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A-30-year old man presented with a slow growing painless swelling involving both jaws, over a period of 2 years. He stated that the swelling was initially small, but gradually enlarged to cause spacing between teeth and noticeable facial asymmetry. This swelling was not associated with pain, paresthesia or pus discharge. History taking from his parents revealed recurrent fractures since the age of 4 years, brown pigmented patches over his trunk since birth, attainment of puberty at the age of 12 years and no similar features in other family members. There was no history of visual impairment, nasal stuffiness or hearing disability. He was a product of non consanguineous marriage, born full term with normal birth weight and milestones. Physical examination showed short stature in comparison to parents (height-142 cm), multiple deformities due to recurrent fractures, shortened right leg, limping and a large café au lait macule over the back crossing the midline. Facial examination revealed frontal bossing, asymmetry on the right side, with an enlargement of the right malar and maxillary bone and chin button deviation towards the left side [Figures and ]. He had a prognathic mandible, with lengthening of the body on the right side [].\nIntraoral examination revealed well defined uniform expansion of the mandible up to the inferior border, extending from the third molar on the right side to the premolars on the left side. The labial and right buccal vestibules of the mandible were shallow due to the swelling. The mucosa over the swelling showed black patchy pigmentation and dilated superficial veins. The swelling was non tender and bony hard on palpation. The right maxilla was enlarged diffusely from the lateral incisor to the second molar with normal mucosa and was nontender with bony hard consistency [].\nThe midline of both maxillary and mandibular teeth had shifted to the left, with an anterior cross bite and spacing between maxillary and mandibular anterior teeth. Grade I mobility and labial tipping were seen in 41, 42. The overjet between the right maxillary and mandibular posterior teeth was reduced. He was diagnosed clinically as a case of MAS. Hormonal profile revealed normal thyroid, adrenal and gonadal axes evaluation. The serum alkaline phosphatase was elevated (388 IU/L), with normal calcium, phosphorus, parathyroid hormone and 25 hydroxy vitamin D levels.\nSkeletal survey by paranasal sinus view of the skull revealed expansile, ill defined mixed radiopaque- radiolucent lesions in the frontal bone, ground glass radiopaque lesion in the right maxilla causing obliteration of the maxillary sinus and an expansion of the right body of the mandible []. The OPG showed an extensive multilocular lesion, extending 1 cm below the sigmoid notch of the ascending ramus of the right side to mesial aspect of the mandibular left first molar []. The lesion caused an increase in width of the right body and symphysis with a loss of normal trabecular pattern. The mandibular canal was displaced inferiorly towards an intact lower border. The right maxillary sinus was occluded and the right maxillary alveolar process in the posterior region showed orange peel pattern. Loss of lamina dura was noted for teeth located within the lesion. Expansive, osteolytic lesions were also seen in right hip and shoulder. He was treated with parenteral bisphosphonates (intravenous Zoledronate 4 mg) and is under follow up for surgical recontouring of the jaws. |
A 23-year-old young woman presented with a 3-year history of experiencing numbness and pain in the right lower leg during exercise. Over the past 2 years, the patient had experienced worsening leg pain when running long distances. The patient had no cardiovascular risk factors. She had been hospitalized in the orthopaedic and physiotherapy clinic due to leg pain prior to admission to our clinic. However, her symptoms continued to persist. Examination of the right leg showed that there was swelling and no pulse below the femoral artery. Pulses were normal in left lower limb. Magnetic resonance imaging (MRI) revealed normal aortic and iliac arteries. Anterior and posterior views of MRA showed an occlusion of the right popliteal and peroneal arteries Figs. ( and ). In this case, intra-arterial thrombolysis was performed. Control angiography showed that there was a thrombus in the artery and a stricture at the mid-PA, with an irregularity of the wall. At the end of two 2 days, the angiogram demonstrated that the thrombus had largely resolved; however, the stricture of PA was present. MRI scanning was subsequently performed, which showed that the medial head of the gastrocnemius muscle, the PA and vein where it inserted in a more lateral position Fig. (). Further evidence from the MRI revealed that the PA crossed below the popliteal muscle in this patient with Type IV PAES. Contralateral limb MRI was normal. Posterior popliteal approach was preferred. An S-shaped skin incision was performed. The PA crossed under the popliteus muscle and there was a hypertrophic band, which was the cause of occlusive pressure on the PA. The hypertrophic bands and the popliteus muscle were resected. PA was opened and it was partially occluded. The tibioperoneal artery was also occluded. A thromboendarterectomy (TEA) was performed. The artery was repaired using a RA. No rest pain was detected after surgery. US showed that the distal arterial system and the RA were patent. A low molecular weight heparin and acetylsalicylic acid were prescribed in the postoperative period. The patient was discharged home in good clinical condition. We prescribed a daily dose of 100 mg of acetylsalicylic acid. The patient was able to run without any symptoms in the lower limb. |
A 59-year-old Chinese woman was admitted to the hospital with the chief complaint of a progressively enlarging mass in the left thoracic wall over the past seven months. At the initial examination, the tumor slightly protruded from the chest wall with the 2 cm in diameter, and gradually grew over in the past several months. In one month ago, she underwent a percutaneous transthoracic needle biopsy of the mass in another hospital. Following the puncture, the tumor promptly increased significantly in size, impacting blood flow to the left arm. On this admission, we conducted a physical examination and palpated the soft painless left lateral chest wall large mass with the 9 cm in diameter. She denied smoking history and had no family history of lung cancer. A review of her systems was noncontributory. The results of a peripheral blood count, baseline serum chemistry screening, and urinalysis were normal on admission, as were tumor biomarker tests and a purified protein derivative test for tuberculosis.\nEnhanced chest computed tomography (CT) with three-dimensional reconstruction of the ribs showed an enormous soft tissue mass in the left chest wall (Figure ), which extended into the left lung and mediastinum, exerted pressure on the heart, skewing it to the right, and had eroded the middle portion of the fifth rib. The density of the tissue mass was uneven and a necrotic area was visible. The maximum cross-sectional diameter of the tumor mass was 13.3 × 15.7 cm2. Moreover, an ECT bone scan also demonstrated the destruction of the middle of the fifth rib. In additional, a CT scan of her abdomen and magnetic resonance imaging of her brain were all normal. Her bronchial tree also appeared normal on bronchoscopic examination, with no indication of malignancy in the biopsy and washings procured.\nAfter anesthesia and a double-lumen intubation had been established, a left posterolateral incision was performed. The chest wall tumor invaded the left upper pulmonary lobe as well as the fourth, fifth, and sixth ribs. The tumor had eroded the middle portion of the fifth rib; the heart was impacted by the tumor and mediastinal pleural adhesions were present. We freed-up the outer margin of the tumor and excised the fourth, fifth, and sixth ribs. Intercostal tissue was included with a margin over 5 cm. We extracted the tumor and the invaded left upper lobe of lung to remove the pressure on the heart. We then performed the left upper pulmonary lobectomy. Finally, we joined four 10 × 10 cm2 polyester surgical patches (knitted type) into one 20 × 20 cm2 patch and this patch was sutured to the chest wall defect for chest wall reconstruction.\nThe neoplasm, which was removed by surgical resection, weighed 2.080 kg and was 20 cm × 18 cm × 9 cm in size, as shown in Figure A. There were multiple nodules on its surface and a cross section of the tumor was honeycombed in appearance. The pathology report described a giant cell malignant fibrous histiocytoma cell tumor (Figure B), with the immunohistochemistry of CD68 (+), Vimentin (+), SMA, CK and S-100 (-) (Figure C), invading the left upper lung lobe and the middle of the fourth, fifth, sixth ribs, with no metastases to the mediastinal lymph nodes. Her postoperative course was uneventful. She was discharged 12 days after surgery and showed no signs of local recurrence or distal disease at an 8-month follow-up visit (Figure ). |
A 47-year-old man was undergoing treatment for severe asthma with high-dose inhaled corticosteroid and long-acting β2 agonist, along with frequent systemic steroid burst twice or more a month. He was a 1.25 pack-year ex-smoker. As symptoms were poorly controlled despite maximal pharmacological treatment, he was admitted to our hospital for BT. Blood testing showed an elevated level of immunoglobulin E at 477 U/mL, and the white blood cell count was 9750/μL with 1.0% eosinophils under administration of 20 mg of prednisolone. Only mild thickening of the bronchial walls in the lower lobe was seen on chest computed tomography (CT).\nThe first two procedures were conducted at an interval of 3 weeks and contributed to the alleviation of asthmatic symptoms. Although he experienced complications of local bronchial oedema and small amounts of bloody sputum after each procedure, these resolved within 2 weeks.\nThe third procedure was performed with 5.4 mg of midazolam and 90 mg of propofol for intravenous anaesthesia for 82 min. The total number of activations was 110, comprising 61 in the left upper lobe bronchi and 49 in the right upper lobe bronchi. Daily pulmonary function tests and chest X-rays were performed to detect immediate adverse events after BT treatment.\nOn postoperative day 2, the patient showed hypoxaemia, and bilateral upper lobes appeared completely collapsed on chest radiographs (Fig. ). To prevent infection due to poor airway clearance in atelectasis, we initiated antibiotics and decided to continue prednisolone at 50 mg/day in order to quell the strong airway inflammation. Findings on chest radiographs did not show any changes for 4 days, but on postoperative day 6, a pulmonary cyst about 85 mm in diameter with air-fluid level suddenly appeared in the right upper lung field. Before we noticed this drastic change, the patient underwent a routine daily pulmonary function test, in which he experienced sudden right chest pain. Chest CT after this episode revealed a pulmonary cyst in the right middle lobe and right pneumothorax, in addition to complete atelectasis of bilateral upper lobes (Fig. ).\nWe placed a thoracic drainage tube in the right pleural space. However, pneumothorax and upper lobe atelectasis remained until postoperative day 9. When atelectasis improved on postoperative day 9, pneumothorax also improved, and the cyst diminished and shifted towards the right lower outer field, as seen on chest X-ray. We tapered steroid dosage and removed the thoracic tube on postoperative day 12. A CT on postoperative day 16 revealed shrinkage of the cyst in the right middle lobe, and follow-up CT after 2 months showed disappearance of the cyst. |
A 68-year-old, right-handed male presented to his primary care physician with several months of gradually progressive cognitive changes, gait disturbance, and headache. Magnetic resonance imaging (MRI) of the brain revealed a heterogenously enhancing lesion in the anteromesial right frontal lobe which was associated with significant edema [Figure and ]. The patient was immediately referred for neurosurgical evaluation.\nThe patient’s past medical history was considered closely. The patient was diagnosed with a plasmacytoma of the left frontal skull 8 years prior to this presentation and was initially treated with radiation therapy to this isolated lesion. This treatment took place at an outside institution and involved conventional external beam radiation using a 20 MeV electron beam. The initial radiation treatment was delivered with a 10 cm × 10 cm cone, at 100 SSD, with the beam positioned perpendicular to the left frontal scalp and with a 0.5 cm wet bolus. The patient received 2.5 Gy per fraction for 7 fractions, followed by decreased dose of 2.0 Gy per fraction for additional 11 fractions. The total cumulative dose to this treatment field was 39.5 Gy. The treatment field was then coned down to 6 cm × 6 cm, with three more fractions of radiation treatment at 2.0 Gy per fraction. The total accumulated dose to the boost field was thus 45.5 Gy.\nShortly after the conclusion of radiation therapy, the patient developed additional sites of systemic disease and underwent an autologous stem cell transplant for multiple myeloma. He remained disease-free since that time and was treated with chronic immunosuppressive agents to prevent rejection.\nUpon neurosurgical evaluation, a radiographic differential diagnosis was formulated and included high-grade glioma, metastasis, abscess, radiation-induced malignancy, and radiation necrosis. Radiation necrosis was considered a relatively unlikely diagnosis due to the timing of the presentation. Additionally, the reported total radiation dose to the brain parenchyma was low and was divided into numerous small fractions and the plasmacytoma targeted with radiation was contralateral to the new intrinsic lesion. However, the detailed radiation plan from the original treating facility was destroyed, and without the ability to review this document, treatment error was considered possible. The use of additional imaging modalities such as MR spectroscopy or FDG-Positron Emission Topography (PET) was considered, but these results were considered unlikely to change the treatment recommendations. After a discussion with the patient and his family, the decision was made to proceed with a craniotomy for pathologic diagnosis and relief of mass effect without further preoperative workup.\nShortly after referral, the patient underwent a right frontal craniotomy for resection of the mass lesion. Frameless stereotaxy was used to localize the lesion which was resected with conventional microsurgical techniques. The lesion was noted to be firm and white and extended medially to the pial border of the interhemispheric fissure. A large central portion was delivered in its entirety and sent to neuropathology for frozen and permanent section. The frozen section was notable for hyalinized blood vessels, calcification, and an absence of gross cellular atypia. With a pathologic impression favoring radiation necrosis, the craniotomy was completed with a goal of internal debulking of the lesion for relief of mass effect.\nThe entire specimen, consisting of large fragments of tissue measuring approximately 4 cm in aggregate, was submitted for microscopic examination. This showed extensive bland, granular, coagulative necrosis, with smaller areas of viable, reactive brain tissue [Figure –]. Areas of necrosis contained hyalinized blood vessels [] and coarse calcium deposits []. Few macrophages were present. Viable brain tissue was gliotic but only modestly hypercellular, with moderately atypical cells [] and benign, perivascular chronic inflammation. Focal capillary proliferation resembling a telangiectasia was present. There was no evidence of malignancy or infection. A diagnosis of radiation-induced necrosis was made.\nPostoperatively, the patient returned to his neurologic baseline. A postoperative MRI demonstrated near-total resection of the lesion with some residual nodular enhancement. After a fall from standing, the patient developed a wound complication requiring exploration on postoperative day 2, in which a subgaleal hematoma was identified and evacuated. He subsequently recovered well and was discharged to a rehabilitation facility several days later.\nSince his craniotomy and diagnosis, the patient has been followed for 18 months. Follow-up MRI studies have demonstrated continued evolution of this process with initial extension of edema to involve the bilateral frontal lobes []. This correlated with increased symptoms of poor balance and cognitive difficulties and was managed with oral steroids. Alternative treatment strategies including anticoagulation were considered but not employed due to contraindications related to the patient’s systemic illness. At 1 year follow-up, imaging studies revealed stabilization of edema and decreased enhancement []. The patient’s clinical status has continued to improve and he remains functionally independent. |
A 72-year-old man presenting with groin pain irradiated to the thigh with a history of an intersubtrochanteric left hip fracture treated with a long dynamic condylar screw at another institution 8 years before being referred to us. Six years after the index operation the patient started with symptoms that were not able to respond to oral analgesics. Medical history included hypertension, coronary artery disease, cardiac insufficiency, and renal insufficiency without requiring dialysis. Functional preoperative score was 6 points according to the D'Aubigne and Postel score []. Radiographs showed fracture consolidation in 10° of varus in comparison with the anatomical femoral axis and 1.5 shortening of the left leg, with bone ingrowth along the distal 2/3 of the osteosynthesis plate (). We indicated a short-stemmed prosthesis in order to avoid plate removal. Removal of previously fixed metallic devices would have necessitated an extensive soft-tissue dissection and a long operation time, which might have increased the risk of cardiac complications as well as infection. Preoperative assessment in our hospital indicated an ASA (American Society of Anesthesiologists) class 4 []. The patient was classified as a grade C (other severe comorbidities) according to Charnley's classification []. Radiographic preoperative templating using various femoral component designs confirmed that the cannon of the plate would jeopardize implantation of standard-length components. The operation was performed using epidural in lateral decubitus using a posterolateral approach. First step was removal of the 3 most proximal screws of the dynamic condylar screw plate. One of the screws was fractured during removal but the fractured portion remained inside the medial cortical of the femur without making any contact with the broach or the stem. Posterior dislocation was then performed and femoral neck cut was done with 4 sliced cuts to allow dynamic screw visualization.\nRemoval of this screw was performed in an anterograde way as it is not possible to take it away in a retrograde fashion without plate removal. The acetabular cup was first performed with the use of a 58 mm external diameter Trinity cup (Corin, Cirencester, UK) implanting a 40 mm ceramic liner (BIOLOX delta, CeramTec AG, Plochingen, Germany) in order to achieve the most possible stable hip in a patient with such comorbidities. Femoral broaching was performed with the use of an image intensifier in order to avoid cortical perforations. Trial reduction was performed trying to equalize limb lengthening. A number 2 MiniHip stem (Corin, Cirencester, UK) was implanted with a 40 mm ceramic femoral head (BIOLOX delta, CeramTec AG, Plochingen, Germany). Total operative time was 75 minutes. Postoperative radiographs showed no femoral perforations and equalization of limb length. The patient spent 24 hrs in intensive care unit and then started weight-bearing as tolerated with a walker during 2 weeks, followed by a 2-week period with a cane. No clinical complications were observed. Thromboembolic prophylaxis was continued until the 30th postoperative day using enoxaparin 40 mg daily. He was followed up at 45 and 90 days postoperative and then at 1 year, with radiographic signs of both femoral and acetabular bony ingrowth stability (Figures and ) with a functional score of 14 points []. Unfortunately, the patient died in another clinic at 19 months postoperative due to a dissecant abdominal aorta aneurism. The family was requested on the hip function and the widow told us he was walking short distances with the use of a cane. |
A 12-year-old female was admitted to Xinan Hospital of The Third Military Medical University on January 24, 2007 due to two months of intermittent lower left leg pain, which became aggravated in the second month and was accompanied by the growth of a mass. X-ray imaging showed osteoblastic bone destruction of the left distal tibia (). MRI showed a mixed high and low signal intensity, with a visible periosteal reaction and an anterior soft tissue swelling. The patient was diagnosed with osteosarcoma of the distal left tibia by biopsy. The symptoms disappeared following one course of AP (ADR, 60 mg/m2; and DDP, 120 mg/m2) regimen chemotherapy. On March 2, 2007, the patient underwent a sectional removal of the osteosarcoma of the left distal tibia, a reconstruction using inactivated bone and an internal fixation, under general anesthesia. The post-operative pathological examination confirmed the initial diagnosis of osteosarcoma. Chemotherapy with the AP regimen (four courses with three week intervals) was initiated subsequent to the healing of the incision (two weeks post-surgery). An X-ray captured at 29 months post-surgery showed a nonunion between the host bone and the distal side of the inactivated bone, accompanied by a posterior protrusion and varus deformity (). On July 31, 2009, the stainless steel plate-screw fixation was surgically removed from the left tibia. On April 4, 2012, 62 months after the initial surgery, the patient was hospitalized due to one month of ankle pain, which was associated with a mass (). An X-ray examination demonstrated healing between the host bone and the proximal end of the inactivated bone, but a hypertrophic nonunion existed between the host bone and the distal end of the inactivated bone, which was accompanied by a posterior protrusion and varus deformity. Screw residues were left in the inferior tibia and fibula. MRI showed an anterior soft tissue mass in the lower left leg and osteolytic destruction of the left distal tibia, surrounded by edema. ECT showed an abnormal concentration of radionuclides in the left distal tibia, but no obvious abnormalities in the rest of the skeletal system. The patient was diagnosed with a recurrence of osteosarcoma of the left tibia. On May 4, 2012, an amputation of the middle section of the lower left leg was performed under epidural anesthesia. A post-operative pathological examination confirmed the pre-operative diagnosis of fibroblastic osteosarcoma (). The incision stitches were removed at 14 days post-surgery, and the wound healed first time. There was no recurrence or metastasis at 6 months post-surgery. The patient is currently being monitored by follow-up appointments. |
A 23-year-old male normally fit and well reported to the outpatient department of our hospital with a chief complaint of asymptomatic swelling and pus discharge from the left maxillary posterior region since 10 days.\nThere was no significant past medical history. A detailed examination of the maxillofacial region had no significant extra-oral findings. Intra-oral examination revealed a partially edentulous state; teeth 13, 14, 18, 27, 28, 37, and 47 were missing with slight expansion of the buccal cortical plate in the left maxillary posterior region. On exertion of pressure, a white creamy exudate expressed out of the area between 23 and 24, but there was no tenderness or bleeding on further palpation.\nA panoramic radiograph revealed multiple radiolucencies in all four quadrants []. Lesion in the left maxillary quadrant was associated with multiple impacted teeth and retained deciduous teeth. In the lower jaw, well-defined radiolucencies were associated with missing 37 and 47 which mimics dentigerous cysts. Diagnostic biopsy from the maxillary left quadrant was reported as OKC.\nThe patient's chest and skull radiographs were unremarkable. Dermatology consultation did not reveal any cutaneous abnormality. Hematological investigations were within normal limits. The patient was admitted to hospital, and enucleation of the cystic lesions was performed under general anesthesia and the surgical bed was treated with Carnoy's Solution. It was interesting to note that there were two separate entities in the right maxillary region with one of the lesion associated with the impacted canine and they were sent as two separate specimens. Four lesions (excluding the small lesion distal to tooth 36) were enucleated and sent for histopathological examination. The small cystic lesion distal to tooth 36 was kept under observation. The patient recovered uneventfully and was discharged the next day and is presently being kept under observation with regular follow ups at the interval of 3 months are being conducted.\nThe histopathologic report revealed that three out of four lesions were OKC and the other lesion which was associated with the impacted canine in the maxillary right quadrant was dentigerous cyst. Cystic lining of all three Keratocystic lesions was parakeratinized stratified squamous epithelium of uniform 6-8-cell thickness. The lining epithelium consisted of well-defined columnar basal cells in a palisade arrangement and with polarized nuclei. The height of the epithelial cells and the number of nuclei they contained were reduced. Satellite cysts and epithelial remnants were observed in the connective tissue capsule. |
A 54-year-old previous fit and well male patient was brought to the emergency department with a 2-h history of central chest pain. He was immediately transferred to the coronary care unit and had a series of investigations including routine blood tests with cardiac enzymes and serial cardiac enzymes. Blood tests on admission revealed a normal full blood count, renal function and normal cardiac markers (troponin T: <10 ng/L) on initial and on 12-h repeat blood test. The C-reactive protein (CRP) was noted to be mildly elevated at 21 mg/L. The patient’s pain eased with analgesics, and he was subsequently discharged home with no formal diagnosis. Over the next few days, the patient continued to experience intermittent episodes of chest and back pain with radiation of symptoms to his shoulder and arms. He visited his local general practice doctor on two separate occasions at 3 days and 3 weeks following his initial admission. Cardiac causes of chest pain were once again excluded, however, a gradual rise in his CRP was noted of 52 mg/L at 3 days and 68 mg/L at 3 weeks. A chest X- ray was done at 3 weeks and reported normal.\nNearly, 6 weeks following his initial presentation, he presented back to the emergency department with clinical signs of sepsis including pyrexia with a temperature of 38.4°C, tachycardia (heart rate: 109 bpm) and now with severe back pain and worsening central chest pain. On examination, the patient was unable to stand up straight due to the severity of his back pain. He had a diffuse spinal tenderness with localized tenderness in the mid-thoracic level as well as the upper lumbar spine. Lower limb examination revealed weakness in his right hip secondary to pain inhibition with nondermatomal altered sensation to his right leg. He had a positive straight leg raise at 30° on right side. Both knee and ankle reflexes were normal bilaterally with no evidence of clonus and Babinski reflex was normal. Per-rectal examination revealed normal perianal sensation with a normal resting anal tone. Blood markers revealed a CRP of 297 mg/L and an erythrocyte sedimentation rate (ESR) of 77 mm/h. The white cell count was noted to be 7.9 × 103/μL with a neutrophil count of 5.1 x 103/μL. A full septic screen was performed including blood and urine cultures, and the patient was started on broad spectrum antibiotics - tazocin (piperacillin and tazobactam) to treat for sepsis of unknown origin. Plain X-rays of the chest, hips and spine were also conducted revealing no gross abnormality.\nIn view of the now localized thoracic spinal tenderness, a contrast magnetic resonance imaging (MRI) scan of the whole spine was arranged. This revealed destruction of the sixth and seventh disc space with high signal intensity on T2 and short tau inversion recovery images in T6 and T7. There was a prevertebral soft tissue enhancement anterior to these vertebrae but no cord compression ( and ). There was an annular tear at the L4/5 disc, which may have accounted for the lumbar pain. A computed tomography thorax, abdomen and pelvis did not reveal any other septic foci. Blood cultures grew Staphylococcus aureus. The patient was immediately commenced on an appropriate antibiotic regime (intravenous flucloxacillin and oral rifampicin) following advice from the microbiology team. He responded well to the treatment with improvement his thoracic spinal pain and complete resolution of the weakness and altered sensation to his right leg. Within 5 days commencing the antibiotic regime, his CRP dropped to 36 mg/L. A 6- week repeat contrast MRI at 6 weeks still showed edema in T6 and T7 with paravertebral soft tissue shadows ( and ). After 15 weeks of treatment, his pain had completely resolved, and his CRP and ESR levels were within normal limits. His antibiotic regime was subsequently stopped, and the patient continued to be symptom-free at 5 months from his initial presentation. |
The 11-month-old male patient was born at full term to non-consanguineous parents with no complications. His birth weight and height were both normal. He presented with poor motor development and muscle weakness that gradually progressed after birth. He began to raise his head in prone position when he was at 43 days old, and was able to kick frequently at 3 months old, but he was still unable to grasp his feet at 6 months old. Subsequently, he had decreased muscle strength in lower limbs with diminished tendon reflexes at 7 months old. He presented at our hospital with muscle weakness and delayed development. Before coming to our hospital, he had received rehabilitation exercise treatment at the local agency.\nAt the initial visit when he was 6 months old, we first performed neurological and physical examinations of the patient and found decreased muscle strength, especially in the lower limbs, which could not induce the tendon reflex. The remainder of his examination was normal. Next, clinicians evaluated his developmental level based on clinical manifestations. The patient did not reach the milestone for motor development of rolling over and could not sit straight or pronate alone. However, his cognitive development was normal, and he had no significant medical history.\nWe reviewed the patient's family history and found that he belonged to a Chinese family with four members of two generations, including two males and two females. None of the other three family members exhibited any clinical anomalies.\nFurthermore, the patient's electromyogram (EMG) showed a large number of positive sharp waves and fibrillation. High-amplitude coupled with long-duration motor unit potentials (MUPs) were also found in examined muscles, including the tibialis anterior, peroneus, rectus abdominis, and deltoid. No sensory deficits were found in nerve conduction studies. All the above findings indicated motor neuron damage.\nMuscle weakness is a chronic and progressive symptom often caused by neuromuscular transmission disorders. It occurs at an early stage with specific clinical manifestations, which has a special relationship with genetic factors. The various causes of muscle weakness can be divided into neurogenic diseases and muscular diseases; therefore, genetic testing, electromyography, and laboratory inspection are necessary for diagnosis. In this case, muscle weakness, poor motor development, and spinal cord anterior horn cell injury suggested the possibility of SMA, a genetic disorder of congenital muscle weakness that was common in infancy. |
A 39-year-old woman with an abnormal mass in the right cerebellopontine angle was referred to neurosurgery department of our hospital. A giant mass in the right thoracic cavity was detected accidentally by X-ray in a routine preoperative screening process. Physical examination demonstrated some loss of breathing sounds in the right base. Subsequent thoracic computed tomography scan demonstrated a complex lesion (size 15.1 × 12.3 × 15.7 cm) occupying more than two-thirds of the thoracic cavity on the right side. The blood supply to the area of the lesion was from a systemic artery arising from the abdominal aorta, with venous drainage through the inferior pulmonary vein, suggesting an ILPS ( - ). She had no history of weight loss, pneumonia, hemoptysis and dyspnea. After careful consultation, a right temporal craniotomy for intracranial lesion was performed. The intracranial mass was completely excised and histopathological study revealed the tumor as cholesteatoma. The patient's postoperative recovery was uneventful.\nThree months later, an open thoracic surgery for the intrathoracic lesion was performed under general anesthesia. Intraoperatively, lesion appeared hypervascular, because of abundant systemic vascularization (). The massive lesion was compressing the right lung and there was no communication between the tracheobronchial tree and sequestered lesion. Based on the findings of 3D CT angiography, we explored the aberrant artery at the bottom of the chest and carefully ligated it with an absorbable silk suture. After the pulmonary ligament had been completely divided, the lower pulmonary vein was found to be widened. The lesion was adherent to adjacent pulmonary vein branches and was not easily dissected. To avoid major intraoperative blood loss, a right lower lobectomy was performed following resection of the sequestered lesion. Pathologic analysis showed a predominant fatty differentiation with fibroblastic, chondroid and osseous differentiation making the rest ( - ). The residual lung appeared anatomically normal following resection of the sequestration. The postoperative recovery was uneventful and the patient was discharged from the hospital on the eighth postoperative day. |
A 68 year old male patient was presented to the outpatient department with a painful swelling on the dorsum of the right hand without any history of trauma. It was primarily considered to be cellulitis and treated with antibiotics for 10 days by the general practitioner. He had bronchogenic lung carcinoma which was diagnosed 5 months ago. He also had a bone scan done which did not reveal any metastases. Clinical examination revealed a palpable mass at the ulnar part of the dorsum of the hand (Figure ). The hand was warm, red and tender. Flexion and extension movements of the fingers were painful. There was no neurovascular deficit. No epitrochlear or axillary lymph nodes were palpable. The radiographs revealed a lytic lesion of the fifth metacarpal with destruction of its distal part (Figure ). Chest x-ray showed a large mass in the right upper lobe of the lung, in keeping with a bronchogenic carcinoma (Figure ). MRI of the hand revealed a large, solid mass originating from the fifth metacarpal and extending to the adjacent soft tissues (Figure ). Open biopsy showed metastatic carcinoma. The case was discussed with the Oncologist. We decided that, due to the broad extension of the mass to the hand, the patient should not receive any surgical treatment and he was referred to the oncology department.\nThe most common site of metastatic deposits to the hand is the distal phalanx. The incidence of metastasis to the metacarpals is 17%, phalanges 66% and carpal bones 17% []. Keramidas and Brotherston [] published a case with metastasis to both metacarpal and carpal bones, which is extremely rare.\nIt is rare to see bronchogenic carcinoma metastases to the bones distal to the elbow and knee. Floridis was the first to describe this rare entity in the United States in 1934 []. Depass (1958) was the first to report a metacarpal metastasis in the English literature [].\nThe lung is the most common source with 42% followed by the breast and kidney each of which account for 11% [,]. Other sources include colon, prostate, thyroid, oesophageal and bone cancers []. Men are more commonly involved than women []. Metastases in the hand are the first clinical sign of an undiagnosed tumor in only 16% of all metastases [].\nThe exact reason for this rarity of such metastases is not known. In 1889 Paget [] suggested the "seed and soil" theory for metastasis, which states that one needs to have both seed (i.e. tumor emboli) and good soil (or proper site) for this tumor emboli to settle down and grow. Prostaglandins have been implicated as possible chemotactic factors that influence cell migration and adherence to the skeleton []. Tumor deposits occur mainly in the bones hematopoietically active and multiply to produce typical lytic lesions or, occasionally, formation of reactive bone []. The infrequent development of metastases to the hand may be related to the smaller amount of red marrow present in these bones. Piney [] observed, as early as 1922, the absence of bone marrow in phalanges – spared metastasis. Recent trauma and increased blood flow have also been implicated as a nidus for tumor metastasis [,,]. Joll [] suggested that repeated trauma might play a role in reducing the local tissue resistance thus producing a fertile ground for "seed". Shinz [] pointed out that primary malignancies erode veins (systemic or portal) and tumor emboli are filtered by lung or liver. But in the case of bronchogenic carcinoma, the tumor erodes the pulmonary vein and thus has access to systemic circulation and, consequently, widespread metastasis. In contrast to this, the vertebral venous plexus of Batson permits mostly axial skeleton metastases [].\nThe patient usually presents with a painful, swollen, erethymatous and warm hand [,]. The x-rays show lytic bony lesion. The differential diagnosis includes gout, pulp space infection, osteomyelitis, septic arthritis, rheumatoid arthritis, tenosynovitis and reflex sympathic dystrophy [].\nThe prognosis of these patients is poor, with the median survival being usually six months []. This should be taken in account in the management of these patients. Radiotherapy and chemotherapy may be appropriate and amputation could be an option for lesions at the distal phalanx. Reconstructive surgery is not indicated due to poor prognosis []. |
A 55 year old gentleman underwent emergency ascending aortic replacement and aortic valve repair (valve resuspension) for a type A aortic dissection. He made an excellent recovery following this procedure and postoperative transthoracic echocardiogram (TTE) showed mild aortic valve regurgitation. A TTE repeated 4 weeks later showed presence of moderate aortic valve regurgitation. Follow-up investigations at six months showed that the ascending aorta repair was intact and the dissection flap extending to the left common iliac artery with minimal flow in the false lumen. At this stage there was no change in the degree of aortic regurgitation. However, cardiac catheterisation was performed at 8 months which revealed severe aortic regurgitation, systolic pulmonary artery pressure of 51 mmHg and impaired left ventricular function. Gradual failure of the aortic valve repair to resuspend the valve was speculated to be the likely cause of significant aortic regurgitation. Aortic valve replacement was contemplated.\nVarious routes for cannulation for cardiopulmonary bypass (CPB) were discussed due to previous sternotomy and the X-ray finding of close proximity of the repaired ascending aorta to the sternum. During the first operation, an attempt was made to expose the right axillary artery but the artery was not accessible. CPB was established via the right common femoral artery (CFA). The left CFA was not a viable alternative in view of the dissection flap extending down to the left common iliac artery. It was therefore elected to institute CPB through the right common carotid artery (CCA). The right CCA and the left sapheno-femoral junction were exposed. A longitudinal incision was made along the medial border of the sternocleidomastoid muscle at the level of the thyroid cartilage. The internal jugular vein (IJV) and common carotid artery (CCA) were exposed. Two slings were passed behind the CCA to aid the control of the artery for the subsequent steps of the procedure. Skin incision and preparations for the sternotomy were made. Heparin was administered to maintain an activated clotting time (ACT) greater than 400 seconds. Once this was achieved a curved clamp was applied to the exposed carotid artery and a longitudinal 2 cm incision was made. A dacron graft was then sewn onto this incision in such a fashion so as to direct the inflow of the blood towards the aortic arch (figure ). The arterial cannula for CPB was connected to the other end of the graft. The venous cannula was then introduced into the left femoral vein (figure ) via the left sapheno-femoral junction using the Seldinger technique. CPB was instituted with careful monitoring of the head for any evidence of oedema or petechial haemorrhage. Patient was gradually cooled to a core temperature of 32°C initially and then to 28°C. Sternotomy was then performed followed by exposure of the heart and the ascending aorta. The native aortic valve was exposed by making an incision in the previous interposition graft to the ascending aorta. The aortic valve was excised and replaced by a size 25 mm mechanical valve. The aortotomy was then closed. Haemostasis was achieved and the patient was weaned successfully off the CPB machine. The CCA incision was closed with 4/0 prolene followed by skin closure. Once the venous cannula was taken out the great saphenous vein was tied off. Postoperatively, no haemodynamic support was required and the patient was discharged after 6 days with no evidence of neurologic, cardiac or renal impairment. |
The patient was an 83-year-old woman. She had been receiving treatment for hypertension and constipation for more than 20 years. However, she had no other medical history, including psychiatric disorders. There was no family history of psychiatric disorders or neurodegenerative disorders. Following graduation from high school, she began working in a nightclub. She got married in her twenties and had a daughter. She divorced a few years later. Following her daughter gaining employment, she started living alone. She was on public income support during her visit to our clinic. She gradually felt a lack of motivation for outdoor activities at the age of 82 years. Simultaneously, she started facing difficulty with housework and complained of mild amnesia. A few months later, she informed her daughter about the delusional thought that the family doctor drew her blood to kill her. Despite the delusion of persecution, she continued visiting the clinic. Her daughter pointed out that her thought was delusional as it was impossible. Despite all evidence to the contrary, it remained unchanged. However, the delusion suddenly changed a month later, without any specific cause. She believed that her family doctor had fallen in love with her and proposed marriage to her. The delusional conviction seemingly strengthened with time. Moreover, she gradually made up her mind to accept the proposal. Considering the gradual progression of cognitive impairment and apathy, her daughter proposed living together. She refused her daughter's proposal and continued living alone because she was convinced that she would live with her family doctor in the near future. Her daughter recommended that she visit a memory clinic. Although she did not have any insight into her delusional beliefs, she was aware of her cognitive impairment. Therefore, she visited our memory clinic and was admitted to our hospital for examination and treatment at the age of 83 years.\nOn her first visit to our hospital, we did not observe any apparent depressive or manic symptoms. Neurological examinations revealed mild bradykinesia, mild rigidity of the left upper and lower limbs, and chronic constipation. The results of her cognitive assessment were as follows: Mini-Mental State Examination score was 20/30, a Japanese version of the Alzheimer's Disease Assessment Scale-cognitive subscale score was 10/70, the index of subtests of the digit span of Wechsler Adult Intelligence Scale-III was 5, and Mayo Fluctuation Questionnaire score was 5 out of 8, which indicated mild recent memory impairment, attention deficit, and cognitive fluctuation (). We conducted the Neuropsychiatric Inventory 12 to assess her neuropsychiatric symptoms. She scored 20 points, involving the categories of delusion (12/12) and apathy (8/12) (). Blood test results, including vitamins, thyroid function, and infections, were all normal. Brain magnetic resonance imaging revealed mild diffuse cortical atrophy and mild bilateral hippocampal atrophy, compatible with her age (). Perfusion single photon emission computed tomography revealed mild hypoperfusion in the bilateral parietal lobe. Myocardial accumulation of metaiodobenzylguanidine (123I-MIBG) was low (H/M = early: 1.72, delayed: 1.34) (). The aforementioned results indicated a probable diagnosis of DLB ().\nFollowing the examinations, she was prescribed 3 mg of donepezil, the dose of which was gradually increased to 10 mg. She was simultaneously prescribed 25 mg of quetiapine (at night) for the treatment of delusions. However, we soon discontinued quetiapine because of its adverse reactions, such as drowsiness and dizziness. We also prescribed brexpiprazole (1 mg/day) and risperidone (0.5 mg/day). However, their side effects, such as drowsiness, were extremely severe, without any amelioration of her delusion. While she did not refuse the medications, she still had no insight to her delusion. Moreover, she occasionally claimed to visit her family doctor following her discharge. We then prescribed blonanserin (4 mg/day) and continued it, with extremely mild side effects. After 2 weeks, her attitude to the delusional beliefs began to change. She gradually lost passion for her family doctor. Based on our suggestions, she changed her family doctor and was discharged from our hospital. During follow-up, she rarely talked about the previous doctor, who had been the subject of her delusion. She still lives alone, and her delusion has not recurred. She is currently on donepezil (10 mg/day) and a small amount of an antipsychotic agent, with coordination of the circumstances (non-pharmacotherapy). |
64-year-old male with a previous medical history of prior tobacco use, gastroesophageal reflux disease and hypertension presented to the emergency department with recurrent and worsening epigastric abdominal pain for 1 month. The pain was associated with episodic bilious vomiting and which also contained food particles. The patient’s history was negative for recent unintended weight loss, hematemesis, melena or known malignancies. Laboratory findings revealed an elevated lipase level of 1300 U/L and leukocytosis of 18.0×109/L. Based on these initial parameters, the clinical suspicion was acute pancreatitis, although there was no family history of pancreatitis and no personal history of alcohol abuse. The patient subsequently underwent a contrast-enhanced CT scan of the abdomen and pelvis using a dedicated pancreas protocol which included soft tissue and bone algorithms as well as reformatted/MPR images. The total amount of intravenous contrast administered was 95 ml omnipaque 350. Oral contrast was not administered. The CT demonstrated marked dilatation of both the stomach and duodenum with an abrupt transition point corresponding to the location of the third portion of duodenum secondary to mass effect by a large AAA (). Additional findings included diffuse atherosclerotic calcifications of the aorta with aneurysmal dilation measuring 9 cm in transverse and 11 cm craniocaudal dimensions. There was no CT evidence of extravasation of contrast or other signs of impending aneurysmal rupture. The ER clinician consulted both vascular and gastrointestinal surgery. Due to the elevated lipase levels and the acute bowel obstruction, vascular surgery was not a viable management option at the time of presentation. The benefits and risks of open aortic surgery versus endovascular repair (EVAR) were discussed in detail and, following nasogastric tube decompression, the patient underwent EVAR of the AAA as the preferred treatment option.\nThe patient was discharged home after successful EVAR. Despite this, however, symptoms of epigastric pain and vomiting were not relieved. Within the month, the patient presented two more times to the emergency department with clinical features of persistent duodenal obstruction and similar imaging features on repeat CT scans including stable size of the AAA (). Due to symptoms of recurrent obstruction, and a determination that the patient could be a candidate for bypass which would allow gastric emptying in the form of a gastrojejunostomy or a duodenojejunostomy, he subsequently underwent successful robotic Roux-en-Y gastrojejunostomy which bypassed the obstruction. Following the bypass procedure, the patient underwent fluoroscopic evaluation with water-soluble oral contrast material (Omnipaque 240). The procedure was performed with the patient in upright, supine and oblique positions. These images demonstrated contrast within the jejunal loops within the mid-abdomen on the left and a persistent delay in transition, but which was improved when compared with pre-Roux-en-Y gastrojejunostomy (). The patient tolerated a gradual advance in diet and was discharged home. Importantly, the patient’s symptoms were relieved at the follow-up clinic visit 4 months after surgery. The patient continues to have regular follow-up with the vascular surgeon. |
A 42-year-old Caucasian woman was referred to our hospital for pain management by a neurologist specializing in the treatment of daily headaches. She had experienced daily intractable headaches since age 18 years. She also had chronic bilateral occipital neuralgia on the basis of the diagnostic criteria outlined in the second edition of The International Classification of Headache Disorders []. Her occipital neuralgia persisted for more than 15 days monthly and was distributed throughout the greater occipital nerves, beginning in the occipital region and radiating upward to the top of the head. When the occipital neuralgia occurred, her occipital area became very tender to palpation. Complete alleviation of her pain had been achieved for a limited time with diagnostic bilateral greater occipital nerve blocks.\nHer medical history included NF-1, which was first diagnosed in childhood. Several neurofibromas had been removed from her sacrum 10 years previously, as well as many from her upper extremities. She also had had problems with depression, anxiety, alcohol consumption, and smoking. She has been a housewife throughout her adult life. With regard to her family medical history, her mother had died at 68 years of age as a result of heart disease, and her father was alive at 72 years of age with a history of cancer. An older sister has rheumatoid arthritis but not NF-1.\nBefore her referral to our service, she had undergone extensive medical management with biofeedback training, physical therapy, massage, acupuncture, and pharmacological management with narcotic and non-narcotic pain medications. Her medications included sustained-release morphine (30 mg every 12 hours), hydrocodone and acetaminophen (10 mg and 325 mg, respectively, every four to six hours), and pregabaline (75 mg every eight hours). More recently, she had undergone three greater occipital nerve blocks that resulted in complete pain resolution that lasted from two to three days. Because she required an ever-increasing dose of morphine for pain relief, and because she had responded to the occipital nerve blocks, she was considered to be a good candidate for OPNS.\nAt her baseline office visit, the patient underwent a disability and quality-of-life assessment by completing a series of questionnaires (see "Quality-of-life assessment" section below) and was found to be a suitable candidate for a trial of OPNS. After the risks and benefits of the procedure were discussed with the patient and her informed consent was obtained, the trial of OPNS was carried out in October 2008 by using two percutaneous eight-contact leads (Octrode; St Jude Medical Neuromodulation Division, Plano, TX, USA). After a week-long successful trial with more than 80% symptom improvement, the patient was deemed a suitable candidate for permanent implantation and she underwent implantation of two permanent percutaneous eight-contact leads (Octrode) and a conventional implantable pulse generator (IPG) (Genesis; St Jude Medical Neuromodulation Division).\nOn the day of the procedure, which was carried out in an operating room, a slow intravenous infusion of 2 g of cefazolin was started, and the patient was placed in a prone position with pillows under her chest to augment neck flexion. Monitored anesthesia was administered by using intravenous fentanyl and midazolam at a level that allowed the patient to be comfortable but able to interact with medical personnel throughout the procedure. The patient's hair was shaved below a line connecting the external occipital protuberance to the mastoid processes, and her skin was treated with chlorhexidine. A sterilely draped C-arm was introduced to obtain a true anteroposterior image of the cervical spine at the C1-C2 interspace, and the overlying skin was marked with a sterile marker. Thereafter a portable ultrasound with a sterile linear array transducer of 5 MHz to 13 MHz frequency was placed to obtain images of the bilateral occipital fossae and the bilateral greater occipital nerves and arteries. The ultrasound probe was first placed at the midline just below the external occipital protuberance (Figure ). The probe was slowly advanced laterally at the same level until the greater occipital artery and nerve were visualized as two distinct structures: the artery as a hypoechogenic oval structure and the nerve as a hyperechogenic structure (Figures and ). The nerve could be traced from its exiting trunk into two distinct divisions within the substance of the trapezious muscle. The artery was identified by using Doppler ultrasound (Figure ). The locations of the nerve and the artery were marked bilaterally on the skin with a sterile marker. The depths of both the artery and the nerve were found to be consistent at 1.0 cm to 1.2 cm from the skin surface. The skin overlying the greater occipital protuberance was injected with 2 ml or 3 ml of 1% lidocaine as a local anesthetic, and the stimulating electrodes were introduced through a 14-gauge introducer needle (0.5 cm to 0.7 cm below the skin surface) in a mediolateral position. Positioning was guided by the skin markings and was verified by fluoroscopy to complement the ultrasonographic images (Figure ). The electrodes were tested intra-operatively by confirming adequate dermatomal paresthesia within the occipital nerve distribution. Implantation of the electrodes was performed by creating a mid-line subcutaneous pocket at the site of needle insertion. The implantable, programmable, rechargeable generator was permanently implanted in a subcutaneous pocket area in the left buttock. For the implantation, a local anesthetic (0.25% bupivacaine with epinephrine 1:200,000 to a total of 20 ml) was used for skin and tissue infiltration.\nTwo months after the implantation procedure, she developed an infection over the occipital implantation area, and the leads and the IPG were removed (Figure ). Bacterial cultures were not obtained during the removal procedure. Her recovery from the procedure was uneventful. After the infection resolved with antibiotic treatment, she underwent re-implantation of two permanent octapolar leads and a new IPG (Eon Mini; St Jude Medical Neuromodulation Division) in March 2009 without additional complications.\nThe patient's pain level and quality of life were assessed at baseline and again at one, three, and six months after implantation. The questionnaires used in these assessments were the short form McGill Pain Questionnaire [], the Visual Analogue Scale (VAS) [], the Oswestry Disability Questionnaire [], and the SF-36 Health Survey []. The data gathered from these questionnaires were plotted for comparison. Qualitative data were also collected from the patient's medical record.\nAfter the trial implantation, the patient experienced nearly an 80% reduction in headache severity. Although the initial implantation procedure was complicated by infection in the implantation site and the patient underwent reimplantation, she has experienced sustained benefit from the treatment and remains infection-free. Over time, the severity, frequency, and duration of her headaches have improved by more than 60%. She continued to use hydrocodone and pregabaline, but was able to discontinue use of morphine. All outcome measures of pain and quality of life were positively affected by the treatment. She reported improvement in her quality of life, which she characterized as "being more active and enjoying life," being able to exercise, working for longer hours, and having improved mood. |
Our patient is a 53-year-old male who worked as a coal miner. In spring of 2017, he noticed enlarging scalp nodules and right hip pain. He also complained of fatigue but was otherwise asymptomatic. Because of the hip pain and nodules, he came to the emergency department where a CT scan showed an enlarged right frontal scalp mass that measured about 4 cm (). MRI also revealed a right frontal scalp mass and extensive vasogenic edema localized to the right frontal lobe with a 5 mm midline shift at the foramen of Monroe (). A subsequent CT chest, abdomen, and pelvis was performed and showed a lytic lesion in his ilium and a single enlarged right hilar lymph node (not shown). A follow-up nuclear medicine bone scan demonstrated multiple areas of increased uptake concerning for metastasis (). One of the largest areas was in the right frontal scalp. After discussion with the patient and the need for a definitive diagnosis, he was consented for subtotal resection of the right frontal scalp mass.\nHe was taken to the operating room where a right frontal scalp incision was performed for subtotal resection of likely metastatic cancer. The mass was primarily located within the right frontal scalp but extended through the skull into the right frontal cortex. It did not however appear to be involved with the brain parenchyma. The resection consisted of removing scalp mass and taking a core biopsy from the specimen. Histopathology of the biopsy showed a diffuse and monotonous infiltrate composed of small cells with irregular nuclei, condensed chromatin and inconspicuous nucleoli (). On immunohistochemistry, the cells are CD20 positive B-cells and co-express CD10 and Bcl-2 but do not express CD3, 5, 23, 43 and cyclin D1 (). CD21 was present highlighting a disrupted follicular dendritic cell meshwork. Ki-67 proliferation rate was low (less than 20%). By flow cytometry, a dim kappa light chain-restricted B-cell population was identified expressing CD10. The FISH assay revealed t(14;18) IGH (immunoglobulin heavy chain locus)-Bcl-2 fusion. These findings support the definitive diagnosis of follicular lymphoma, WHO grade 1, diffuse pattern stage IV.\nAfter definitive diagnosis was made, the patient was then referred to radiation oncology for follow-up. By time of presentation to radiation oncology, the patient was showing symptoms of lower extremity numbness, personality changes, and some memory loss. The radiation oncologist discussed the diagnosis with the patient and his family and came up with a treatment plan to combat the unusual presentation of follicular lymphoma with the intracranial extension from the calvarium. The treatment plan consisted of repeat MRI’s; local (palliative) XRT (4 Grays over two fractions) and systemic chemo-immunotherapy (6 cycles) followed by rituximab maintenance. Lumbar puncture was done a month after resolution of vasogenic edema to assess leptomeningeal spread later proven negative for malignant cells. MRI showed complete resolution of the right scalp mass post-radiotherapy and after the patient had already underwent 3 cycles of chemo-immunotherapy. PET/CT done approximately 3 months since therapy initiation showed no suspicion for abnormal hypermetabolic activity, which suggested the absence of active malignancy. |
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. |
A 15-year-old female slipped down during gymnastics practice and had a right knee pain localizing to the lateral side. She went to a hospital 5 days after the injury and was diagnosed with OCD of the LFC and anterior defect with posterocentral shift of the discoid lateral meniscus. The patient underwent arthroscopic partial meniscectomy with repair of the lateral meniscus and multiple drilling at the LFC 2 weeks after the injury at the hospital. During 3 months after the surgery, however, her pain had worsened and she could not walk well.\nEventually, the patient was transferred to our clinic at 4 months after the first surgery. Physical examination revealed tenderness on the lateral joint line of the right knee and positive McMurray test on internal rotation of the tibia. Plain radiographs of the right knee showed an obvious OCD lesion with a large bony defect in the LFC and narrowing of the lateral joint space (). Standing alignment of the lower legs demonstrated about 2 degrees of slight valgus of the right knee compared to the left knee (). Magnetic resonance imaging (MRI; Intera Achieva, Philips, Amsterdam, The Netherlands) of the right knee revealed a 2.5 cm×3 cm sized lesion mainly in the posterolateral area of the LFC (). The lesion progressed more compared with the preoperative initial MRI obtained 5 months ago (). The MRI also demonstrated a complex tear of the lateral meniscus where flaps adhered to the OCD lesion of the LFC (). The patient underwent arthroscopic total meniscectomy of the lateral meniscus and debridement of the OCD lesion first. At that time, since the torn lateral meniscus showed severe plastic deformation, we considered there was no regrowth potential of the remnant lateral meniscus. The OCD lesion treated with multiple drilling at another hospital showed a large osteochondral defect without any regeneration (). Therefore, we planned to perform simultaneous osteoperiosteal autologous iliac crest graft implantation for the massive OCD lesion and lateral meniscus allograft transplantation for deficiency of the lateral meniscus with joint space narrowing, considering the patient was a high-level gymnast and wanted early return to previous level of sports activities.\nAt one month after the first arthroscopic surgery performed at our hospital (5.5 months after the surgery performed at another hospital), she underwent osteoperiosteal autologous iliac crest graft implantation and lateral meniscus allograft transplantation as a one-stage procedure.\nAn anterolateral incision was used to expose the lateral compartment of the knee joint. The OCD lesion was identified and completely debrided, then multiple drilling using a fine 1.2–1.5-mm diameter K-wire was performed toward the lesion to break down the sclerotic avascular zone (). In the next step, the size and depth of the defect was measured as 1.6 cm×2.4 cm and 0.8 cm, respectively using various-sized osteotomes. The anterior iliac crest was then accessed by making an incision 2–3 cm posterior to the anterior-superior iliac spine and an osteochondral fragment that matches the size of the lesion was harvested without damaging periosteum (). The defect in the iliac crest was backfilled with allograft bone from the lateral meniscus allograft. The harvested iliac crest plug with periosteum preservation was inserted into the lesion of the LFC and impacted by adjusting to the adjacent cartilage level (). The periosteum layer was placed slightly below the cartilage level. The following step for lateral meniscus allograft transplantation was performed using a "key-hole technique." But, the depth of the bone bridge was made to be 6 mm not to harm the growth plate of the tibia. Knee joint motion was performed to check the stability of the inserted iliac crest plug and the transplanted lateral meniscus allograft. Finally, the integrity and congruency of the grafts were evaluated arthroscopically. After completion of the procedure, occurrence of bleeding from the healthy underlying bone resulting from multiple drilling was checked.\nThe knee was immobilized in a cast during the first 3 weeks after surgery and protected using a brace for 12 weeks. Active quadriceps isometric exercise began on the first postoperative day. A 60° range of motion (ROM) was allowed at 3 weeks and 90° ROM at 6 weeks after surgery. Full weight bearing was allowed 6 weeks postoperatively. Light running was allowed at 3 months after surgery and return to sports at 6 months after surgery, although strenuous contact sports were prohibited.\nPlain radiography and 3-dimensional computed tomography (3D CT; Aquilion 64, Toshiba, Tokyo, Japan) were carried out on the first postoperative day, which showed a well integrated bone plug in the LFC and an allograft in the lateral tibial plateau (). At 24 months after surgery, the Lysholm score improved from 47 to 85, the International Knee Documentation Committee subjective knee form improved from 57 to 75, and the Tegner activity score improved from 4 to 8. The visual analogue scale was 0 point. There was no donor-site complication such as pain and sensory loss as well as growth deformity. Isokinetic muscle strength test, follow-up MRI, and second-look arthroscopy were performed at 30 months after surgery. The deficit of isokinetic muscle strength (flexor peak torque/body weight) of the involved side was 9.2% and the hamstring-quadriceps ratio was 59%. On follow-up MRI and second-look arthroscopy, the iliac crest plug was well incorporated with the LFC, and the OCD lesion healed with fibrous cartilage regeneration as well as stabilized lateral meniscus allograft (). The surrounding cartilage revealed no progression of degeneration or formation of a kissing lesion. She could return to previous level of gymnastic activities without any swelling or pain at final evaluation at 24 months after surgery. |
A 63-year old male patient with a history of symptomatic osteoarthritis of the left knee underwent a Total Knee Arthroplasty (TKA) of posterior cruciate ligament retaining design (Kinemax, Stryker, Mahwah, New Jersey, USA) without a patella component. The postoperative course was uneventful. Three weeks later he presented to our out patient clinic with sudden swelling and discomfort of his left knee. Clinical examination demonstrated medial joint line tenderness and confirmed the patient's impression of joint effusion. Radiographs demonstrated a well-aligned TKA. All complaints, with exception of the knee effusion, declined progressively over a period of months. Two years postoperatively, the patient developed increasing pain and complained of "catching" of the knee. Physical examination showed a stable knee with a normal range of motion of 130 degrees flexion with no extension deficit. There was a moderate swelling and joint line tenderness medially. Standard radiographs showed a well-aligned TKA with no signs of loosening or polyethylene wear (Figure ). Laboratory analysis including a complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein and knee aspiration for cell count and culture excluded infection. A technetium 99m diphosphonate bone scintigraphy showed an increased perfusion in the early phase and increased uptake in the static phase at the medial side of the femoral and tibial component and in the patella of the left knee (Figure ).\nA diagnostic arthroscopy was performed to differentiate between a mechanical and a soft tissue related problem. Arthroscopy revealed a remnant of the posterior horn of the medial meniscus impinging between the posterior part of the femoral component and the polyethylene insert. There was also an important delamination of the anteromedial part of the insert with a crack at the ventral side associated with substantial synovitis and polyethylene debris scattered all around the joint. Slight delamination of the posterolateral part of the insert was visible. An arthrotomy showed no loosening of the femoral and tibial components of the TKA. There was no malrotation of both components. The tibial slope was not excessive (almost neutral). The trapped posteromedial meniscus remnant was removed (Figure ) and a total synovectomy with an isolated exchange of the polyethylene insert was performed. Intraoperative cultures from both the fluid aspiration and the remnant meniscus yielded no micro-organisms. Postoperatively there were no complications with a complete resolution of all complaints and symptoms. At 3 years follow-up he remains complete symptom free with an unrestricted range of motion. |
A 73-year-old male patient was sent to the emergency department because of high fever (40°C) with chills and right upper abdominal colicky pain. He complained of nausea and had dark urine as well as jaundice. His medical history revealed a cholecystectomy 33 years earlier. Fifteen year before the current presentation he was diagnosed with stones in the common bile duct for which he underwent ERC, papillotomy, and stone extraction. He was without complaints until the current presentation. Laboratory results were consistent with cholestasis (Table ). Ultrasound imaging showed dilated intra- and extrahepatic ducts with the suggestion of stones in the common bile duct. Aerobilia was present, and sludge was seen in the hilar region. The patient was treated for ascending cholangitis with fluid resuscitation and intravenous antibiotics. An ERC was performed. The previous papillotomy was not visible anymore, hence a new one was done. Many stones were extracted from the common bile duct.\nThe patient recovered well. However, 3 months later he experienced recurrent complaints. Ultrasound showed retained stones in the common bile duct. In two ERC sessions all these stones were removed. Contrast cholangiography showed complete clearance of the bile ducts.\nOver the next 4 months the patient experienced four episodes of chills with a temperature of 38–39°C and right upper abdominal complaints without colics. The laboratory findings during these episodes are shown Table . Repeated ultrasound investigations showed no abnormalities. The bile ducts were normal. On each occasion the patient received antibiotics, with excellent clinical response. Blood cultures remained negative.\nRenewed medical history revealed that the patients had done heavy lifting work, such as moving furniture, the day before each of the four episodes. It was concluded that the repeated episodes of cholangitis resulted from influx of duodenal contents into the common bile duct due to heavy lifting in the presence of a papillotomy. The patient was advised to refrain from further lifting. He has been doing well ever since. The cholangitis has not recurred for over 8 months. |
A 19 year-old male was admitted to hospital 10 days after a car accident trauma. The admission examination results were as follows: Temperature, 39.8°C; heart rate, 124 beats/min; respiration, 24 beats/min; and blood pressure, 75/50 mmHg. The results of the laboratory examination were as follows: white blood cell count, 3.5×109/l. An X-ray of the left lower extremity indicated left tibia and fibula fractures. The diagnosis concluded there was: i) Avulsion and severe infection of the skin and soft tissues of the left lower extremity; ii) fracture of the left tibia and fibula; and iii) septic shock. Visual examination () revealed a wide range of soft tissue loss and wound contamination below the knee, to the ankle of the left leg. In addition, it indicated a large area of necrotic tissue and heavy purulent discharge, and the tibia and knee joint cavities were partially exposed (). Certain muscles of the left leg were noted to be affected by infection and necrosis during the surgery. A number of areas of sediment and purulent discharge were observed on the wound (). The muscles had automatically self-separated from the gastrocnemius and soleus and the tibia and fibula after the surface of the skin was cut (). Following debridement, the ruptured Achilles tendon was connected with the gastrocnemius and soleus (). The sections of the skin and subcutaneous tissue affected by infection and necrosis were removed and a large sheet of XADM was used to cover the wound. Several holes were opened in the covering for drainage on the left lateral leg () and left medial leg (). Following 10 days of XADM covering, the wound granulation tissue appeared fresh with fine particles and the wound bed preparation was complete (). Wound closure was achieved 12 days after the conduction of a large sheet edge autologous skin graft of the left lower extremity (). The follow-up was conducted one year after the surgery and the shape and function of the left lower extremity exhibited good recovery (). |
Mr. E.A., 46 years old, father of 6 children, the patient had a history of pulmonary tuberculosis treated 20 years ago and pericardial effusion drained 6 years ago, chronic tobacco user at 26 PA weaned 7 years ago. Symptoms go back to 4 months, marked by the appearance of terminal clot hematuria without other associated signs.\nThe abdominal examination is without abnormalities. The rectal examination finds a homogeneous prostate of 25 g without a suspect nodule. All evolving in a context of declining general condition (ASA2).\nAbdominal ultrasound revealed a heterogeneous tissue process budding endovesical, the site of a few cystic areas and calcifications, with irregular contours, vascularized by color Doppler. This process measuring 67.4 × 53 × 42.4mm, continues at the top and follows the path of the urachus ().\nThe patient underwent a cystoscopy which found a budding tumor with a large implantation base in the anterior wall and bladder dome. The histological study, after endoscopic resection, revealed a tumor proliferation made up of tall columnar cells, provided with a large nucleus, a fine chromatin. These cells are arranged in a villous structure, and dilated tubes filled with mucus. It is an isolated tubulovillous adenocarcinoma and infiltrating the superficial chorion of the bladder mucosa.\nAn immunohistochemical study which objectified an aspect compatible with a moderately differentiated CK7 positive adenocarcinoma (TTF 1 and CK20 are negative).\nComputed tomography revealed the presence of a budding wall thickening of the anterior wall of the bladder, with endo and exophytic development in the peritoneum with preservation of a fatty border of separation with the digestive loops. It measures 52 × 49 mm. He also presents in the lungs an inferior left lobe tissue process (, ).\nThe chest x-ray showed a left basal opacity and at the level of the left middle arch associated with a mediastinal widening with widening of the angle of the carina ().\nThe patient underwent a bronchoscopy which showed a budding tumor located at the bottom of the left main bronchus with thickened keel. The bronchial biopsy discovers the presence of glandular-looking carcinomatous masses, concluding in a bronchial localization of a glandular-like carcinoma suggesting a secondary localization of a urachal adenocarcinoma.\nAfter multidisciplinary consultation, it was decided to treat the patient with chemotherapy alone due to the metastatic aspect. He received three courses of Folfox-type chemotherapy. Fifteen days later, he presented aplastic anemia with grade 3 mucositis and oral candidiasis.\nThe patient received medical treatment, rehydration, and increased monitoring for the risk of infection. After his discharge, the patient was lost to follow-up. |
A right-handed, 63-year-old Chinese woman, with 12 years of education, was admitted to our hospital in September 2018 at the request of her family members.\nIn 2016, the patient had developed psychotic symptoms, including delusions and auditory hallucination, without an apparent cause. She said someone wanted to harm her and was talking about her. Sometimes she told her family members that she heard knocking on the door, and she exhibited diminished emotional expression and avolition. She required the support of family members to conduct daily activities and communicate with others. Her sleep quality was poor, but she showed no disturbance of consciousness. She did not seek medical advice and receive any remedy at that time.\nAfter these symptoms had continued for about 12 months, she was taken by her family to the outpatient department of our hospital. Brain magnetic resonance imaging (MRI) did not reveal any obvious structural abnormalities (Fig. ). She was diagnosed with schizophrenia by an experienced psychiatrist based on criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders []. Delusions and hallucinations disappeared after the patient took 5 mg of olanzapine every night for 1 month. We monitored the blood glucose, blood lipid, blood pressure and weight every month to investigate the possibility of metabolic syndrome after treatment with olanzapine. However, she began to walk slowly, her neck became rigid, and she experienced episodic memory impairment, leading her to forget new events, ask the same question repeatedly and get lost in new places. Her physical functions, such as dressing and eating, were also impaired. However, she did not develop language dysfunction, and she was able to communicate smoothly with family members. She was treated with benzhexol hydrochloride at 2 mg every night for extrapyramidal symptoms, but the symptoms did not improve. The daily dose of olanzapine was reduced to 2.5 mg in July 2017, but the symptoms still did not improve after 1 month. Therefore, we believe that her symptoms did not cause by olanzapine then stop using benzhexol hydrochloride. In May 2018, her neck stiffness became worse and gradually spread to the limbs. She developed severe neck, limb and postural rigidity, but no tremor. She walked unstably, exhibited bradykinesia and memory decline, and showed obvious decline in her ability to take care of herself. On the other hand, she did not exhibit socially inappropriate behaviors, apathy, or dietary changes, and she responded normally to family members’ feelings.\nAt her admission to our hospital in September 2018, the patient reported never smoking or drinking. She had previously undergone gallbladder surgery. She was in good health and had no family history of mental disorders. The patient had good support from family members and did not report any major adverse life events. The patient and her family members denied any drug abuse. She did not have any history of violence, agitation and suicidal behavior during the course of her illness. Her vital signs were stable, and no abnormal physical signs were detected at admission. Blood and urine tests, blood glucose level, liver and renal function and thyroid function were normal, and the patient showed no evidence of infection. Electroencephalography, electrocardiography, and transcranial doppler ultrasound results were normal. Mental status examination showed no signs of hallucinations or delusions. The patient had stable mood but temporal disorientation and deficits in attention, calculation and language competence, as well as delayed recall. She also exhibited impairments in visuospatial organization and abstract thinking. She had no insight into her disease. The total score on the MMSE was 16 and on the MoCA was 9.\nDuring hospitalization, brain MRI showed mild frontotemporal atrophy relative to the MRI in 2016 (Fig. ). She scored 16/30 on the Mini-Mental State Exam (MMSE). She exhibited temporal disorientation and deficits in attention, calculation and language competence, as well as delayed recall. She scored 9/30 on the Montreal Cognitive Assessment (MoCA), indicating impairments in visuospatial organization, attention, language ability, temporal orientation, and abstract thinking. Her total score on the Activity of Daily Living Scale (ADL) [] was 54, indicating difficulty in performing daily life activities (Table ). Based on her two-year history of using antipsychotics and hypermyotonia, she was diagnosed with tardive dyskinesia. After consultation with experts in the neurology department, her diagnosis was changed to Parkinson’s disease on the basis of her bradykinesia and hypermyotonia. Olanzapine treatment was replaced with the combination of levodopa and benserazide hydrochloride (375 mg/d), pramipexole hydrochloride (0.75 mg/d), Selegiline hydrochloride (5 mg/d), and benzhexol hydrochloride (3 mg/d). Her bradykinesia, rigidity and shuffling gait improved after 2 weeks, but not her memory. She was discharged in October 2018.\nDuring a follow-up visit 2 months after discharge, 53 genes associated with dementia were analyzed (Table ). The only mutation detected was a heterozygous variant in SORL1 (chr11:121340726, c.296A > G). She showed a higher score of 20/30 on both the MMSE and MoCA. She was prescribed with memantine (10 mg/d) and donepezil (10 mg/d) and stopped taking benzhexol hydrochloride, but her cognitive function showed no change at follow-up in July 2019. At follow-up in August 2019, brain MRI detected moderate frontotemporal atrophy that appeared more serious than in 2018 (Fig. ), while 18F-fluorodeoxyglucose-based positron emission tomography/computed tomography demonstrated bilateral frontal and caudate hypometabolism (Fig. ). The score on MoCA improved to 23/30, but the score on the ADLS fell to 31. She was unable to complete many daily life activities (Table ).\nOur patient was diagnosed with probable AD because of early, significant episodic memory impairment, medial temporal lobe atrophy, brain glucose hypometabolism based on PET and AD-associated genetic mutation []. She was prescribed memantine (10 mg/d) and donepezil (10 mg/d). At her last follow-up in October 2019, the patient showed poor memory, slow reaction and bradykinesia, but no psychotic symptoms.\nThe patient had temporal disorientation and deficits in attention, calculation and language competence, significant episodic memory impairment. She had significant temporal lobe atrophy, brain glucose hypometabolism based on PET and AD-associated genetic mutation. A timeline of the historical and current information is shown in Fig. .\nThe psychotic symptoms of the patient occur after the age of 60, but disappeared after treatment with antipsychotics in 1 month. She did not display the clinical course typical of patients with schizophrenia. Frontotemporal dementia: The patient did not display the impaired language function typical of semantic variant primary progressive aphasia or the non-fluent/agrammatic variant of primary progressive aphasia [, ]. She also did not display early behavioral disinhibition, apathy, loss of sympathy or empathy, dietary changes, or deficits in executive tasks typical of the behavioral variant of frontotemporal dementia []. |
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. |
A 19-year old male presented to us in the outpatient department with complaints pain on lifting weight with the right arm, deformity and limited range of motion of the right elbow for five months. The patient had fallen down and sustained the injury to his right elbow while hanging from the rootlets of a Banyan tree, following which, he had pain, swelling, and deformity of the right elbow. He had sought treatment from a local bone setter for four weeks following which pain and swelling decreased, but the deformity and elbow stiffness had persisted, for which he attended our hospital.\nOn examination, the Beighton hyperlaxity score of the patient was 5/9. There was flexion deformity of the elbow joint and wasting of muscles of the arm and forearm. The olecranon process was displaced from the olecranon fossa of the right humerus and an abnormal bone mass was palpable on the anterior aspect of the distal humerus. There was a flexion deformity of 40 degrees of the elbow joint with further flexion of 70 degrees. Pronation and supination were normal. There was a valgus laxity of the right elbow joint. The differential diagnoses were neglected dislocation of the elbow joint (posterior/anterior) and mal-united supracondylar fracture.\nAntero-posterior and lateral radiographs of right elbow demonstrated an anterior dislocation of the elbow joint with an anterior bone mass at the distal humerus. The bony anatomy of the elbow appeared unclear on radiography, and a Computed Tomogram (CT) with 3D reconstruction () confirmed an anterior dislocation of the right elbow joint with a bony projection from the anterior border of the distal humerus. We hypothesised that because of hyperlaxity the patient had sustained anterior dislocation of the elbow joint without associated fracture. Massage and attempts to reduce the elbow joint by the bone setter had led to the formation of a heterotopic bone mass on the volar aspect of the humerus.\nWe performed an open reduction of the elbow by combined medial and lateral approach based on findings of the CT scan. We were successful in excising the bone mass but failed to reduce the elbow joint. There was some early degeneration of the articular cartilage of the distal humerus and olecranon. It was impossible to reduce the olecranon posteriorly. We extended the approach through the subcutaneous plane to the posterior aspect and performed an olecranon osteotomy. The humerus was reduced into the osteotomy, and it was fixed with tension-band wiring. Indomethacin was started at 25mg eight hourly after surgery for three weeks after the operation. We did not immobilise the elbow and started active assisted mobilisation of the elbow joint after surgery as tolerated by the patient. The patient was discharged after wound inspection on the 5th post-operative day and advised to attend the rehabilitation department for physiotherapy for six weeks.\nAt review one year postoperative he had a painless range of motion of 30 degrees to 120 degrees at the elbow joint. He has excellent pronation and supination and could perform light activities. The olecranon osteotomy healed well () though there was a reduction in the joint space of the elbow. |
A 70-year-old woman with end-stage renal disease secondary to hypertensive nephrosclerosis had been on hemodialysis for 6 years. Her past medical history included left mastectomy, diverticulosis, parathyroidectomy due to secondary hyperparathyroidism, and coronary artery disease for which she received a 4-vessel coronary artery bypass graft. Her dialysis was scheduled 3 times per week via an upper extremity arteriovenous graft, each session of 3 hours and 45 minutes and with a dry weight goal of 68.6 kg. She was in her usual state of health until approximately one year earlier when the results of routine laboratory tests revealed persistently elevated potassium levels (). In addition to the use of a low-potassium dialysate, intense efforts were made to modify her diet, but failed to correct hyperkalemia. Her medication list did not include any ACE inhibitor or other medications that could potentially cause hyperkalemia (). She was initiated on sodium polystyrene sulfonate (in water suspension) at a dose of 15 grams twice daily after meals and continued taking it for a year. The patient never received sodium polystyrene sulfonate in sorbitol as an oral preparation or as a retention enema. One week prior to her hospitalization, she began to have occasional constipation with intermittent loose bowel movements and the stool guaiac tested positive. The patient underwent an esophagogastroduodenoscopy and colonoscopy. She was found to have gastritis and duodenitis in the upper gastrointestinal tract, with a mass on the upper lip of the ileocecal valve () and internal hemorrhoids. A biopsy of the mass was done. An abdominal computed tomography () identified the presence of an ill-defined 5-cm cecal mass with localized inflammatory changes. She was admitted to the hospital for a subtotal colectomy. On the morning of the scheduled surgery, the histological examination did not reveal any evidence of carcinoma and the surgical intervention was postponed. She underwent a second colonoscopy with biopsy, which again did not show tumor cells. However, the histological examination revealed the presence of rhomboid mosaic crystals, surrounded by a mixed population of inflammatory cells including eosinophils, macrophages, plasma cells, and lymphocytes (Figures and ). There was also presence of fibroblasts, collagenous materials, and mucosal erosion. It stained negative for the presence of calcium, implying that the mass was not the result of the high calcium intake. The surgery was cancelled and the patient was discharged from the hospital. |
A 15-year-old male presented to the emergency department following a direct blow from his bicycle handlebars to his groin. His chief complaint was pain and swelling in the right inguinal region. His abdominal examination was unremarkable, except for a small abrasion and visible mass in his right groin. Peripheral pulses were palpable bilaterally. After exclusion of other abdominal or chest injuries, he was discharged on the same day with a diagnosis of right groin haematoma and follow-up in 6–8 weeks.\nHe presented to his general practitioner 2 weeks later with claudication. His symptoms included pain and paraesthesia in his right buttocks on mobilization >100 m. He was found to have absent peripheral pulses in his right leg, although it appeared well perfused with a normal capillary refill. An arterial Doppler ultrasound showed a right external iliac artery thrombus occluding the proximal two-thirds of the vessel. A computed tomography scan of the abdomen and pelvis with intravenous contrast identified complete occlusion of the right external iliac artery ∼1 cm beyond its origin. However, the common femoral artery and profunda femoris remained patent via collaterals (Fig. ).\nHe underwent a right external iliac thromboendarterectomy with patch repair using a saphenous vein graft. A suprainguinal incision was initially made in attempt to expose the proximal external iliac artery. Due to its extent, retrieval of the entire thrombus was incomplete and a second groin incision near the junction of the common femoral with external iliac (at the inguinal ligament level) was required. The patient subsequently underwent a proximal and distal thrombectomy, and the arteriotomy was extended between the two incisions identifying an intimal stricture with significant fibrosis (Fig. ). An intimal flap was identified in the distal region and tacked down with a 7-0 prolene suture. The long saphenous vein was harvested and the defect closed with patch repair extending from proximal iliac to proximal femoral vessel. He had an uneventful recovery. At the initial 2-week follow-up, the vessels remained patent and patient was progressing well. Subsequently, regular biannual follow-up was planned to monitor for any longer-term complications. |
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 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 52-year-old male was admitted to the urology department due to sudden purulent urethral secretion. He reported a painless progressively developing palpable mass anterior to the pubic symphysis which he first noticed 18 months prior to his admittance. He also reported that the mass had subsided after the appearance of the purulent exudate. The patient had no lower urinary tract symptoms. Clinical examination revealed a palpable painless mass anterior to the pubic symphysis, and after close inspection a second epispadic urethral meatus was observed. The patient was nonfebrile with normal blood count and biochemistry. The urine culture was sterile.\nA contrast-enhanced CT was performed that revealed a low-density 7 cm wide cystic mass anterior to the pubic symphysis, in the anatomic region of the suspensory ligament of the penis and in direct contact with the bladder (). Consistency with the prostatic and membranous urethra was also reported. An MRI of the pelvis showed a large, cystic mass. Its distal part was located in the soft tissue, frontal to the pubic symphysis, and extended to the dorsal surface of the cavernous body of the penis. The central part was located in the abdomen in front of the bladder and extended through the urogenital diaphragm reaching the distal part and communicating with it through a narrow neck. The prostate was dispensed dorsally by the mass ().\nThe patient underwent an operation for removal of the mass. In front of the bladder and in direct contact with it, a large cystic mass was found (). The mass was unrelated to the upper urinary system, and after gross inspection there was no communication with the normal bladder. The purulent content of the cystic mass drained through a complete supernumerary urethra with an epispadic urethral meatus (). The accessory bladder was emptied and then removed leaving the normal bladder untouched. The patient was discharged five days after the surgery. The pathology report of the specimen confirmed the diagnosis of accessory bladder with transitional cell epithelium followed by a fibromuscular layer (). |
A 42-year-old pregnant woman with CHD and severe PAH was admitted to our hospital for the management of pregnancy and delivery. The patient was diagnosed with CHD and severe PAH in 2013 by color Doppler echocardiography, right cardiac catheterization, and pulmonary perfusion imaging. Color Doppler echocardiography showed that the patient suffered from CHD with a left to right shunt and an ostium secundum type of ASD. A right cardiac catheterization revealed that the mean pulmonary arterial pressure (mPAP) was 104 mm Hg while pulmonary perfusion imaging revealed a bilateral pulmonary perfusion injury. No significant improvements or deteriorations were detected in the patient's medical condition before the current pregnancy. There was no history of CHD or PAH in her family and patient had a healthy lifestyle.\nPatient was admitted to the pulmonary vascular department at 21 weeks and 3 days of gestation. The complete process of diagnosis and treatment is presented in Table .\nThe patient was first treated with a cardiac stimulant (digoxin), diuretics (spironolactone, furosemide, and torasemide), an anticoagulant (warfarin), and targeted drugs (ambrisentan and sildenafil) in 2013 after being diagnosed with ASD and PAH. However, after 7 days of treatment, patient developed fever, swelling, and other symptoms. Hence, the investigators decided to withdraw all treatments. After 3 years, the symptoms did not worsen significantly. Reexaminations repeatedly showed that the mPAP was approximately 110 mm Hg, while the cardiopulmonary exercise test revealed a moderate limitation in activity. The patient previously had 1 caesarean section 12 years ago when she was not diagnosed with PAH, in addition to a history of 5 induced abortions. The patient had cough, chest tightness, shortness of breath, and recurrent epistaxis after 5 months of gestation. Her mPAP at this stage had increased to 140 mm Hg. The patient and her family were informed of the maternal, fetal, and neonatal risks due to exacerbated PAH. However, they decided to continue with her pregnancy. Patient was then admitted to our hospital at 21 weeks and 3 days of gestation.\nThe patient's pulse, blood pressure, body temperature, respiratory rate, and oxygen saturation on admission were 104 beats/minute, 121/64 mm Hg, 37.2°C, 16 breaths/minute, and 77% to 91%, respectively. A physical examination showed that the patient had slight cyanosis of the lips, clubbed fingers and toes, a second cardiac sound of pulmonary artery hyperactivity, an audible second intercostal of left thoracic duct, and a systolic murmur of grade II. Laboratory examinations revealed an increased brain natriuretic peptide level of 159 pg/mL. A pulmonary computed tomography revealed no obvious signs of pulmonary embolism.\nAfter admission, oxygen inhalation and PAH-targeting treprostinil injection were used to reduce pulmonary artery pressure. Initially, the dose of treprostinil was 1.25 ng/kg/minute which was gradually increased to 8.75 ng/kg/minute with a subcutaneous micropump, resulting in an increase in resting pulse oxygen saturation (SpO2) from 77% to 90%. At the 26th week of gestation, the fetal body mass was estimated to be 1000 g. Five milligrams of dexamethasone was injected 4 times, every 12 hours, for a total dose of 20 mg, to accelerate the fetal lung maturation. A reexamination using a color Doppler echocardiography revealed that mPAP was 126 mm Hg after the treatment.\nAt 27 weeks and 5 days of gestation, the patient condition worsened. Patient had an obvious chest tightness and shortness of breath, and the SpO2 could only be maintained at 82% to 88% under continuous high flow of oxygen inhalation (35 L/min, 95% oxygen concentration). Hence, an emergency operation was conducted. The patient was placed under an extracorporeal membrane oxygenation (ECMO) under local anesthesia before the operation. Then, a caesarean section, bilateral ascending uterine artery ligation, bilateral ovarian artery communicating branch ligation, and bilateral oviduct ligation were performed under general anesthesia. A baby boy weighing 1150 g was delivered successfully. The Apgar scores were 8, 9, and 7 at 1, 5, and 10 minutes, respectively, and the baby was placed under intensive care. Uterine contraction was promoted by pouring 20 units of oxytocin after amputating the umbilical cord. The total bleeding volume was 250 mL during the operation. The vital signs were found to be stable after the operation.\nThe patient was given cardiopulmonary support, in addition to cefoxitin to prevent infection, ambroxol to reduce phlegm, esomeprazole for alkalization, treprostinil to control PAH, and diuretics to improve cardiac function and maintain a stable internal environment in the intensive care unit. A total of 170 mL of lochia was excreted within 24 hours postpartum, and the uterus contracted well. After the treatment, however, it was difficult to improve the cardiopulmonary function of the patient. Eleven days postpartum, the patient underwent “repair of atrial septal defect (ASD) and bilateral lung transplantation with shell incision under cardiopulmonary bypass.” After the operation, patient was put under ventilator-assisted respiration and ECMO support. Treatments with antibiotics, noradrenaline pressor; sedation with midazolam; analgesia with remifentanil; diuresis with furosemide; immunosuppression with cyclosporine and prednisolone were performed methodically. Human serum albumin was also given for improved recovery. ECMO was successfully removed 16 days after delivery. The patient was discharged 86 days after cesarean section.\nThe premature infant was treated with ventilator-assisted breathing, antibiotic treatment, pulmonary surfactant replacement, and phototherapy in the neonatal intensive care unit. A color Doppler echocardiography revealed a patent ductus arteriosus of the infant, an ostium secundum defect of 2 mm, and a small amount of left to right shunt. The infant was discharged 55 days after birth, weighed 2140 g, and had feeding tolerance, and no neurological abnormalities were seen. |
A 59-year-old male presented to our trauma center after sustaining a fall while transferring from a chair to wheelchair. He was on dabigatran for treatment of deep vein thrombosis in both lower extremities. His past medical history also included coronary artery disease, chronic kidney disease and a cerebral vascular accident. In the trauma bay, he reported left chest and left upper quadrant abdominal pain. On physical examination he was hemodynamically stable but tender to palpation over the left ninth and tenth ribs along the mid-axillary line. A Computed Tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrated a large expanding left lateral chest wall hematoma, which appeared to be dissecting into the abdominal wall and peritoneum. Active contrast extravasation originating from an intercostal artery (Fig. ) was associated with intraperitoneal blood in the perisplenic region and left paracolic gutter (Fig. ). A selective angiogram of multiple left intercostal arteries and the deep circumflex iliac branch of the left external iliac artery did not show any active contrast extravasation. The patient was admitted to the intensive care unit for close monitoring and administered idarucizumab (praxbind) for reversal of his anticoagulation. Eight hours later, he developed worsening abdominal pain and became hemodynamically unstable with a systolic blood pressure of 80 mmHg. An exploratory laparotomy was then performed through a left subcostal incision. Upon entry into the peritoneal cavity 500 ml of clot was evacuated. A significant hematoma in the lateral abdominal wall just under the lower ribs had caused a tear in the peritoneum leading to the intraperitoneal blood. Active arterial bleeding could not be appreciated however a small amount of continuous bleeding from the left abdominal wall was controlled with suture plication. The patient received two units of packed red blood cells during the operation and was stable in the immediate postoperative setting. He was restarted on dabigatran on post-operative day four. His post-operative course was otherwise unremarkable and he was discharged home after five days. |
This report presents a case of aggressive periodontitis in a 23-year-old female who had previously received periodontal therapy. She was presented to the Department of Periodontics, Seoul National University Dental Hospital in 2004 with the chief complaint that her gums had been swelling (). She requested for dental treatment to address the issue of gum swelling and tooth mobility. Her medical history was unremarkable. Subsequent clinical and radiographic examination led to the diagnosis of generalized aggressive periodontitis (, ). The patient reported of becoming aware of swelled gums and mobile teeth when she was at the age of 13. At that time, she had received scaling and root planning in conjunction with systemic antibiotics which were periodically repeated through the years with no definitive results.\nIn 2008, the patient was referred to the Department of Prosthodontics for evaluation and treatment planning. The objectives of treatment were patient motivation and education, improvement of oral hygiene, improvement of esthetics, and a stable and predictable outcome.\nAll teeth including the canine in the maxilla and left mandibular lateral incisor through right mandibular canine, and left mandibular second premolar were extracted.\nInitially fixed prosthesis using implants in the maxilla were planned, but rapid and severe bone resorption after extraction was observed. Because the maxillary lip required additional support as a consequence of bone loss, the fixed prosthesis treatment plan for the maxilla was changed to an implant-supported overdenture. Facebow transfer and mounting on the casts on the articulator were performed for the diagnostic wax-up procedure.\nThe remaining teeth in the mandible were prepared for the fixed partial prosthesis. A provisional complete denture in the maxilla and provisional fixed partial dentures in the mandible was delivered. A computerized tomography scan with implant stent was taken to select suitable implant sites in the maxilla. In the maxilla, US II external-type implants (Osstem, Seoul, Korea) were placed at the sites of right maxillary first premolar, right maxillary lateral incisor, left maxillary first premolar, and left maxillary first premolar following a two-stage delayed-loading schedule. After the first implant surgery, the interim complete denture in the maxilla was relined with Coe-Soft™ (GC America Inc., Alsip, IL, USA).\nAfter 7 months of healing, the impression of the implants in the maxilla were made. An individual tray was fabricated. Pickup impression copings were connected, and splinted with DuraLay resin (Reliance Dental Mfg. Co., Worth, IL, USA). The functional impression technique using polyvinylsiloxane impression material was used. The occlusal plane was evaluated using the TRUBYTE™ occlusal plane plate (Dentsply, York, PA, USA). Facebow transfer and mounting the maxillary cast on the articulator was performed. A bar for the clip attachment was incorporated in the maxilla.\nWax denture try-in for the maxilla and zirconia framework try-in for the mandible were done. The all-ceramic restoration between the left mandibular canine and right mandibular first premolar was designed to a six unit restoration, because the lack of MD space was expected. The other all-ceramic restorations in the mandible were fabricated separately. Lower all-ceramic restorations using Lava system™ (3M ESPE, St. Paul, MN, USA) were completed (). Final cementation was carried out using resin cement (Multilink, Ivoclar Vivadent Inc., Lichtenstein, Germany). A Hader bar® (Attachments International Inc., San Mateo, CA, USA) for the maxillary implant-supported overdenture was fabricated (). Marginal fits of the Hader bar were evaluated with one-screw test, screw resistance test, Fit Checker II (GC Corporation, Tokyo, Japan) and periapical radiograph. After delivery of the final prostheses, soft tissue profiles were evaluated in the frontal and lateral view (, ). A daily maintenance care by patient's effort was instructed using interdental cleaning aids (). A regular maintenance program was instituted with periodontal recall every 3 months following delivery of the definitive restorations. |
A 60 year old male patient attended a private dental clinic with pain to the area of the upper left second molar. The patient’s medical history included hypertension, heavy smoking and alcohol consumption and he did not have syndromic features. His dental history included tooth mobility due to severe periodontitis. The panoramic radiograph incidentally revealed the existence of a fully formed impacted parapremolar located on the right side of the mandible between the first premolar and the canine (). It was decided not to perform a cone beam computer tomography (CBCT) examination to evaluate the presence of root resorption of the adjacent teeth since they had a very poor prognosis. The patient’s 34 year old son attended the same dental clinic. In his medical history he reported frequent respiratory infections, the removal of his thyroid gland a year ago and he did not present any syndromic features. Concerning his dental history, his bilateral lower third molars had been extracted. An incidental finding in the panoramic radiograph of the son () was a fully formed parapremolar in the mandible, located diagonally with its crown mesial to the second left premolar and its apex distal to the left second incisor. In order to better evaluate the exact location of the parapremolar and the potential risk of root resorption to the adjacent teeth, a cone beam computer tomography (CBCT) was performed (). As seen in the CBCT the parapremolar was located lingually. The supernumerary tooth as a whole was lingually located in the root of the lower left first premolar and was tangent to the latter. In particular, the distal portion of the supernumerary tooth’s crown was located proximal to the middle third of the root of lower left second premolar. The root of the supernumerary was located lingually and slightly below lower left canine. Moreover, it presented an abnormal morphology. The patient did not want to proceed with a surgical extraction of the supernumerary tooth and so observation was decided upon instead. |
A 64-year-old man developed a painless nodule or mass in the nasopharynx. He had a history of dizziness and headache for more than 10 years without obvious cause. The patient also had a history of hypertension. After taking antihypertensive drugs regularly, the headache was relieved. However, the dizziness and headache later increased further for 1 week, and on February 27, 2019, he was admitted to a hospital. The patient underwent surgical treatment for benign prostatic hyperplasia in May 2006. The patient had no history of trauma, no family history of any hereditary illness, and his neurological examination findings were normal.\nHead computed tomography (CT) examination showed a low-density mass in the nasopharynx that protruded into the cavity and had a regular shape and uniform density. The left eustachian tube and pharyngeal orifice had disappeared and the right pharyngeal crypt had become shallow (). Video laryngoscopy also revealed a left nasopharyngeal mass. To confirm the diagnosis, enhanced CT of the nasopharynx was performed, revealing a mass-like shadow on the posterior lateral wall of the left nasopharyngeal roof (). The enhanced CT image was very uneven in the arterial phase () but became intense in the venous phase, and small, patchy, low-density shadows were observed (). Based on the preoperative imaging results, the patient was provisionally diagnosed with nasopharyngeal angiofibroma. Angiography revealed a hypervascular tumor fed by branches of the left carotid artery. To control intraoperative bleeding, the patient underwent preoperative endovascular embolization. Subsequently, the otolaryngologist performed surgical removal of the tumor through a nasal endoscope. During the surgery, it was noticed that the tumor tissue pedicle was located on the posterior lateral wall of the left nasopharyngeal roof. The tumor was completely removed along its pedicle without the occurrence of massive intraoperative hemorrhage. The tumor tissue had a medium texture and abundant blood supply. Postoperative head CT and video laryngoscopy showed that the tumor was completely resected (), and there was no tumor recurrence following a 14-month follow-up after tumor resection.\nThe resected tumor specimens were fixed in 10% neutral-buffered formalin and processed for immunohistochemistry (IHC) following standard protocols. Paraffin-embedded blocks were sectioned at a thickness of 5 μm and stained with hematoxylin and eosin, and with various antibodies. The antibody clones, their working dilutions, and commercial sources are listed in .\nIn gross examination, the surgically excised tissue in fragments, a tissue size of 6.5 cm × 4.0 cm × 2 cm, was surgically excised, which included the tumor tissue and tissue at the edges of the tumor. Part of the tumor was polypoid-shaped with a firm or gelatinous, white-to-gray colored cut surface. No bleeding or necrosis was noticed.\nHistologically, low-power microscopy revealed that the tumor comprised areas of moderately proliferating bland spindle- or stellate-shaped cells alternating with hypocellular areas (). While some areas were composed of compactly proliferating spindle-shaped cells arranged in a storiform or fascicular growth pattern, there were other areas where tumor cells were randomly distributed (–). Some areas were observed with loose myxoid or hyaline stroma, in which collagen fibers of different thickness and shape were interspersed among multinucleated giant cells ( and ), but no necrosis was observed. Interstitial blood vessels were widely distributed with marked perivascular hyalinization (). High-power microscopy revealed hypercellular areas containing fusiform or oval cells, with no apparent atypia, few cytoplasm, large and deep-stained nuclei, and oval nuclei as well as some vacuolated nuclei and some tumor cells with nucleoli. Mitotic figures were 2/50 HPF (). Tumor cells in less cellular dense areas were polygonal or irregular in shape. They also lacked significant cytologic atypia. In addition, multinucleated giant cells varied in size and shape, with the nuclei mostly nested in the cytoplasm in a wreath-like or lobulated-shape (). The pathological results supported the diagnosis of SFT.\nIn some areas, tumor cells were arranged in a wavy pattern (), the stroma was apparently myxoid (), and showed significant collagenization. Multinucleated giant cells were found in the pseudovascular spaces () that were also distributed among the spindle-shaped tumor cells (). These findings were consistent with the characteristics of GCF. Therefore, further evidence was needed to confirm or rule out GCF.\nIHC revealed cells that were diffusely positive for CD34 (), BCL-2 (), and CD99 (), and negative for S100, SOX10, SMA, EMA, and MUC4 (), supporting the diagnosis of SFT. However, CD34 expression is also a feature of GCF and dermatofibrosarcoma protuberans. Furthermore, nuclear staining for STAT6 by IHC has been shown to be a highly sensitive and specific marker for SFT (). These results helped to differentiate between SFT and GCF. Moreover, IHC for CD68 showed focal cytoplasmic positivity in giant cells (), which is a characteristic of SFT. GCF, on the other hand, is typically characterized by strong and diffuse CD68 expression. In addition, only scattered cells were positive for the proliferative marker Ki-67, with a labeling index of 3% (). Based on these morphological features and immunohistochemical findings, pathological diagnosis of GCRSFT was made. |
A 76-year-old male patient sought a maxillofacial surgeon because of difficulty in swallowing and in chewing, pain complaint, and an internal nodule hardened on the tongue. On visual and palpatory clinical examination, a free and well-defined rounded nodule was found, with the tongue showing normal color, but with an enlarged aspect in the central region (). In the initial clinical interview, the patient did not remember whether he had eaten anything that had hurt his tongue. To assist in the diagnosis and try to elucidate the fact, the patient was asked for a complementary ultrasound examination of the tongue. The ultrasound device was a linear matrix probe, with a frequency of 12 Mhz. In the result, it was possible to observe a 5 mm hyperechoic linear image with a 1.2 × 0.7cm granuloma formation. The lesion was located on the left lateral border of the distal third of the patient's tongue, 0.1 cm from the surface.\nThe echographic aspect suggested a foreign body inside, showing an image compatible with a spine, with granuloma formation (). On the patient's return, when asked about the possible spine on the tongue, he recalled that he had eaten pequi a while ago but that he was not sure exactly regarding the time, leading us to a more consistent diagnostic hypothesis of a foreign body granuloma caused by a pequi spine. Complete surgical enucleation of the lesion was then performed, with bilateral anesthetic block of the lingual nerve. Surgical access was performed through a linear incision in the lingual dorsum on the left side, close to the most superficial region of the lesion (). The lesion was divulsed, using blunt-tipped instruments, from the adjacent tissue planes, having been cleaved without the rupture of its evident lining capsule (). No vascular rupture with subsequent hemorrhagic accident occurred, despite the close proximity of the lesion with lingual arteries and veins. The visualization of these large lingual vessels was perceived by the surgeon during the operation. After total enucleation without compromising the capsule (), the synthesis was performed both in deep muscle planes and on the epithelial surface using simple isolated points. The surgical specimen removed by excisional biopsy was sent for anatomopathological examination, which confirmed the initial diagnostic hypothesis of a foreign body granuloma from the penetration of a pequi spine. Histopathological examination revealed a nodule of fibrous tissue well delimited by means of a capsule, with thick collagen fibers richly peripherally vascularized and with sparse chronic inflammatory cells, in addition to numerous macrophages that stand out in the midst of immunoinflammatory cells (). |
The patient was a 30-year-old male presenting with chronic right sided low back pain beginning three months ago. He reported that he “threw out his back” while getting out of his truck, which led him to being unable to move the next day and required transportation by ambulance to a hospital for treatment. Upon arrival he reported receiving an oral steroid prescription and then being discharged home to rest for a few days. Over the next few weeks, he reported taking things easy and refraining from all of his previous exercise and activity. After two to three weeks, he reported that he began playing golf and resumed his prior resistance training program with full return to all normal activities within the next month. His complaints consisted of a tight achy pain in the right lower back with prolonged sitting, sleeping (slept on his side and/or back) and with playing golf. He stated that it was typically worse the day following exercise or activity. The patient reported that he can gain relief from the pain with stretching his lower back and taking a hot shower. He reported playing a full 18-hole round of golf two times per month and is at the driving range every other day. When he is at the range, he reported that he would hit both a large and small bucket each time (approximately 150 balls) with twenty of those consisting of chips and pitches. His current workout routine consisted of rotating through chest, back, arm, and leg workouts 2-3 times each week. Overall his past medical history is unremarkable, and he is not currently taking any medications to manage his pain. His goal with physical therapy was to play golf and resistance train without LBP. The patient was informed that the data concerning his case would be submitted for publication. The U.S. Health Insurance Portability and Accountability Act (HIPPA) was discussed and an informed consent was obtained to allow for the use of his medical information.\nThe results from the review of systems can be seen in . Significant findings were found in the neuromuscular system for balance, as well as several deficits within the musculoskeletal system. The details of the deficits found in the musculoskeletal system can be found within .\nWith the patient’s complaints of mainly right sided lower back pain beginning approximately three months prior, there were multiple diagnoses to consider for this patient. The working hypotheses were a facet joint dysfunction, lumbar intervertebral disc protrusion, and SI joint dysfunction. The hospital visit and his intake forms did not yield any positive red flag findings. The subject was referred to skilled physical therapy to address his LBP with a goal of returning to playing golf. Based on his history, there were concerns about his core stability and endurance as well as general mobility since he is very active and hitting a large number of range balls weekly. |
A 57-year-old female patient presented with the diagnosis of cT3N1 right breast invasive ductal carcinoma. No distant metastatic disease was noted on staging imaging. After completing neoadjuvant chemotherapy, the patient underwent a right skin-sparing mastectomy, sentinel lymph node biopsy and targeted axillary lymph node dissection, and immediate stage I breast reconstruction with tissue expander placement. Intraoperatively, 1 of 3 axillary lymph nodes was positive for malignancy on frozen section and a level I and II right axillary lymph node dissection was completed. Multiple bulky and soft nodes were found in the axilla. The wound was irrigated, and no bleeding or lymphatic leakage was noted. The remainder of the operation was completed without complications. One drain was placed in the right axillary dissection region, and two additional drains were placed at the right breast following the tissue expander placement.\nOn the first postoperative day, all three drains were found to have serosanguinous drainage at 12 hours postoperatively. At approximately 18 hours postoperatively, the patient was noted to have 100 CC of milky fluid in the right axillary drain. The differential diagnosis for the milky drainage included lymphatic obstruction due to the bulky lymph nodes found at the time of dissection and a right-sided chyle leak. Triglyceride level was sent on the drainage and returned elevated at 1,425 mg/dl. Drain fluid triglyceride levels > 100 mg/dl confirm the diagnosis of chyle leak []. The patient was managed in a conservative fashion with pressure dressings to the right axilla. She was instructed to follow a low-fat diet and discharged home on postoperative day 2.\nThe patient followed up in clinic on postoperative day 12. She reported that axillary drain fluid turned serous and decreased in output, approximately 50 cc/day. It was recommended that the patient continue conservative management with the drain in place and pressure dressing. One week later, the patient reported 27 cc of serous drainage in the past 24 hours. The patient was recommended to discontinue the pressure dressing at this time. The patient presented two days later with scant serous discharge in her drain. The drain was removed on postoperative day 20. |
A 45-year-old female with a history of diabetes mellitus presented with complaints of episodic intense itching and tingling sensation on the lower half of the body for one week. These episodes began and ended suddenly within a few seconds. She also complained of difficulty in walking and bilateral prickling sensation in the upper limbs for the last week, following the recent flu. She also has a history of multiple admissions in the hospital due to recurrent walking abnormalities and numbness and tingling of both hands. These symptoms were resolved after a few days and she experienced similar symptoms in lower parts of the body. She also reported intermittent psychiatric symptoms including severe fatigue, aggression, and loss of energy for the last two years. She also had a history of falls following the signs and symptoms. There was no history of trauma, cough, or contact with a person with a chronic cough, and no band like sensation. She is not an alcoholic and does not smoke.\nInitial evaluation revealed a temperature of 98 °F, blood pressure of 110/80 mmHg, heart rate of 95 beats per minute, respiratory rate of 19 per minute, and oxygen saturation of 98% on room air. On an extensive neurological examination, she had spastic quadriparesis with lower limb muscles affected more than the upper limbs. The general sensations were reduced in the lower limbs. However, numbness and sensory loss were noted in the glove and stocking pattern in the upper extremities. There was no sign of meningeal irritation or cranial nerve deficit. On the psychopathological examination, the patient exhibited reduced incitement and a slow thought process.\nThe symptoms were suggestive of central brain lesions, and magnetic resonance imaging (MRI) was performed, which revealed multiple small rounded periventricular plaques in both hemisphere and along with the long axis of the corpus callosum (fluid-attenuated inversion recovery/FLAIR sequence) and multiple fresh inflammatory areas after gadolinium enhancement (Figures and 2). MRI of the spine was normal. On further workup, the patient was negative for hepatitis B virus, human immunodeficiency virus, syphilis, hepatitis C virus, autoimmune antibodies including antinuclear antibody, double-strand DNA antibody, phospholipid antibody, antineutrophil cytoplasmic antibody, perinuclear antineutrophil cytoplasmic antibody, and paraneoplastic syndrome with normal erythrocyte sedimentation rate and C-reactive protein. The cerebrospinal fluid analysis revealed positive oligoclonal bands, suggestive of MS diagnosis.\nShe was started on methylprednisolone 2 g and carbamazepine which led to gradual resolution of her signs and symptoms. She was discharged with monthly natalizumab and she was doing well on her follow-up. |
A 28-year-old male patient reported to the Conservative Department of the Maulana Azad Institute of Dental Sciences, New Delhi, with a chief complaint of pain in right upper front central tooth for that he had already seen a fewer private clinics. The tooth was opened and debrided. However, the symptoms and signs including spontaneous pain and pain on percussion did not subside, and he was referred to our hospital.\nMedical history was noncontributory, but there was a history of trauma to maxillary anterior region 5 years ago. Intraoral periapical radiographic examination showed an oval radiolucent lesion in the middle third of the root canal of right maxillary central incisor, and the lateral incisor was already root canal treated []. The central incisor had a temporary restoration, and the root canal treatment had already been started in a private clinic. To confirm the diagnosis, a CBCT scan in the axial and sagittal plane was advised. The scan showed a communicating resorption defect in the middle third of the root canal []. The defect was present at the palatal aspect approaching toward the center of the canal []. Such defects start at the cementum adjacent to the periodontal ligament, and neither the periodontal nor the bone breakdown develops at the site of the portal.[]\nSuccessful treatment relies on the complete removal or inactivation of a resorptive tissue as well as debridement and obliteration of the root canal system.[] As the portal of entry was well within the bone, and could not be located through the root canal system, extraction of the involved tooth after root canal therapy, followed by debridement and obturation of the resorption defect, and replantation of the tooth was planned. Tooth replantation carries its own risks,[] but due to the inaccessibility of the resorption defect, it had to be included in the treatment plan.\nAccess to the canal system was reestablished, and the working length was confirmed with apex locator ROOT ZX II (J Morita, Irvine, CA, USA). The root canal was instrumented with stainless steel hand K-files (Dentsply Malliefer, Switzerland), until an apical stop of ISO #60 could be created. The root canal was repeatedly irrigated with 2.5% sodium hypochlorite followed by normal saline, and calcium hydroxide dressing was placed. The patient was recalled after 2 weeks. However, in case of pain/swelling, the patient was advised to report immediately.\nOn the subsequent visit, the root canal was obturated using Gutta-percha cones (Dentsply Malliefer, Switzerland) and AH-Plus (Dentsply Detrey, Konstanz) endodontic sealer by lateral condensation technique []. After anesthesia, the tooth was extracted with only dental forceps to minimize the damage of the periodontal ligament as undue trauma to the ligament can hamper the replantation process []. The resorptive defect was cleaned of the granulation tissue and 90% aqueous solution of trichloroacetic acid was applied for approximately 2-3 min using a micro applicator tip so that the area of acid application could be confined to the resorption defect only. The irregular borders of the defect were smoothed with a small round bur []. Biodentine (Septodont, St. Maurdes Fossés, France) was mixed according to the manufacturer's instructions and was firmly condensed in the cavity []. During the time (15 min) that the tooth was treated extra-orally, the tooth was held in a wet gauze piece. The best prognosis of a replanted tooth is indirectly related to the amount of time the tooth is maintained extraorally during the procedure. It has been stated that the potential for resorption in replanted teeth increases if they remain outside the mouth for more than 30 min.[]\nThe tooth was replanted back to its socket, and splinted with adjacent teeth using fiber-splint and composite. A periapical radiograph was taken for future comparison []. The patient was recalled after 2 weeks when the splint was removed.\nThe case was followed up clinically and radiographically, which showed satisfactory results at 3, 6, 12 and 18 months post-operatively [Figures -]. There was no pain on percussion, percussion sound was normal; and radiographically there was no sign of replacement resorption. |
A 62-year-old woman with no significant medical history presented to our clinic with a complaint of a lesion on her right heel. She had a trauma to her heel about 15 years earlier with chronic non-healing wound. The wound had been managed with repeated dressings and antibiotics without significant improvement.\nPhysical examination of the right foot showed a 10 × 15 cm ulcer with fungating everted edges on the heel and ankle region (Fig. ). The distal pulses were normal and symmetrical. The regional lymph nodes were not palpable.\nCore biopsies confirmed the diagnosis of SCC and abdominal and chest computed tomography scans did not show evidence of distant metastasis.\nIntra-operatively, a wide local excision of the ulcer with safety margins was performed. The right heel and ankle region was exposed at the end of the excision (Fig. ).\nWith the patient in the right lateral position, the skin paddle was designed in a bilobed fashion (Fig. ). The muscle was contoured to cover the defect with exposed calcaneal surface and the tailored skin paddle was wrapped around in a way that covers the area with thick skin. The donor site was closed primarily with two suction drains inserted. The micro-vascular anastomosis was performed by the senior author as interrupted end-to-end using 10/0 black nylon sutures.\nPost-operatively, the flap viability was monitored closely for the first few days. The flap was bulky, thus primary closure was judged to be risky (Fig. ). The pathology report revealed a Grade-1 SCC with free surgical margins. The donor site healed with no complications.\nSix weeks post-operative, significant reduction in the flap size was noticed due to fibrosis of the denervated muscle. At that stage, closure of the skin edges was judged to be safe and weight bearing was allowed after complete healing of the wound. A small area about 1 cm at the inner aspect of the flap was not closed completely. This was managed with repeated dressings and healed completely without complications (Figs and ).\nFollowing initial rehabilitation, clear instructions were given to the patient regarding the need for long-term follow-up and foot care. At 34 month’s follow-up, the patient was mobile with no flap complications. |
Our patient, a 58-year-old Caucasian male, presented to the emergency department with the acute onset of quadriplegia extending from C5 throughout the rest of the pan neuroaxis while awakening from bed the morning of presentation. Upon initial physical examination there were no signs of trauma noted that were significant to the presenting symptoms, additionally, patchy sensation was noted in the upper and lower extremities with clonus in the legs only and hyperreflexia in both arms and legs. Initially, our patient was administered one intravenous dose of methylprednisolone and allowed to enter a state of permissive hypertension which improved our patient's arm strength bilaterally to 2/5, but had no positive effects on the lower extremity paraplegia. As a result of minimal improvement, immediate imaging of the cervical spine was ordered and highlighted a severe cervical stenosis from C3 to C7, as seen in Figure , due to extra-axial posterior compressive spinal mass with cord signal change.\nAdditional imaging of the brain was completed as a precautionary measure and was normal. Upon obtaining full patient history and medical records from nearby hospitals, it was found that our patient was on a prolonged regimen of warfarin for many years due to a prior diagnosis of congestive heart failure without regulation and regular INR/prothrombin evaluation. Our patient also did not follow up with his primary care physician throughout the duration of the warfarin regimen. At presentation, our patient's INR was found to be 5.0 necessitating the prompt correction with intravenous injection of fresh frozen plasma (FFP) and vitamin K. Additional magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed large compressive acute epidural hematoma posteriorly compressing the thoracic spinal cord from T6 to T10, visualized in Figure , with cord signal change, as well as L4-S1 posterior acute epidural hematoma compressive of the cauda equine, visualized in Figure .\nUpon a complete review of the patient history, presenting symptoms, and radiological imaging results our patient was deemed a prime surgical candidate that would significantly improve both motor function, sensation, and ultimate restoration of our patient's quality of life. Our patient was emergently taken to the operating room for stage 1 of a two-part surgical procedure. Stage 1 involved a posterior T3 to L1 decompression, epidural hematoma evacuation and instrumented fusion. Three days later, our patient was taken to the operating room again for stage 2 of the planed procedure which involved a posterior cervicothoracic C2 to T2 decompression and instrumented fusion with evacuation of acute epidural hematoma. |
A 26-year-old male patient was suffering from chronic kidney disease and was on maintenance hemodialysis twice a week for 6 months. The patient came to the institute for workup of cadaveric renal transplantation before 2 months. His right radial artery was punctured for ABG analysis in ward as a routine workup for sending a patient to dialysis. Special BD 2cc (heparinized) ABG syringe with 23-gauge needle was used for puncture of radial artery. Only one puncture was attempted for collecting the sample. First year resident of Anesthesia Department with experience of about 6 months punctured the radial artery. Compression of about 5 min with bandage was given over the punctured site. After 2 days of procedure, he noticed pulsatile swelling near his right wrist joint over volar aspect without overlying erythema []. The patient denied fever or chill. Allen's test was negative. His hand movement was not restricted. Thrill was palpable over the swelling. Lesion was not painful; hence, the patient was referred to our Radiodiagnosis Department for Doppler ultrasound of his right wrist joint swelling. As the patient had not fever and tenderness over local site, methicillin-resistant Staphylococcus aureus test was not done. On ultrasonography, swelling appeared to be cystic in nature measuring about 14 mm × 9 mm in size, communicating with the right radial artery at wrist joint. On color Doppler imaging, it had typical swirling pattern of flow []. Spectral Doppler imaging revealed a classic to and fro waveform confirmed the diagnosis of PA []. There was no evidence of thrombosis within PA, in radial artery or arteries of the right upper limb. Due to smaller size and asymptomatic nature of PA, the patient was not offered any treatment and close follow-up is advised. Size and patency of PA were checked every time, it did not seem to increase in size. The patient was discharged from our institute after completion of his cadaveric transplantation work-up. On follow-up Doppler study, it appeared to be thrombosed after 1 month. |
The patient was a 26-year-old woman who had first referred to a physician 4 months prior to admission due to facial edema and dyspnea on exertion which was attributed to upper respiratory infection. After 2 months she developed generalized edema, jaundice and pruritus. Because of abnormal liver tests, an abdominal sonography was done which was in favor of liver cirrhosis and so she was admitted to a tertiary care center for better management.\nOn admission she had blood pressure of 110/70 mm Hg, pulse rate of 80/min, respiratory rate of 20/min, temperature of 36.5°C orally. She was icteric, had pale conjunctiva, generalized edema but neurologically she had no signs of encephalopathy. Interestingly she had elevated jugular vein pressure and a harsh systolic murmur best heard in pulmonic area.\nIn order to assess the cardiac murmur, an echocardiography was done which demonstrated normal left ventricular size and function, but severe right ventricular hypertrophy and dilation with concomitant dysfunction and liver congestion. Further evaluation revealed severe valvular pulmonary stenosis associated with a gradient of 170-180 mm Hg which was later confirmed with a trans-esophageal echocardiography.\nUpon this finding, the patient’s cirrhosis was attributed to pulmonary stenosis and because of favorable valvular morphology, percutaneous transvalvular pulmonary valvuloplasty was scheduled for the patient.\nAfter enough hemostasis with fresh frozen plasma, she was transferred to the catheterization unit. Her angiogram showed thick and domed pulmonary valve and she had a peak to peak transvalvular gradient of 180 mm Hg (). We used a 15 × 40 mm balloon initially to predilate the stenotic valve and then used a 20 × 45 mm balloon to fully dilate the pulmonary valve. The peak to peak transvalvular gradient dropped to 40 mm Hg after the procedure.\nThe patient was observed a few hours in the recovery room and was then transferred to the ward. After a few hours the patient gradually developed dyspnea and decreased oxygen saturation. Noninvasive oxygenation with facial mask was initiated. Her examination revealed blood pressure of 100/80 mm Hg, pulse rate of 128/min, respiratory rate of 28/min, cyanotic lips, diffuse bilateral fine rales over the lung fields and a harsh systolic murmur best heard in pulmonic area. Her blood gas analysis demonstrated mixed respiratory and metabolic acidosis and significant hypoxia and desaturation. A repeat echocardiography revealed trans-pulmonary valve gradient of 45 mm Hg associated with mild regurgitation without any other new findings. Portable chest X-ray revealed bilateral diffuse haziness (). As she was unresponsive to non-invasive oxygenation with mask, she was intubated with endotracheal tube and transferred to the intensive care unit (ICU). In ICU she was ventilated with assist control mode with a rate of 12/min, tidal volume of 500 mL, partial oxygen fraction of 100% and PEEP of 5 mm Hg. Her 24-hour fluid intake was restricted to 1500 mL and she was given intravenous furosemide. Despite initial increase in arterial oxygen saturation, her condition remained critical with further deterioration in hemodynamics with decreased systolic blood pressure to 80 mm Hg and increased heart rate to 145/min. Her ICU course was further complicated by ventilator associated pneumothorax which was managed with chest tube insertion. Unfortunately despite all efforts, she died less than 3 days after being transferred to ICU due to shock state and severe oxygen desaturation. |
A 46 year old male presented with severe pain in the left arm for 1 week. Six months earlier, he had sustained a closed fracture of the left clavicle and upper five ribs. This was managed nonoperatively with an arm sling. Following a duplex scan, a left brachial embolus was diagnosed and an embolectomy was done; but this had to be repeated a few days later, as he presented again, with the same symptoms. As his pain and numbness did not abate after two explorations, the patient was referred to this center.\nAt the time of presentation to us after the second embolectomy, the left arm was cooler than the right and finger pressure was zero. The left brachial, radial and ulnar pulses were absent. Sensation was decreased below the elbow and motor power was grade 4 (Medical Research Council Grade). On examination of the clavicle, there was a bony discontinuity palpable along the middle one third, with abnormal mobility. There were no pulsatile swellings or palpable bruit at the nonunion site. A chest X-ray revealed an atrophic nonunion of the middle third of the clavicle with significant over riding of the ends []. A computed tomography angiogram (CTA) showed a pseudoaneurysm of the left subclavian artery, adjacent to the nonunion of the clavicle [].\nPatient underwent excision of the pseudoaneurysm and fixation of the clavicular fracture. The vessel was approached via an infraclavicular incision. Proximal and distal control of the subclavian artery was obtained followed by identification of the pseudoaneurysm. The sac was opened and thromboembolectomy was done. The defect was then closed with a primary repair []. This was followed by operative stabilization of the clavicle. The atrophic ends of the nonunion were dissected and the intervening fibrous tissue resected. The distal end of the nonunion was found to be in close proximity to the aneurysm and had probably button holed into the subclavian artery causing the primary injury. A 3.5 millimetre precontoured locking plate was applied on the superior surface along with bone graft harvested from the ipsilateral iliac crest. At 12 months following the surgery, he remained asymptomatic, with a good range of movement at the shoulder. The radiographs confirmed clinical union of the clavicle. |
A boy aged 3 years was referred to our emergency room after falling from a height of 3 m. He was conscious with slight tachycardia (140 per min). A physical examination revealed a 4 cm skin injury on the posteromedial side of his right elbow. The neurovascular examination was normal with intact radial and ulnar pulses. Antero-posterior and lateral plain radiographs displayed a supracondylar humerus fracture with segmental bone loss. In light of above findings, the initial diagnosis was considered as a Gustilo-Anderson Type-IIIA supracondylar humerus fracture. An intravenous antibiotic regimen was introduced with cefazolin 500 mg 4 times daily for 7 days, gentamicin 40 mg twice daily for 3 days, and metronidazole 200 mg twice daily for 3 days. No additional cranial, chest and abdominal injury were evaluated.\nThe patient was immediately taken to the operating theater, which was within 4 h of the injury. Under general anesthesia, the patient was put to sleep in the supine position without fastening a tourniquet. First, radical debridement was enforced, and a 3 cm × 4 cm segment of avascular and grossly contaminated bone was noted and removed (, ). Acceptable thick periosteal coverage was achieved after the debridement of contaminated tissues including the segmental bone. After the repair of the remaining periosteum, the lack of sufficient bone mass in the distal humerus was observed. A defect spanning multiplanar tubular external fixator that bridged the elbow was considered as a suitable choice of treatment to restore the original length of the humerus. After making this decision, a fixator was employed at 90° of elbow flexion, neutral forearm rotation, and proper humeral rotation, to ensure the length and alignment of the humerus (-).\nThe patient was closely monitored in the inpatients unit in terms of vascular compromise and compartment syndrome. Gentamicin and metronidazole were stopped on the 3rd day of the follow-up period, and the patient was discharged. Intravenous cefazolin 500 mg 4 times daily was continued until the 7th post-operative day. A standard dressing was applied, and sutures were extracted 2 weeks after the operation. No sign of infection was noted during follow-up. To check healing of the bone defect, post-operative serial elbow radiographs were taken at the 1st, 2nd, 4th, and 6th week follow-ups. The external fixator was removed in the 6th week of follow-up after three cortices were seen in the plain radiograph (). Gentle elbow range of motion exercises were started as soon as the fixator was the 12th month follow-up, supination and pronation were full. At 48th month follow-up, 120° of elbow flexion, full extension, and full forearm rotation were observed ( and ). A physical examination showed that carrying angle was 15° of a cubitus varus (); radiologic examination showed a slight varus angulation of the distal humerus, a decreased Baumann’s angle, and a normal lateral capitellohumeral angle, when compared with the healthy side (). In addition to the above findings, pain intensity, motion, stability, and function parameters of the elbow were assessed as being excellent with 100 points using the Mayo elbow performance score. |
A 26-year-old Caucasian woman was referred to the Head and Neck surgery outpatient clinic at Imam Khomeini training Hospital in Urmia. Two years ago, she was noticed to have a cervical mass on the right side. A thyroid nodule was diagnosed and followed-up by a physician, but subsequently, the nodule was enlarged rapidly since five months, so she was referred to the endocrinologist. A fine needle aspiration (FNA) puncture was performed and the result was compatible with thyroid papillary cell carcinoma, then she was referred to the surgeon. She had no surgical history before. She was received medical therapy with levothyroxin for a while, but the preoperative thyroid function tests, all of them were in normal ranges. His physical examination was unremarkable and only a firm three to four cm nodule was palpated in the right lobe of thyroid without any adhesion to the environment. No other enlarged mass or lymphadenopathy was observed in the neck in the first exam in the surgery clinic.\nAccording to the result of FNA, the surgeon decided that she should undergo total thyroidectomy, which was the 270th thyroidectomy of the surgeon.\nUnder general endotracheal anesthesia, a three to five inch low collar incision is made perpendicular to the length of the neck and carried down through the subcutaneous tissue and platysma muscle. Superior and inferior subplatysmal flaps were developed and the strap muscles are divided vertically in the midline and retracted laterally.\nThe skin and subcutaneous tissue was dissected and the thyroid gland and blood vessels were exposed. Blood supply to the thyroid gland was clamped off and ligated by two 2-0 and 3-0 silk sutures.\nFirst, the left lobe of thyroid was resected in association with isthmus. Then the right lobectomy was done by dissecting the superior peduncle of the right lobe.\nThe right inferior thyroid artery was identified. Careful dissection was done to find the right recurrent laryngeal nerve in the area between inferior thyroid artery and mid-cervical (mid-tracheal) line, but despite diligent dissection, no recurrent nerve was observed.\nSo with suspect to have the anatomical variation (non-recurrent laryngeal nerve), the area above the inferior thyroid artery was dissected. The inferior laryngeal nerve usually penetrates the cricothyroid muscle to enter the larynx. The nerve was founded where penetrating the cricothyroid muscle and was followed in a retrograde manner [].\nThe nerve emanated from the right vagus nerve and entered the larynx three to four cm after its origin without showing any recurrent course. The left recurrent laryngeal nerve was observed too, and it was in normal recurrent fashion.\nThe surgery and postoperative period was uneventful and no change on the voice of patient (any hoarseness) was observed.\nGiven the invariably association of NRLN with vascular abnormality (right clavian artery originated directly from the aortic arch), the computerized tomography (CT) angiography imaging was performed which confirmed the presence of vascular anomaly []. Because of being asymptomatic, as usual, no extra measure was considered in this regard. |
A 72 year old male Caucasian patient was referred to our unit with a metastatic bony deposit involving his left proximal femur from a known primary prostatic carcinoma. Commonly, prostatic metastases are sclerotic in nature. However detailed radiological evaluation demonstrated a large lytic lesion in this case (Figure ). Due to the high risk of an impending pathological fracture, the decision was taken to perform prophylactic intramedullary nailing of the left femur (Figure ). In order to reduce the increased intramedullary pressure during nail insertion, venting of the distal end of the femur was performed (Figure ).\nThe patient did not have any other significant past medical history and he was not known to be allergic to any medication. He had surgical procedures for other conditions in the past requiring general anaesthesia and had an uneventful recovery in every case.\nDuring the procedure, the patient suffered a cardiac arrest. Fat embolism was initially thought to be the cause of this event due to the increased intramedullary pressure during reaming and nail insertion. Following successful resuscitation, a marked generalized erythematous rash was noticed which lasted for about thirty minutes. This raised the concern of a possible hypersensitivity reaction to one of the anaesthetic agents. Our patient received in total eight different drugs namely propofol, atracurium, morphine, ondansentron, dexamethasone, gelofusine, paracetamol and diclofenac. Interestingly, it was noted that the cardiac arrest occurred following a dose of atracurium and an infusion of gelofusine. Consequently, it was thought that either one of those two agents could have been responsible for the anaphylactic response.\nSerum mast cell tryptase levels taken one hour following the event, demonstrated a level of 190 ng/ml, which dropped to 60 ng/ml upon repeating the levels twelve hours later (normal range 3–23 ng/ml). The raised levels of mast cell tryptase were consistent with mast cell degranulation. The latter strongly suggested a hypersensitivity reaction. Furthermore, allergy skin prick tests were performed to all the drugs used during the procedure. Interestingly, they showed a positive reaction to gelofusine only, confirming it as the causative agent. |
A 56-year-old woman with acute respiratory failure and bilateral ptosis, with a past medical history of arterial hypertension was referred by regional hospital to Intensive Care Unit at the Department of Neurology. On admission to the previous hospital she presented with nausea and vomiting. One day after the onset of the disease she experienced dysphagia and blurred vision. She was first diagnosed with a brainstem stroke but CT of her brain was normal. 24 hours later bilateral ptosis and dyspnea developed. On admission to Intensive Neurological Care Unit she had sever dysarthria, her hypoventilation and hypoxia progressed to respiratory failure. Detailed neurological examination revealed external and internal ophtalmoplegia (equal unreactive pupils), deep tendon reflexes were relatively brisk. No other abnormalities, including limbs muscles paralysis, were observed. The patient was intubated and mechanical ventilation was commenced. Both brain CT and MRI scans were normal. Serum electrolytes, glucose and blood count were normal. CSF parameters were within normal limits. Nerve conduction studies showed slightly decreased amplitude of CMAP in the median nerve, with normal conduction velocities and normal conduction parameters in other motor nerves. Sensory NCV studies were within normal limits. Electrophysiological repetitive stimulation test of ulnar and facial nerve was normal. Other electrophysiological tests, such as SFEMG and SSR, were not done because the patient tolerated examination very poorly. Although repetitive stimulation test was negative, after detailed anamnesis with her family presumptive diagnosis of botulinum toxin poisoning was made and trivalent ABE antitoxin was administered on the day of her admission to our department. Serum sample was sent for botulism mouse inoculation test. The results reported 4 days later were positive for type B Clostridium botulinum toxin. The patient gradually improved and regained strength but remained on mechanical ventilation for 7 days. Finally, a possible source of botulism was established: the patient was only person in her family who had eaten a jar of pate one day prior to her admission to hospital. The pate was not available for toxicology testing.\nFour months after the onset of the disease the patient still experienced episodic palpitation and chronic fatigue. On neurological examination only slow reaction of pupils to the light and convergence was found. Detailed cardiovascular and autonomic function tests are presented in Table . All tests showed significant but not life threatening signs of autonomic system involvement. |
A 33-year-old man presented to our clinic with complaints of watering, redness, and purulent discharge in the right eye. The patient reported seeing a physician a year earlier in Georgia due to fatigue, nausea, vomiting, and diarrhea. After his diarrhea and vomiting had resolved, he had swelling of the lymph nodes on the right side of the neck. After returning to Turkey for treatment, he had received cephalosporin and penicillin for suspected pharyngitis. When night sweating and weight loss were added to his complaints, he had presented to another hospital where his treatment was changed to amoxicillin-clavulanic acid 1 g 3 times a day and ciprofloxacin 750 mg twice a day, and incisional drainage was performed on the lymph nodes of his neck. When his symptoms failed to resolve completely, he had presented to the department of infectious diseases of a different university hospital. Serum agglutination test was positive for F. tularensis at a titer of 1/1280 and he was prescribed streptomycin 1 g per day for 9 days followed by 1 g twice a day for 5 days for a total of 14 days, followed by doxycycline 100 mg twice a day for 1 week. Ultrasound examination of the neck had revealed multiple abscesses in the right submandibular region and pathological lymph nodes including multiple calcifications in the right cervical chain, while magnetic resonance imaging of the neck showed retropharyngeal abscess narrowing right nasopharynx and oropharynx and submandibular lymphadenopathies (LAP) including cystic and necrotic areas (). He reported that the LAPs had resolved after a few months with no recurrence, but complaints of watering, swelling in the lacrimal sac area, hyperemia, and pain in the right eye developed a few weeks later. The patient presented to our clinic with recurrent swelling around the lacrimal sac, hyperemia, and purulent discharge.\nOn examination his best corrected visual acuity was 20/20 in both eyes. Intraocular pressure measured by automatic tono-pneumometry was 15 mmHg in each eye. On slit-lamp examination, epiphora was noted in the right eye and the left eye was normal. There was swelling in the area of the right lacrimal sac (). Fundus examination was normal in both eyes. In nasolacrimal lavage, the patient’s right nasolacrimal duct was occluded and the common canaliculus was patent. Discharge of purulent material from the right lower punctum was noted after lavage. A sample of the purulent discharge was collected and sent to the microbiology laboratory for culturing and the patient was started on oral amoxicillin-clavulanic acid 1 g twice a day and topical ciprofloxacin drops 4 times a day. Antibiotherapy was discontinued because the culture was negative. Consultation from the otorhinolaryngology (ENT) department was requested to rule out any intranasal pathology. The patient underwent ENT examination, followed by nasal endoscopic examination. In addition, to rule out intranasal pathologies that may present an obstacle to surgery, the paranasal sinuses were examined using computed tomography. No intranasal pathologies were detected in ENT evaluation. Dacryocystorhinostomy surgery was recommended to the patient, but he refused the procedure. |
A 4-year-old girl was admitted with left neck swelling. The physical findings showed a huge mass with erythema in the left neck. Enhanced computed tomography showed a large abscess (). After incision and drainage, a barium swallow examination and direct fistulography from the wound showed no fistula. Five months later, she was hospitalized for the second time for left neck swelling. After incision and drainage, a direct fistulography from the wound showed a fistula from the abscess cavity to the left pyriform sinus (). She was diagnosed with a pyriform sinus fistula (PSF). She was followed in the outpatient clinic with serial ultrasonograms for elective surgery, but after 5 months, she was readmitted with recurrent left neck swelling before surgery was scheduled. Thus, she underwent an open-neck surgical procedure for recurrent PSF. First, the catheter was inserted into the opening of the fistula through an endoscope and contrast medium was injected, which did not reveal a fistula from the left pyriform sinus to the abscess cavity. Next, after direct injection of contrast medium and indigo carmine into the abscess cavity, an open-neck surgical procedure was performed with coring out of the stained fistula, but a fistula was overlooked near the upper lobe of the left thyroid, and the scar tissue with abscess was removed (). Finally, a guide wire was successfully inserted through the endoscope into the fistula; the wire was gripped with forceps under fluoroscopic guidance and removed (). As a modification of the surgical approach and treatment for the orifice of the PSF, a catheter was exchanged through the guide wire, and a nylon thread was passed into the catheter (). The tip of the nylon thread from the oral side was fastened and fixed to a gauze ball () []. After removing the nylon thread, the gauze ball was also removed and the orifice of the PSF was noted (). The orifice of the PSF was doubly closed with absorbable sutures of the thropharyngeal and cricopharyngeal parts of the inferior constrictor of the pharynx (). She was discharged uneventfully and doing well without a recurrence 12 months postoperatively. |
A 9-month-old fit and healthy boy underwent posterior 2/3 calvarial remodelling surgery for sagittal synostosis (Fig. ). This was carried out in the supine position while the head was supported on a horse-shoe head rest with the head well flexed. A gel pad for was used for chin rest. This is the usual patient position for such procedures in our institution. The mean arterial pressure was monitored throughout the procedure continuously via arterial cannulation, and there was no period of hypotension or excessive blood loss noted during surgery—with the lowest recorded intraoperative haemoglobin (Hb) being 82 g/L. No ventilation problems were encountered during the procedure. Immediately postoperatively, the Hb was noted to be 70 g/L and he was transfused 1 unit of red blood cells.\nOn second postoperative day, it was apparent that he was not moving his legs and could only flex his arms to the mid chest. A CT head scan did not reveal any acute intracranial pathology to explain his clinical findings. Subsequent MRI of his brain and spinal cord revealed high T2 intramedullary signal between C2 and T2, with concomitant expansion of the cervical spinal cord (Figs. and ). MRI brain imaging was normal. No traumatic injury was encountered peri-operatively, and this was evident from the lack of signal changes on the MRI in the vertebrae and cervical spinal ligaments. There was no suggestion of any viral illness or evidence of myelitis. A profound hypotensive episode was neither encountered clinically nor suggested on the radiological assessment. There was no evidence of cerebral hypoperfusion insult.\nCardiac imaging did not show any abnormality and coagulation profile was found to be normal for his age. This included standard coagulation profile with prothrombin time, APTT ratio, derived fibrinogen and INR. This also included PT 20210 gene screen for FII gene mutation, lupus anticoagulant, thrombophilia screen, antiphospholipid antibodies including cardiolipin antibody and B2-glycoprotein IgG and lastly, factor V Leiden mutation. This flaccid paralysis lasted for up to 12 days after surgery when he was seen to move his legs. The left arm regained more movement first, followed by his right arm in the initial postoperative period. An intense rehabilitative physiotherapy regimen was commenced. By 28th postoperative day, he was noted to have MRC grade 4 power in the right arm, grade 3 in the left arm and grade 2 in both legs. Truncal tone improved by day 33 postop, when he started sitting upright with support. A repeat MRI at 6 weeks post surgery showed improvement in cord swelling but with persistent signal change secondary to myelomalacia. The images were degraded due to motion artefact and are not included here.\nHe continued to engage in a physiotherapy programme, and after initially being supported with a rigid spinal brace, he was subsequently provided with a lycra corset. Follow-up review 21 months after this event revealed significantly improved right arm function. He was able to sit and stand unsupported but required significant support while walking. |
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 study has been approved by the Committee for Human Research at Navy General Hospital, and written informed consent was collected from the patient.\nA 71-year-old Asian man was referred to the orthopedic clinic of Navy General Hospital with the main complaint of chronic neck pain for 5 years and increased difficulty in swallowing solid food over the past 3 years. The neck pain was dull and progressive but generally tolerated by the patient. Sometimes neck pain would become sharp with certain body movements such as twisting or bending over. Over the past year he had altered his diet to include only soft foods and liquids, and he had an approximately 5 kg weight loss over that period of time.\nEsophagogastroduodenoscopy had been done 2 years before, and the results were unremarkable. He denied difficulty in breathing and any symptoms suggestive of cervical radiculopathy or myelopathy. The patient had had type 2 diabetes for 12 years and had been admitted to the local hospital on two previous occasions for control of his disease.\nOn physical examination, the patient was alert, afebrile, and well oriented, with stable vital signs. Cervical range of motion was significantly decreased, and a hard lump could be felt deep in the anterolateral cervical region. The neurological exam and the patient’s reflexes were normal. The patient did not show clinical, radiological, or serological evidence of rheumatoid arthritis or of ankylosing spondylitis. His neck disability index score was 62% and the visual analogue scale score for neck pain was 7 while hospitalized in our clinic.\nLaboratory tests including blood cell count, C-reactive protein, erythrocyte sedimentation rate, and autoimmune panel were normal. The lateral radiograph of his cervical spine showed characteristic flowing ossification along the anterior aspect of the cervical vertebrae from C2–C5, with relative preservation of the disc spaces (). The facet joints and spinous processes did not appear ankylosed. The bony mass compressed the esophagus anteriorly and resulted in marked swallowing tube stenosis. The computed tomography scan of the cervical spine revealed continuous but irregular flowing hyperostosis alongside the anterior aspect of all the cervical vertebrae as well as local ossification of the posterior longitudinal ligament (). There were especially striking osteophyte outgrowths covering the anterior side of the vertebrae and projecting into the soft tissues of the neck from the level of C2 to C5 (). The largest bony excrescences measured 16.32 mm thick. The anterior edge of the body of the vertebrae was clearly visible at the posterior limit of the outgrowth except at C4. Sagittal T2-weighted magnetic resonance imaging showed bone marrow signal abnormality (high signal intensity) in C5–C7 as well as in the outgrowth hyperostosis (). Magnetic resonance imaging did not show obvious spinal stenosis and cord compression. The features were characteristic of DISH or Forestier’s disease. |
A fifty-seven-year-old male was treated with THA for primary osteoarthritis of right hip. The bearing surface used in cementless THA was ceramic on metal. He made a good recovery without any complications and remained well for 10 years. In July 2011, he presented to us with the complaint of weakness in his right lower limb for the last one month, and an inability to lift limb for the last two weeks. There was no history of trauma, fever or weight loss. Hip examination revealed no significant findings with a normal range of movements. The patient on neurological assessment, was found to have femoral nerve palsy with weakness of hip flexion and knee extension without any sensory deficit. Distal pulses were normal on both the sides.\nPlain radiographs of the hip (Fig. ) showed no signs of loosening or osteolysis. Lateral inclination and anteversion of acetabular cup were 45° and 25 ° respectively. Thefemoral stem was in neutral alignment. Blood investigation revealed that complete blood count, ESR and CRP were within normal limits. Serum metal ions were within normal limits. Electromyography and nerve conduction study of right lower limb revealed femoral nerve palsy. Ultrasound examination of the groin demonstrated a large intrapelvic cystic lesion between THA prosthesis and femoral vessels and nerve. Fascicular swelling overlying the femoral nerve was also noted, probably due to mass effect. Fluid-fluid level was also seen within the cystic lesion. There was no definite evidence of intra-articular extension of the lesion to the adjacent hip joint. Ultrasound-guided aspiration was deferred in view of the large size of the lesion, fear of introducing any infective pathogen and risk of recurrence. Further CT evaluation of the right hip confirmed the presence of a large iliopsoas cystic lesion (Fig. , ) along with an overhang of anterior portion of the acetabular component beyond the margins of the true acetabulum (Fig. ). There were no signs of acetabular cup loosening or osteolysis in the CT scan. Lesion size was found to be 7cm x 4 cm. Based on these findings, we propose that a local reactive response, due to irritation of the iliopsoas bursa caused by the overhanging anterior part of the acetabular component, resulted in the formation of a cyst that secondarily compressed the femoral nerve resulting in neurological signs and symptoms.\nExploration of the swelling was carried out using a modified ilio-femoral approach with osteotomy of the anterior superior iliac spine. A dumbbell shaped iliopsoas bursa containing a light brownish inflammatory fluid was identified (Fig. ). Severe fibrosis and adhesions causing hip impingement were also found around the iliopsoas. On frozen section study, no neoplastic cells or metal debris were identified and neutrophil counts per high power field were not raised. The whole extent of the swelling was identified and excised along with the bursa. Joint capsule was exposed to check for any inflammatory signs. No communication of bursa was found with the hip joint. There was no evidence of wear debris and metallosis in the hip joint. No hip impingement was found after the bursectomy. Exploration and external neurolysis of femoral nerve was performed and the nerve was found in continuity. After thorough irrigation and debridement, wound was closed in layers over suction drain. The histopathology revealed chronic inflammation with granulation tissue. There was no foreign body reaction suggesting metal debris. Culture of fluid and tissue was negative.\nPostoperatively, a repeat ultrasound done two weeks later and CT scan done eight weeks later showed no cystic collection. The patient was given a hinged knee brace with drop-locks for walking to prevent knee buckling and falls. Review after 6 months showed complete recovery with no neurological symptoms. Another CT scan was done 18 months postoperatively confirming no local recurrence of bursal collection.\nWritten informed consent was taken from the patient for publication of this case report. |
A 23-year-old man with severe non-traumatic right elbow pain and decreased range of motion was referred to our clinic. He had been suffering the symptoms for two years. The pain began insidiously and increased over six months before admission. The patient described the pain radiating up and down the elbow. The pain increased over the time and was persistent with nocturnal aggravations interfering with patient’s sleep. He mentioned NSAIDs would temporarily relieve the pain and he could not go asleep without taking them. The patient was otherwise healthy, and had no other accompanying symptoms such as weight loss and nocturnal sweating.\nOn physical exam, the overall appearance of the elbow looked normal. The joint was stable with no palpable mass and effusion. There was moderate local anterior tenderness in front of the elbow with marked atrophy of the muscles. The elbow flexion-extension range of motion was restricted to 30 to 90 degrees but supination and pronation were normal compared to the non-affected side and wrist and shoulder movements were fully preserved. There was not any neurovascular deficit.\nThe plain antero-posterior and lateral radiographies of elbow did not add much to our findings. We obtained a CT scan of the involved elbow which revealed a 6 mm radiolucent lesion with a nidus at the center surrounded by thickening of adjacent cortex located at anteromedial of distal humerus []. The patient had an MRI which suggested bone edema, synovitis and mild joint effusion. The bone scan revealed focal uptake of radioisotope compatible with the location of the lesion in CT scan []. Laboratory investigations including the C-reactive protein, sedimentation rate and electrolytes were normal. The EMG-NCV studies were normal as well.\nAfter making the diagnosis of osteoid osteoma based on clinical examination and radiographic findings, the patient was scheduled for operation to excise the lesion. Under general anesthesia the elbow joint was approached anteromedially, the ulnar nerve was explored, the neurovascular bundle was retracted laterally and elbow arthrotomy was performed. At the time of arthrotomy, about four ml of clear joint effusion was drained. Synovial hypertrophy was obvious in the joint. The anteromedial aspect of distal humerus was exposed. An abnormal bony protuberance was clearly noticed. A part of the cortex was removed using oscillating power saw, there was significant sclerosis at the site and the interior was evacuated by curettage and all were sent for pathological study []. No graft was used to fill the cavity. Post operative histological examination confirmed the diagnosis of osteoid osteoma [].\nThe patient reported a prompt pain relief just the day after surgery. Elbow physiotherapy was started in the first week after operation. The patient achieved 20 to 120 arc of motion three months after operation (). He returned to full activity and no postoperative complication reported two years after operation. In the last follow-up radiographies, the defect was filled completely. |
A 14-year-old mentally challenged boy presented to our hospital with a swelling of the upper lip and the right side of his face for the past 3 days []. His parents accompanied him. The patient had a history of fits 10 days back following which he sustained fracture of the upper front teeth. Following extraction of the fractured tooth, he developed a wound in the same location that started to increase in size. He had severe and continuous pain over the wound. The parents also noticed worms in the mouth. The patient also has a history of seizures for which he is under medication. The patient was of a low socioeconomic status, poorly built, apprehensive and febrile. Diffuse swelling was seen over the right side of the face. Periorbital edema was present and the upper lip was swollen.\nIntraoral examination revealed a necrotic area in the maxillary anterior region involving the vestibular sulcus and labial mucosa extending from the right canine to the left canine, measuring 6 cm × 4 cm. A number of maggots were seen in the necrotic area []. The surrounding area was erythematous and swollen. The patient had poor oral hygiene. The teeth in the necrotic area 12 and 21 exhibited significant mobility, and 21 was decayed. Based on the clinical findings, the case was diagnosed as oral myiasis. Hematological analysis was within normal limits.\nThe treatment was performed by oral and maxillofacial surgeons of our hospital. The patient was hospitalized for 3 days. The treatment included flushing the affected area with turpentine oil followed by the administration of local anesthesia and manual removal of maggots with tweezers []. Around 50–60 maggots were harvested. Teeth 12 and 21 were extracted. The area was then washed with saline, followed by irrigation with betadine. Broad spectrum antibiotics amoxycillin with clavaualnic acid and ibuprofen with paracetamol were prescribed. This procedure was repeated again until the maggots were completely removed. The next day the edema had subsided considerably. The parents were given extensive environmental and personal hygiene instructions. The maggots were sent to a Veterinary Parasitology Department in Chennai Veterinary College for identification. The maggots were 12–15-mm long, whitish and without obvious body processes. The peritreme of the posterior spiracle was open and the anterior spiracle had four to six lobes. These features were compatible with Chrysomya bezziana larvae. The larvae were thus identified as Chrysomya bezziana species. The wound was left open to heal by secondary intention []. The patient was reviewed 1 week later and the results were satisfactory. |
A 34-year-old man was referred to our hospital in May 2014 with a history of pain and swelling of the right hand for a duration of 3 months. The patient sustained an electrical shock to the right hand while repairing a domestic electrical appliance. He denied any cutaneous injury, loss of consciousness or injury to any other body part due to the electrical shock. He noticed pain in his right hand within one week of injury, which was treated with analgesics without relief. He noticed a subsequent swelling, deep aching pain, cutaneous hypersensitivity and discoloration of the right hand. The patient denied aggravation of symptoms during exposure to cold or any diurnal variation of the symptoms. The patient indicated severe pain, which he rated as 9 on a 10-point visual analogue scale (VAS). He was treated with a short course of oral prednisolone with physiotherapy at a peripheral hospital, but the improvement was not significant. The patient is employed as an infantry soldier, and the condition prevented him from being able to handle any weapons. He was also unable to use his right hand for activities of daily living. The patient denied alcohol consumption or tobacco use, and his previous medical history was unremarkable. Examination revealed stable vital parameters, and systemic examination was unremarkable. His right hand was markedly tender, hyperemic with diffuse swelling and cutaneous hypersensitivity (Figure ). Other vasomotor changes were absent, and the radial pulse was normally palpable on the right side. Muscle atrophy was not apparent, and there was generalized weakness of the hand muscles, likely because of the reduced effort by the patient.\nHis hematological and biochemical parameters were all normal, including the C-reactive protein, creatine kinase, calcium, phosphorus, alkaline phosphatase and 25-hydroxy vitamin D levels. A nerve conduction study and electromyography of the left upper extremity showed no evidence of neuropathy or myopathy. A Dual Energy X-ray Absorptiometry (DEXA) scan revealed a significant reduction in bone mass of the right side (0.47 g/cm2) compared to the left (1.1 g/cm2) side (Figure ). He was diagnosed as a case of CRPS type I based on the clinical features, and he was treated with Zoledronic acid (4 mg, intravenously once monthly). Zoledronic acid was considered the best option in our patient because of the failure of conventional therapies, including analgesics, glucocorticoids and physiotherapy. He experienced partial pain relief over the next 7 days, and he rated the current pain as 5/10 on the VAS. He was given a repeat injection of Zoledronic acid after one month, and the pain during the last follow-up was reduced to 2/10 VAS with a complete reduction of the swelling. He started handling and firing fire arms last month, but he is unable to use his right arm completely for all activities. Currently, the patient has no resting pain, and he is able to use the right hand for all activities of daily living. However, the patient has mild pain during prolonged use of the hand, and he is unable to lift heavy objects using the right hand. We did not evaluate the upper hand disability initially with an objective assessment for comparison after treatment. Currently, the patient has no resting pain, but he has minimal pain with prolonged use of the limb muscles. A repeat DEXA scan at the end of 3 months revealed minimal improvement in bone mass (0.78 g/cm2) on the right side. |
A 55 year-old man had previously undergone radiochemotherapy (5FU-CDDP-based) for a double localization of a locally advanced SCC of the upper and median 1/3 of the oesophagus. A complete response had been established in 2002. One year later, follow-up endoscopy revealed recurrences on both initial sites, without significant symptoms. On EUS, the upper tumor was graded T1N0 and the lower tumor appeared to infiltrate the muscularis propria, without evidence of lymph node involvement. Both tumors did not exceed 4 mm in thickness. It was decided to attempt ultrasound therapy. A first treatment session was undertaken with decreased power output in order to prevent transmural necrosis and possible fistula. At control endoscopy at 8 days, there was no evidence of tissue ablation and biopsies showed persistence of carcinoma cells. A second treatment session was subsequently proposed, with the same treatment parameters. The control endoscopy 10 days after this second treatment demonstrated non significant change and still positive biopsies. Three months later, the patient presented with mild dysphagia and a moderate weight loss. On the patient's request, a 3rd treatment session was decided; since the tumor thickness had increased in the meantime to reach a maximum of 7 mm, usual treatment parameters were applied. Recovery was uneventful, a mild cervical pain requiring 2 g paracetamol IBD during 3 days was noted, and dysphagia disappeared completely within 10 days, along with an improvement in the patient's performance status. Control endoscopy at 10 days showed a complete necrosis of the proximal lesion (Fig. ) and an estimated 90% necrosis of the more distal one were achieved after three ultrasound treatment sessions. At 1 month, the patient maintained the same performance status (Karnofsky 90%), had a steady weight and no dysphagia. Endoscopy showed no stenosis, an infiltrating, non-stenotic aspect of the distal lesion and a nearly complete regression of the proximal lesion. Two months later (3 months after the third ultrasound session), the patient presented with recurrent dysphagia and deteriorating general condition. He was admitted in a primary referral centre, where no endoscopy was done, and a complementary radiotherapy was discussed. During this hospital stay, a sepsis developed with a septic shock and coma. Blood cultures and cephalo-rachidian fluid were positive for E. coli sp., leading to the diagnosis of meningo-encephalitis secondary to a septicaemia of unknown origin. |
A 61-year-old woman was evaluated for complaints of severe headaches, nausea, and vomiting for 6 h. Her CT examination was negative and lumbar puncture confirmed a subarachnoid hemorrhage. The patient had a history of repeated angina pectoris at rest within 2 weeks. Her neurological evaluation showed normal and Hunt-Hess grade was I. Brain MRA showed two small aneurysms of the bilateral internal carotid artery. An ejection fraction of 40% was reported by cardiac echocardiography examination. After right femoral artery puncture, cerebral angiography showed a 3 mm un-regular aneurysm of the posterior communicating artery segment of the left ICA and a 2 mm aneurysm of the supraclinoid portion of the right ICA arising medially and inferiorly. The neck of the aneurysms was wide. []. The cardiac team performed a cardiac angiogram for further evaluation before the aneurysm treatment. Coronary artery disease was noted with critical disease in the proximal segment of the right coronary artery with 85--90% stenosis of the midcircumflex artery. Because of the combined problems of ruptured aneurysm and severe cardiac disease, the intervention teams decided to do concomitant coiling of the aneurysms and coronary artery stenting procedures. The anesthesiologist suggested that general anesthesia was risky because of the heart disease. The interventions were performed under sedation with consciousness. The patient was premedicated with a loading dose of 300 mg aspirin and 300 mg clopidogrel per oral. The posterior communicating artery aneurysm was coiled with a 3.5 × 15 LVIS stent (Microvention, USA) assistance. The paraclinoid ICA aneurysm was treated with the same technique. After aneurysmal embolization, the patient was premedicated with another loading dose of 300 mg clopidogrel. The cardiovascular intervention team performed the coronary artery stenting (drug diluting stent, 2 stents of 2.75 × 38 mm and 1 stent of 2.5 × 40 mm, Medtronic, USA) []. The total procedure time was 80 min. Postoperatively, the patient did not develop any neurological deficits and she has returned to all her independent activities at 3-month follow-up. |
A 34-year-old white male with the background of type 1 diabetes which was complicated by retinopathy and nephropathy (under hemodialysis since July 2014) scheduled for kidney transplantation and the surgery was done at April 2015 from a live donor (sibling). Opium addiction and hypertension from 2 years ago were other main points in his past medical history. In preoperative imaging (CT) the significant finding was heavily calcified mural atherosclerotic plaques in abdominal and iliac arteries.\nDuring surgery, the right internal iliac artery had severe atheromatous plaque which after endarterectomy was anastomosed to renal artery in an end-to-end fashion, with ligation of anterior and posterior divisions. Because of insufficient renal filling and no change in renal color, anastomosis was revised in the same location with acceptable outcome in color and firmness.\nIn recovery room he had an apnea with drop in oxygen saturation, which required resuscitation. He was then transferred to ICU and was under observation for the next 24 hours. After becoming stable, he was transferred to ward with no complication, although the urine output was <500 cc/day the whole time. Doppler showed normal flow in the transplanted kidney.\nOn postoperative day 2, he complained of pain and inability to move his right leg since the night before. On physical exam, there was an ischemic area 2 × 2 cm in diameter on the right hip. This ischemic area progressed to a large necrotic area 7 × 7 cm in the following days (). Neurologic exam revealed diminished strength in hip flexion (3/5) and knee extension (3/5) with 4/5 strength in ankle dorsiflexion and plantar flexion and toe extension. Sensation was poor in all the right extremity and the patellar and ankle reflexes were lost. He also had no urine and fecal control. EMG study documented profound sensorimotor polyneuropathy and right lumbosacral plexopathy. Lower limb Doppler US was unremarkable.\nOn the following days, because of expanding tissue necrosis, he underwent serial wound debridement. Meanwhile, the transplanted kidney did not function (humeral rejection) and was ultimately removed. In the following weeks, mild improvement was seen in motor control and continence and also the wound showed promising signs of granulation tissue ().\nUnfortunately the patient died three months postoperatively of sepsis induced multiple organ failure. |
A 50-year-old woman underwent a bilateral total hip replacement for rheumatoid arthritis in 1999. Subsequently, a revision total hip replacement on the right side was done in May 2007 using a cemented acetabular component along with a bone substitute. She presented to us 2 months after this acetabular revision with complaints of severe pain in right hip and an inability to bear weight. She was bedridden and had a Harris Hip Score of 4. X-rays [] and CT scan [ and ] revealed a failed acetabular component with a Type III b acetabular defect according to Paprosky classification. There was a pelvic discontinuity with superomedial migration of the acetabular component, break in Kohler's line, and complete loosening of the acetabulum at bone–cement interface.\nPreoperative workup including bone scan, ESR, and CRP showed no evidence of any infection. The acetabular revision was done in accordance to the technique described by Paprosky et al.\nThe hip joint was exposed using the posterior approach. The acetabular component was found to be lying loose. A thorough debridement revealed a large combined cavitary and structural defect along with pelvic discontinuity and loose pieces of bone mineral substitute lying in the defect area. After debridement and removal of the components, synovial white blood cell counts, gram staining of specimens of synovial fluid, and histological examination of frozen sections of inflammatory tissues were performed, and these excluded the possibility of infection.\nAll acetabular membranes were removed until the acetabular rim was completely exposed and bleeding bone encountered. An irradiated (25 kilogram) fresh frozen hemipelvis was procured from the bone bank. This allograft was thawed in povidine iodine and normal saline solution.\nThe acetabular allograft was shaped to buttress the host bone. The superior pubic and ischial rami of the graft were cut at a point distal to the acetabular confluence with a length remaining to fill the defects in the host pelvis. The iliac crest of the allograft was cut in a curvilinear manner from the greater sciatic notch to the anterior inferior iliac spine. Repeated fitting and trimming of the graft was performed to ensure the appropriate amount and placement of bone resection.\nA tongue was created in the remaining rim of the host acetabulum. A groove was created in the medial aspect of the acetabular allograft using a burr [ and ]. Such a tongue-in-groove mortise ensures an optimum contact and stability of the construct and also helps in union of the graft to the host. The acetabular allograft was held in a bone vice and reamed to remove the cartilage and minimum amount of subchondral bone. Morselized allograft was harvested from the remaining hemipelvis and packed into the defect.\nThe acetabular allograft was seated in place and manipulated to ensure that it lay in its most stable position. After further trimming the graft, it was impacted using an acetabular impactor to ensure a press fit in the tongue and groove mortise. Large-fragment, partially threaded cancellous-bone screws were placed in the superior rim of the iliac bone of the allograft to lag it to the thin iliac wing of the host allowing a bicortical purchase.\nA Burch Schneider reconstruction cage (Zimmer, USA) was used to augment the fixation of the allograft. The acetabular allograft was then fashioned to ensure the support of cage along the posterior column. A cage with a diameter of 50 mm was chosen, as it allowed intimate contact with the host, and more importantly with the graft without over reaming and possible weakening of the bone.\nThe cage was then manipulated into position and fixed to the allograft bone and the remaining host bone using screws in the dome and iliac flange of the cage to ensure close approximation of the host bone and the allograft. An acetabular liner (size 47 mm) was then cemented into the cage. The morselized allograft was also impacted into the remaining defects and into the junction between the host and the allograft.\nThe femoral stem was not revised as it was found to be well fixed. A 28-mm femoral head with short neck length was implanted on the stem and a stable reduction was achieved [Figure and ].\nPostoperatively, the patient was kept from weight-bearing for 6 weeks. The patient was then mobilized toe-touch weight-bearing for another 6 weeks and progressive weight-bearing was started thereafter.\nAt a follow-up of 1 year and 3 months [], the allograft had united with the host bone and there is no evidence of any loosening, osteolysis, or resorption around the allograft. The patient is walking unaided and has a Harris Hip Score of 88. |
A 70-year-old male patient was presented to us with a huge swelling measuring 35 cms in greater dimension arising anteriorly from the neck more on the left side which was hanging up to the umbilicus (). The swelling was painless, slow growing and had acquired the present size in approximately 20 years. There was no history of treatment in the past. Patient was completely asymptomatic, except for ulceration of the overlying skin. On palpation, the swelling was smooth, painless and non-tender. Skin over the swelling was stretched, shiny and showed ulceration over the lower most part. There was no lymphadenopathy or any other palpable mass.\nENT examination of the patient was normal. Thyroid hormonal evaluation showed no abnormality. On ultrasound, the “mass” was iso-echoic with subcutaneous fat. It laid in front of the left lobe of the thyroid which was normal in size and echogenicity and moved freely with swallowing under the mass. The mass appeared to have an ill-defined capsule with several thin echogenic septa seen coursing through the substance of the mass. The ultrasound findings were suggestive of a soft tissue lesion. Computed tomography (CT) scan of the neck showed a hypodense mass in the left side of the neck with fat density, measuring 17×9 cm with multiple internal septations.\nIt originated in the left anterior triangle of the neck and extended up to the upper chest cavity. The mass was seen to be causing mild pressure effects with displacement of left parapharyngeal and oropharyngeal spaces. The trachea and the major vessels were displaced to the right and both the lobes of the thyroid seemed normal. Findings were suggestive of a soft tissue lesion possibly lipoma. A fine needle aspiration was performed and samples were taken from multiple levels of the swelling for adequate and representative cytological material.\nAll cytological smears yielded mature adipose tissue fragments. In view of ultra-sonographic finding and CT evaluation, a diagnosis of giant subcutaneous lipoma of neck was made (). A complete removal of the mass was further advised. On surgery, a skin crease incision was made, and a large lobulated fatty mass was removed from the subcutaneous plane. The base was ligated and cut, and the mass was removed completely. A large flap of overlying skin was also removed. There was no localized lymphadenopathy or adherence to the surrounding tissues.\nOn gross examination, excised specimen was yellow in color and lobulated in appearance. It measured 32 cm in the longest diameter and weighed 2500 grams; parts of the thin capsule could be seen over the resected specimen (). Overlying skin flap showed ulcerations (). Exhaustive sampling of the specimen was done and on microscopy it showed capsulated mature adipose tissue with lobular appearance (). There was no evidence of malignancy or heterologus element in multiple microsections studied. A final diagnosis of giant anterior neck lipoma with pressure ulcer was made. |
A 5-year-old boy presented with prominence of the right eyeball since the past 5 months. There was a past history of the parents noticing whitish reflex in the right eye since past 1 year. There was no positive family history. Examination under anesthesia revealed the right eye to have proptosis of more than 8 mm with extraocular mass, and anterior segment details were all obscured []. The left eye anterior segment was normal and the fundus showed a 4 × 3 × 2 mm partly calcified tumor in the supero-nasal periphery and a 1 × 1 × 1 mm fully calcified regressed tumor in the infero-temporal periphery. Computed tomography (CT) scans were classical of a bilateral retinoblastoma with right eye extraocular and optic nerve extension. However, there was no intracranial extension []. A systemic workup including bone marrow biopsy and cerebrospinal fluid (CSF) analysis was done. Bone marrow was positive for tumor deposits of malignant round cells. The cells were small with scant rim of cytoplasm and a round hyperchromatic nucleus with prominent nuclear molding. The CSF cytology was within normal limits. Based on this, a diagnosis of metastatic retinoblastoma stage IV a (distant metastatic retinoblastoma without CNS involvement) was made. The patient was started on a 3-weekly high-dose chemotherapy protocol with vincristine, etoposide and carboplatin (VEC regime). Following four cycles, the right eye proptosis resolved and there was atrophic bulbi with total vascularized corneal scar. The left eye tumor regressed completely.\nThe patient was then lost to follow-up and again presented with mild proptosis in the right eye. Examination under anesthesia revealed right eye upper periocular edema and numerous firm and tender swellings on the forehead and scalp [] with large areas of thin scleral ectasia. Left eye was found to have regressed tumors. CT scans showed the right eye to have similar findings as noted in the initial visits, but in addition, there was diffuse heterogeneous mass involving the frontal bones and the superior orbits with diffuse, irregular bony erosions []. Fine needle aspiration cytology (FNAC) of the forehead lesion, bone marrow biopsy and CSF analysis were done. Bone marrow biopsy and FNAC were positive for tumor deposits of malignant round cells []. The systemic condition of the child was poor. An impression of extensive skeletal metastasis was made and the patient is currently on a palliative chemotherapy with high dose of vincristine, etoposide and carboplatin. At current follow-up of 4 months following palliative therapy, the patient is stable. |
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. |
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. |
A 68-year-old man was brought to the emergency room with pelvic pain after an accident with a motorcycle. No open wound was observed on pelvic examination and the patients had no tenderness on the anterior pelvis. However, the patient complained from severe tenderness on the lumbosacral junction with limited mobility due to extreme pain. Motor and sensory functions and circulation of the lower extremity were normal without any neurological symptoms. In the plain radiographs, bilateral vertical fractures were observed on the upper aspect of the first sacral foramen (). In three-dimension reconstruction computed tomography (CT), bilateral vertical fractures on Zone II of the first sacrum with communition of the anterior cortex was observed. This U-shaped fracture passed through the first sacral foramen to connect through the first and second sacral vertebrae (). This sacral fracture of spino-pelvic dissociation was relatively stable because the comminuted fragment was small and not displaced. To achieve early ambulation, we scheduled percutaneous iliosacral screw fixation.\nUnder general anesthesia, the patient was placed on a radiolucent table in the supine position with pelvic support using multiple layers of operation drapes on the sacral region to relax the gluteal muscles. A true lateral image of the pelvis was obtained with an overlap of both greater sciatic notches using a C-arm image intensifier. After localizing the safe area, a 1-cm incision was made on the left gluteal area on the central upper part of the first sacrum and posterior to the ilio-cortical line in the lateral image. Muscular areas were widened with a straight hemostatic forceps to reach the outer cortex of the iliac bone. Then, a guide pin sleeve was introduced to reach the outer cortex of the iliac bone to subsequently place a horizontal 3.2-mm-sized guide pin on the safe area of the first sacrum (). It was then passed through the opposite side of the first sacral body under monitoring of the pelvic inlet and outlet views with a C-arm image intensifier. In sequence, a 1-cm skin incision was made on the corresponding right gluteal area and a guide pin sleeve was inserted using the same method. A guide pin was placed 7 mm posterior and inferior to the left guide pin (). It was completed with insertion of the pin into the opposite side of the first sacral body under C-arm guide (). In the next step, reaming was performed along the right postero-inferior guide pin with a 5 mm cannulated reamer (), bright red arterial bleeding was noted when the reamer was retrieved. The bleeding site was packed with gauze but the bleeding could not be controlled. Since the vital signs of the patients were stable, a full threaded 120-mm-long, 7.0-mm-diameter cannulated screw (Zimmer®, Warsaw, IN, USA) was inserted and gauze packing was applied. A same size cannulated screw was inserted towards the center of the first sacral body through the guide pin that was introduced from the opposite side. After reaming, no arterial bleeding was observed on the left side (). The left incision was closed but arterial bleeding continued on the right side after removal of gauze. We tried to find the bleeding site by gentle exploration, which turned to be unsuccessful. Therefore, the incision was temporarily closed after gauze packing and the patient was immediately transferred to the angiography room.\nThrough the left femoral artery, a guide catheter was introduced along the right internal iliac artery to perform right superior gluteal artery angiography. Arterial bleeding was localized to the upper branch of the deep branch of the right superior gluteal artery (), which was adjacent to the insertion site and the extension line of the right iliosacral screw. Arterial embolization and bleeding control was achieved by coiling of the deep branch of the right superior gluteal artery (). The patient had well-controlled vital signs throughout the whole procedure. Post-operative AP, inlet/outlet and lateral pelvic radiographs confirmed proper-positioned iliosacral screws on both sides. No fracture displacement was seen (). In CT imaging, both iliosacral screws were not invading the first sacral foramen and were positioned in the safe area. Screws had passed the opposite side of the sacral fracture but had not crossed the opposite sacral wing. The left antero-superior iliosacral screw was positioned from the postero-superior aspect of the left iliac cortex along an antero-inferior direction towards the opposite sacrum. The right postero-inferior iliosacral screw was laid from the antero-inferior aspect of the right iliac cortex along a postero-superior direction towards the opposite first sacral body. Three-dimension reconstructed CT angiography showed that the head of the right side screw is in close proximity to the deep branch of the superior gluteal artery (); however, there was comparatively more space between the screw head and the deep branch of the superior gluteal artery on the left ().\nOn the following day, right-sided packed gauzes were removed under local anesthesia and no bleeding was noted. The skin incision was closed and the patient recovered without any noticeable complication. |
A 47-year-old female patient with history of osteoporosis presented with severe low back pain refractory to conservative analgesic therapy. Her past surgical and family history was otherwise non-contributory, and physical examination revealed lumbar pain with palpation and paraspinal tenderness from L2 to L4. A lumbar radiograph revealed a vertebral fracture and degenerative disc disease. Magnetic resonance imaging (MRI) confirmed a compression fracture of the L2 vertebral body with 40% height loss.\nThe patient subsequently underwent elective percutaneous vertebroplasty for vertebral body augmentation and stabilization of the compression fracture. The procedure was performed under conscious sedation and local anesthesia by a bipedicular approach with fluoroscopic guidance. Opacified PMMA cement (6 mL) was slowly injected into the L2 vertebral body until good filling in a symmetrical fashion was observed. The bones of this osteoporotic vertebra were very soft, and the needle was readily guided into the vertebral body. The patient was discharged from the radiology suite in excellent condition, and her postoperative course was uneventful.\nFour years later, the patient developed a respiratory infection, and chest radiographs revealed an incidental finding of multiple dense linear and branching opacities bilaterally (). Non-contrast chest computed tomography (CT) confirmed the presence of tubular high-attenuation material within the right lower lobe pulmonary artery and its branch vessels as well as a small linear high attenuation focus within the anterobasilar aspect of the left lower lobe (). There was also high attenuation material filling a portion of the left lumbar vein adjacent to the second lumbar vertebra extending up to its junction with the inferior vena cava.\nBased on the clinical course, the history of vertebroplasty, and the imaging characteristics, the diagnosis was pulmonary cement emboli following venous cement extravasation. Given that the patient has been asymptomatic without complicating pulmonary features, prophylactic anticoagulation was thought to be unnecessary. Interval surveillance imaging demonstrated no change in the position and size of PMMA to date, and the patient has done well without any long-term consequences. |
A 28-year-old Caucasian male was brought to the emergency department (ED) by his wife and parents due to sudden onset, intense suicidal ideations. He had no significant past medical or psychiatric history except for a 6-month history of depressed mood and anxiety in the context of several stressors in his family and at work. The family reported that the patient developed blunted affect and significantly reduced vocalization over those 6 months. He did not have any prior history of suicide attempts or psychiatric diagnoses or hospitalizations. He reported drinking 3 beers up to 4 times a week but he denied any other history of substance abuse or any family history of psychiatric problems. Following the evaluation at the ED, the patient was admitted to the inpatient psychiatric care unit with suicide precautions. During the initial inpatient evaluation, the patient reported feeling depressed and anxious, as well as having episodic nightmares once every few months due to having witnessed many scenes of death as a firefighter, including a suicide by hanging and violent car wrecks. He reported that, for the previous 3 months, he had been having thoughts about killing himself which was worsened with seeing firearms, razor blades, or pocket knife. He reported that the thoughts of suicide started after witnessing the carnage of a car wreck 3 months before. Earlier in the day, prior to admission, he had held an unloaded gun to his head, which was witnessed by his family and was the ultimate reason the family brought him to the ED. He also reported not being able to relax, feeling on edge, and feeling like he should always be doing something. All potential medical or substance related causes of the patient's psychiatric condition were ruled out. The initial list of differential diagnoses included major depressive disorder (MDD), bipolar disorder, and cyclothymia (due to the reported symptoms of depression and impulsivity). The patient's progress through the initial hospital admission is outlined in . The patient was ultimately discharged with olanzapine, divalproex extended release, prazosin, clonazepam, and appointments for a therapist and an outpatient psychiatrist.\nTwo days after being discharged from the inpatient psychiatric care unit, the patient was readmitted with continuing suicidal thoughts which he was unable to control. The patient reported that, during the previous admission, he had told the clinical staff that his symptoms were improving so that could be discharged from the hospital. During the ensuing interview, the patient described in a greater detail the nature of his suicidal thoughts. He reported that he was having sudden onset, intense, recurrent (5-6 times a day), short lasting (a few minutes each), anxiety provoking, unwanted, and distressing thoughts of committing suicide for the past 3 months, since witnessing a car wreck. He reported that he did not believe that his family would be better off without him and that thinking about what his death would do to his wife also caused him significant anxiety and distress. He reported that he rapidly became overwhelmed and panicked with each intense thought of suicide. The patient's social and occupational life was significantly affected due to the obsessive thoughts, becoming more isolated from his family members and skipping work due to fear of triggering suicidal obsessive thoughts. The patient denied any compulsive rituals or repetitive behaviors to reduce the anxiety in relation to obsessive suicidal thoughts. However, he did report trying to block those thoughts by distracting himself, attempting to redirect his thoughts, or seeking reassurance from his family. He expressed a sense of hopelessness and helplessness regarding the intrusive suicidal thoughts. He also reported low self-esteem and negative self-image due to his inability to control those distressing thoughts. He said, as the thoughts continued to return, he did think about acting on those thoughts to make them stop. At the same time, he noted that harming himself was not something that he wanted to do and that he wanted to get help so that he would not actually do so. Once again, all potential medical or substance related causes of the patient's psychiatric condition were ruled out and according to the Diagnostic Statistical Manual of Mental Disorders, 5th ed. (DSM-V), the patient was diagnosed with OCD with obsessive suicidal thoughts without compulsions.\nThe patient was started on a pharmacotherapy regimen including sertraline 25 mg oral tablet once daily for OCD, PTSD, and MDD, olanzapine 10 mg oral tablet at bedtime for impulse control, and clonazepam 0.5 mg oral tablet three times a day for anxiety. In the ensuing days, the patient was treated with exposure and response prevention (ERP) therapy, an effective cognitive-behavioral therapy for OCD. During the ERP therapy sessions, the patient was instructed to focus on a suicidal thought, report the level of anxiety to the therapist, and avoid calling for an ambulance or calling his wife for reassurance. The patient's anxiety levels were high during the initial sessions of ERP. Motivational interviewing techniques were used to provide encouragement and support in helping the patient continue the therapy. Once the patient's anxiety was decreased and the thought became nondistressing, the patient was encouraged to focus on a different suicidal thought and continue pondering on those thoughts within the ERP therapy regimen, until the thought was no longer distressing. The patient received multiple ERP sessions during the hospitalization, each with different types of suicidal thoughts. Later ERP sessions included cues to more disturbing suicidal thoughts. By the end of the hospitalization, the patient reported a change in his relationship with the obsessive suicidal thoughts and learned that he did not have to engage in suppression or avoidant strategies when those thoughts occurred.\nOver the next several days, his sertraline dose was also gradually increased to 150 mg once daily. The patient continued on sertraline, olanzapine, clonazepam, and individual CBT. He reported a decrease in the occurrence of his obsessive suicidal thought, decreased distress when it did appear, and no further need for avoidant behaviors related to the thought. The patient gradually became more verbal, his affect returned to full range, and he actively began participating in group therapy sessions. The clonazepam was tapered off and the patient was discharged on hospital day 8, with sertraline and olanzapine. He was scheduled for follow-up with an individual therapist to help him continue to develop skills to better manage his anxiety and obsessive suicidal thoughts. |
A 21-year-old male reported to the dental office, who was in need replacement of missing anteriors. He had a history of an accidental fall when he was 9 years of age, following which he had lost all the maxillary anterior teeth with dento-alveolar fracture of the maxilla. Three years ago, he underwent replacement with a fixed partial denture fabricated in metal with acrylic facing. For the past 6 months, the prosthesis underwent repeated dislodgement due to the cementation failure (). On examination, there was missing maxillary anterior teeth, right and left first premolars had been prepared to receive a fixed partial denture. The attached gingiva thickness measured about <3 mm and there was a reduction in the labial vestibular depth. The maxillary premolar teeth were pulpally and periodontally healthy.\nWith the background of the examination findings, the treatment plan for a fixed removable prosthesis was developed for the patient. The mounted diagnostic casts with facebow transfer provided visual appeal of the existing smile and about the plan for the prosthetic smile (). Diagnostic wax-up of the finished prosthesis was made with wax with incisal guidance kept as close to zero as possible. Try-in of the metal framework was carried out and pick up impression was made with putty (condensation silicone) and sent to the lab, for the fabrication of removable partial denture ( and ). Putty indices were made and sent to the laboratory along with the diagnostic wax up and hence that the metal framework of the bar could be fabricated within the substance of the removable acrylic segment.\nThe fixed part had metal ceramic crowns cemented to the prepared premolar teeth with a Hader bar over the edentulous ridge with adequate tissue relief (). Final try in of the fixed and removable segment of the prosthesis was carried out. The removable partial denture was a conventional removable partial denture without a palatal extension which would anchor over the bar by means of retentive clips, which were fabricated chair side using auto polymerising acrylic resin ( and ). The patient was trained to remove and insert the prosthesis. He was also encouraged for periodic recalls and checkups for the maintenance of the prosthesis and the components. Follow-up in the 1st month revealed that he was extremely happy with the esthetics and able to use the prosthesis for chewing and other routine functions with ease ( and ). |
In March 2008, a 4.5 year old female child who presented with sudden onset of left leg pain and limping over the last 10 days was admitted with impression of osteomyelitis. She did not have any history of trauma. Her appetite and weight were normal for her age. There was no history of fever. She had no other skeletal or joint complaints. She did not suffer from any major medical problems, either. She was afebrile and her general condition was goodl. A mild swelling, tenderness, hotness and pain on motion were detected in her right leg, and in otherwise general physical exam including skin and neurological exam she was normal. There was no family history of skeletal problems.\nFull blood count, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were normal. Blood culture was negative for pyogenic organisms. X-ray of her left leg revealed periosteal reaction of diaphysis of left tibia with soft tissue swelling (). Isotope bone scan revealed increased uptake on the late films along the left tibial bone (). Antibiotic therapy was started and open biopsy and curettage was performed. Cultures of bone specimen did not yield any organisms. Pathologic evaluation of the samples, reported the inflammatory changes and fibrosis which were consistent with subacute and chronic inflammation and there was no evidence of neoplasia. After 10 days, the clinical signs and symptoms of the patient resolved. The patient was followed in out-patient clinic as a case of chronic osteomyelitis and received oral clindamycin.\nIn September 2008, she was readmitted due to limping and pain on the left leg and clindamycin continued intravenously. She was afebrile. A tenderness on the left leg and mild tenderness in the left arm were detected in physical examination. Full blood count, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were again normal. Blood culture was negative. Isotope bone scan revealed active bony pathology in nearly all parts of the left humerus and left tibial shaft (). MRI of the left leg revealed a significant increase in signal intensity on STIR sequence at the shaft of the left tibial bone and extension of signal change into distal metaphysis of bone and evidence of significant inflammatory change in deep soft tissue structures around the tibial bone. MRI of right tibial bone showed an increase in signal intensity on STIR sequence at the mid shaft, however, there was no evidence of inflammatory change in the surrounding soft tissue structures (). There was no evidence of collection or abscess formation in the soft tissue structure of the right leg. Bone biopsy of the left tibia did not reveal any organism and pathologic findings were compatible with chronic inflammation. Acid fast and KoH staining were negative. Immunological work ups including immunoglobulin levels, CH50, nitroblue tetrazolium test and flow cytometery for white blood cells were normal. Serology for HIV was inconclusive. Based on the history and physical examination findings, the patient was diagnosed as a case of chronic recurrent multifocal osteomyelitis (CRMO). Accordingly, clindamycin was stopped and non-steroidal anti inflammatory medication (ibuprofen) started. She did not exhibit recurrence of pain in any her limbs and no sequella was developed during the 18 months follow up. |
A 30-year-old male visited our hospital for evaluation of both eyes. Four years ago, he experienced visual deterioration after drinking a 20% alcoholic beverage (soju) contaminated with methanol. One day after a single shot of this alcoholic beverage, visual symptoms began to occur, and he presented to a university hospital the next day. His initial visual acuity in both eyes only allowed for visualization of hand motion, and no light reflex was observed. Initial intraocular pressure was 18 mmHg by Goldmann applanation tonometry in both eyes. Depth of the anterior chamber was deep, and all quadrants of angle were opened by gonioscopy in both eyes. There were no signs of uveitis on slit lamp exam. Cup/disc (C/D) ratio of both eyes was about 0.5. There were no specific fundus findings except for edema of both optic discs (). Laboratory studies showed metabolic acidosis and mildly elevated methanol levels in his serum. He had no significant past medical history and no other physical symptoms besides visual deterioration. He had no home medications, including eye drops. After initial conservative treatment, he was lost to follow up. On presentation to our hospital 4 years later, he wanted an evaluation of both eyes. His visual acuity still only allowed for visualization of hand motion in both eyes and was not corrected. No nystagmus was found in either eye on the optokinetic nystagmus test. The intraocular pressure was 15 mmHg by Goldmann applanation tonometry in both eyes. He had not taken any other antiglaucomatous eye drops during the follow-up loss period. The pupils were dilated to approximately 4 mm, and direct light reflex was barely visible in either eye. No new vessels of the iris were observed on slit-lamp examination. Angles were open and no new vessels were observed on the iris or angles by gonioscopic exam in either eye. From red free photographs, diffuse retinal nerve fiber layer defects were observed in both eyes (). On fundus exam, optic discs were pale in both eyes, and C/D ratio of the right eye was 0.5. C/D ratio of the left eye was higher than 0.9, which appeared as glaucomatous disc cupping (). Filling of fluorescein in the optic disc did not appear in either eye on fluorescein angiography. The thickness of the retinal nerve fiber layer (RNFL) by optical coherence tomography (OCT) was 43.55 µm in the right eye, 43.57 µm in the left eye, which was less than 1% in normal distribution of all sectors around the optic disc (). The left eye was bigger than the right with respect to the cup area, C/D area ratio, horizontal C/D ratio, and vertical C/D ratio in OCT (). To rule out other reasons for the optic atrophy, brain magnetic resonance imaging (MRI) and visual evoked potentials (VEP) were performed. No special signals from the brain MRI were noted, and N75, P100, and N145 wave forms were not observed from VEP ().\nIn summary, the patient's intraocular pressures in both eyes were within normal limits on initial and follow up examination. There was no structural problem of the eyeball, including angle closure or new vessels of the anterior segment that could lead to glaucoma. The patient did not have any ophthalmological diseases such as uveitis, retinal vein occlusion, or diabetic retinopathy that could increase intraocular pressure. The C/D ratio of the right eye had been unchanged for four years. If his left eye had glaucoma, the C/D ratio of the right eye may have increased because normal tension or open angle glaucoma usually occurs bilaterally. Based on these findings, we concluded that methanol poisoning could have led to glaucomatous disc cupping in the patient's left eye. |
We encountered the case of a 63-year-old male with a past medical history of type 2 diabetes mellitus for 20 years, hypertension for 10 years, and coronary artery disease with percutaneous transluminal coronary angioplasty in 2008. He presented in January 2020 to a nearby hospital with complaints of chest pain where he was evaluated and on angiography was found to have triple vessel disease and appropriate stents were placed on February 5, 2020. He was then discharged home with changed medication. He was started on rosuvastatin 40 mg in place of his 20 mg atorvastatin and other medication changes as shown in Table .\nPost-procedure after a few medication changes, he traveled back to his hometown and first noticed progressive symmetric muscle weakness. At first, he was not able to walk or rise from his bed. He did not report any sensory loss or difficulty swallowing. He reported worsening fatigue, weakness, nausea, and decreasing urine output. He presented to his primary hospital where he was found to have acute kidney injury with a serum creatinine of 6.4 with hyperkalemia.\nHe then presented to our hospital where physical examination showed preserved higher mental functions, intact cranial nerves with visual defects, and normal sensory findings with reduced proximal muscle strength symmetrically in both upper and lower limbs (2/5) without any weakness of distal muscles in both upper and lower limbs strength (5/5). There were no fasciculations, swelling of the affected muscles, or skin rash. Muscle bulk was unaffected (4/5). Reflexes were universally weak. Other systems were within normal limits.\nThe course of progression of muscle weakness in relation to his serum creatinine phosphokinase levels and serum creatinine levels has been tabulated in Table . In view of severe renal failure and oliguria, he was initiated on hemodialysis through a temporary hemodialysis catheter and he was dialyzed on a schedule as shown in Table . Even after stopping rosuvastatin, he continued to be dialysis dependant for the next two weeks. His creatine phosphokinase levels steadily came down and his urine output gradually started improving after two weeks. His myopathy also improved significantly and he was discharged. On follow-up, his creatinine levels came to 3.8 mg/dl (Figure ) and he was weaned of hemodialysis. He was also advised not to take statins and discuss with his cardiologist for shifting him to an alternative lipid-lowering medication in the future if the need should arise. |
We report a case of a 29-year-old male patient with chief complaints were pain and instability on his left knee. He got injured when playing futsal with knee twisted externally. He suffered severe pain, swollen and difficult to walk. The magnetic resonance imaging (MRI) examination after the injury revealed ACL and PCL rupture of the left knee. He underwent arthroscopic surgical reconstruction for both ACL and PCL by previous surgeon. Two years after surgery, he felt instability, swollen knee without pain and no history of other trauma during the time after operation. On the physical examination we found posterior sagging and positive posterior drawer test as well as quadriceps active test. Anterior Lachman test for anterior cruciate ligament was negative.\nOn the MRI, we found failure of PCL graft with intact ACL. On the MRI and three dimensional CT scan, with more clear projection for bone structure, it was found that the tibial tunnel placement done in previous surgery was not placed on its anatomical position. The tunnel was placed too anterior to the PCL footprint ().\nSubsquently we performed the PCL revision reconstruction surgery. We performed the arthroscopic-assisted reconstruction surgery using transseptal portal approach. We avoided to use only the jig to guide us when tunnelling the tibia instead, we used additional technique to see the posterior aspect of proximal tibia clearly. In this case, we choosed to make a transseptal portal that penetrated from posteromedial side of the knee inside-out to the posterolateral side of the knee (). An incision was made on the posteromedial side of the knee with guidance of arthroscopic view and also transiluminatic arthroscopic light. Blunt obturator with sheath was inserted gently passed through intercondylar notch to posterolateral side of the knee and we made inside-out incision on it.\nDuring arthroscopy procedure, we found that the PCL was gone with small PCL remnant on femoral site. The ACL was still intact and adequately attached. We performed the reconstruction of PCL using peroneus longus tendon as the graft from the left ankle. When tunneling the tibia, we used jig guide for tibial tunnel placement, we also made a transseptal portal from medial to lateral in order to get better view of posterior aspect of the tibia ( and ). We used it as the graft because hamstring tendon was already used in previous surgery. showed post-operative X-ray of the left knee that tibial tunnel was revised to appropriate site of its footprint. The shadow of two endobuttons on the lmedial femoral condyle was seen because the endobutton of previous surgery was not removed. |
We present a case of a 24 years old pregnant woman, G2, P2, who was addressed to our department for a second trimester ultrasound scan.\nShe had one previous pregnancy 2 years before, complicated with late term preeclampsia. She did not receive prophylactic therapy with aspirin as none of the risk factors were identified at that moment. The male fetus was delivered by caesarean section at 38 weeks and 4 days of gestation. There was no history of twinning in her family, nor taking ovulation inducing drugs.\nObstetric ultrasonography showed a diamniotic dichorionic twin pregnancy, both fetuses alive, with discordant growth. Measurements for the first fetus were appropriate for 25 weeks and 4 days of gestation with normal amniotic fluid volume, whereas the biometry for the second one revealed much lower dimensions corresponding to 18 weeks and 4 days of gestation with low amniotic fluid volume. No fetal anomalies were seen. A Doppler scan showed increased pulsatility and resistivity indices in the umbilical artery for the growth restricted fetus (PI: 1.64, RI: 0.94, absent diastolic flow and sinusoidal pattern of the venous umbilical flow) ().\nIn these circumstances, counseling was offered regarding the potential unfavorable outcome for the pregnancy in general and especially for the second fetus, who already showed signs of distress.\nA second ultrasound scan, performed after 3 days, revealed a normal growing fetus appropriate for 26 weeks of gestation along with the second dead fetus.\nThe case was managed conservatively with regular monitoring of the maternal coagulation profile, along with intensive fetal surveillance for the surviving twin ( and ).\nLow-molecular-weight heparin in prophylactic dose was prescribed until the birth. Maternal monitoring included once every 2 weeks CBC and coagulation profile (PT, INR, APTT, and serum fibrinogen). All were within the normal limit until delivery. Fetal monitoring included an ultrasound scan every 2 weeks, and a nonstress test (NST), started at 32 weeks biweekly, which was all reactive.\nFour doses of 6 mg dexamethasone each, 12 h apart, were given for lung maturation at 32 weeks of gestation.\nAfter consultation with a pediatrician and anesthesiologist, the patient delivered by cesarean section under spinal anesthesia at 38 weeks and 5 days of gestation a live female fetus weighted 3100 g Apgar score 8 at 1 min and 9 at 5 min with good adaptation, as well as a second macerated female fetus of approximately 400 g ().\nThe dead fetus, with its very thin trivascular umbilical cord measuring approximately 20 cm in length and the placenta of 17 cm in diameter weighing 180 g were sent for autopsy, which showed no detectable cause for fetal demise.\nThe postpartum course was uneventful. Both the mother and the baby were discharged at the sixth postoperative day. |
A 47-year-old woman sought evaluation at our hospital for a palpable and occasionally painful lump that had been gradually increasing in size and it had persisted for three years in the left breast. The physical examination revealed a tender, movable, palpable mass in the left upper breast. Mammography demonstrated a well-defined, isodense mass in the left upper center quadrant (). A breast US exam showed three well-defined hypoechoic masses in the subcutaneous layer. The lesions had first been noticed three years previously, and at that time the lesions were thought to be benign masses such as epidermal inclusion cysts on breast US due to the imaging findings and their superficial location in the skin and subcutaneous layer (). It was recommended that the patient undergo routine follow-up. The current US examination demonstrated an apparent increase in the size of the masses as compared to that seen on the breast US examination performed three years earlier (), and the lesions were shown to be solid rather than cystic. The patient underwent an US-guided 14-gauge core needle biopsy for pathologic evaluation. The pathologic findings on core needle biopsy were consistent with an eccrine spiradenoma of the breast. A breast MRI exam using a dedicated bilateral breast coil showed low signal intensity on the T1-weighted images, low- to intermediate-signal intensity on the T2-wighted turbo spin echo images, high signal intensity on the turbo inversion recovery magnitude (TIRM) sequence and homogeneous enhancement on the gadolinium-enhanced T1-weighted images (). The patient then underwent surgical excision for pain relief and due to the potential for malignancy. The surgical specimen showed superficially located masses in the breast that each measured approximately 1 cm in size (). Microscopy demonstrated the presence of masses in the dermis without obvious continuity with the epidermis (). A histologic examination showed a characteristic biphasic population of outer small cells with darkly staining nuclei surrounding larger cells with pale cytoplasm and tightly packed cells arranged in a jigsaw puzzle pattern without epidermal connections (). A histopathologic examination confirmed the diagnosis of a benign, adnexal skin tumor in the breast, and this was all consistent with an eccrine spiradenoma. |
A 56-year-old Caucasian man presented from an outlying facility 2 h after acute onset of substernal chest pain at rest with diffuse ST segment depression. Sixteen years ago he had triple vessel CABG with two subsequent cardiac catheterization procedures and percutaneous coronary interventions in the last few years.\nOn presentation, the physical examination was unremarkable. Electrocardiogram had shown diffuse ST segment depression. Laboratory data were unremarkable, including cardiac biomarkers. He underwent cardiac catheterization with coronary and SVG angiography. It revealed severe native vessel coronary artery disease with 100% occlusion of all three native vessels. Left internal mammary artery graft to the left anterior descending artery was patent. SVG to right coronary artery (RCA) angiography revealed two aneurysms, one in the mid-body of the vein graft measuring 3 cm, followed by another 5 cm large aneurysm at the distal segment []. There appeared to be a leak of the contrast into the right atrium (RA) from the distal aneurysm. The aneurysm also had a posterior descending artery (PDA) runoff through the prior placed stent to the PDA at the anastomosis.\nThe patient was hemodynamically stable and reviewing the coronary anatomy we did not find any lesions that were amenable to intervention. He was monitored on the cardiac floor and had further imaging studies for better visualization of the SVG leak. A poorly defined right atrial mass was also appreciated in the subcostal view of the transthoracic echocardiogram for which he underwent a transesophageal echocardiogram (TEE). TEE revealed the aneurysm measuring 5.0 cm × 5.3 cm with Doppler flow within and extending from the structure into the RA []. A chest computed tomographic scan with contrast revealed a partially thrombosed aneurysm measuring 2.8 cm × 3.0 cm about 3.4 cm distal to the RCA graft origin and a large aneurysm measuring 5.0 cm × 4.2 cm distal to the first aneurysm both in the SVG to the RCA. The aneurysm also demonstrated a fistulous connection to the RA [ and ].\nThe cardiovascular surgical consultation was requested regarding further management options given the above findings. Percutaneous treatment including covered stent placement across the aneurysmal segments of the SVG was discussed. After a thorough discussion with the patient, he decided conservative management at the point. |
A 10-year-old male patient reported to the department of Pedodontics complaining of pain in the lower lip that began 15 days before. The patient’s medical history revealed traumatic injury to the upper anterior teeth in addition to a lower lip laceration due to a fall while playing approximately 10 months previously. However, at the time, no attempt was made to locate the fractured tooth fragment at the site of the accident neither by the patient nor by his parents. The patient consulted a nearby general medical practitioner for the soft tissue injury, and the lip laceration was sutured by the medical practitioner. Subsequently, the patient did not receive any treatment for the fractured upper teeth. For approximately 10 months, the patient did not feel any discomfort in the lip. Fifteen days before presenting at the clinic, the patient began to have pain in the lower lip. Clinical examination showed scarring and discoloration of the skin to the right of the midline of the external aspect of the lip [Figure ]. On palpation, a small hard mass was felt in the lip mucosa. Intraoral examination revealed an Ellis and Davey class II fracture involving the permanent maxillary right central incisor. Suspecting a foreign body, a radiograph of the lip was taken, which showed a radiopaque structure similar to that of the fractured tooth fragment [Figure ]. Based on the patient’s history and on clinical and radiographic findings, the present case was diagnosed as a case of embedded fractured tooth fragment in the lip following trauma. The embedding of the tooth fragment in the lower lip was explained to the patient, and its removal under local anesthesia was planned. A small incision was made under local anesthesia in the proximity of the hard mass, which exposed the embedded tooth fragment [Figure ]. The tooth fragment was completely removed followed by suturing with 3−0 black silk suture [Figure ]. Examination of the tooth fragment [Figure ] confirmed that it was a tooth fragment that had been embedded and undetected in the lip for almost 10 months. The patient was reviewed regularly, and healing was uneventful. The fractured tooth fragment was discarded, as the patient did not agree to the reattachment procedure. Later, the fractured upper anterior tooth was restored with composite. |
A 55-year-old female patient was brought to the emergency ward because of severe dyspnea and cyanosis and she went into the apnea state rapidly. During resuscitation and endotracheal intubation, an obstructing mass was seen in the laryngeal lumen and therefore she was intubated with great difficulty and then admitted to the ICU. She had dyspnea since 2 years, first in the exertional form and then even during rest. Six months before presenting with these symptoms she had a change of voice and dysphonia. When lying down on her right side, her dyspnea became more severe. She also complained of dysphagia but suffered no weight loss. She didn't smoke or drink alcohol and there was no history of infectious disease, or positive family history. During direct laryngoscopy and video laryngoscopy, a large and firm tumor was seen, filling about 90% of the intra laryngeal lumen. It was pink in color with a distinct and marked vascular pattern over its capsule ().\nThe pedicle of this mobile tumor was toward the lower parts in the larynx and could not be palpated easily. In the CT scan, the tumoral lesion was seen from the ventricle and above the base of the epiglottis ().\nThe excised tumor was an encapsulated tumor with a mucosal lining and its size was about 3.3 x 5.4 centimeters ().\nUpon microscopic description, groups of epithelial cells in a mixoid ground were reported ().\nAlthough the diagnosis of pleomorphic adenoma is easily possible with light microscopy in most cases, some special immunohistochemical stainings are also helpful (). Mitotic features are not common in the lesion. Pseudoepitheli- omatous hyperplasia in the mucosal lining of a mixed tumor in the oral cavity was reported in an article (). Also there is a report of myoepithelial carcinoma within a tumor accompanied by a pathologic diagnosis of a pleomorphic adenoma in the buccal mucosa (). Fortunately, there were no similar features in the pathologic description of the presented case. |
A 19-year old male presented to us in the outpatient department with complaints pain on lifting weight with the right arm, deformity and limited range of motion of the right elbow for five months. The patient had fallen down and sustained the injury to his right elbow while hanging from the rootlets of a Banyan tree, following which, he had pain, swelling, and deformity of the right elbow. He had sought treatment from a local bone setter for four weeks following which pain and swelling decreased, but the deformity and elbow stiffness had persisted, for which he attended our hospital.\nOn examination, the Beighton hyperlaxity score of the patient was 5/9. There was flexion deformity of the elbow joint and wasting of muscles of the arm and forearm. The olecranon process was displaced from the olecranon fossa of the right humerus and an abnormal bone mass was palpable on the anterior aspect of the distal humerus. There was a flexion deformity of 40 degrees of the elbow joint with further flexion of 70 degrees. Pronation and supination were normal. There was a valgus laxity of the right elbow joint. The differential diagnoses were neglected dislocation of the elbow joint (posterior/anterior) and mal-united supracondylar fracture.\nAntero-posterior and lateral radiographs of right elbow demonstrated an anterior dislocation of the elbow joint with an anterior bone mass at the distal humerus. The bony anatomy of the elbow appeared unclear on radiography, and a Computed Tomogram (CT) with 3D reconstruction () confirmed an anterior dislocation of the right elbow joint with a bony projection from the anterior border of the distal humerus. We hypothesised that because of hyperlaxity the patient had sustained anterior dislocation of the elbow joint without associated fracture. Massage and attempts to reduce the elbow joint by the bone setter had led to the formation of a heterotopic bone mass on the volar aspect of the humerus.\nWe performed an open reduction of the elbow by combined medial and lateral approach based on findings of the CT scan. We were successful in excising the bone mass but failed to reduce the elbow joint. There was some early degeneration of the articular cartilage of the distal humerus and olecranon. It was impossible to reduce the olecranon posteriorly. We extended the approach through the subcutaneous plane to the posterior aspect and performed an olecranon osteotomy. The humerus was reduced into the osteotomy, and it was fixed with tension-band wiring. Indomethacin was started at 25mg eight hourly after surgery for three weeks after the operation. We did not immobilise the elbow and started active assisted mobilisation of the elbow joint after surgery as tolerated by the patient. The patient was discharged after wound inspection on the 5th post-operative day and advised to attend the rehabilitation department for physiotherapy for six weeks.\nAt review one year postoperative he had a painless range of motion of 30 degrees to 120 degrees at the elbow joint. He has excellent pronation and supination and could perform light activities. The olecranon osteotomy healed well () though there was a reduction in the joint space of the elbow. |
A 79-year-old female presented with progressive deterioration of her cognitive function over a period of 10 months. She became bedridden and was referred to our department due to convulsive seizure. She scored only three points with a mini-mental state examination (MMSE) at the time of admission. Magnetic resonance imaging diagnosed prominent DAVF in the right transverse sinus. Numerous flow voids corresponding to varicose veins were observed over the superficial and deep surfaces of the brain. A subsequent diagnostic angiogram showed DAVF at the junction of the right TSS fed by several branches originating from the right external carotid artery, involving the middle meningeal artery, occipital artery, posterior auricular artery, and accessory meningeal artery. The tentorial artery arose from the right internal carotid artery also fed the fistulae [Figure and ]. The right sigmoid sinus and left transverse sinus were occluded. The patency of the right jugular bulb and an internal jugular vein was obscured by the angiogram. Retrograde venous drainage was directed toward the straight and superior sagittal sinuses. Markedly dilated cortical veins were noted. A reverse flow was primarily observed in the dilated left superficial middle cerebral vein toward the cavernous sinus and vein of Labbe toward the left sigmoid sinus [Figure and ]. The DAVF was diagnosed as Cognard Type IIa + Type IIb and Borden Type II.[]\nThe cerebral circulatory disturbance was due to venous congestion, which was caused by TSS DAVF and bilateral venous sinus occlusion []. The clinical symptoms of the patient were considered to be due to this cerebral circulatory insufficiency, and therefore sinus restoration may be a more preferable treatment than TAE or TVE to improve the cerebral venous return. Considering the sinus restoration strategy, we performed computed tomography (CT) venography preoperatively, which precisely revealed an occluded segment [] and the right jugular bulb and internal jugular vein were both patent. The patient and her family were thoroughly informed of the nature of the intended procedure; they understood its potential risks and benefits and agreed to the treatment. The patient was given 100 mg of aspirin and 75 mg of clopidogrel daily, started 7 days before the intervention.\nThe endovascular procedure was performed under general anesthesia. Bilateral groin access was used. A 4-French diagnostic catheter was advanced into the right external carotid artery to obtain the diagnostic angiograms and roadmaps. An 8-French guiding catheter (Launcher; Medotronic Inc., Minneapolis, MN) was advanced into the right internal jugular vein, and a 0.035” guidewire (Radifocus; Terumo, Tokyo, Japan) over a 4-Fr diagnostic catheter was successfully penetrated through the occluded portion and advanced to the right transverse sinus. Subsequently, the Radifocus wire was replaced with a 0.014” micro guidewire (Chikai; Asahi intecc, Aichi, Japan), which was advanced to the superior sagittal sinus. Balloon angioplasties (Gateway 3 mm × 12 mm; Stryker Neurovascular, Fremont, CA) were repeatedly performed from the distal (closer to the torcula) to the proximal (further from the torcula) portion. A subsequent angiogram showed that antegrade venous flow was restored [], and an additional balloon angioplasty (Bandicoot RX 6 mm × 40 mm; Kaneka, Osaka, Japan) was performed at the lower part of the sigmoid sinus []. Next, a self-expanding stent (Precise 8 mm × 40 mm; Codman, Raynham, MA) was deployed between the sigmoid sinus and jugular bulb, which resulted in complete restoration of the venous flow in the occluded right sigmoid sinus []; the Cognard Type II DAVF was converted to a Type I. After stenting, cortical venous reflux had disappeared and only antegrade flow into right jugular bulb remained. Bilateral internal carotid angiograms showed a remarkable improvement in cerebral perfusion []. After the treatment, the patient showed no complication or convulsion. She was discharged our hospital with independent gait 6 months after the treatment. Her cognitive function gradually improved with MMSE score improved 26 points at 12 months after the treatment. She received the aforesaid double antiplatelet therapy until 3 months after the stenting, but was continued on a single 75 mg dose of clopidogrel for 1-year. |
We report the case of a 58-year-old female patient with a history of acute pancreatitis with conservative treatment 2 years ago, chronic alcohol consumption with affirmative abandoning in the last 12 months, and an admission for a left pleural effusion one month ago, with resolution under antibiotic treatment. Due to the persistent abdominal pain, the patient underwent an abdominal ultrasound and CT scan which showed biliary lithiasis and the presence of 3 distinct large cystic masses in the pancreas and spleen (Figures and ). Surgery was proposed but the patient refused it.\nThe patient was subsequently admitted for intense abdominal pain with altered general status (blood pressure 90/60, pulse 110) and a drop of the hemoglobin level to 8.2 g/dL. An emergency CT scan showed the same cystic lesions and raised the suspicion of a ruptured splenic artery pseudoaneurysm and splenic hematoma. Due to the obvious signs of important bleeding and the impossibility to perform emergency arteriography, we decided to perform an emergency laparotomy.\nIntraoperatively, we found a small amount of intraperitoneal blood and a large pancreatic pseudocyst filled with clots and fresh blood, extending into the retroperitoneum and spleen, corresponding to the 3 cystic lesions identified on the preoperative CT scan (). An active pulsatile bleeding from the splenic artery was identified in the cyst cavity (). Anatomic dissection of the splenic vessels at the level of the upper pancreatic border failed due to fibrosis and adhesions. We performed splenectomy, partial cystectomy with ligation of the splenic artery at the level of the vascular erosion (), cholecystectomy (lithiasis), and multiple drainage.\nThe immediate postoperative course was favourable, with discharge on postoperative day 19. The patient presented 2 postoperative complications: an elevated level of platelets which required prolonged anticoagulation (low molecular weight heparin followed by oral warfarin treatment) and a pancreatic fistula with a 100–200 mL/day output which closed spontaneously after 5 months. At 2-year follow-up the patient presents with no abdominal complaints and no recurrence. |
A 61-year-old male with a history of surgically corrected Tetralogy of Fallot presented with fatigue, edema, weight gain, and worsening renal insufficiency. He exhibited marked jugular venous distension, ascites, and edema on examination. Historically, he had undergone complete surgical repair at age 11, a right ventricular outflow tract reconstruction and pulmonary valve replacement at age 47, and a percutaneous pulmonary valve replacement at age 59. In the months prior to admission, the patient exhibited worsening signs and symptoms of volume overload requiring escalating diuretic doses. Prior to admission, a cardiac MRI demonstrated marked biatrial enlargement, right ventricular dilation and dysfunction, and moderate pulmonary and tricuspid regurgitation (Supplemental ). An echocardiogram on admission demonstrated right ventricular dilation with an estimated right ventricular systolic pressure of 54 mmHg, moderate tricuspid regurgitation, and mild pulmonary conduit stenosis. Electrocardiogram at the time of admission demonstrated sinus rhythm with a stable right bundle branch block ().\nThe patient was admitted for treatment of presumed decompensated right heart failure. MAP was 64 mmHg, and CVP was markedly elevated at 27 mmHg. He was started on intravenous diuretics and dopamine and successfully diuresed over 12 days to a negative fluid balance of 16.5 L with an improvement in renal function ().\nThree days after discharge, the patient was readmitted with frank hypotension, hyperkalemia, and oliguric renal failure. Dopamine infusion was resumed with improvement in renal function and urine output. Repeated attempts to wean the dopamine were associated with dramatic drops in blood pressure and oliguric renal failure (). Simultaneous right and left heart catheterization performed off dopamine surprisingly demonstrated elevated CO and low SVR consistent with distributive shock (). Additionally, the patient was noted to have concordance of ventricular pressures that suggested of restrictive physiology (). The pulmonary artery catheter was left in place, and subsequent measurements were made once the patient was placed back on dopamine ().\nPotential reversible causes, including adrenal insufficiency and sepsis, were excluded. After a failed trial of dopamine weaning, a phenylephrine infusion was started. He was subsequently converted to oral phenylephrine and midodrine with stable hemodynamics, urine output, and renal function. Three weeks after discharge, he reported good exercise tolerance and urine output, with a stable creatinine.\nOn outpatient follow-up assessments, the patient remained stable on this medication regimen for several months until he suffered a mechanical fall at home and eventually died of complications related to this event. |
Our patient is a 67-year-old Hispanic male who presented to our hospital for the chief complaint of progressive worsening of shortness of breath of 3 weeks duration and was admitted for acute respiratory distress due to interstitial lung disease of unknown etiology. His medical history includes coronary artery disease, status postpercutaneous coronary intervention in 2010, hypertension, hyperlipidemia, and diabetes mellitus type 2. He has a significant smoking history of 20 to 30 pack-years and a significant history of alcohol drinking consuming 12 cans of beer per day for 30 years. He has quit smoking and drinking for 10 to 15 years. He works as a janitor and has no significant occupational exposure to asbestos or silicone.\nSix months prior to the day of admission, the patient had complaints of dry cough for which he visited his primary care physician and was prescribed over-the-counter cough suppressants with no relief. The patient had a chest X-ray done at this time which showed mild hazy changes in bilateral lung fields (). The patient continued to have dry cough and eventually developed progressive shortness of breath with no dyspnea at rest. The patient continued to ignore his symptoms until few weeks prior to the day of admission he had significant shortness of breath to the point to which he could not walk to the bathroom in his house. Concerned of this he came to the hospital for further evaluation.\nIn the ED, the patient was brought in by his daughter and he had significant shortness of breath during ambulation which caused him to rest after every few steps. His initial SpO2 on room air was 77% and he was put on 3-litre O2 on nasal canula and his SpO2 improved to 93%. His blood pressure was 134/76 mm of hg, heart rate was 78/min, and respiratory rate was 22/min. On physical examination the patient was awake, alert and oriented, his neck was supple with no jugular venous distension, his heart sounds were audible with no murmurs or gallops, and auscultation of his chest revealed bilateral breath sounds with significant velcro rales on all the lung fields bilaterally. Abdomen was soft and nontender and the patient had no focal neurological deficits. Examination of his extremities revealed no pedal edema but grade 3 clubbing of his finger nails. The patient denied fever, chills, hemoptysis, orthopnea or paroxysmal nocturnal dyspnea, recent travel, or sick contacts.\nChest X-ray in the emergency department showed reticular and hazy markings throughout the both lungs, being worse compared to the previous chest X-ray (). A CT scan of the chest showed extensive honeycombing and bronchiectasis of both lungs which were markedly worse when compared to a CT scan done 4 years ago (). X-rays of both hands and wrists showed early inflammatory arthropathy but the patient denied any joint pain (). 2D echocardiogram showed ejection fraction of 59% with mild mitral regurgitation and no pulmonary hypertension, which was not consistent with CHF.\nConcerning his chest X-ray and CT scan findings, ILD was now the working diagnosis. The differential at this time was idiopathic versus rheumatoid arthritis. Laboratory data showed elevated erythrocyte sedimentation rate 98 (N 0–20), elevated C-reactive protein 17.4 (N ≤ 7.0), elevated rheumatoid factor 275 (N ≤ 10), and elevated cyclic citrullinated peptide >250 (N < 20). To exclude causes of falsely elevated rheumatoid factor, hepatitis C Ab was done which was negative. ANA and DsDNA were both negative.\nThe complete blood count, electrolytes, and renal and liver functions were within normal limits. Lung biopsy was avoided due to the complications of an invasive procedure.\nA diagnosis of interstitial lung disease of the usual interstitial pneumonia (UIP) variant due to rheumatoid arthritis was made. The patient was given intravenous solumedrol 40 mg TID which was tapered and changed to oral prednisone 60 mg daily upon discharge. During his hospital stay he was on nasal O2 3 litres and had episodes of desaturation on ambulation; hence he was discharged with home oxygen. He was advised to continue the rest of his medications for his comorbidities and to follow up with his primary care physician and pulmonologist as outpatient. Eventually the patient was referred to a tertiary care center for lung transplant. The patient is currently on the waiting list for his lung transplant. |
A 4-month-old female infant weighing 2.4 kg was referred to us on mechanical ventilatory support. History revealed prematurity, treatment for aspiration pneumonia in the early neonatal period, and frequent hospital admissions elsewhere for respiratory distress. As symptoms progressed to severe respiratory distress with inspiratory stridor, it necessitated an emergency tracheostomy at a peripheral center followed by prolonged ventilation. Three weeks later, after several unsuccessful attempts at weaning from mechanical ventilation, the infant was referred to us for further evaluation and treatment. Upon arrival, the baby had substantial respiratory compromise despite the tracheostomy tube in situ. The inability to ventilate through the tracheostomy tube raised the suspicion of a tube block or a probable malposition. The infant was emergently intubated through the oral route with a 3.5 mm uncuffed endotracheal tube after sealing the stoma with adhesive opsite over a small gauze dressing. It was noted that ventilation with bilateral equal air entry could only be achieved by stabilizing the tube at 12 cm depth at the angle of mouth. Any displacement above or below this level was causing suboptimal ventilation with severe desaturation, raising the suspicion of an extrinsic compression of trachea. Other corroborative findings included respiratory acidosis with PaCO2 of 70 mmHg and hyperinflated lung fields with infiltrates suggesting air trapping on chest radiograph. High-resolution computerized tomography (CT) scan revealed a left dominant double aortic arch [] forming a complete vascular ring compressing the trachea just above the carina []. At the time of radiological evaluation, the endotracheal tube needed to be pulled out proximal to the site of compression to clearly demarcate the site radiologically []. As preliminary investigations confirmed bacterial and fungal sepsis with pneumonia, the patient was optimized with broad-spectrum antibiotics and antifungal agents before proceeding with corrective surgery. For optimal ventilation during surgery, the endotracheal tube was changed to a 3.5 mm microcuffed tube (Kimberly Clark Inc., Roswell, USA). The tube was stabilized at 12 cm from the angle of mouth to ensure that the tip was placed beyond the site of compression. A pressure-controlled volume guaranteed mode of ventilation was chosen to limit the peak airway pressures and prevent barotrauma.\nAlthough a left thoracotomy is the standard approach to vascular rings, the critical need to avoid displacement of the endotracheal tube during surgery, borderline hemodynamics, and concomitant lung pathology prompted us to favor the sternotomy approach. Once all the arch vessels were identified and looped, the right arch was divided from the dominant left arch, just proximal to the origin of the left common carotid artery []. After inspecting the site of tracheal narrowing externally, it was concluded that the extent of malacia might not be significant to warrant tracheal surgery. Postoperatively, the position of endotracheal tube was optimized with the help of chest X-ray. Postoperative respiratory management included lung toileting for retained secretions and lung-protective ventilation strategy with a tidal volume of 6–8 ml/kg. The infant required prolonged postoperative ventilation due to the preoperative morbidity and coexisting bacterial sepsis. Following extubation on the 8th postoperative day, nasal continuous positive airway pressure (CPAP) was electively instituted anticipating airway collapse due to tracheomalacia. This was later transitioned to high flow nasal cannula and thereafter to a regular nasal cannula for oxygen supplementation as the child tolerated weaning off CPAP without respiratory distress. The remainder of the stay was uneventful and child was discharged home on the 15th postoperative day. The infant is currently asymptomatic and is doing well on the most recent follow-up. |
A 68-year-old man normally fully independent with a history of atrial fibrillation, controlled with apixaban, presented to the ED with sudden onset mid-back pain following a long-haul flight. There was no history of trauma. He was investigated for suspected pulmonary embolus (PE) given the history of recent air travel, however D-Dimer was not raised and observations were stable. His pain self-resolved with no focal neurology present. He was discharged with analgesia and a diagnosis of mechanical back pain.\nHe represented 2 days later with a more severe recurrence of the pain through his shoulder blades, described as a ‘burning’ pain. Due to new nature of the pain, new onset hypoxia seen on arterial blood gas and stiff calves, a CT aortogram was performed to rule out an aortic dissection or PE. As there was no evidence of dissection on the imaging, he was discharged with antibiotics for a presumed infection as some reactive lymph nodes were found.\nHe presented for the third time the next day as a primary care referral due to urinary retention. 1300 mL of urine was seen on bladder scan and he was successfully catheterised. At this time normal power and sensation in his lower limbs were noted and there was normal anal tone on rectal examination. After an assessment by urology it was thought the retention was secondary to constipation, having started codeine recently. Bowels had last opened 3 days previously and an enema was administered in the ED with satisfactory results. He was discharged with laxatives and an indwelling catheter.\nThe following day after his third discharge he presented for the fourth and final time, with headache, neck stiffness, vomiting and dramatically reduced coordination in his lower limbs. On examination he was alert with no photophobia or confusion, and normal power and sensation in his upper limbs. However, power and coordination were reduced bilaterally in his lower limbs and reflexes were difficult to elicit. A broad-based, ataxic gait was observed. He was admitted and apixaban was stopped due to a clinical suspicion of haemorrhagic spinal pathology. Urgent CT of his head showed a small possible subarachnoid haemorrhage and MRI of his spine was initially reported by the radiologist as showing a thoracic syringomyelia in T1–T5 (), with extension in L4–S1. However, this was later determined to be a spinal subdural haematoma.\nAfter being transferred to a tertiary neurosurgical centre, he was discussed in the spinal multidisciplinary team meeting. The decision made was for conservative management due to the bleeding risk of operating, and that this was a subacute presentation by the time he was transferred; reversal of symptoms were thought to be unlikely with surgical intervention. Had this been an acute presentation it was more likely that reversal of apixaban and surgical intervention would have been carried out. Further imaging was requested to determine if there was a vascular abnormality. Spinal angiogram was abandoned due to intraoperative complications. CT angiogram and magnetic resonance angiogram were performed instead, which showed no vascular abnormality. He remained neurologically stable and was discharged to a spinal injury rehabilitation centre. He made a good neurological recovery and is doing intermittent self-catheterisation with no bowel disturbances. Mobilisation is aided with a tripod stick indoors and a wheelchair outdoors. Repeat MRI 1 month following the initial imaging demonstrated near complete resolution of the haematoma (). |
A 5-year old boy presented to the clinic with a congenital anterior right chest wall defect. The delivery was by normal vaginal delivery after a full-term pregnancy. There was no breathing difficulty at birth, and no history of paradoxical breathing. There were no other congenital abnormalities, and development was normal. Medical advice was taken from his local town and this child was referred to our center at age of 5 years. Examination showed an otherwise healthy child with an anterior right chest wall defect. There was no paradoxical breathing and oxygen saturation at rest was 99%. There was no history of breathing problems even with exercise. The clavicle was absent but the sternum was intact. The anterior rib defect extended from the first to the fifth rib. The defect was felt upon inspiration (A) and the right lung protruded through the bony defect upon expiration; and the bulge became more prominent and tense when crying (B). A CT scan showed the defect with the skin adherent to the pleura. There were no pectoral muscles across the defect (both the pectoralis major and minor were absent) (). Surgery was done by a team of plastic and thoracic surgeons. The patient was put in the semi-lateral position. A longitudinal skin incision was made anteriorly over the chest wall defect and care is given not to injure the pleura while dissecting off the skin (A). Another longitudinal skin incision was made over the latissimus dorsi muscle. The muscle was dissected off based on the neurovascular bundle. The thoraco-lumbar fascia was incorporated with the lower part of the muscle. The composite flap was then tunneled to the anterior chest wall defect as a pedicled flap (B). Drill holes were made in the sternum and remaining ribs at the edges of the chest wall defect. The muscle-fascia composite flap was then sutured over the defect using polypropylene sutures anchored to these drill holes. Two drains were inserted (one anterior drain and one posterior drain), and the skin was closed with absorbable sutures. There were no post-operative complications. At final follow-up 11 years later, the chest wall depression was still present but to a lesser degree when compared to the pre-operative depression. There was no bulging of the lung through the defect upon expiration, exercise or crying (A, B). A CT scan showed the thick muscle-fascia composite flap over the pleura (). The patient was offered implant coverage at age of 18 years, but the parents refused and stated that they will think about it. |
Routine undergraduate dissection for medical students in our department revealed a unilateral non-rotated kidney on the left side in a 97-year-old male cadaver. The body was donated to our department for teaching and research purposes. The cause of death was cardiopulmonary arrest.\nThe right kidney was found to be normal in its location, shape, size, and ureter formation. Varied vasculature was observed in the form of branches of the renal artery and formation of the renal vein. The left kidney was found to be at a lower position than usual, at the level of the second, third, and fourth lumbar vertebrae. The inferior pole was at the level of the L4-L5 intervertebral disc. The kidney was broader near its middle third and inferior pole. The cratered hilum of the left kidney, instead of being at its medial border, occupied a large part of the anterior surface and was situated nearer to the lateral than the medial border. The renal vein and ureter were the two structures traversing through the hilum, but the renal artery was entering the renal parenchyma through the medial border.\nThe structures emerging from the hilum of the kidney mainly comprised the renal vein and the tubular ureter. The renal vein had two major tributaries, superior and inferior. The inferior tributary was formed by joining two tributaries emerging from the inferior region of the renal parenchyma and proceeded obliquely upward and medially to join with the superior renal vein. The left gonadal vein drained into this inferior tributary. The main trunk of the renal vein traversed its usual course between the abdominal aorta and superior mesenteric artery to drain into the inferior vena cava. There was no well-defined renal pelvis; instead the tubular ureter had four divisions entering into the renal parenchyma at the hilum of the kidney (labeled a, b, c, and d in ). The course of the ureter was then downward and medial to the urinary bladder.\nThe abdominal aorta was tortuous all along its course in the abdomen. The Main Renal Artery (MRA) is described as a single vessel, at a more or less constant position opposite the renal hilus, from the abdominal aorta, and which continues undivided (except for several small branches- the inferior suprarenal, the perirenal and the ureteral arteries) in its straight course to the renal hilus. The MRA was thin and originated from the abdominal aorta at a level just inferior to the origin of the superior mesenteric artery, entering the kidney through its medial border after giving off 3 branches (represented by red asterisks in and ) to the left suprarenal gland. The accessory renal artery (AcRA) arose from the aorta just lateral and inferior to the origin of the inferior mesenteric artery, entering the renal parenchyma through the medial border of the kidney. The AcRA divided into two segmental arteries before piercing the lower part of the medial border of the kidney ().\nThe case was observed in a body donated to our department for educational and research purposes. Body is accepted only after taking consent of the deceased/next of kin which is in accordance to Anatomy act of India. |
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 man presented with dry cough of five years duration with no associated breathlessness or wheezing. He did not report a post nasal drip or systemic symptoms. He was diagnosed to have Crohn's disease with gastro duodenal involvement ten years earlier. The diagnosis was established based upon typical features on a duodenal biopsy. He was treated with prednisolone and mesalazine. The Crohn's disease was in remission in less than a year following which prednisolone and mesalazine were discontinued. He was continued on treatment with a proton pump inhibitor. He worked as a university lecturer. He was an ex-smoker of ten pack years and had stopped smoking ten years earlier. On examination he did not have cyanosis, digital clubbing or significant lymphadenopathy. Examination of the respiratory system was unremarkable. A chest radiograph demonstrated bilateral apical infiltrates (Figure ). A full blood count, biochemical profile, angiotensin converting enzyme levels and total as well as specific immunoglobulins were all normal.\nA fibre optic bronchoscopic examination was macroscopically normal. The appearance of the trachea and the bronchial tree was entirely normal. Based on the chest radiograph, a bronchial wash as well as bronchial and trans-bronchial biopsies and were performed from the left upper lobe. The bronchial wash was sterile and negative for acid fast bacilli on stain and culture. The bronchial biopsy showed evidence of a mild inflammatory cell infiltrate, including eosinophils, in the sub epithelial connective tissue. The trans-bronchial lung biopsy was normal. The trans-bronchial biopsy was complicated by a small pneumothorax which did not need any intervention. A high resolution computed tomography (CT) scan showed a normal trachea and normal proximal airways which narrowed and then dilated peripherally. These dilated peripheral bronchi appeared fluid filled. These changes were seen bilaterally, well demonstrated in the left upper lobe (Figure ). Areas of patchy air space shadowing were seen bilaterally. Adjacent to these areas of consolidation small branching opacities consistent with small airways involvement were also noted. It was thought that these changes were due to Crohn's disease and treatment with prednisolone was initiated at a dose of 10 mg once daily. He responded well to treatment with complete resolution in symptoms. A CT scan done 6 weeks following initiation of treatment showed good improvement in the changes seen earlier (Figure , ). Nine months later prednisolone was tapered and stopped. However he relapsed on discontinuing prednisolone and this had to be re-instituted. His symptoms resolved with the re-introduction of prednisolone. He remains asymptomatic on treatment with 2.5 mg of prednisolone along with inhaled budesonide. |
A 19-year-old G1P0 female with a fetal demise at 17 weeks and 4 days of gestational age presented to the emergency department (ED) with light vaginal bleeding. An ultrasound examination performed one week prior to her presentation demonstrated a nonviable fetus in the right horn of a suspected bicornuate uterus. The patient was referred for dilation and evacuation and was awaiting her appointment at the time of her ED visit. In the ED the patient was hemodynamically stable and was not actively bleeding. Since dilation and evacuation were already planned for the following day, an attempt was made to insert osmotic cervical dilators into the cervical canal under ultrasound guidance. A cervical dilator was easily advanced into the left uterine horn; however, the dilator could not be advanced into the horn that contained the fetus. The procedure was therefore discontinued.\nA pelvic MRI was ordered and results did not reveal a communication between the cervix and the gravid right uterine horn (). Although MRI has limitations in the diagnosis of rudimentary uterine horns, it is among the most accurate noninvasive diagnostic modalities []. The patient was counseled that the fetus could not be removed via dilation and evacuation. We recommended laparotomy with hysterotomy and the patient consented to proceed.\nAt surgery, an infraumbilical vertical midline skin incision was made and exploration of the pelvis revealed an enlarged right uterine horn (). Hysterotomy was performed with a transverse incision and the fetus was evacuated with placenta, without difficulty. Palpation of the uterine cavity did not reveal communication with either the cervical canal or the left uterine horn. The hysterotomy was closed in three layers with delayed absorbable suture. Following evacuation and contraction of the right uterine horn, the external aspect of the uterus appeared bicornuate (). The abdominal incision was closed.\nPathologic examination revealed an anatomically normal fetus. The patient was discharged home after an uneventful postoperative recovery. The patient underwent insertion of an etonogestrel implant (Nexplanon) at her postoperative appointment. Three months after her surgery, the patient underwent hysterosalpingography (HSG), which revealed a left unicornuate uterus without communication with the right uterine horn (). |
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 76-year-old woman came to our clinic with a large mass of the left iliac region.
According to the patient's history, she had a pelvic tumor removal surgery in 2006 and she was reoperated on for local recurrence in 2009. During admission to our oncosurgical clinic, an incisional hernia and a large mass of left iliac region were diagnosed. The patient was neurovascularly intact.
Radiological studies showed a mass at the left iliac area that infiltrated sciatic notch and extended from posterior iliac region towards the anterior side of iliac bone through the sciatic notch and incisional hernia. The mass was also penetrating the abdominal cavity through the fascial defect and infiltrating the mesosigmoid that herniated through the fascial defect out of abdominal cavity (Figures and ). Surgical intervention was planned. Since the tumor infiltrated the sciatic nerve, hemipelvectomy was indicated. Patient refused hemipelvectomy. Therefore, palliative debulking surgery was considered.
The tumor was approached through the utilitarian pelvic incision that extended into the inner side of thigh and lateral border of the abdomen (the incision begins at the posterior inferior iliac spine and extends along the iliac crest to the anterior superior iliac spine. It is separated into two arms: one is carried along the inguinal ligament up to the symphysis pubis and the other turns distally over the anterior thigh for one-third the length of the thigh and then curves laterally just posterior to the shaft of the femur below the greater trochanter and follows the insertion of the gluteus maximus muscle).
The tumor in the pelvic and paravertebral area was marginally excised (). Abdominal exploration was also performed using the same incision and tumors which infiltrated the omentum and mesosigmoid area were excised (). Pelvic region and the abdominal cavity were separated using prolene and vicryl suture materials and hernia repair was done without using mesh. The operation lasted 8 hours. Recorded blood loss was 1500 mL and urine output was 1200 mL. The |
During a routine dissection at Jeju National University Medical School in 2011, a case of hypoplasia in left vertebral artery was observed in an 82-yr-old Korean woman cadaver, whose cause of death was 'unknown'. Hypoplastic VA was defined as a lumen diameter less than 2 mm in an anatomical study () or as with diameter less than 50% of the contralateral side in radiological study ().\nIn this case, each VA originated from the subclavian artery with an external diameter of left 4.6 mm and right 5.0 mm; and entered to the foramen transversarium with a diameter of left 3.3 mm and right 5.0 mm (). The extracranial parts of both VAs did not show macroscopic anomaly, but intracranial part of the left VA had hypoplasia with a total length of 21 mm (). The external diameters of the intracranial parts of VAs were found to be 3.7 mm on the right side and 1.0 mm on the left side. The vertebrobasilar junction was found to be at the level of bulbopontine sulcus. The posterior inferior cerebellar artery bilaterally arose from the basilar artery 2.5 mm from the vertebrobasilar junction. The other brain vessels had no anomalies in their course or in the origin of their branches on either side.\nHistopathologically, FMD is heterogeneous with various degrees of collagen hyperplasia, internal elastic lamina rupture, and disorganization of the tunica media (, ). For histopathological classification of FMD, tissue sections were stained with hematoxylin and eosin (), Orcein for elastic fiber (), and immunohistochemistry with anti smooth muscle actin antibody for tunica media () and anti-CD31 antibody for endothelium (). Compared to the right VA (), both extracranial and intracranial left VA pathologically diagnosed as an intimal type of FMD. Left VA has long smooth narrowing of lumen with circumferential or eccentric deposition of collagen in the tunica intima and disrupted internal elastic lamina (). The stenotic lumen was not caused by hypertrophy in medial smooth muscles. In extracranial VA, neovascularization (rectangle in ) in the hypertrophied intimal layer was seen with immunopositivities of smooth muscles (). But the immunoreactivity with smooth muscles was not obvious in intracranial VA as compared to the extracranial VA (). |
A 54-year-old Japanese female visited an oral surgery clinic with a complaint of swelling in the inner region of the left cheek for the past one month. On clinical examination, a mobile swelling (size, 1 cm x 0.75 cm) with a clear boundary was observed on the left buccal mucosa. No associated pain was reported and the overlying mucosa was normal in appearance. The swelling was clinically diagnosed as benign buccal mucosa tumor. The tumor was excised under local anesthesia and was diagnosed as acinic cell carcinoma (AcCC) after histopathological examination. The margins were still positive for the tumor and further resection was advised. The patient reported to the Health Sciences University of Hokkaido Hospital for resection of the residual tumor two months after the initial surgery. Clinically, the patient was asymptomatic. The level 1B lymph nodes on both sides were palpable, bean sized, mobile, elastic, and soft. Intraorally, a surgical scar of about 7 mm was present on left buccal mucosa. There was no pain on pressure in the region of the scar (). The patient had a history of noninvasive ductal carcinoma (ductal carcinoma in situ [DCIS]; Tis N0M0) in the right breast, which was treated by excision and 57 Gy of radiotherapy five months ago. On investigation for oral lesion, no obvious abnormalities were detected on the computed tomography- (CT-) scan, contrast MRI, and ultrasonogram. Positron emission tomography- (PET-) CT did not suggest transition to and from any of the distant organs. The margin was resected under general anesthesia and sent for histopathological examination (). No relation to the parotid gland was found at the time of surgery.\nHistopathologically, the excised margin appeared as a fragmented tissue with no encapsulation. The tumor tissue was composed of cells with dominant microcystic structure with eosinophilic cytoplasm and eosinophilic secretory material. Papillary and tubular pattern of cell arrangement were also found but were limited to small area. A few vacuolar cells and some areas with hemosiderin deposition were observed. Furthermore, normal muscle tissue and atrophied salivary gland tissues were also seen ().\nThe secretory material was positive for diastase digested Periodic acid-Schiff (d-PAS), Mucicarmine, and Alcian Blue staining. No zymogen granules were found in the tumor cells. Immunohistochemistry (IHC) revealed strong positive reactions to vimentin, cytokeratin-19, and S100 protein. Mammaglobin was strongly positive, whereas discovered on gastrointestinal stromal tumors 1 (DOG-1) showed a negative reaction (). The histological sections of breast carcinoma were examined in suspicion of metastases; however, features of ductal carcinoma in situ that appeared completely different from those of buccal mucosa tumor were noted. Based on these histomorphologic and IHC profiles, the case was diagnosed as SC of the minor salivary gland in the buccal mucosa. |
A 21-year-old male was admitted after a road traffic accident. He had a posterior dislocation of the left hip with a fracture of the posterior acetabular wall (Type III Thompson and Epstein classification) and maxillo-facial fractures. The posterior dislocation was reduced in emergency room under a short general anesthesia using Bigelow reduction maneuver. A follow-up CT scan next morning showed concentric reduction but revealed retained intraarticular fragments. There were two fragments less than 1 cm in size []. Hip arthroscopy was performed to remove the intraarticular fragments.\nThe patient was placed in supine position with the hip to be operated in 10° of flexion, 15° of internal rotation, 10° of lateral tilt and 30° of abduction. An extra wide perineal post was used to minimize the risk of pudendal nerve injury. Traction was applied to break the joint's vacuum seal. Adequate 10 mm of joint distraction for safe surgical instrument clearance was confirmed under image intensifier. Minimal counter traction was also applied to the contralateral leg to reduce the amount of traction necessary on the operative leg.\nThe anterolateral portal was placed first for the introduction of the arthroscope. An 18-gauge spinal needle was placed under fluoroscopic guidance at the anterior superior corner of the greater trochanter and directed perpendicular to a line drawn from the anterior superior iliac spine (ASIS). Starting as closely as possible to the greater trochanter allows easier passage of the needle under the free margin of the labrum. Once the needle position was confirmed fluoroscopically, a guide wire was introduced and the position of the wire verified under image intensifier. The needle was then removed and a cannulated trocar introduced over the wire after adequate skin incision. The blunt end of the trocar was used to create a tract upto the capsule and the sharp end was used to pop through the thick capsule. The cannula for the arthroscope was then passed over the trocar and finally the camera introduced after starting the irrigation fluid.\nThe anterior portal was established next. An 18-gauge needle was placed so that it entered the skin at the intersection of a sagittal line drawn distally from the ASIS and a transverse line drawn across the superior margin of the greater trochanter. The needle was directed 45° cephalad and 30° toward the midline, as recommended by Byrd. Once return of outflow through the spinal needle had been established, the wire was introduced and the anterior portal established. This portal proved useful for direct visualization of the superior aspect of the femoral head and served as a working portal for instrumentation. An accessory third posterolateral portal was needed and was placed adjacent to the anterolateral portal in line with it but approximately 2 cm more posteriorly.\nWith the arthroscope in the anterolateral portal and shaver in the anterior portal, a grabber was passed through the accessory portal. Both the retained fragments [] were removed under vision using the grabber. There was a small unstable partial labral flap tear which was debrided.\nPatient was mobilized out of bed after first day, initially partial weight-bearing and then full weight-bearing at one week. He was advised not to place the leg in the adducted and flexed position for the next six weeks. A repeat scan and radiograph was taken and revealed normal joint. At 10-month follow-up, the patient was asymptomatic and the follow-up radiograph and MRI scan did not show any changes of avascular necrosis. |
A 77-year old male was referred to our hospital for known coronary artery disease and a history of antero-septal myocardial infarction and syncope. Coronary angiography showed severe triple vessel disease. Computed tomography revealed severe diffuse calcification from the aortic arch to the abdominal aorta. In particular, just proximal brachiocephalic artery was shown to be circumferentially calcified and 90% stenosed (Fig. ). Proximal left carotid artery and left subclavian artery were also shown to be calcified. But there were no significant stenosis at the origin of right carotid artery and vertebral artery. The peak blood pressure of the right arm was 40 mmHg lower than that of the left arm. Carotid ultrasonographic examination revealed 50% stenosis of right internal carotid artery and subclavian steal phenomenon in right vertebral artery. And post stenotic high flow pattern was observed in proximal brachiocephalic artery. We planned to perform an aorto-brachial or aorto-right subclavian artery bypass using a prosthetic graft and concomitant off-pump CABG.\nA median sternotomy was performed, and the bilateral internal thoracic arteries were dissected. At the same time, a saphenous vein graft was dissected. A direct ultrasonographic examination revealed severe atheromatous plaques inside the brachiocephalic artery; hence, we chose the right subclavian artery as the distal anastomosis site for the prosthetic bypass conduit. An 8-mm polytetrafluoroethylene graft was anastomosed to the right subclavian artery, and then the proximal end of this graft was anastomosed to the aorta with a side-biting clamp. Off-pump CABG was then performed using a method described previously []. The left internal thoracic artery and the free right internal thoracic artery were anastomosed to the left anterior descending artery and the left circumflex artery, respectively. Two saphenous vein grafts were used for the diagonal branch and the distal branches of the right coronary artery. Proximal anastomoses between the saphenous vein grafts and the aorta were performed with proximal suturing devices. Lastly, a proximal anastomosis of the free right internal thoracic artery to the saphenous vein graft as a V-composite graft was performed [].\nPostoperatively, no neurological deficit was observed. The blood pressures of the bilateral upper extremities were identical. Computed tomography demonstrated the patency of the coronary bypass grafts and the aorto-right subclavian artery bypass graft (Fig. ). Postoperative radionuclide imaging showed no cerebral ischemia. |
A 22-year-old mother (gravida 2, para 1, with about 37 weeks of amenorrhea) was admitted through emergency to the Labor Room of Midnapore Medical College and Hospital, Midnapore, India, with chief complaints of intermittent lower abdominal pain and watery vaginal discharge since the previous evening. She had been married for 9 years and had a girl baby via institutional vaginal delivery 7 years previously. The patient was from a poor socioeconomic status and was referred from the local Block Primary Health Center (BPHC) as a case of pregnancy with a huge ovarian cyst.\nThe medical records available from the patient showed that she had been previously admitted to our institution for a disproportionate increase in the abdominal size in the second trimester of pregnancy. Ultrasonography detected a single live intrauterine fetus of 22 weeks of gestation, together with a huge cystic mass arising from the right adnexa. At the time, she refused surgical intervention and returned home against medical advice. After 4 weeks, repeated ultrasonography also revealed a huge multiloculated cystic space-occupying lesion, almost taking up the entire abdomen (ovarian origin), along with a single live intrauterine fetus of 26 weeks of gestation (maturity grade 3 with adequate liquor). Furthermore, the placenta was adhered to the posterior upper segment. When the patient was admitted to our institution with abdominal pain, the gestation period was calculated to be about 37 weeks based on previous ultrasonography reports.\nGeneral survey and systemic examination showed no abnormality, except for mild pallor and poor nutritional status. On abdominal examination, no fetal parts were palpable due to huge tense abdominal swelling. Even the fetal heart sound could not be located, although the patient perceived fetal movement. Internal examination on admission revealed 6 cm cervical dilatation with 90% effacement, vertex presentation, station +1, and bulged membrane. She delivered vaginally a boy baby within 4 hours of admission. The baby had a good Apgar score at 1 minute and 5 minutes, but his birth weight was 1.75 kg. A pediatrician was consulted on account of the baby’s low birth weight and features of IUGR. Labor and postpartum period were uneventful.\nGiven the patient’s history, clinical examination, and previous sonography reports, the abdominal mass was provisionally diagnosed as cystic adnexal swelling. She had a huge abdominal swelling even after the delivery of the baby. demonstrates the patient’s hugely distended abdomen after vaginal delivery. After proper counseling, decision for laparotomy was taken in the postpartum period. All the preoperative investigations were within normal limits. On the 8th postpartum day, laparotomy was performed under general anesthesia. A cystic mass (approximately 40 cm×30 cm×25 cm in size, pinkish in color, and with a smooth surface) arising from the right ovary was found. The left fallopian tube and ovary was healthy. The right ovary, along with the mass and fallopian tube, was removed. Infracolic omentectomy and left tubectomy was done (as per patient and her husband’s consent). The intact cyst was multiloculated, weighed 11,000 gm, and was filled with fluid. demonstrates the cystic mass after it was removed via laparotomy. There was mild omental adhesion, but no ascites was observed. Specimens and peritoneal washing were sent for histopathology examination. The intraoperative and postoperative periods were uneventful, and she was discharged on the 8th postoperative day. In subsequent follow-up, no abnormality was detected.\nThe ovarian cyst was sectioned in the Pathology Department of our institution. The inner surface of the cyst exhibited multiple trabeculae, without any solid component or hemorrhagic area. The cyst was filled with mucinous fluid. Unfortunately, the pathologist failed to provide us with the photograph of the macroscopic cut section. The mucinous ovarian cyst had features of infarction, so the histopathology slides could not be stained with specific Periodic Acid Schiff (PAS) stain to confirm diagnosis with an alternative method. The histopathology examination report revealed features of a mucinous cystadenoma. shows the histopathology of the mass, demonstrating features of a mucinous cystadenoma with no malignant cells in peritoneal washing. |
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. |
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