the pelvic cavity above the pediculized omental flap to restore the pelvic floor.\nThe mesh was then sutured:- Posteriorly and laterally with Mersilene® 2.0 on the fibrous structure corresponding to the insertion of the previously resected left and right levator ani muscles. - Superiorly with Vicryl® 2.0 to the umbilical fascia.\nWe did not immediately remove the excess skin. The immediate postoperative period was marked by urinary retention, requiring a bladder catheter for 5 days and urinary tract infection treated by antibiotics. Perineal pain was relieved and the patient was satisfied with the result. At 6-month follow-up, the patient remained asymptomatic with no perineal hernia recurrence on clinical examination and imaging (Fig. ). |
A 49-year-old African American female with a past medical history of hypertension, migraine headaches and mild intermittent asthma presented to emergency room with a severe right-sided headache for the last 3 days. The patient gave a 14-year history of migraine headaches described as a slow onset unilateral throbbing headaches without aura accompanied by nausea and lasting 2–3 days. The patient stated that her migraine attacks were decreasing in frequency and severity for the past 2–3 years until the past year when she started experiencing different kind of headache. At the time of examination, she described the headache as sharp, intermittent, non-radiating pain with sudden onset behind her right eye lasting 1–2 days. During the last 3 days the pain became more intense, reported as 10/10 on the pain scale 1 to 10, with associated photophobia, dizziness and nausea, with diplopia that was worsened with gaze to the right lateral field. Her past medical history was significant for hypertension and asthma which were stable. Her past surgical history is significant for adenoidectomy at age of 12. Her family history is significant for a sister with breast cancer, and a father who died of renal cancer. A complete review of systems was otherwise negative.\nOn physical examination the patient displayed right lateral rectus muscle palsy (6th cranial nerve palsy) with inward deviation of her right eye. There was numbness in all three divisions of the right trigeminal nerve, suggesting involvement of the fifth cranial nerve. There was no evidence of right 3rd, 4th, 7th or 8th nerve involvement. Motor and sensory examination of her extremities was normal. The rest of the examination was negative. The patient was admitted to the inpatient service. Her pain was controlled with medications. All laboratory studies, including complete blood count, biochemical studies and syphilis screening were negative. A Magnetic Resonance Imaging (MRI) of the brain and brain stem revealed a large mass in the clivus extending anteriorly, involving the nasopharynx and sphenoid sinus, and posteriorly destroying the clivus laying anterior to the pons. There was destruction of the pterygoid plate and right cavernous sinus (Figure ). Neurology consult recommended starting the patient on phenytoin and dexamethasone for seizure prophylaxis. A pituitary profile was ordered which revealed a slight elevation of prolactin level 39.1 ng/ml (normal 20 ng/ml). On day number 2 of admission, neurosurgery and otolaryngology were consulted and the patient underwent sinus endoscopy with biopsy of the right sphenoid sinus. From days 3 to 6, the patient was stable, and pain was controlled. On day 6th pathology revealed a tumor with a cribriform pattern. The neoplastic cells were monotonous and intraluminal basophilic material was noted. No perineural invasion was identified. The neoplastic cells were strongly positive for cytokertain AE1/AE3 and positive for S-100 and CD117. This histology indicated ACC of the minor salivary glands. Oncology consultant recommended resection followed by radiation. Additional work up included a thin cut computerized tomography (CT), which revealed bone invasion. Chest, abdomen and pelvis CT scans were negative for metastatic disease. The patient underwent total gross surgical resection. A postoperative CT scan showed partial resection of the tumor and the patient was scheduled for a second surgery followed by postoperative radiation. |
A 4-year-old girl was previously diagnosed with asplenia, single right ventricle, and supracardiac TAPVC. She underwent pulmonary artery banding at the age of 1 month, followed by a bidirectional Glenn procedure and TAPVC repair at the age of 5 months. She did not demonstrate symptoms of PVO, and there was no evidence of delay in the excretion of contrast media in cardiac catheter examination before Fontan procedure. Extracardiac Fontan palliation was subsequently performed at the age of 19 months. At the age of 3 years, although right lower PVO occurred because of the compression of the vertebra, she did not demonstrate symptoms of PVO (). At the age of 4 years, she underwent a cardiac catheterization to evaluate her hemodynamic parameters after Fontan procedure (). She was taking oral aspirin, warfarin, and enalapril. After a routine hemodynamic assessment, NO and oxygen tests were performed. A pigtail catheter was placed in the single ventricle, and a wedge catheter was positioned in the pulmonary artery. We performed the pulmonary vasodilator examination in the same way as when doing the examination in patients with pulmonary hypertension []. Subsequently, 20 ppm NO was administered via face mask. After 5 minutes of NO administration, her hemodynamic parameters were measured. Following a washout period of 5 minutes, 100% oxygen was administered, and after 5 minutes of oxygen administration, her hemodynamic parameters were again measured. To measure the pulmonary arterial wedge pressure and pulmonary arterial pressure accurately, the waveform was monitored carefully (Figures and ). After the administration of NO, the single-ventricle end-diastolic pressure, bilateral mean pulmonary arterial pressure, and cardiac index did not change. Oxygen saturation did not change at 95%, and pulmonary resistance index decreased from 2.1 to 1.0 Um2. However, the right lower pulmonary arterial wedge pressure increased from 8 to 12 mmHg, and the left lower pulmonary arterial wedge pressure increased from 7 to 9 mmHg. The cardiac index remained almost the same. Similarly, following the administration of oxygen, the single-ventricle end-diastolic pressure did not change; however, the right lower pulmonary arterial wedge pressure increased from 8 to 14 mmHg and the left lower pulmonary arterial wedge pressure increased from 7 to 12 mmHg. The bilateral mean pulmonary arterial pressure increased from 13 to 15 mmHg. Although angiography was performed after the inhalation of NO and oxygen, there was no evidence of left pulmonary venous obstruction or delay in the excretion of contrast media (Figures and ). A systemic-to-pulmonary shunt was also nonexistent. On echocardiography, there was no acceleration of blood flow at the left pulmonary vein or surgical anastomosis between the pulmonary venous confluence and the atrium. There was also no stenosis of the atrioventricular valve. Despite the inhalation of NO and oxygen, there was no acceleration of blood flow, and stenosis was not identified at the surgical anastomosis between the pulmonary venous confluence and the atrium (). |
A five-year-old male with congenital heart disease, developmental delay, and GJ tube dependence presented to his pediatrician’s office for a routine checkup. The patient had been attempting to transition to oral feeding, but it was determined that he still required enteral supplementation with GJ feeds. Although the family did not report problems with the GJ tube, it was noted that he had not had an exchange for eight months, for which he was referred to the interventional radiology (IR) clinic for GJ replacement. The following day he presented to the IR clinic for his GJ exchange. As the interventional radiologist began retracting the GJ tube, he met increasing resistance as the tip of the tube approached the gastrostomy stoma. The GJ tube could not be fully extracted and further attempts to remove the tube led the patient to become increasingly uncomfortable. Additional fluoroscopic evaluation identified a mass surrounding the end of the tube that was preventing successful removal (Figure ). General surgery and gastroenterology were consulted. The more proximal end of the GJ tube was cut and clamped at the stoma until further endoscopic intervention could be undertaken to identify the mass and attempt extraction.\nDuring the esophagogastroduodenoscopy, it was found that the tip of the tube was surrounded by a mass of food debris and plastic that was caught in a web of the patient’s hair (Figure ). The endoscopic team then used an endoscopic grasping net to grasp the bezoar, pushed the remaining GJ tube into the stomach through the stoma, and extracted the remaining portions of the GJ tube and bezoar with the endoscope. A new GJ tube was then successfully placed through the original stoma.\nAfter describing the findings to the family, they subsequently endorsed the patient had been pulling out and eating his own hair and chewing on plastic materials for several years. He was then discharged home with outpatient follow-up with his pediatrician and psychiatry to address his trichotillomania (hair pulling), trichophagia (hair swallowing), and pica (eating non-nutritive substances). |
A 50-year-old woman was admitted on January 2014 with complaints of vomiting, hiccups and generalized fatigue for 11 days, paraesthesias of bilateral upper limbs and lower limbs for 5 days. As the patient was a type 2 diabetic for 7 years, peripheral neuropathy was diagnosed in local hospital and treatment was given. She became asymptomatic after 15 days. Her investigations (complete blood count, differential count, renal function tests, liver function tests, B12 levels, folic acid levels, hemoglobin) were normal during that time. However, HBA1C was 9.8, fasting blood sugar was 300 mg/dl and postprandial blood sugar was 416 mg/dl for which dosage of insulin was increased. The patient was not evaluated with MRI or CSF analysis and was managed for diabetic neuropathy during the first episode.\nThe thyroid profile was abnormal, suggestive of hyperthyroidism for which she refused to take medication (Table 3 ). No history of smoking, illegal drug use or alcohol consumption was noted. No history of fever, cough and shortness of breath was noted. No history of hypertension, heart disease and other autoimmune disorders was obtained. In August 2014, the patient was admitted with weakness of bilateral lower limbs and upper limbs along with a band-like sensation around the chest at the level of T4 vertebra. The patient also complained of visual disturbances in the form of difficulty in seeing distant objects in bilateral eyes right > left. The CSF analysis done in the government neurology center was found to be normal during the episode.\nA MRI scan of brain and spine showed increased T2 signal and expansion of the cord in some areas of the spinal cord at the levels of C2–C5, and C7 to T12. The patient was given methylprednisolone 1 gram intravenous for a period of 5 days and oral steroids for 4 weeks. Thyroid function tests were reported to be normal (Table 3 ). The patient showed marginal improvement in vision and reduction of sensory abnormalities by about 50% over a period of 6 weeks. In April 2015, the patient was admitted with cough associated with mucopurulent expectoration, shortness of breath, paraesthesias and diminished vision. The patient showed minimal improvement in sensory symptoms or vision. In May 2015, the patient was admitted with progression of bilateral lower limb weakness, bilateral upper limb weakness (distal > proximal) and a band-like sensation around the chest, syncope, vomiting and hiccups. Clinical examination revealed normal higher mental functions with diminished vision to finger counting in the right eye. Other cranial nerves were normal.\nHypertonia was noted in all limbs. The power was 2/5 bilaterally in the proximal upper limbs and distal muscles. The lower limb power was 1/5 on admission, but improved to 2/5 in 15 days. Upper limb reflexes were 2+ and knee and ankle reflexes were 2+. The Babinski reflex was present bilaterally. Loss of joint position and vibration sense till the lower boarder of the sternum was noted. THe abdominal reflex was absent. Antibodies to HSV1, HSV2, CMV, EBV, HBV, VZV, HCV and HIV in serum and cerebrospinal fluid, as well as sarcoidosis and tumor markers in serum revealed no abnormality. Polymerase chain reaction in CSF for HSV1 and HSV2 was negative. Cerebrospinal fluid analysis demonstrated no oligoclonal bands.\nImmunological tests for ANA titer were 1:320, tests for anti-ENA, anti-dsDNA, anti-cardiolipin, anti-β2GPI, lupus cells, antibodies to GAD65, IA-2, insulin and cryoglobulins were negative. MRI brain and whole spine revealed 1) hyperintensity in cervical cord C5 to C7 level (Figure 1 , Figure 2 , Figure 3 ); 2) hyperintensity in the thoracic cord till T12 level (Figure 4 , Figure 5 , Figure 6 ); 3) hyperintensity in the right optic nerve head (Figure 7 ). The clinical features and investigations (NMO IgG was positive) fit into the criteria of neuromyelitis optica. The thyroid profile was suggestive of hypothyroidism (Table 3 ). Laboratory studies confirmed the presence of antithyroid antibodies (Table 4 ). Fine needle aspiration of the thyroid showed lymphocytic infiltration of the thyroid gland (Figure 8 , Figure 9 ). The patient was treated with prednisolone 1 g/day for 5 days and azathioprine (2.5–3 mg/kg/daily). The patient showed improvement in motor symptoms and sensory symptoms approximately by 60% after a period of 2 months of treatment. Patient was started on thyroxine 50 μg and later dosage was increased to 100 μg. |
A 53-year-old man presented with transient acute onset of left-sided numbness and speech disturbance one week prior to admission. These symptoms lasted for only several minutes and spontaneously resolved. Transient ischemic attack or acute cerebral infarction were possible diagnoses, so MRI and MR angiography were performed, showing an occlusion of his right MCA at the proximal M1 segment without any acute ischemic lesion or infracted area on MRI, including diffusion-weighted images. The next day, a conventional angiogram was taken and revealed a tapered occlusion at proximal M1 segment of right MCA, collateral pathways through perforating arteries, rich pial collateralization from distal anterior cerebral artery, and a shift of the watershed zone (). These findings were compatible with the long-standing stage of the occlusion of MCA rather than the acute occlusion. He also has an incidental saccular aneurysm at left posterior communicating artery (P-com) origin. The brain single photon emission computed tomography (SPECT) showed mildly decreased perfusion in right middle cerebral artery territory and the vascular reserve was also decreased mildly after acetazolamide injection (). An echocardiogram and myocardial SPECT excluded cardiac embolus as the etiology of the occlusion. Although the patient had no past medical history, untreated hypertension and diabetic mellitus were found during evaluation. In this setting of presumably chronic occlusion, surgical, endovascular and thrombolytic therapies would cause serious complications. Therefore conservative managements were selected for this patient. The patient was initially treated with antiplatelet and circulating drug and carefully observed for two weeks. He had no further neurologic symptoms.\nAfter two months, the left P-com aneurysm was managed by the microsurgical aneurysmal neck clipping and there were no developing or new neurologic symptoms after surgery. Immediate postsurgical computed tomography angiogram (CTA) showed persistent right MCA occlusion and complete aneurysm clipping (). The medications were continued during the follow-up period. The brain CTA of 21 months after neck clipping developed recanalization of the previously occluded right MCA. A subsequent conventional angiogram confirmed nearly complete patency of the right MCA with focal mild stenosis, normal blood flow through MCA, and the normalization of the shift of watershed zone (). Our patient experienced late spontaneous recanalization and restoration of blood flow by an unknown mechanism within 21 months, without any neurologic deficit. |
The patient is a 52-year-old female who presented to plastic surgery clinic to discuss functional and cosmetic reconstruction of her right lower extremity. The patient was involved in a traumatic injury requiring fixation of the right leg along with several subsequent skin grafts that led to dense scarring and volume loss along the entire right leg. The patient suffered from neuralgias, stiffness and severe psychosocial stigmata associated with the scar formation (see Fig. ) and sought definitive reconstruction.\nThe patient underwent the initial autologous staged fat transfer procedure on 9 April 2012. Approximately 500 cc of fat was harvested from the abdomen, knees, hips and flanks. This fat was then processed into several tuberculin syringes and prepared for injection. Prior to injection, the patient underwent circumferential release of the 8 cm extremity scar via excision and sharp dissection through use of sharp-tipped steel dissection scissors. The processed fat was injected into multiple areas of the scar subcutaneously in 2 cc injections at a time. A total of 57 cc of fat was injected in the lower extremity during this procedure and elevated the scar tissue from the bone.\nThe patient underwent the second stage of release of scar and fat transfer in 17 August 2012. Approximately 80–90% of the fat transfer from the previous injection had incorporated into the right lower extremity. The second stage began in similar fashion with liposuction and processing of fat obtained from knees, hips and flanks via loop lavage. The port sites were closed with fast-absorbing catgut suture and Steri-strips. After removing ∼700 cc via Coleman catheter, the patient had the fat instilled into her right lower extremity in 1–2 cc aliquots. Approximately 144 cc of fat was instilled into areas of tendon exposure superficially to release the contracture of the scar from her previous operations. The patient had dry sterile non-woven gauze dressing, and an elasticated bandage was placed around this extremity for compression and would follow up in 1 week.\nThe post-operative course was not complicated, and a drastic improvement was noted in both form and appearance of the patient's lower extremity after the staged fat transfer reconstruction procedure (see Fig. ). The patient noted improvement in mobility and decreased neuralgic pain that she had described prior to the procedure. Most importantly, the patient appreciated the symmetry between her lower extremities and reported improved self-esteem and decreased anxiety regarding her medical condition (see Fig. ). |
A 53-year-old woman visited our out-patient psychiatric clinic in March 2013. Her daughter reported that she had become excessively talkative, impulsive, and verbally aggressive. The changes in her personality had begun to appear in 2008 and her symptoms of hostility had become more severe recently. Her premorbid personality was described as reserved, diligent, frugal, and calm and she had worked in a market for more than 20 years. However, during the previous 5 years, she had begun to speak garrulously and often lost the thread of a conversation and included many irrelevant details when providing an explanation. She had become much more easily irritable and angry, which took the form of yelling and throwing objects. She had also begun to argue over seemingly unimportant matters with her neighbors. She had also begun to impulse buy multiple items also make many unnecessary purchases for her family. She had also become very hyperactive in her work life and social life. She did not display any sleep or eating disorders at the time of her visit.\nThe patient’s husband had an explosive temperament and alcohol problems which were a source of great stress and concern for her. Since 2000, she had begun to irregularly attend a local psychiatric clinic to receive medications for a depressed mood and insomnia. At the time of these visits, she was taking both antidepressants and sleeping pills. However, she and her family denied that she had experienced any depressive episodes or had ever been diagnosed with a mood disorder. She had no history of head trauma but had hypertension and diabetes, both of which are cardiovascular risk factors. There was also no history of migraine, a prior TIA, or stroke reported by the patient.\nHer family history further revealed that her father had died at 76 years of age after having suffered a stroke and that he had hypertension, diabetes and a history of depression including a suicide attempt. However, her mother is 76 years old and in good health. She has three younger brothers, the oldest of whom is 51 years old and has been diagnosed with cerebellar atrophy. He also has dysarthira and cerebellar ataxia. Those symptoms had gradually developed within the previous 2 years. Her second brother had suffered from depression and had committed suicide 20 years previously. Her youngest brother had no health issues, but his 17-year-old son had been diagnosed with epilepsy. She also has a son and a daughter. Her son suffers from migraine attacks but her daughter is healthy.\nWhen her mental condition was assessed she showed no evidence of delusions or hallucinations, but she did have pressured speech, circumstantiality, labile moods, poor impulse control, and made grandiose plans. She demonstrated no insights into the changes in her personality and behavior. Bedside neuropsychological testing revealed total scores that were within the normal range (K-MMSE 29/30). However, a Montreal Cognitive Assessment test (MOCA-K 25/30) revealed a failure to perform the trail making test (TMT) and copy cube. In the attention subtest, she tapped on the wrong letters and failed to correct this. In the language subtest, she could speak more than 11 words in 60 seconds but the all of the words began with the same sound with a different suffix, for example, like, liked, likely, look, looked, looking. In a delayed recall subtest, she recalled only two words correctly out of five. She was successful with Clock drawing, the Luria’s fist-edge-palm test and the loop test.\nDue to a suspected late-onset bipolar disorder with chronic manic features in this case, neuropsychological testing was performed by a clinical psychologist. To evaluate this patient’s comprehensive cognitive function, we performed the following tests: BGT, Clock Drawing Test, Color Trail Test (CTT) 1/2, Korean Auditory Verbal Learning Test (K-AVLT), Stroop Test, Word/Figural Fluency Test, Executive Complex Figure Test, Grooved Pegboard Test, Finger Tapping Test, Hand Dynamometer, MMPI-II, Sentence Completion Test (SCT), Wisconsin Card Sorting Test (WCST) and Rorschach Test.\nThe K-AVLT findings showed that the patient had a normal ability to encode and retrieve verbal information. However her abilities in terms of tracking sequential stimulations, dividing her attention and inhibitory control function were found to be severely impaired, with a poor score in terms of attention and executive function in the CTT tests (<1% percentile). Cognitive productivity was also poor as reflected in impaired word/figure fluency. In the WCST, the patient showed 18 perseverative responses (50% percentile) and 47 non-perseverative responses (<1% percentile). Her potential for perseveration was therefore low, and she showed an impaired efficient sorting tendency. The results of the Rorschach test indicated a strong cognitive rigidity in this patient as she only responded to the same content repetitively. Finally, the results of the MMPI-II showed that scales 1 and 9 were all higher than 65 T, indicating that this patient was complaining of physical pain or discomfort and making efforts to cope with difficulties in her cognitive function.\nIn conclusion, neuropsychological testing of our current case revealed an intact memory, but impairment in both attention and executive function. Although the patient’s perseveration tendency was not clear, she revealed a high level of cognitive rigidity in the Rorschach test. The results of the neurological examination of this case were unremarkable and other systemic examinations showed no abnormalities. The results of routine laboratory tests including VDRL, HIV antibodies and thyroid function were also unremarkable apart from hyperlipidemia. MRI analysis of the brain was performed and revealed severe leukoencephalopathy. There was a high signal intensity found by T2 weighted images (T2W1) and low signal intensity in the left pons. In fluid-attenuated inversion-recovery (FLAIR) images, a high signal intensity was prominent on the periventricular white matter, both basal ganglia, thalamus, and the external capsule. These magnetic resonance imaging (MRI) findings are very consistent with a diagnosis of CADASIL. Since the clinical and MRI findings for this patient were highly suggestive of CADASIL, genetic testing for NOTCH3 mutations was performed. As expected, a heterogeneous mutation was detected in this patient that causes an arginine to proline substitution in exon 3 of chromosome 19 p13.2-13.1 (c.224G > C).\nDuring her hospital treatment, her manic symptoms, including a labile mood, talkativeness and impulsivity, partially responded to atypical antipsychotics (quetiapine, 800 mg) and benzodiazepine (bromazepam, 6 mg) treatment. She was also prescribed with amlodipine (novasc), metformin (diabex), and atorvastatin (lipitor) for the management of the vascular risk factors, hypertension, diabetes, and hyperlipidemia, respectively. She was able to be discharged after two weeks in hospital. At the time of discharge, she was no longer hostile or aggressive but still showed slight impulsivity and mood instability symptoms. Her initial Montgomery-Asberg Depression Scale (MADRS) and Young Mania Rating Scale (YMRS) scores were 24 and 37, respectively. Two weeks after treatment, these values were lowered to 17 and 25, respectively. Her Clinical Global Impression-Severity Scale (CGI-S) score was 6 (severely ill) at initial presentation and 4 (moderately ill) at hospital discharge. Her Global Assessment of Functioning (GAF) score also slightly improved from 50 to 60 after treatment. |
A 48-year-old man was admitted to our institute with worsening cough and blood sputum. Enhanced chest computed tomography revealed a hilar mass in the right lower lobe with no mediastinal lymph node swelling and only one pulmonary vein on the right hilar site draining into the inferior vena cava, right superior bronchus, and pulmonary artery was absent (Figure ). The abnormality as a PAPVC was diagnosed. Fiberoptic bronchoscopy revealed occlusion of the B6-10 bronchus by an endobronchial lesion with absence of B1-3 bronchus. Transbronchial biopsy revealed squamous cell carcinoma.\nEchocardiogram showed normal left ventricular function with 65% ejection fraction; the right ventricle systolic pressure was 35 mmHg; and no remarkable abnormality such as an atrial septal defect was present. A pulmonary function study showed a forced expiratory volume in 1 s of 75% of the predicted value, a forced vital capacity of 96% of the predicted value, and a carbon monoxide diffusing capacity of 60% of the predicted value. An arterial blood gas analysis revealed a PaO2 of 87 mmHg and a PaCO2 of 45 mmHg in room air.\nThe planned operation for his lung cancer was a right pneumonectomy due to absence of right upper lobe and the abnormal pulmonary vein connection. The anomalous pulmonary vein was found draining into inferior vena cava; it was divided at its insertion point (Figure ). His postoperative course was uneventful without any cardiac or respiratory failure. Pathological stage was IIIA (T2a N2 M0) for lung cancer. An arterial blood gas analysis revealed a PaO2 of 83 mmHg and a PaCO2 of 40 mmHg in room air.\nThe patient received radiation therapy and four cycles of chemotherapy; the patient was in good health with good exercise tolerance 2 years after operation. Ejection fraction was 63% measured by echocardiogram; the right ventricle systolic pressure was 38 mmHg.\nPAPVC includes those cardiovascular anomalies in which one to three pulmonary veins connect to the right atrium directly or indirectly by way of different systemic venous connections. It occurs in about 0.6% to 0.7% of the population [], according to autopsy data, but the actual incidence could be greater []. PAPVC can occur as an isolated anomaly, although it is commonly associated with a sinus venosus type of atrial septal defect (ASD). Some reports have suggested that PAPVC occurs approximately 10 times more frequently in the right pulmonary vein than in the left pulmonary vein []. Most cases of right PAPVC are likely to connect to the superior vena cava or right atrium. In this case, it connected to the inferior vena cava.\nPAPVC without an atrial septal defect is possibly asymptomatic and clinically insignificant. When the PAPVC is located in the resected lobe, no hemodynamic problems should occur during the procedure. In this case, based on patient’s cardiac considerations and the ipsilateral lung cancer and PAPVC with absence of right upper lobe, pneumonectomy was performed without surgical correction of vessel anomaly. However, when the anomalous vein is located in the other lobe, serious complications may occur, such as right ventricular heart failure caused by increased left-to-right shunt flow []. Black and associates reported a patient with fatal right heart failure after right pneumonectomy for lung cancer with a missed contralateral PAPVC []. Besides, the surgical treatment of PAPVC has been recommended for patients with a Qp/Qs greater than 2.0, regardless of associated cardiac defects []. Generally, a PAPVC on the left side is corrected by a simple end-to-side anastomosis to the left auricular appendage or the left atrium or end-to-end anastomosis to the stump of the resected normal pulmonary vein without extracorporeal circulation []. When the PAPVC is located on the right side, cardiopulmonary bypass is usually required due to the shortness of the anomalous vein. Sakurai and associates reported a case of right PAPVC repair using total cardiopulmonary bypass before left pneumonectomy for lung cancer []. The treatment strategy depends on the location of the PAPVC.\nTherefore, the preoperative discovery of asymptomatic PAPVC would be very important for patients with planned lung resection. Careful interpretation of the findings of the existing architectural structure is needed, including pulmonary artery, vein, or bronchus, as well as a tumor on the chest computed tomographic scan. Most of the findings of PAPVC can be identified by enhanced chest computed tomography. Conversely, if the findings of right heart overload are preoperatively detected, heart defects such as atrial septal defect or PAPVC should be considered. If patients with an asymptomatic PAPVC require major lung resection, the PAPVC should be corrected before lung resection to prevent fatal postoperative heart failure. |
A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. The pain had started suddenly in the evening three days ago accompanied with vomiting three to four times. The vomitus consisted of dark brown fluid. The pain was initially in the left hypochondrial region and had lately become more generalised, constant, and increased in intensity. Her General Practioner, who had prescribed antiemetics for her symptoms, initially saw the patient. She had appendicectomy in the past, and had been diagnosed with diverticular disease on Barium enema and colonoscopy.\nOn examination, her vital parameters were normal. She had abdominal distension with generalised tenderness, abdomen was resonant on percussion, and she had decreased bowel sounds. Her routine blood tests were normal, and urine analysis showed increased ketones.\nX-rays of the abdomen and chest were suggestive of dilated loops of small bowel (figure ). A CT scan of the abdomen and pelvis showed dilated fluid filled small bowel loops with a point of abrupt change in calibre and angulation of bowel loop in the central abdomen. The small bowel beyond that point was collapsed. There was a small amount of free fluid in the pelvis. The CT scan was suggestive of adhesive small bowel obstruction, probably affecting a distal jejunal loop, with diverticular disease in sigmoid colon without any overt signs of active inflammation, and no free intraperitoneal air (figure ).\nA clinical decision was made to proceed with laparoscopy. On laparoscopy, there was dilatation of the small intestine up to the distal jejunum (figure ) with collapsed bowel beyond that point. The serosal surface of the small intestine looked normal. There were no adhesions between bowel loops; mesentery was normal with no evidence of lymphadenopathy. There was an area of sudden change in calibre with dilated proximal and collapsed distal segment in distal jejunum. The dilated segment of distal jejunum was brought out by a midline mini-laparotomy of five centimetres (figure ). A foreign body, dried undigested apricot, was extracted (figure ). The bowel at the point of impaction was normal and closed in two layers. Laparoscopically, we were unable to identify any other abnormality in the small bowel.\nThe patient had an uneventful post-operative recovery, and went home after ten days. On questioning she informed us that she had eaten few dried apricots while shopping three days before admission in A&E. She was followed up in the outpatient clinic with a Barium meal and follow-through, which was normal and did not show any abnormality in small intestine (figure ). |
This patient is a 68-year-old female, known case of hypertension for the last eight years, presented to us with complaints of anterior neck swelling for about 40 years which had gradually started increasing in size for the last four years. She developed progressive difficulty in swallowing and breathing for the last three months. On examination, there was a presence of large neck swelling, multinodular, which moved on deglutition, with lower limit of swelling not palpable. Prominent dilated veins were appreciated on the neck. A computed tomography scan was done which showed enlarged thyroid with multiple internal calcifications and retrosternal extension up to the level of ascending aorta with multiple collateral vascular channels around mass lesion in anterior mediastinum (). She also underwent total thyroidectomy, sternotomy, and excision of mass lesion. The intraoperative findings were enlarged multinodular goiter with thyroid gland reaching the manubrium. The mediastinal component was also large and separately capsulated from cervical component, extending up to the arch of aorta and superior vena cava with compression of brachiocephalic vein (). The mass was carefully dissected from the above vessels. Specimen was sent for histopathology. Postoperatively, the patient remained well. She was given intravenous analgesia and deep venous thrombosis prophylaxis. She developed respiratory distress on 2nd post-op day, and a chest X-ray showed elevation of the right hemidiaphragm (most likely due to iatrogenic right phrenic nerve injury) and right lower lobe atelectasis and hence was shifted to the intensive care unit for observation. She was managed conservatively with chest physiotherapy, nebulizers, and application of BIPAP. She responded to supportive therapy and recovered well. She also developed asymptomatic hypocalcaemia and was managed with both intravenous and oral replacement. She was discharged from the hospital on eighth postoperative day.\nShe did well on follow-ups. She was kept on oral thyroxin and calcium. Her histopathology revealed benign nodular hyperplasia with degenerative changes in both tissues with lymph nodes showing benign reactive changes. Both tissues were negative for malignancy. She was also advised to continue regular follow-ups in endocrinology clinic for further management. |
The patient was a 71-year-old Japanese man who, 21 years earlier, had fractured the left tibial plateau and underwent open osteosynthesis. He did not experience symptoms until 21 years after the injury, when he became aware of pain in the left knee joint and visited our clinic for the first time. Range of motion in the left knee joint was −5° extension to 135° flexion. An anteroposterior radiograph of the left knee showed degenerative joint changes. The tibia had shortened due to the fracture. A lateral radiograph showed that the posterior articular surface of the tibia had collapsed and had significant posterior angulation. Deformities were identified as a 9° of varus deformity and a 27° of flexion deformity (Fig. ).\nIf tibial osteotomy was performed perpendicular to the tibial axis using the lowest point of the tibial articular surface as a reference point, there was a risk of cutting the tibial tuberosity. Conversely, tibial osteotomy performed proximal to the lowest point of the tibial articular surface would markedly decrease the articular surface coverage by the implant. For these reasons, we decided that extension corrective osteotomy was necessary. We performed a preoperative simulation using a three-dimensional (3D) model with 3D image-processing software. The line that passes through the hinge point perpendicular to the tibial bone axis was identified as the osteotomy line, and we planned to perform a 13° corrective closing osteotomy. The width of the anterior tibia necessary for corrective osteotomy was 10 mm (Fig. ). We created a life-size 3D bone model and performed a mock surgery. The medial parapatellar approach was used as the method for open surgery. We dissociated soft tissue from the deep layer of the medial collateral ligament to the enthesis of the semimembranosus muscle, adjusted the balance of medial and lateral soft tissue, and subsequently performed a distal femur osteotomy. Examination of the intra-articular knee joint revealed that the tibial articular surface was irregular and had severe posterior angulation. Next, we performed an osteotomy of the tibia. A Kirschner wire was inserted perpendicular to the tibial bone axis in the sagittal plane from the anterior tibia toward the posterior hinge point as determined preoperatively, and another Kirschner wire was inserted from 10 mm proximal to the first insertion point toward the hinge point. With these osteotomy lines as references, we performed a wedge osteotomy using a flat osteotome and removed the bone fragments. We then performed an oblique osteotomy of the fibula, manually corrected the alignment, and temporarily fixed the bone using a Kirschner wire. A four-surface osteotomy of the femur was subsequently performed using the epicondylar axis as a reference, followed by an osteotomy of the tibia using an intramedullary guide with the lowest point of the tibial articular surface as a reference. The osteotomy did not affect the patellar tendon enthesis. Finally, we detached the superficial layer of the medial collateral ligament enthesis and achieved good medial and lateral ligament balance. We utilized a long-stem implant on the tibia and a resurfacing implant on the femur. To reinforce rotational stability of the corrective osteotomy site, we used a one-third tubular plates. For postoperative therapy, the patient began range-of-motion exercises the day after the operation and began partial weight bearing at 3 weeks postoperatively. We permitted full weight bearing at 6 weeks postoperatively, and the patient was able to walk without assistance. After 17 months, he was diagnosed with late infection of the left knee, which improved with irrigation, debridement, extraction of a one-third tubular plates and antibiotic treatment. At 2-year follow-up, the patient had no pain while walking and range of motion was 0° extension to 125° flexion. There was no evidence of recurrence of infection. Radiographs at 24 months postoperatively showed that bone union of the osteotomy site was achieved (Fig. ). |
A 70-year-old white man developed right knee pain and swelling followed by left ankle pain and swelling over a week. Over the next 4 months, his symptoms progressed to include both knees, both feet, and both hands. Due to the severity of his symptoms he was unable to ambulate or carry out normal activities of daily living. He initially took ibuprofen 800 mg three times daily with some mild improvement, but at the time of presentation, it offered no relief.\nIn addition, he endorsed morning stiffness that persisted for most of the day. Due to the stiffness in his joints, he could no longer ambulate and presented to our clinic in a wheelchair. He previously was fully functional and independent in his activities of daily living. He was an avid fisherman and was unable to pursue his interests at all.\nHis past medical history was significant for metastatic melanoma initially diagnosed 2 years ago. His initial lesion was located over the left side of his neck and he had a Mohs procedure with negative margins. He was monitored closely for 1.5 years until he was found to have new right lower lobe lung nodules on positron emission tomography (PET)/computed tomography (CT) with increased fluorodeoxyglucose (FDG) uptake. Wedge resection of the right lower lobe revealed metastatic melanoma with wild type BRAF and no C-KIT mutations. Continued surveillance demonstrated an increasing number of right pulmonary nodules over the next 6 months. Dual therapy nivolumab (1 mg/kg every 3 weeks for four doses followed by 240 mg every 2 weeks) and ipilimumab (3 mg/kg every 3 weeks) immunotherapy was started. After the second cycle of his immunotherapy he developed severe non-infectious colitis requiring hospitalization. His immunotherapy was stopped and his colitis resolved with supportive care and glucocorticoids. Without further immunotherapy, he developed new left pulmonary nodules within 6 months that were increasing in size. Single agent immunotherapy with nivolumab (240 mg every 2 weeks) was started 4 months before his presentation to Rheumatology. With single agent immunotherapy, the pulmonary nodules receded fully and no further metastatic disease was seen on subsequent PET/CT imaging 3 months later.\nHis medical history was also notable for hypertension and benign prostatic hypertrophy.\nHe was treated with hydrochlorothiazide, aspirin, and nivolumab. He had no known drug allergies.\nThere was no family history of connective tissue disease or inflammatory arthritis. His mother died from colon cancer in her 80s and his father had coronary artery disease. He was married with three living children. He served in the Navy during the Vietnam War and worked as a mechanic after his military service until retirement. He denied any history of recreational drug or alcohol use. He reported a 20-pack year tobacco smoking history, but quit over 10 years ago.\nHe denied having any chest pain, shortness of breath, rashes, oral or nasal ulcers, alopecia, Raynaud’s disease, fevers, chills, night sweats, or unintended weight loss. He did endorse feeling weak because of his chronic condition.\nHe appeared his stated age and in no apparent distress. His temperature was 37 °C, blood pressure 116/78, heart rate 70 beats per minute, and oxygen saturation 100% on ambient air. His musculoskeletal examination was significant for tender boggy synovitis of his bilateral metacarpophalangeal joints (MCPs), proximal interphalangeal joints (PIPs), wrists, elbows, knees, ankles, and metatarsophalangeal joints (MTPs). There was no palpable effusion in any joint but he had significant soft tissue pitting edema present over his extremities. There was +3 pitting edema over the dorsum of both hands and feet extending up to his wrists and mid-shins respectively. There was mild erythema and warmth present over his joints, most notable over his MCPs (Fig. ). There was decreased range of motion in his hands, feet, ankles, elbows, and knees. There also were extensor tendon rubs noted on range of motion of his MCPs bilaterally by palpation and auscultation. The remainder of the musculoskeletal examination and general physical examination was unremarkable. There were no rheumatoid nodules noted on examination.\nResults of the laboratory evaluation are shown in Table . Our patient’s erythrocyte sedimentation rate and C-reactive protein (CRP) were quite elevated. The remainder of his laboratory tests was unremarkable. Ultrasound and X-ray imaging of his hands were obtained (Figs. and ) demonstrating soft tissue swelling and extensor tenosynovitis. There were no erosions present.\nHe was started on prednisone 40 mg (0.5 mg/kg per day) and tapered gradually over the course of 6 weeks to 10 mg daily. He had a very rapid response to the prednisone with almost complete resolution of his symptoms. Once his prednisone was decreased below 10 mg he began noticing a steady return of his symptoms. During this time period he continued treatment with nivolumab and on surveillance imaging he had complete resolution of metastatic disease. Due to the marked response of his melanoma to immunotherapy, it was felt that paraneoplastic RS3PE was unlikely. Although at the time there were no published reports of nivolumab or other checkpoint inhibitors causing a RS3PE picture, it was felt that because of the temporal relationship between the nivolumab and the acute onset of his symptoms that they were related. The numerous previously described autoimmune conditions associated with checkpoint inhibitors raised the possibility that this presentation of RS3PE was another rheumatological manifestation. The clinical dilemma we were left with was that our patient had previously demonstrated a very rapid relapse of his stage 4 melanoma when off treatment, yet was incapacitated with the side effect of the treatment. After a careful discussion with his oncologist, we elected to maintain a steady dose of prednisone of 7.5 mg daily to control rheumatological symptoms and continue nivolumab. At 9 months, he demonstrated minimal pitting edema, no inflammatory arthritis, and continued full response from nivolumab therapy. |
A 4-year-old girl was previously diagnosed with asplenia, single right ventricle, and supracardiac TAPVC. She underwent pulmonary artery banding at the age of 1 month, followed by a bidirectional Glenn procedure and TAPVC repair at the age of 5 months. She did not demonstrate symptoms of PVO, and there was no evidence of delay in the excretion of contrast media in cardiac catheter examination before Fontan procedure. Extracardiac Fontan palliation was subsequently performed at the age of 19 months. At the age of 3 years, although right lower PVO occurred because of the compression of the vertebra, she did not demonstrate symptoms of PVO (). At the age of 4 years, she underwent a cardiac catheterization to evaluate her hemodynamic parameters after Fontan procedure (). She was taking oral aspirin, warfarin, and enalapril. After a routine hemodynamic assessment, NO and oxygen tests were performed. A pigtail catheter was placed in the single ventricle, and a wedge catheter was positioned in the pulmonary artery. We performed the pulmonary vasodilator examination in the same way as when doing the examination in patients with pulmonary hypertension []. Subsequently, 20 ppm NO was administered via face mask. After 5 minutes of NO administration, her hemodynamic parameters were measured. Following a washout period of 5 minutes, 100% oxygen was administered, and after 5 minutes of oxygen administration, her hemodynamic parameters were again measured. To measure the pulmonary arterial wedge pressure and pulmonary arterial pressure accurately, the waveform was monitored carefully (Figures and ). After the administration of NO, the single-ventricle end-diastolic pressure, bilateral mean pulmonary arterial pressure, and cardiac index did not change. Oxygen saturation did not change at 95%, and pulmonary resistance index decreased from 2.1 to 1.0 Um2. However, the right lower pulmonary arterial wedge pressure increased from 8 to 12 mmHg, and the left lower pulmonary arterial wedge pressure increased from 7 to 9 mmHg. The cardiac index remained almost the same. Similarly, following the administration of oxygen, the single-ventricle end-diastolic pressure did not change; however, the right lower pulmonary arterial wedge pressure increased from 8 to 14 mmHg and the left lower pulmonary arterial wedge pressure increased from 7 to 12 mmHg. The bilateral mean pulmonary arterial pressure increased from 13 to 15 mmHg. Although angiography was performed after the inhalation of NO and oxygen, there was no evidence of left pulmonary venous obstruction or delay in the excretion of contrast media (Figures and ). A systemic-to-pulmonary shunt was also nonexistent. On echocardiography, there was no acceleration of blood flow at the left pulmonary vein or surgical anastomosis between the pulmonary venous confluence and the atrium. There was also no stenosis of the atrioventricular valve. Despite the inhalation of NO and oxygen, there was no acceleration of blood flow, and stenosis was not identified at the surgical anastomosis between the pulmonary venous confluence and the atrium (). |
A 78-year-old female with past medical history significant for type 2 diabetes mellitus, hypertension, and obesity with (body mass index, BMI of 34 kg/m2) was admitted to our tertiary care hospital following an acute stroke, which resulted in dysarthria and left-sided hemiparesis. Computed tomography of the head ruled out intracranial hemorrhage, and magnetic resonance imaging of the brain showed an acute infarct in the right genu of the corpus callosum. The patient was started on dual antiplatelet treatment (aspirin and clopidogrel), as per the recommendations from the stroke neurology team. Her hospital course was prolonged with multiple complications, including a code blue for pulseless electrical activity, most likely secondary from a hypoxic event caused by aspiration pneumonia. Return of spontaneous circulation occurred in about 2 min as a result of good cardiopulmonary resuscitation. Speech and swallow services evaluated the patient, but she failed multiple swallow studies. Thus, a decision was made to insert a PEG tube for long-term enteral nutrition.\nInterventional radiology was consulted for PEG placement. During the procedure, the stomach was inflated through the existing nasogastric tube. Fluoroscopic evaluation of the abdomen in the anterior projection revealed an air distended colonic loop in front of the stomach (). A lateral view of the stomach confirmed the colonic loop anterior to the stomach, and thus the procedure was aborted given the high risk for colonic injury. The gastrointestinal team then evaluated the patient, and a decision was made to hold clopidogrel for 5 days before attempting PEG placement endoscopically. A pre-procedural abdominal X-ray demonstrated paucity of bowel gas in the colon with no colonic loops visualized anterior to the stomach. The patient was then deemed safe for endoscopic PEG placement.\nPrior to the procedure, the patient was placed in supine position, and the stomach was insufflated to oppose the gastric and abdominal walls. A site was located in the body of the stomach with excellent transillumination and manual external pressure for placement. The abdominal wall was sterilized, anesthetized and a trocar needle was introduced through the abdominal wall into the stomach under direct endoscopic view. A snare was then introduced through the endoscope in the gastric lumen, and a guide wire passed through the trocar into the open snare. The endoscope and snare were removed, pulling the wire out through the mouth. The PEG tube was inserted through the mouth into the gastric lumen over the guide wire and then pulled out from the stomach through the skin. The position of the PEG tube was confirmed by relook endoscopy, and skin marking was noted to be 8 cm at the skin and 8.5 cm at the external bumper. The patient tolerated the procedure extremely well, with no immediate complications.\nPost-procedure, a computed tomography of the abdomen was obtained due to pre-procedural concerns for colonic injury. Imaging showed that the gastrostomy tube had traversed the lateral margin of hepatic segment 3, with an adjacent hematoma measuring 2 × 2 × 4 cm (). On abdominal exam, the PEG tube was freely rotatable; the site was clean and dry, with no blood or drainage. The patient’s hemoglobin remained stable after the procedure. Enteral nutrition was started 24 h after PEG tube insertion, and the patient tolerated tube feeds extremely well, with no complications. The patient was safely discharged to a nursing home for further care. Unfortunately, when contacting the nursing home 1 week later, it was discovered that the patient expired on day 3 of her nursing home stay. The exact etiology of her death remains un-established, as the patient’s family denied completion of an autopsy. |
A 63-year-old female with a history of renal transplantation and chronic immunosuppression was admitted to the tertiary care center for respiratory symptoms. During her hospitalization, she progressed to respiratory failure and found to have disseminated histoplasmosis. After failed attempts at extubation, the patient underwent an open tracheostomy. She was discharged to a long-term acute care facility (LTAC).\nThe patient developed bright red blood per rectum during her stay at the LTAC without evidence of bleeding at the tracheostomy. Her hemoglobin level was 4.5 mg/dL; a blood transfusion was initiated at the facility and she was transferred to the local community hospital's intensive care unit (ICU). During routine morning patient care, the nursing staff noticed minor non-pulsatile bleeding around the tracheostomy and immediately alerted the ICU physician team. On initial inspection, there was no noted bleeding of the exterior surfaces while the patient was positioned with the head of the bed at 30 degrees. Bleeding recurred when the patient was placed back into the supine position, prompting urgent surgical consultation.\nThe surgical team and the ICU team proceed to evaluate for bleeding sources. A flexible fiberoptic scope was used to investigate the upper airway and no bleeding was seen from her nasopharynx or oropharynx. The tracheostomy was also evaluated and no bleeding was seen distal or proximal to the tracheostomy site, while the tracheostomy cuff was deflated. Due to the recurrence and unidentifiable source of bleeding, surgical evaluation and management were needed. While prepping the patient, pulsatile bleeding was observed from the tracheostomy. The patient started to develop hemodynamic instability and surgical management deemed necessary. Interventional radiology was not considered at this time because the service was not immediately available on site. The cuff was hyperinflated, which stopped the bleeding and the patient was emergently taken to the operating room with the general surgery team. The thoracic surgeon on call was notified and would meet the team in the operating room.\nThe patient was prepped for surgery. A median sternotomy is used to gain access to the great vessels. The pericardium was opened to provide additional visualization and mobilization of the great vessels. The innominate vein was first mobilized and provided exposure to the innominate artery. The innominate artery's course was traced and fistula palpated on the posterior wall of the artery. Vascular clamps were applied proximal to the fistula and distally, ensuring that the thyrocervical trunk remained intact. The proximal end of the vessel was ligated using a vascular stapler. The distal end was oversewed in two layers using a 4-0 prolene suture. Thymic tissue was mobilized and placed over the tracheal fistula. This method provided quick control and coverage of the defect. The sternotomy was closed and resuscitation continued until the transport team arrived in the operating room to take the patient to the tertiary care center. |
A 16-year-old female, presented with problems of excessive social media use. She was the only child to working parents. Her mother reported emotional and other difficulties at home with respect of her daughter's increased Internet usage, due to which she quit her job in the recent past, to address her technology use. Adolescent's father was reported to be over-involved with her, and had gifted a computer to her a computer at the age of 12 years for her academic accomplishments. Accessibility to the device caused her to develop the habit of reading through applications. This further led to frequent distractions, subsequently causing a drop in her grades, which led to negative family dynamics in terms of altercations among the parents and the adolescent. This negative family dynamics further caused the client to distance herself from her family in order to avoid the discomfort associated with the same. This also led to increased screen time. She began to enjoy the appreciation, she was receiving on various online platforms, causing her to start spending approximately 6–7 hours/day on social media. Her preoccupation with social media gradually spread across to different areas, with her trying to find other areas of interest on the Internet. The client's academics were severely affected after she stopped going to school and decided to take a year off. At this time she was bought to the SHUT clinic for intervention. She was assessed for addiction to the Internet, and got a high score on the Internet Addiction Test[] indicating 'severe addiction'. In addition to Internet addiction, her parents reported behavioral changes like irritability, anger outbursts, and self-harm threats, whenever the devices were taken away or when there was a fluctuation in net connectivity and when the Internet speed was slow. The client attributed these anger outbursts and behavioral changes to the inability to connect with others. Her behavioral changes even prompted her parents to change the network to control/ and manage her anger. The treatment plan involved educating her about cyber issues, healthy use of technology, and the possible reasons and repercussions associated with excessive Internet and social media use. In addition, there was also a focus on behavioral management of her anger. Further, parents were also educated about parenting skills and counseled to improve the family atmosphere. The client's sleep and communication styles improved through the course of treatment. |
A 24-year-old African woman of Bantu origin presented to us in 2010 with sudden bilateral loss of vision and progressive weakness in both her lower limbs for one day. She had been previously well with no known chronic medical conditions, like hypertension or diabetes mellitus, and had no preceding vaccinations or viral infections noted. She has lived all her life in Uganda. Her brain computed tomography (CT) scan was normal and her blood test results were negative for polycythemia, thrombocytosis, and diabetes mellitus. Her systemic clinical examination, including the neurological assessment at the time of her initial medical presentation, was normal. She was treated as if she were a patient suffering a transient ischemic attack, with low-dose aspirin (ASA), which she later decided to stop over the course of time.\nEight months later, she presented to us with inability to walk and urinary incontinence for three days. This was preceded by parethesias in the lower limbs followed by unsteady gait and subsequently, an inability to use both her lower limbs and urinary incontinence. She reported no history of recent vaccinations, ingestion of tinned meats or beef and no recent sore throat. Her vision this time was normal with no complaints of double vision or visual field defects. Her upper limbs were normal. She was nulliparus and reported normal menses. She reported no history of hypertension or diabetes, and was not receiving any regular medications.\nClinically, she had muscle power grade 2 on the Medical Research Council (MRC) scale bilaterally, with spasticity and brisk reflexes of the knees and ankles bilaterally, with bilateral upgoing plantars. She had a symmetrical sensory deficit below T10 to fine touch and pressure. Her vision was normal with no visual field defects or double images and no optic atrophy or optic neuritis was detected on fundoscopy. She had urinary retention and a urinary catheter was placed in situ. Her series of blood test requests returned negative results for human immunodeficiency virus (HIV)1/2 testing and the treponema pallidum hemagglutination assay (TPHA)/Venereal Disease Research Laboratory test (VDRL) test for syphilis. Her peripheral blood film report revealed no malarial parasites or other hemoparasites. The full blood counts showed the following: the white blood cell count (WBC) was 10.2 × 103/L, absolute neutrophils 7.1 × 103/L, lymphocytes 1.3 × 103, hemoglobin 11.6g/dL and platelets 252 × 103. She had elevated acute-phase reactants with an erythrocyte sedimentation rate (ESR) of 25mm/hr (Westergren method) and C-reactive protein (CRP) of 17mg/L but her antinuclear antibodies test was negative. A lumbar puncture performed showed the cerebrospinal fluid (CSF) was clear and colorless, with a normal blood glucose level. However, the CSF protein content was elevated at 60mg/dL, while the WBC count in the CSF was less than 5 cells/uL. Indian ink staining on her CSF for Cryptococcus was negative and the Gram stain revealed no organisms. The Ziehl-Neelsen stain for tuberculosis revealed no acid-fast bacilli. The VDRL on the CSF was nonreactive and cytology revealed no malignant cells. She had no clinical evidence of sarcoidosis, vasculitis, systemic lupus erythematosus (SLE) or Sjogren’s syndrome. A brain and spinal magnetic resonance imaging (MRI) scan was requested for further evaluation.\nHer MRI of the cervicothoracic spine revealed large multiple ill-defined hyperintense lesions involving the cervical and thoracic spinal cord up to the T4 to T8 vertebral levels on T2-weighted images (Figure ). These appeared hypointense on T1-weighted images, probably representing myelitis or demyelination. No cord compressive lesions were found on her spinal MRI and her brain MRI was normal. A diagnosis of neuromyelitis optica was made based on the diagnostic criteria excluding the antibody assays [].\nShe was started on pulse methyprednisolone 1g for five days and had complete resolution of her symptoms. She was discharged from hospital on tapering oral steroids but the patient stopped the low-dose oral steroids after two months of treatment. Due to lack of prior experience of the disease, she was not started on long-term steroid-sparing immunosuppressants like azathioprine or mycophenolate mofetil, which are readily available within the country though costly.\nIn February 2011, that is four months later, she returned to our care with sudden loss of sensation and numbness in the upper limbs and weakness in the lower limbs. Her power grading using the MRC scale was four minus in the upper limbs and two in the lower limbs respectively. We were unable to repeat the MRI scan due to limited resources and therefore unable to evaluate the presence and extent of any new lesions. The patient then received pulse therapy of methyprednisolone 1g once a day for five days, there was improvement in her lower limbs, and her power increased to four minus after about two weeks’ admission. She was able to walk with support and was started on daily tapered prednisolone and azathioprine starting at 2mg/kg/day, divided into two daily doses. She was not tested for the thiopurine S-methyltransferase (TPMT) mutation. Individuals who have this mutation can develop significant bone marrow toxicity with azathioprine; however, she gets a routine monthly blood check especially for the WBC counts. She was recommended to physiotherapy for muscle-strengthening exercises and bladder training. She has remained fairly stable, able to walk with the aid of a walking stick and is still under our follow-up care. She is currently maintained on azathioprine 100mg daily and the oral steroids have been gradually tapered off. We are continuing to monitor her WBC counts every month for leucopenia and liver function associated with azathioprine toxicity. She has remained stable and has not suffered any more relapses since then.\nWe are unable to perform the AQP4 antibodies test in our setting. |
A 31-year-old female sustained a fall while climbing a mountain, resulting in an injury of her left hip, causing pain and an inability to weight bear. She saw a local doctor, who diagnosed a dislocation of her hip and attempted a reduction, which failed, as the hip remained painful und unstable. Six months after the injury, the patient consulted an orthopedic surgeon, who attempted an open reduction of the hip, but he was unable to reduce the hip and abandoned treatment (Figs. , , , ).\nEighteen months after the initial injury, the patient saw another orthopedic surgeon, who attempted a closed reduction with skeletal traction. The hip remained unreduced despite 2 months of continued traction, and the treatment was discontinued due to pin track infection of the skeletal traction pin.\nWe saw this patient 2 years after the initial injury complaining of hip pain. She was walking with an antalgic gait and had a decreased range of motion of her hip. The limb was in fixed adduction and internal rotation. She had a leg length discrepancy due to shortening of 6 cm. Her hip movements were restricted and painful. Radiographs confirmed a persistent dislocation of the hip, with a false acetabulum in the left supra-acetabular region.\nInitially a total hip replacement combined with a sub-trochanteric osteotomy was planned for this patient with 2 weeks prior skeletal traction. During surgery, we encountered necrotic soft tissues, with the proximal end of the femur devoid of all muscular attachments. A debridement of all necrotic tissue was performed, and tissue was sent for histopathology, which did not isolate any microorganisms. A delayed THR with a constrained acetabular insert for stability was performed a week later. The leg lengths were equalized, and the postoperative recovery was uneventful. Roentgenograms showed satisfactory position and fitting of the prosthesis. Her physiotherapy was started soon postoperatively, and she was discharged on the twelfth postoperative day. Her functional status improved on every successive follow-up visit, and the HHS score improved from 48 (preoperatively) to 81 (postoperatively). She had no pain, a mild residual Trendelenburg gait due to her abductor insufficiency and excellent function. |
A 53-year-old Japanese man who complained of epigastric pain and hematemesis visited our emergency room. The patient had no particular family history, but a history of SLE, pancreatic pseudocyst, and chronic pancreatitis. He took 5 mg of prednisolone, camostat mesilate, and berizym. He had epigastric pain since midnight of the day of visit, and vomited blood five to six times an hour after the onset. Upper endoscopy performed after the visit revealed that an ulcer was formed on a submucosal tumor-like lesion (Fig. ). He bled from the ulcer, and the bleeding was stopped using thrombin. Upper endoscopy on the next day showed that the bleeding from the ulcer was stopped. However, he was suspected to have penetration into a hollow viscus after the removal of clots (Fig. ). We performed computed tomography (CT) scan analysis to identify the hollow viscus. The CT result revealed the accumulation of fluid around the pancreas and penetration of pancreatic cyst into the stomach (Fig. ). Blood test performed on the same day indicated that the serum amylase level was 164 U/L, which is higher than normal level. Considering the CT image finding, the patient was diagnosed as gastric penetration caused by acute pancreatitis episode in chronic pancreatitis. We considered surgery, but we decided that we can take a wait-and-see approach, since hemostasis was confirmed on the upper endoscopy. He had abdominal pain 5 days after hospitalization, and blood test and CT scan were performed. The blood test result showed a slight increase in inflammation and no elevation of serum amylase level. The CT scan result indicated no new findings but revealed left pleural effusion. We suspected that he might have secondary pleural effusion. However, since we cannot deny the possibility that he had pancreatic cyst and diaphragmatic penetration, the thoracostomy tube was inserted 7 days after hospitalization. Only a small amount of pleural effusion was obtained, and the amylase level in the pleural effusion was normal. To identify the cause for the small amount of pleural effusion, we performed CT scan analysis 8 days after hospitalization. The CT result revealed that there was no problem with the insertion position of the thoracostomy tube, and the cause for the small amount of pleural effusion remained unclear (Fig. ). We took a wait-and-see approach, since he had fever but had been stable up to this point. However, he had massive hematemesis and melena 9 days after hospitalization, and his condition rapidly deteriorated. Blood transfusion was performed but had no effect, and he died on that day. Autopsy performed on the day of death showed that the large amount of bleeding was not from an aneurysm but from the cyst wall, and revealed that he actually had pleural thickening, which is not caused by accumulation of left pleural effusion but by severe pleural inflammation, indicating that he had pleural inflammation. In addition, accumulation of cardiac effusion was also observed, and he was suspected to have pericardium inflammation. We therefore performed additional blood and urinary tests 9 days after hospitalization. The test results were as follows: platelet count, 8.1 104/UL; anti-dsDNA antibody titer, 92.8 IU; complement component, C3, 29 mg/dL; C4, 4 mg/dL; CH50 < 10 U/mL; red blood cell count in urine, 20–29 per high-power field (HPF). Considering that he had fever, pleural inflammation, and pericardium inflammation, it turned out that SLE had high disease activity in this patient, resulting in bleeding. |
A 37-year-old woman with a past medical history of type 2 diabetes mellitus and a complete resection of a giant cell tumor of the right femoral diaphysis presented to our clinic for initial evaluation after enlarging pulmonary nodules were discovered on surveillance imaging. Two years prior to referral to our clinic, she had undergone resection of an incidentally discovered giant cell tumor of the right distal femur. The maximum dimension of the tumor was 5 cm, and a 1.2-cm negative surgical resection margin was reported. The extent of resection and invasion of articular space required total replacement of the knee. Computed tomography (CT) of the chest at the time of the initial diagnosis revealed several subcentimeter nodules that were not amenable to biopsy by CT guidance or endobronchial ultrasound. The patient endorsed chronic cough but denied sputum production, hemoptysis, fever, or other symptoms. The patient’s family history was negative for malignancy; in particular, no bone tumors were reported. Her physical exam revealed changes consistent with total joint replacement of the right knee but was otherwise unremarkable. Her blood laboratory testing was unrevealing. Bone scan at diagnosis revealed persistent local radiotracer uptake at the site of the right knee, likely related to surgical intervention. Local radiotracer uptake resolved on subsequent bone scans. The patient had periodic cross-sectional imaging studies of the chest for assessment of the initially discovered lung nodules. After a period of 1.5 years of no growth, several lung nodules had significantly enlarged on chest imaging. Based on CT of the chest, abdomen, and pelvis as well as a nuclear bone scan, the lungs were the only site of metastatic involvement. To confirm the suspicion of lung metastatic disease, the patient underwent CT-guided transthoracic core biopsy of one of the lung nodules. Histology showed metastatic giant cell tumor with morphological features similar to the patient’s right femur mass.\nThe patient’s case was presented in our institutional tumor board, and a consensus decision was reached, recommending therapy with denosumab, based on results from phase II trials demonstrating safety and efficacy of denosumab in the treatment of metastatic giant cell tumors of bone (GCTBs). After comprehensive dental treatment, the patient was prescribed denosumab 120 mg via subcutaneous injection, with weekly loading doses on days 1, 8, and 15 of a 28-day cycle and then switched to 1 injection every 28 days. After 2 cycles of denosumab, contrast-enhanced CT scan of the chest showed reduction in size and number of all previously enlarged nodules, consistent with a partial response by RECIST 2.0 criteria (). Several of these lung nodules that were not calcified initially became calcified on radiographic follow-up. A CT-guided core biopsy of one of the nodules after 2 cycles of denosumab showed histological response, with absence of giant cells (). The patient received additional injections of denosumab without further shrinkage of the lung nodules after 4 and 6 cycles, respectively. She reported a significant improvement in her cough. There were no side effects noted or reported. The patient did not have denosumab-related serious adverse events such as osteonecrosis of the jaw or hypocalcemia. Currently, she receives maintenance subcutaneous injections of denosumab 120 mg every 28 days. Additionally, she has a physical examination and evaluation for denosumab-related toxicity every 3 months. Contrast-enhanced cross-sectional imaging of the chest is done every 6 months. |
A 52-year-old woman was consulted by a surgeon for a derivative felt in her abdomen. The patient said she felt a growing derivative in the abdomen about a month ago.\nThere was also slight abdominal ache and discomfort while sitting and cycling.\nDuring the initial examination, deformation of the abdominal wall is observed and a painless derivative is felt in the lower left quadrant of the abdomen (). Externally, the object was palpable in the range of about six centimeters. It was stiff and partially mobile.\nUltrasound examination revealed a cystic derivative with clear boundaries.\nHowever, ultrasound is not the first-choice research for assessing the intestine and mesentery derivatives, due to difficulty in assessing a clear relationship with the surrounding tissues and structures.\nTherefore, CT scan was performed.\nA cystic derivative (13 cm × 11 cm × 10 cm in size) was found in the left lower abdominal quadrant according to the CT data. The derivative has no radiological evidence of malignancy. There were no signs of overgrowth into other structures, as well as no clear contact with large blood vessels. Radiologically, the derivative was most similar to a mesenteric cyst. Mild hydronephrosis due to pressure in the left ureter is also observed ().\nThe patient underwent laparotomy, during which a movable, thin-walled, cystic derivative (about 12 cm in size) with transparent content in a sigmoid colon mesentery was found. Complete excision of the cyst within healthy tissues was performed, protecting the surrounding blood vessels (Figures and ).\nThe surgery had no complications.\nThe patient was discharged on the fourth postoperative day with an uneventful postoperative process. The patient underwent two ultrasound examinations during the first year of postoperative treatment, one after three months and the other after six months. Both examinations were free of visible pathological changes. One year after the operation, abdominal and pelvic computed tomography was performed; no visible pathology was found.\nThe pathological findings were a thin-layered cyst with a focal fusion of the inner monolayer of the epithelium.\nThe conclusion was that this was a simple mesothelial cyst.\nHowever, when the pathologist suspected that the diagnosis might be inaccurate, additional immunohistochemical tests were performed: derivative lining endothelial cells D2-40(+++) (cytoplasmic response), 100%; CD34(+)(cytoplasmic response), 10%; Calretinin(-); WT1(-); CD10(-); panCK(AE1/AE3)(-); CK7(-); and estrogen receptors(-) (Figures and ).\nImmunohistochemical tests showed that the proper diagnosis was mesenteric lymphangioma (ML). |
The patient, a 31-year-old Caucasian female, was diagnosed with primary EM at the age of 18. She was later diagnosed with exophthalmos and concomitant megalocornea and with bilateral congenital glaucoma resulting in loss and severe impairment of vision at the level of right and left eye, respectively. The symptoms of primary erythromelalgia started at the age of 6 with intermittent painful skin redness and swelling of both her feet and lower parts of the legs. Over time her symptoms increased in frequency and severity often requiring hospitalization. A chronic treatment with NSAIDs and exposure of lower legs to cold compresses were provided resulting in an improvement of symptoms. She was hospitalized once more in October 2008, because the worsening of symptoms evolved into constant erythema and warmth of the lower extremities with associated pain. Her symptoms were aggravated even further by exertion, stress, weight-bearing, and gravity dependency and she spent most time immersing her feet in cold water. She could not wear socks or shoes or cover her feet or legs and she was unresponsive to any of her current medications. Because of severe pain with intense burning to the extremities, the patient was then moved from the Dermatology Unit to our division. Physical examination revealed increased skin temperature to the lower extremities, very strong burning pain, and swollen ankles. There was evidence of chronic immersion injury to the skin on her feet which was thickened, reddened, and macerated with ulcerations. The patient rated her pain as 10/10 on a 0 to 10 scale value (numeric rating scale pain intensity, NRSPI) when lying completely still. She displayed secondary allodynia at the level of the perimalleolar areas and bilateral hyperalgesia at the level of the gastrocnemius and of the instep. As first line of treatment, we started with pregabalin 75 mg twice a day and oxycodone 5 mg twice a day. The drug dosage was then increased in the following weeks up to 150 mg twice a day and 20 mg twice a day for pregabalin and oxycodone, respectively. This therapeutic regimen yielded a considerable improvement of the symptoms such as pain relief (NRSPI score: 3-4), decreased burning sensation to the extremities with need for less cold medications, and regular nocturnal sleep; however, the swelling of lower limbs remained unchanged. The improvement of symptoms lasted until February 2010. In March 2010, the patient was again hospitalized in our unit, since she reported an escalation of pain without apparent triggers. The disabling pain was unresponsive to the therapy; thus, we decided to perform opioid rotation and to replace the anticonvulsant. However, the increase of the drugs yielded heavy side-effects as drowsiness, constipation, and profound asthenia, so we decided in favor of an implantable intrathecal pump drug delivery system. To determine whether the patient will benefit from an implant we performed a proper trial phase. During the trial, the planned drugs were infused through an indwelling catheter that was placed intrathecally. We started with the administration of an anaesthetic at low dose followed by administration of an opioid at low dose 24 hours later. The trial performed with administration of 0.03 mg morphine revealed an improvement of painful symptoms; however, the appearance of intense itching on her face occurred; thus, we decided to use Ziconotide. A fortnight after the test the patient underwent the implant of a spinal port a cache for Ziconotide titration in our unit. The drug was administered through a micropump (CADD 7300 MS3-7400 model) following a low titration schedule starting from the dosage of 0.3 mcg/die to the dosage of 1.2 mcg/die. As a result we observed a clear-cut improvement of the symptoms with pain relief (NRSPI score: 3) and disappearance of allodynia and hyperalgesia. The administration of the anticonvulsant was interrupted and the dosage of opioid, orally administered, was reduced to 5 mg twice a day. At the end of titration the patient was again hospitalized once more in our division to be subjected to the final implant of the intrathecal pump drug delivery system (10 mL Tricumed model/delivering 0.26 mL/daily) with a dosage of 1.8 mcg/die of Ziconotide. We also observed an unexpected result following administration of Ziconotide: the legs and feet of the patient which at the time of admission were swollen and tumefied dramatically improved after one week (). In April 2013, the patient made the pump recharging with a delay of 4 days and came to our observation with her legs and feet swollen along with burning pain. Two days after refill with the usual dosage of Ziconotide the legs were no longer swollen, with no burning pain and with noticeable improvement after one week (). |
Case 2. A 50-year-old non-insulin-treated woman with diabetes sustained a right distal radius fracture after a slip on ice. She was casted for six weeks and developed right hand and wrist pain by the end of the six weeks. X-rays revealed that the fracture healed well. She was assessed one year after injury and reported diffuse hand and wrist pain. She was unable to make a complete fist on the right, and there was loss of joint extension. In particular, the 5th digit was contracted at the interphalangeal joints; the hand was not uniformly swollen. The digits were all flexed at rest. Due to the late presentation and maturity of the contractures, she was sent for hand therapy, an extension splint, and a bone scan. Four days after this visit, she was involved in an accident and sustained a left wrist fracture of the distal radius and ulna. She required open reduction internal fixation and underwent a bone scan several weeks after the second fracture. The right side, the older fracture, showed no significant periarticular uptake. In contrast, on the newly fractured left hand, there was diffuse hyperemia in the left wrist, distal forearm, and fingers, as well as uptake at the left sided ribs in the 5th, 6th, 7th, and 10th ribs, consistent with fractures. On the newly fractured left arm, she had developed swelling in the digits and capsular restrictions. The 5th digit was difficult to extend. There was an obvious deformity in the left wrist. She experienced pain with MCP compression. While the right hand had continued to settle, the left hand was acutely swollen and a diagnosis of CRPS was made. She was treated with the titrating dose of prednisone with instructions to monitor her blood sugars. The inflammation rapidly improved; however, her blood sugars proved difficult to control and her weaning was escalated. She gained improvement in the left hand and wrist, with the return of normal range of motion, skin contour, and wrinkling of the phalangeal joints. On the original right hand, she remained unable to fully extend the digits, and a right 5th digit contracture remained (see ). |
A 54-year-old male presented with abdominal pain, starting in the epigastrium in the middle of the night with nausea and one episode of vomiting. Physical exam revealed tenderness in the right upper and lower quadrants. Laboratory tests included complete blood count, basic metabolic panel, and liver enzymes. All tests were within normal limits except for slightly elevated alkaline phosphatase, amylase, and lipase. Computed tomography scan showed unusual configuration of the gallbladder, suggestive of septated gallbladder with evidence of cholelithiasis. Radiologist could not exclude a duplication but there was no hint of duplicated cystic duct on computed tomography. Abdominal ultrasound showed cholelithiasis with the gallbladder being borderline enlarged ().\nThe patient was scheduled for LC with intraoperative cholangiogram the next day. After taking down the peritoneal reflection off the triangle of Calot, we identified 3 separate structures. The most lateral structure, connected directly to the gallbladder and appearing to be the cystic duct, was dissected and isolated circumferentially. Cholangiogram was performed using iodinated contrast under fluoroscopic guidance (). We noticed flow into the common bile duct (CBD) and duodenum, and retrograde flow into the common hepatic and intrahepatic radicals. The second structure was found to be connected to the CBD distally and appeared to run parallel to the CBD and end abruptly. On further skeletonizing this structure, it appeared to be connected directly to the gallbladder. A second cholangiogram was performed and found flow through this structure to CBD, duodenum, common hepatic and intrahepatic radicals (). Two separate cystic arteries were identified and clipped. The gallbladder was taken off the fossa and opened for further examination. The configuration of the gallbladder was that of a single gallbladder. Opening it revealed a longitudinal septation with a duct on each side. Both these ducts were shown to open separately into the CBD. The pathologist favored a single gallbladder that was septated. The procedure was completed laparoscopically. Given concern for duct injury due to aberrant anatomy, postoperative magnetic resonance cholangiopancreatography was done, which showed no CBD obstruction or ductal injury. The patient was discharged on postoperative day 2 without any complications. |
A 59-year-old woman was admitted to the Department of Neurosurgery due to a lesion localized inside the bone in the right frontal area, discovered accidentally in the CT (computed tomography) scan of her head performed for another reason. Before the diagnosis, the patient complained about occasional headaches and recent memory disorders.\nThe medical history did not prove any past head injury or any other pathology. The physical examination showed a proper neurological state.\nThe performed CT scan of the head revealed blotchy areas of osteolysis in the right frontal area, measuring approximately 24 mm in diameter. The CT examination suggested an eosinophilic granuloma (Figures -). The intracranial mass was not found in the area of the osteolytic defects. The MR (magnetic resonance) imaging showed irregular areas of an increased signal intensity on the T2 weighted image in the area of the calvaria and a mixed signal intensity on the T1 weighted image, with contrast-enhanced features, involving only the structure of the bone (Figures –).\nThe ambiguous image suggested the foci of a myeloma, untypical metastases. The results of the laboratory tests were correct. The patient underwent an operation. During the operation bluish discoloration was found on the surface of the bone. After removing the bone flap, a lesion localized inside the bone and adjacent to the dura mater was discovered (). There were singular lesions revealed under the dura mater, forming part of the tumour and measuring approximately 2-3 mm in dimension on the surface of the arachnoidea above the area of the bone foramen, which were removed and coagulated, preserving the venous system intact. The bone flap with the tumour and the dura mater were excised. The reconstructive operation of the dura mater and the bone defect was performed with the use of the Neuro-Patch material and the cranioplastic type of material, respectively. After the wound had healed, the patient in the same neurological state as before the operation and without any deficiency signs was discharged from the hospital.\nThe histopathological test was performed in its final form following additional immunohistochemical tests (EMA (+) (epithelial membrane antigen), CK AE1/AE3 (+) (cytokeratin), Ki 67 (positive in singular cells), CD 31 (+) (cluster of differentiation 31), and CD 34 (+) (cluster of differentiation 34) in the area of blood vessels). The microcystic variant of meningioma was diagnosed (Figures –). |
A 68-year-old female presented to the emergency room with complaint of gross hematuria, intermittent right-sided flank pain, and forgotten right ureteral double J stent. A CT scan showed an enhancing 7 cm solid pelvic mass displacing the bladder and rectum ().\nShe had a history of T3N0 rectal cancer status post low anterior resection with diverting colostomy followed by adjuvant chemotherapy in August 2006. Two years later, she developed pulmonary metastases. Early in 2007 she underwent right ureteral stent placement for hydronephrosis at an outside hospital. Her followup was interrupted due to her moving between two different parts of the country and between several hospitals.\nShe was seen at our institution in September 2007 for small bowel obstruction that required abdominal exploration, lyses of adhesions, and small bowel resection with primary anastomosis. Final pathology revealed no carcinoma. Later that year she had progression of her pulmonary metastasis and was started on additional chemotherapy. In February 2008, she developed a small right-sided extraperitoneal bladder perforation with a possible small colovesical fistula. At this time she denied any trauma, recent surgery, pneumaturia, or fecaluria. Cystoscopy and biopsy were negative. Her fistula was managed with catheter drainage alone and at 3 months a cystogram showed complete healing.\nOn this hospital admission at initial evaluation, given her active hematuria and pelvic mass she was taken to the operating room for cystoscopy, possible transurethral resection of tumor, control of bleeding, and possible removal of retained stent. Given the length of time the stent was indwelling, the stent was likely encrusted and would require more invasive maneuvers to remove. Given that her main problem was hematuria from an apparent pelvic mass, the likely encrusted and retained stent was a secondary objective at the time of surgery.\nOn cystoscopic exam, her bladder showed no lesions or tumors. There was an old patch of scar on the right bladder wall consistent with the known area of bladder perforation. There was no active bleeding present. The stent was surprisingly not encrusted despite being in place for almost two years. It was removed easily with a cystoscope. Upon removal of the stent, pulsatile bleeding began from the right ureteral orifice. A retrograde pyelogram was attempted but due to the chronic indwelling stent, the ureter was patulous and contrast material would not fill the ureter but rather freely extravasate into the bladder. A guide wire was fluoroscopically advanced into the right renal collecting system and a ureteral catheter was placed into the kidney. An antegrade pyelogram showed a normal intrarenal collecting system. As the catheter was withdrawn and contrast was instilled an ureteroiliac fistula was demonstrated (). Pulsatile arterial blood flow could now be seen coming through the ureteral catheter through the cystoscope.\nIntraoperative vascular surgery and interventional radiology consultation were obtained. Given the history of prior pelvic radiation, colovesical fistula, and presumed recurrent rectal cancer in the pelvis, an open reconstructive procedure was not advised. The decision was made to proceed with placement of an intravascular stent. In order to aid in the proper positioning of the stent, an open-ended ureteral catheter was placed back into the right ureter up into the kidney.\nThe patient was taken to the interventional radiology suite. Through a right common femoral access an angiogram failed to confirm or localize the fistula. Using the ureteral catheter as a guide to localize the ureter, an 8 mm × 40 mm covered vascular stent was deployed spanning the intersection of the artery and ureter (). As a complication of the stenting the distal common femoral artery became thrombosed as evidenced on poststent angiogram. The patient was taken emergently back to the operating room where femoral thrombectomy was performed.\nPostoperatively the patient had a percutaneous nephrostomy tube placed and she recovered with no further evidence of bleeding. At 2 months followup, an antegrade nephrostogram showed complete occlusion of the distal ureter at the prior fistula site. She is currently undergoing evaluation for additional chemotherapy for her metastatic and locally advanced rectal cancer. |
Patient 2 (40–45 years old) presented with severe agitation. He was threatening, screaming, scratching, and spitting, and refused a conversation. He thus showed a similar clinical picture as patient 1 but also appeared to experience auditory hallucinations and to actively talk to them. Patient 2 was in a state of poor hygiene. Taking into consideration his manner of response, one could assume that patient 2 has experienced psychiatric treatment in the past. When the nurse asked him if he had any experience with psychiatric medication, he yelled at her and clarified his wish to refuse haloperidol. He seemed to feel especially threatened by the police and the psychiatric staff, not only due to psychotic symptoms but also due to previous aversive experiences with psychiatric treatment. Once again, the staff members involved in the situation discussed the clinical case in a multiprofessional setting and weighed out every possible option. The team suspected that patient 2 suffered from an acute exacerbation of a disorder that persisted for a longer period of time or a psychotic relapse. In this case, the team decided that patient 2—due to his previous aversive experiences—would have extraordinarily suffered from compulsory treatment, which may exacerbate previous traumatic experiences. Also, he calmed down a bit when given a space to withdraw and did not immediately endanger himself or others; however, he remained tense for several days and threw objects whenever members of staff tried to engage him in a conversation or offered oral medication. When left alone, he did not appear aggressive or present improper handling, showed a regular food intake, and welcomed the possibility to smoke. Somewhat later, he was seeking a medical consultation and expressed the need for a low-dosage medication. To this day, 6 years later, he regularly receives outpatient care and short-term crisis intervention treatment on a psychiatric ward, although he has felt threatened and deprived of his identity by the state and the psychiatric system of another city for more than 25 years. |
A 23-year-old male was taken to a general hospital after the car he was travelling in collided with a tree at fifty miles per hour. CT demonstrated free fluid in the pelvis, likely from a mesenteric bleed, but no free air and no solid organ damage (). He was transferred to a major trauma centre where he was managed conservatively and discharged the next day.\nFive days later he represented to a third hospital with severe abdominal pain. A repeat CT showed an increase in the volume of pelvic free fluid and he was immediately taken to theatre for exploratory laparotomy. This revealed a mid-small bowel point of obstruction caused by adhesion to a mesenteric haematoma. Extensive adhesions were evident (the patient had an appendicectomy age nine), but there was no prior history of symptoms of obstruction. Proximal adhesiolysis was performed to allow mobilisation of bowel but this was limited by extensive peritoneal contamination and patient stability; distal and pelvic adhesions therefore remained.\nAlthough there was no full thickness or serosal injuries to the small bowel, it was completely detached from the mesentery and showed signs of ischaemia. A 20 cm section of small bowel was resected, with a side-by-side anastomosis fashioned. Histology from the resected section of small bowel showed only inflammatory and fibrotic changes compatible with trauma.\nAfter four days in ITU, a repeat CT scan was performed as NG aspirate volumes and inflammatory markers remained high. This showed a small left iliac fossa collection with no clear features of perforation. There was small bowel dilatation with a change of calibre in the region of the anastomosis, raising the possibility of obstruction (Figures and ). This most likely represented a paralytic ileus and it resolved without further intervention. The patient was discharged twelve days after surgery.\nHowever, he represented later that day with a leaking abdominal surgical wound. The fluid had the appearance of undigested food, raising the possibility of an enterocutaneous fistula (ECF). A further CT scan revealed two suspected collections in the lower abdomen and pelvis, with one of these communicating with small bowel at the anastomosis and fistulating through the anterior abdominal wall. After seven days of IV antibiotics, the wound output reduced to nothing and his inflammatory markers resolved.\nThe patient was reviewed in the outpatient clinic five weeks later. The surgical wound had healed well, with no discharge and no signs of herniation. |
An 8-year-old girl with a history of congenital profound hearing loss in the left ear presented to a local ENT hospital with an acute onset of ipsilateral facial palsy. She was treated with oral prednisolone; however, the facial palsy progressed to complete paralysis. Otoscopy revealed a pulsatile mass in the left middle ear. A detailed medical history revealed that she had been able to perform tandem walking at the age of four, but became unable to do so at the age of six. She had never been examined by MRI to find the cause of congenital hearing loss.\nOn physical examination, she had a left complete facial paralysis (House-Brackmann grade VI). Electroneurography showed no visible reaction on the affected side (0%). Her left tympanic membrane was swollen, and a pulsatile tumor was visible in the middle ear, which was first found since the diagnosis of congenital hearing loss. Pure tone audiometry showed profound hearing loss in the left ear and less than 20 dB in the right ear. Auditory brainstem response done at the age of five had revealed 100 dB hearing threshold in the left ear, and auditory steady-state response had showed hearing thresholds of the left ear as 80 dB at 1000 Hz, 85 dB at 2000 Hz, and 90 dB at 4000 Hz. Computed tomography (CT) examination revealed a multilocular tumor in the inner ear extending into the middle ear (Fig. a), and osteosclerosis around the edges of the tumor. In the middle ear, the tumor pressed on the ossicles, and the facial nerve canal could not be identified. On MRI, the tumor presented mixed signals of high and low intensities on T2-weighted images and was sparsely enhanced with gadolinium on T1-weighted images (Fig. b). We performed an endoscopic transcanal biopsy of the tumor. It was soft, with a thick fibrous capsule and filled with mucinous fluid (Fig. ). The pathological findings revealed only blood components in the tissue fluid, and the biopsy specimen revealed collagen fibers, smooth muscle, and small blood vessels.\nSubsequently, we decided to perform a transmastoid tumor removal with facial nerve monitoring using nerve integrity monitoring. A retroauricular incision was made, the external auditory canal (EAC) and the tympanic membrane were removed, and a blind sac closure of the EAC and canal wall down mastoidectomy were performed. A hemorrhagic mass was visualized filling the middle ear toward the epitympanum. We removed most of the tumor in the mastoid cavity, the inner ear, and the petrous apex, and the facial nerve was completely dissected and delineated from the horizontal to the vertical portion. However, we decided to spare the tumor in the deep part near the epitympanum and the internal auditory canal because facial nerve monitoring signals were completely lost, and identification of the geniculate ganglion and the labyrinthine portion of the facial nerve was impossible as the tumor had engulfed the nerve at these regions. Anatomical preservation of the facial nerve was considered significant to retain any chances for recovery of the facial palsy after surgery (Fig. a). No intraoperative or postoperative complication such as spinal fluid leakage was observed. Pathological diagnosis showed a malformed salivary gland structures consisting of smooth muscle tissue proliferation on immunostaining, which led to the diagnosis of SGCh. One year after surgery, the palsy recovered to House-Brackmann Grade II. Two years after surgery, MRI showed no increase in size of the residual tumor (Fig. b). |
A 42-year-old woman with type 2 diabetes and ischemic coronary disease was referred to our institution with pain in the right inguinal region with a duration of two months, swelling of the lower leg, inability to fully extend the hip joint for one month, and a palpable mass that had been noticed two weeks prior to the referral. She had had selective coronary arteriography six months earlier with ultrasound-guided access through the right femoral artery. Sonography at that time failed to detect any abnormality. No peri- or postinterventional complications had been recorded.\nClinical examination revealed a tender, dense, hardly movable mass in the left inguinal region measuring about 10 cm by 10 cm. Pain was exacerbated by hip extension and relieved by flexion. Ipsilateral calf circumference was 1 cm greater than the contralateral calf. Plain radiography showed a well-circumscribed ovoid radiopaque mass with a structure resembling that of cancellous bone with a thin cortical shell ( and ). Those findings were confirmed by magnetic resonance tomography (MRT). The MRT showed that the mass was confined to the iliopsoas muscle belly distal to the inguinal ligament with non-infiltrative growth and no perifocal edema in the surrounding muscle and it was displacing the femoral neurovascular bundle ( and ). Biopsy was bypassed because of the markedly benign imaging characteristics and the proximity of the neurovascular bundle where a scarred open biopsy tract would create unnecessary difficulty in the subsequent excision. Surgery was performed through a longitudinal incision in the lateral part of the femoral triangle; the femoral nerve, artery, and vein were mobilized and retracted medially and the mass was removed from within the belly of the iliopsoas muscle by sharp and blunt dissection. The wound was closed in layers over a drain in the usual manner. The specimen had bone density and it seemed to be covered by a thin fibro-cartilaginous layer. When sectioned, it had cancellous bone structure and a thin cartilage-like covering thicker only in the proximal pole ( and ). Microscopy showed a typical structure of osteochondroma with thin mature cartilage at the periphery and cancellous bone with bone marrow in the intertrabecular spaces (–). Perioperatively, standard deep vein thrombosis prophylaxis was administered and the postoperative course was uneventful apart from painless swelling of the limb that required no other treatment and resolved over the course of three weeks. There were no complications or local recurrence on 1.5 years follow-up. |
A 24-year-old unmarried female patient presented to us with a persistent fistula in the right iliac fossa following an appendicectomy done in another hospital 6 weeks previously. On further questioning, she informed us that she had presented to this hospital with a 2-week history of abdominal pain, confined to the right lower abdomen. She complained of general ill health and occasional altered bowel habits for 6 months prior to this acute episode.\nAn enquiry with the doctors who had initially seen her revealed that at the time of presentation for acute appendicitis she was quite unwell with fever, tachycardia, and dehydration. Her abdomen was tender all over with guarding, more pronounced over the right lower half. Her white cell count was 24 × 109/L. An X-ray of her abdomen showed a few fluid levels and an ultrasound scan revealed free fluid in the abdomen with an associated right iliac fossa mass.\nA diagnosis of pelvic peritonitis secondary to acute appendicitis was made by the physicians, and she was taken up for surgery after adequate resuscitation. The abdomen was approached through a right McBurney's incision. There was pus in the abdomen with an appendicular mass, and the appendix appeared oedematous, thickened, and congested. An appendicectomy was carried out followed by a thorough irrigation of the abdominal cavity. The abdomen was closed after placing a drain, which was removed on the 3rd post-operative day. In spite of antibiotic administration, she developed a wound infection and persistent pyrexia. She was managed conservatively with antibiotics and anti-inflammatory medication and eventually improved, except for a persistent purulent discharge from the wound. She then decided to seek our opinion and was admitted under our care for further investigation and management.\nThe appendicular histopathology was retrieved from the previous hospital and revealed transmural inflammation with granulomas suggestive of Crohn's disease. A computerized tomography (CT) scan of the abdomen carried out in our hospital showed pericaecal collection with an inflammatory mass in front of the caecum ().\nThe abdomen was surgically explored through the previous incision after excising the fistula leading into the caecum. An inflammatory mass associated with the caecum was noted. The appendicular stump had not healed, and was draining into a cavity which was communicating with the wound, indicating a complex enterocutaneous fistula. A limited right hemicolectomy was carried out and continuity established with a primary anastomosis of macroscopically-appearing healthy bowel of the ascending colon and terminal ileum. A specimen of the resected caecum revealed the cobblestone appearance of the mucosa, strongly suggesting the possibility of underlying caecal Crohn's disease (). The histology was reported as inflammatory bowel disease (IBD) consistent with Crohn's disease (). The patient's post-operative recovery was uneventful. She was referred to a gastroenterologist and was being treated with mesasalazine and a regular annual colonoscopy. When last seen at two years post-surgery she continued to remain in good health. |
A 31-year-old male, who is an office worker presented to emergency department complaining of central abdominal pain for 2 days. d with nausea, dyspnea but no vomiting.\nThe patients had many attacks of similar pain but of milder intensity for the last years which was diagnosed as irritable bowel syndrome, the surgical histories were unremarkable and the family history was negative for chronic illnesses and malignancies.\nThe patient had tachycardia (the pulse rate was 110 b/m) with normal temperature and blood pressure. Other parts of the general examination were normal.\nThe abdominal examination revealed a mildly distended abdomen, with guarding and tenderness mainly in the right lower abdominal quadrant. There were no any palpable masses or organ enlargement. The bowel sounds were normal.\nThe white blood cells count was elevated (14,000 c/mm) and the hemoglobin and the urinalysis were normal.\nAbdominal ultrasound showed an evidence of 10*7 cm multiloculated thick walled lesion in the right lower abdomen which was located lateral to the iliac vessels, suggesting the possibility of an appendicular abscess .\nThe patient was admitted for 2 days and he received broad spectrum parenteral antibiotics with little clinical improvement.\nThe decision was done for surgery. Therefore, a laparotomy was performed at which there were 2 yellowish cystic lesions that were arising from each side of the small bowel and related to its mesentery causing luminal narrowing. The lesion was located approximately 60 cm from the ileocecal valve. Resection of the affected bowel segment was done with end-end anastomosis by a slowly absorbable suture material. The other parts of the bowel were examined and there were no other pathologies detected & .\nThe resected sample was sent for the histopathological examination which showed an evidence of numerous and variable sized lymphatic channels in the mucosa and the submucosa of the bowel, there was intense inflammatory cell infiltration and the sample was negative for malignant cells. The diagnosis was lymphangioma of the ileum.\nThe patient was well in the post-operative period and he was discharged home after 5 days with no post-operative events. |
The patient is a 48-year-old female who presented to our institution following a slip and fall on the ice landing directly onto her low back 1 month before presentation. The patient was evaluated at an outside hospital at the time of initial injury where a computed tomography (CT) scan of the lumbar spine was performed. The CT scan of the lumbar spine demonstrated a non-displaced fracture of the left L5 transverse process and a large subcutaneous fluid collection measuring 15 cm×16 cm×7 cm (-). No additional imaging or laboratory studies were performed and the patient was discharged home.\nUpon presentation to our institution, she was complaining of persistent low back swelling that prevented her from sitting or lying on her back comfortably. Physical examination of the patient revealed a large fluctuant mass in the lumbar region, measuring approximately 20 cm×20 cm. No overlying erythema, warmth, or ecchymosis noted. Diffuse tenderness to palpation of the mass was noted. The patient exam was otherwise unremarkable.\nThe patient was informed of the presence of a persistent fluid collection and given that the patient would likely benefit from operative evacuation, she was offered an open incisional drainage. Treatment options were discussed with the patient and family, and after explaining the risks, benefits, and alternatives to surgery, the patient elected to procedure with surgical irrigation and debridement of the persistent fluid collection. Pre-operative testing was performed with basic laboratory studies; however, no additional imaging studies were obtained.\nThe patient was taken to the operating room 1 week after the initial clinic visit. She received general anesthesia and was placed on the operating table in the right lateral decubitus position. Pre-operative antibiotics, cefazolin 2 g, were given before incision. The patient was prepped and draped in the typical sterile fashion, and a 2 cm midline incision over the proximal aspect of the fluid collection was made that extended through the subcutaneous tissue, opening the superficial fascia. At this time, a large amount of serosanguinous fluid began exuding from the incision. No purulence noted or obvious necrotic tissue. The fluid obtained was sent for culture and cell count. In total 900 ml of serosanguinous fluid was evacuated. On intraoperative examination of the lesion, it was felt that the fluid collection demonstrated a defined walled-off lesion. The cavity was the irrigated with copious amounts of a normal saline 0.9%/betadine solution. A small wound vacuum-assisted closure (VAC) sponge was placed inside the cavity to aid in absorption of any remaining free fluid and to eliminate the present dead space. Negative pressure therapy was then initiated with machine settings at 175 mmHg continuous. The patient recovered well from anesthesia, no complications were encountered and she was transferred to post-anesthesia care unit (PACU) in stable condition. She was discharged home from the PACU and was instructed to continue the wound VAC therapy until her first follow-up appointment in 4 days, at which a wound VAC change will be completed.\nAt the first post-operative clinic visit, the wound VAC was removed with good wound healing and dead space closing noted. The incision with then closed with 2-0 Novafil under aseptic conditions. The patient reported improvements in her symptoms and no complications at that time. Intraoperative culture results were finalized on post-operative day 5, demonstrating no anaerobic, aerobic, or fungal growth. The 2-week post-operative visit demonstrated a well healing surgical incision with no evidence of infection or drainage. The patient stated that she was now able to comfortably lay and sit down. |
A 45-year-old man, who suffered from pain in the left posterior maxilla and a bad smell from the nose, was referred to our department. A 4 × 6 × 3 cm cyst was found in the left maxillary molar region on radiological examination (). After treating the acute infection, the patient underwent cyst enucleation under general anaesthesia (). Six months postoperatively, the area had a severe bony defect extending to the zygomatic buttress superiorly and hamular notch posteriorly. After computed tomography (CT) and model analysis of the defect, we decided to reconstruct it using transport distraction. Under general anaesthesia, a vestibular incision was made and a mucoperiosteal flap was raised to expose the lateral wall of the maxilla. The bone between the number 23 and the number 25 maxillary teeth was cut vertically with a saw and then connected to a horizontal bone cut 5 mm above the apex of the second premolar running posteriorly on the buccal side. The bone on the palatinal side was cut horizontally with curved osteotomes, gently to avoid damaging the palatal mucosa. Before mobilising the transport segment including number 25, the distractor was adapted to its stabilising plates with screws, and then the segment was mobilised using osteotomes (). Before suturing the surgical site, the distractor was checked to ensure that the transport segment was being moved into the proper position.\nAfter a 7-day healing period, the distractor was activated by 1 mm once daily for 15 days. After full activation, the distractor was left in situ for the consolidation phase. Six weeks later, the distractor was removed and two dental implants were placed in the new bone. After 3 months for osseointegration, we realised that the implants were not aligned on the proper axis and position on CT (). To correct this situation, a subapical osteotomy including the implants was performed and a block autogenous graft was taken from the mandibular symphysis and adapted to the superior border of the osteotomy line.\nPermanent prosthetic rehabilitation was started 4 months after the subapical osteotomy. Metal-supported porcelain restorations were constructed using conventional methods. The patient was followed up 3, 6, 12 and 24 months after the prosthetic rehabilitation (Figures and ). |
A 14-year-old boy reported to the department of oral maxillofacial pathology, (Vinayaka Mission Dental College, Salem) with the chief complaint of swelling on left cheek region for the past 5 years. Previous history revealed that patient had swelling since birth and it was operated at age of 3 years through extra oral approach and a scar was present in the left cheek region []. After which the patient was apparently normal, then at the age of 9 years again the swelling appeared in the same region, which was growing slowly and attained the present size of 4 × 3 cm [], and was not associated with pain. Patient complained of difficulty in mastication and speech, unaesthetic appearance. No history of bleeding and pus discharge associated with the swelling, no history of swelling in other parts of the body.\nIntraoral examination showed a diffuse swelling measuring around 4 cm × 3 cm in size in relation to occlusal line of left buccal mucosa extending anteriorly from the corner of the lip to the retromolar region posteriorly, surface of the swelling had pebble like appearance. On palpation swelling was soft and nontender and nonpulsatile and had no dilated veins. Extraoral examination: A diffused extra oral swelling present in the left cheek region of about 5 × 6 cm in size; anteroposteriorly extending - from the left corner of the mouth to the anterior preauricular region, superoinferiorly-from the left ala of the nose to lower border of the body of mandible, no dilated veins over the swelling no pulsation felt [] skin is pinchable with no sinus and fistula formation. There is scar over the swelling due to previous surgery and measuring about 3 × 0.5 cm [].\nA provisional diagnosis of intra oral lymphangioma of the buccal mucosa was established. A differential diagnosis of arteriovenous malformation. Routine blood investigations were found to be normal. An incisional biopsy was performed under local anesthesia and specimen was subjected to histopathological examination. Microscopically, it showed numerous dilated lymphatic vessels lined by thin endothelial cells, characteristically located just beneath the epithelial surface and spaces within the lymphatic vessels contain proteinaceous fluid [Figures and ]. This superficial location results in the translucent, vesicle-like clinical appearance []. The entire lesion was excised, no recurrence has been observed and the patient is under follow-up []. |
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