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A 32-year-old female with no comorbidities presented to us with a history of a cough with expectoration of 1-month duration. The intensity of cough has been increasing in intensity over the last 1 month. She also has a history of low-grade fever, malaise, and easy fatiguability of the same duration. There was a history of right flank pain and dysuria accompanying her respiratory symptoms.\nHer medical history relevant to this illness started 1 year back when she had fever and lower urinary tract symptoms during the second trimester of her second pregnancy. On evaluation, she was told to have UTI and was treated with oral antibiotics. Despite treatment, she lost her baby owing to spontaneous abortion in the 5th month of her pregnancy. She gave a history of 2–3 episodes of UTI following her pregnancy in the past 1 year. All these episodes were managed with oral antibiotics. She gave a history of 20 kg weight loss during the past 1 year.\nOn clinical evaluation, she was found to have fever, pallor, and mild pedal edema. Her systemic examination revealed a palpable lump in the right lumbar region and reduced breath sounds at the right infrascapular area. Her initial investigations are shown in . Cultures of the urine and sputum grew the same organism (Proteus mirabilis which was sensitive to cephalosporins, quinolones, aminoglycosides, and carbapenems). The similar sensitivity of the bacterial isolate from the urine and the sputum made us suspect a single source (most probably urinary). She was started on appropriate intravenous antibiotics.\nHer computed tomography of the abdomen and chest revealed a grossly enlarged right kidney with obstructive renal calculi. There was a breach on the upper aspect of the kidney suggestive of a ruptured abscess with perinephric extension []. The ruptured abscess was found to be indenting into the lower surface of the right lobe of liver with parenchymal invasion []. The ruptured abscess was also seen to have an intrathoracic extension [Figure and ]. A urology opinion was taken, and after a DTPA scan which showed a completely nonfunctional right kidney, she was advised nephrectomy.\nThe patient underwent total nephrectomy; intraoperatively, there was an enlarged right kidney which measured 12 cm × 8 cm × 6 cm with a bosselated external surface []. Cut section showed dilated calyces filled with purulent and yellowish mucoid material. Certain areas of the kidney, especially the lower pole had yellowish discoloration []. Intraoperatively, the retroperitoneal space revealed edematous perinephric tissue. There was a large defect on the inferior surface of the liver []. Pus flecks were seen on the inferior surface of the right lobe of the liver. Above the liver, another large defect was seen in the right hemidiaphragm with pus collection in the pleural cavity []. The microscopic examination of the nephrectomy specimen revealed the presence of lipid-laden foamy macrophages and few giant cells suggestive of xanthogranulomatous pyelonephritis []. These cells stained positive with CD68 on routine immunohistochemistry. There was no evidence of monoclonal staining.\nThe patient underwent a nephrectomy, extensive toileting of the perinephric and infrahepatic space, external drainage of the collected intraabdominal pus, and closure of the right diaphragmatic defect. She was discharged on the 7th post-operative day in a stable condition. On follow-up after a month, she is afebrile, gaining weight, and doing well. |
The patient, a 31-year-old woman, was admitted to the department of neurosurgery at The First Hospital of Jilin University due to a “right occipital mass for 5 months”. The patient was in good health, and her family members did not have similar lesions. A physical examination showed that the mass was in the right occipital region at the upper margin of the sternocleidomastoid muscle and exhibited slight tenderness without obvious pulsation or vascular murmurs during auscultation.\nA head CTA examination at admission suggested that the lesion was approximately 3 × 5 cm in size, was mainly composed of vascular components, presented as a “wool mass”, was located in a subcutaneous region, involved the muscles, and showed obvious enhancement. The lesion was mainly supplied by the occipital and muscular branches of the vertebral arteries. The venous drainage of lesion communicated with the suboccipital venous plexus and the paravertebral venous plexus, and the venous drainage communicated with the subcutaneous cervical superficial veins (Figs. and 2).\nA further DSA examination revealed that the blood supply of the lesion was mainly from the occipital artery and less from the muscle branches of the vertebral arteries (Fig. ). The lesion was considered an AVM based on its imaging characteristics and was recommended for surgical removal. The surgery was carried out under general anesthesia. The lesion could be touched when the occipital skin was incised during the operation. The lesion showed a clear boundary. The occipital artery touched the anterior margin of the lesion, was exposed and ligated, and was removed around the lesion. The lesion consisted of massive blood vessels, and the surrounding muscles were swollen, indicating IH.\nAfter the lesion was removed, the normal muscle tissue around the lesion was also removed. The specimen was sent to pathology, and postoperative pathology confirmed that the lesion was IH accompanied by thrombolytic recanalization. HE staining showed that the lesion almost purely consisted of capillaries with only rare cavernous components among the muscles. CD31 staining was positive in the vessel endothelium, indicating that the lesion was an IH (Fig. ). The patient achieved a good recovery after surgery and was discharged from the hospital. A head CTA review performed one year later showed partial residual IH (Fig. ). The patient had no obvious discomfort, and the hemangioma could not be touched from the surface, and the patient was recommended for radiation therapy. The patient refused radiation therapy. Follow-up 2 years later showed no enlargement of the IH. |
A 66-year-old man was admitted to the head and neck department of our hospital because of recurrent penetrating temporo-occipital headaches mostly located on the left side of the head. Headaches started five years ago which were relieved with paracetamol and/or nonsteroid anti-inflammatory medication per os. The patient referred to our hospital because the episodes of headache had become more frequent and aggravating during the last three months.\nMRI revealed a left pterygopalatine fossa sizeable mass-forming lesion (Figure -). Magnetic resonance angiography showed lack of neovascularization without any other abnormal finding, indicating a potential benign lesion (Figure , ). Subsequently, the patient was admitted to the head and neck department. A CT scan of the sinuses was performed, demonstrating an imprint on the posterior wall of the maxillary sinus due to compression. There was no bone erosion, a second indication that the lesion was not malignant. In addition to these radiological studies, high definition CT scan and three-dimensional (3D) reconstruction were performed to assess the exact location of the mass and its relationship to the surrounding structures. The latter showed that the medial maxillary artery was crossing the tumor (Figure , ). All the routine preoperative exams were normal. The segmental removal of the lesion along with its surrounding tissue was achieved through an endoscopic transnasal approach to the pterygopalatine fossa (Figure , ). The mass then was sent for a frozen section biopsy which was negative for malignancy. Ligation of the medial maxillary artery was performed due to intraoperative bleeding, followed by a maxillary sinus and anterior nasal packing at the end of the procedure. The package was removed after three days without any postoperative bleeding, and the patient was discharged from the hospital on the fifth postoperative day with no further complications. One month after surgery, the healing process of the posterior wall of the left maxillary sinus was almost completed (Figure ).\nMicroscopic examination of the lesion revealed the existence of storiform fibrosis (Figure ), obliterative phlebitis (Figure ) and diffuse dense lymphoplasmacytic infiltrations forming several lymphoid follicles. A small number of eosinophils were also present. The immunohistochemical study demonstrated abundant IgG4 positive plasma cell infiltration (Figure ) and a high IgG4 to IgG ratio. The combination of morphological and immunohistochemical findings established the diagnosis of IgG4RD.\nTwo months after surgery, serum immunofixation test showed an elevation of immunoglobulin G. Serum protein analysis by capillary electrophoresis showed normal levels of Gamma-globulin fraction. A QuantiFeron-TB enzyme-linked immunosorbent assay (ELISA) test was negative thus excluding a Mycobacterium tuberculosis infection. Furthermore, all other routine tests were normal. The patient received orally hydroxychloroquine 200 mg 1 x 2, methylprednisolone 8 mg x 1, calcium 500 mg 1 x 1 and metformin 1000 mg 1 x 2 per day. Eighteen months following surgery the patient shows no signs of recurrence on imaging studies and remains disease-free as evidenced by postoperative CT-scan (Figure , ). |
The present case is about a 48-year-old, female patient had presented fullness of abdomen, right flank pain and on and off hematuria for last 1 month. Computed tomography (CT) imaging revealed a large localized tumor of the left kidney with features not suggesting of any metastasis []. Right radical nephrectomy was done and grossly it was a 18 cm × 15 cm × 6 cm tumor replacing upper pole of kidney. Histopathology came out as clear cell RCC with Furhman's grade III with no capsular invasion and adrenal and hilar vessels were free of tumor. In the routine follow-up at 3 months, she had no complaints and CT scan was unremarkable. After 9 months of surgery, she complained of pain in the right hypochondrium radiating to shoulder. Ultrasonography followed by CT chest and abdomen was performed which delineated multiple liver metastasis, few lung metastasis and small ovarian mass (3 cm × 4 cm) [Figure and ]. Fine-needle aspiration cytology of the liver lesion confirmed it as metastasis from RCC []. Bone scan of the whole body did not show any evidence suggestive of skeletal metastasis.\nThe patient received sunitinib via an expanded access program at standard dose of 50 mg orally continued for 28 days followed by 14 days off. She was kept under strict follow-up for complications and objective response of the tyrosine kinase inhibitor (TKI). After two 6-week cycles side-effects experienced by the patient included grade 1 mucositis, grade 1 skin changes, grade 2 taste and grade 1 fatigue. Due to this, the patient was converted to dosage of 37.5 mg orally once daily (for 28 days followed by 14 days off). The patient tolerated this regimen well with no further adverse events. After eight 6-week cycles of sunitinib she complained of lower abdomen discomfort. A reassessment CT scan of the patient's chest, abdomen and pelvis showed an excellent partial response with the almost complete disappearance (90%) of liver and lung metastasis []. However, the adnexal mass had increased in size (10 cm × 8 cm) and the possibility was thought of second malignancy []. The decision was taken to remove this adnexal mass and intra-operative the mass was found to be adherent with a part of omentum. Excision of the mass along with omentectomy performed. Histopathology of the mass depicted metastatic RCC with Furman's grade III having micro papillary growth in few areas along with compressed ovarian parenchyma with remnant follicles at periphery. Furthermore, omentum showed metastatic deposits along with vascular emboli [Figure and ]. At 6 months of follow-up after second surgery she had stable disease with no new complaints. |
A 3-year-old Middle Eastern boy presented with a defect in the midline of his neck. He was born at full term by normal vaginal delivery and had no significance in his past medical history. There was no family history of congenital defects or consanguinity. The anomaly was located in the ventral midline of his neck (Fig. ). The superior aspect was composed of a skin tag leading to a short mucosa-like raw surface. Inferiorly, there was a sinus present with a greenish, thick residue occluding the opening. There was no contracture of the neck. He did not appear to be troubled by the lesion and a full examination was otherwise normal, except for adenoidal hypertrophy.\nHe had an MRI done elsewhere, indicating a soft tissue mass without any fistula tract. Despite contrast material being injected through the opening at the caudal end of the lesion, the diagnosis of MCC was established. No evidence of any other neck anomaly was found (Fig. ). The sinus, less than 1 cm in length, was found to extend caudally to the suprasternal notch. There were no attachments to underlying structures.\nA surgical removal and immediate closure with multiple Z-plasties were performed. Surgical removal was done with an incision 1–2 mm from the periphery of the lesion, deepened down to the supraplatysmal plane (Fig. ). During the surgery, the sinus at the caudal end of the lesion was probed and followed caudally until it ended, which was found to be approximately 2 cm long. This underdeveloped fistula tract ended right above the thymus gland. The cranial end of the defect had a fibrous band extending up to the mandible and this band was resected together with the cervical lesion. The midline lesion was found to be superficial and hence the excision was done at the subdermal level. A double Z-plasty was found to be sufficient for the closure. Closure was done with 5–0 vicryl interrupted sutures at the subcutaneous level and 6–0 rapid vicryl interrupted sutures for skin closure (Fig. ).\nA pathological examination of the specimen confirmed our clinical diagnosis. The findings were consistent with stratified squamous epithelial cells covering the cleft with few adnexial structures at the dermal level (Fig. ).\nOne month follow-up examination revealed an uneventful healing period, with redness along the incision scar and some nodularities, which were most probably due to the subcutaneous suture material. He was able to move his head in all directions without any restriction or pain (Fig. ).\nA 14-month follow-up examination showed an acceptable level of scarring causing no restriction of neck movements (Figs. and ). |
A 57-year-old female patient was transferred to the University General Hospital of Patras from a secondary hospital, with the diagnosis of traumatic rupture of the descending thoracic aorta, after a high-velocity motor vehicle collision with two dead passengers on the site of the accident.\nOn the primary survey, she had airway patency, her breathing rate was 29 per minute, her oxygen saturation was 96% with the use of oxygen supplementation, she had 89 beats per minute, and her blood pressure was 115/70. She had a good level of consciousness, and her Glasgow Coma Scale was 15/15. Clinical examination showed bilateral tenderness over her anterior chest wall, with subcutaneous emphysema on the left, tenderness over her cervical and thoracic spine, as well as over both her scapulas and right humerus, and forearm fractures. She had no abdominal tenderness. She did not have any focal neurologic deficits. She had a chest tube on the left with small drainage of bloody fluid. From her routine laboratory tests on admission, her hemoglobin and hematocrit values were 8.1 g/dl and 23.4%.\nThe patient's medical history included an angioplasty for myocardial infarction one month ago, and she was under dual antiplatelet and b-blocker therapy.\nShe was immediately transferred into the operating theatre where she was subjected to endovascular repair of the traumatic aortic rupture. The operative findings were traumatic rupture of the descending aorta distal to the origin of the left subclavian artery, at the location of the aortic isthmus, with mediastinal hematoma and bilateral pleural effusion. A GORE TAG Thoracic Endograft with Active Control System (31 mm proximal, 26 mm distal) was placed through the right common femoral artery. The proximal edge of the endograft was placed distal to the left subclavian artery (zone 3). Intraoperative angiography demonstrated a good endograft position without endoleak and with the normal angiographic appearance of the left subclavian artery. Postoperative computed tomography confirmed these findings and also showed bilateral lung contusions with pleural effusion and multiple rib fractures, left pneumothorax with subcutaneous emphysema, bilateral scapula fractures, T4 spinal body fracture, multiple cervicals, and thoracic spinal transverse process fractures and minor injury of the superior splenic pole with small amount of free intra-abdominal fluid and suspicion of pseudoaneurysm in peripheral locations of the superior splenic pole. She was transferred to the Intensive Care Unit where she remained hemodynamically stable. Repeated computed tomography scan after 2 days showed good endograft position without endoleak, while no pseudoaneurysm suspicion of the superior splenic pole was raised in this exam (Figure ). After she remained intubated for 10 days in the Intensive Care Unit, she was transferred to the cardiothoracic department from where she was discharged in good condition 12 days later, after repeated consultations from general surgeons, neurosurgeons, orthopedic surgeons, infectious diseases specialists, and psychiatrists. After one year of follow-up with CTA at 3, 6, and 12 months, the patient remains in excellent clinical condition. |
A 58-year-old female with a past medical history of hypertension presented after a fall where she sustained a supracondylar fracture of the left elbow. Initial surgery consisted of ORIF of the medial and lateral columns through a chevron osteotomy of the ulna. She failed to show signs of union at 5 months postoperatively and underwent bone stimulator therapy for 4 months. Radiographs showed loosening of hardware and a persistent nonunion. The patient then underwent removal of hardware, repeat fixation with 90/90 plating and iliac crest bone graft (ICBG). Unfortunately, she developed a deep surgical site infection 4 weeks postoperatively necessitating debridement, removal of hardware and 6 weeks of antibiotic therapy followed by repeat ORIF with contralateral ICBG. Six months postoperatively she fails to demonstrate union and to avoid yet another failure of fixation the decision was made to use a MFCF.\nA para-tricipital and anteromedial approach was performed, with dissection and exposure of the brachial artery, median nerve and ulnar nerve. The fracture site at the medial column was debrided and cancellous graft was placed without removing the plate. After harvest of the MFCF as described above, the graft was placed in the medial column crossing the fracture site and secured with two 2.0 mm cortical screws after elevating the periosteum about 5 mm at both ends of the graft. The pedicle was anastomosed to the brachial artery in end-to-side fashion. Five months after surgery, there was no pain, elbow flexion of 110 degrees and her elbow extension lag of 30 degrees. Her left-hand strength was 30 pounds compared with the right side that was 40 pounds. Subsequent radiographs demonstrated signs of consolidation with bone bridging at the medial column and residual radiolucency at the lateral column. The patient reported no complaints, with flexion of 110 degrees, extension lag of 30 degrees and complete prono-supination at the time of her final follow-up visit. The result of a DASH score performed 2 years after her last surgery was 0.8 (). |
A woman in her seventies was referred to our surgical unit, presenting with a history of pulsation on her abdomen and a left abdominal mass that she noticed one month earlier. She had no history of abdominal disorders or surgery. Computed tomography showed a huge mass (16 × 10 × 20 cm) arising extraluminally from the stomach ().\nThe tumor was diagnosed as GIST by an immunohistochemical examination of the specimen from endoscopic ultrasound fine-needle aspiration. We started neoadjuvant chemotherapy using imatinib but discontinued it two months later due to febrile neutropenia. The patient underwent surgery, and intraoperative inspection showed a large tumor pedunculated from the dorsal wall of the upper body of the stomach (). There was no visual evidence of metastasis or dissemination. The tumor was resected, including the pedicle and a small contiguous part of the stomach, without capsule rupture.\nGrossly, the tumor (30 × 20 × 6 cm in size) proliferated from the gastric muscularis propria. The mass showed a mixture of solid and cystic areas, calcification, hemorrhage, and necrosis (). Histologically the mitotic index was over 10 per 50 high-power fields (). The final diagnosis was GIST, categorized as high risk of recurrence by all major prognostic criteria. The surgical margin was negative.\nThe patient was discharged without complications, deciding against adjuvant chemotherapy despite being informed of the high risk of recurrence. Nine months later, a 2.2 cm mass appeared at the anterior part of the tail of the pancreas, adjacent to the gastric stump (), and the patient chose chemotherapy in lieu of surgery. We started chemotherapy with low-dose imatinib (200 mg/day) because of the history of febrile neutropenia, subsequently lowering the dose to 100 mg/day due to side effects. She was able to continue the chemotherapy for four years without progression of metastasis.\nFive years after the surgery, the mass had gradually expanded, indicating resistance to imatinib. This time, the patient elected to have surgery rather than the 2nd-line chemotherapy. The mass was attached to the splenic artery and vein, so we performed both distal pancreatectomy and splenectomy. The mass originated from the pancreas, not the stomach, with little adhesion to the gastric stump (). No other metastatic lesion was observed.\nThe tumor in the specimen was 3.5 × 3.5 × 2.5 cm in size (). The morphology and immunohistochemical staining showed features resembling those of the primary gastric GIST, although the tumor cells showed more atypism (). The final diagnosis was GIST recurrence with a negative surgical margin. Now, six months after the second surgery, she is continuing low-dose imatinib therapy without recurrence.\nWe conducted a genetic alternation analysis of both the primary gastric GIST and the metastatic pancreatic tumor. Both tumors had the deletion of codons 557 and 558 of the c-kit exon 11, and the recurrent tumor had the additional substitution of Val with Ala in codon 654 (V654A) of the c-kit exon 13. |
A 24-year-old male had no history of previous medical problem , but complained of acute upper gastrointestinal bleeding (hematemesis). A submucosal tumor located about 3 cm distal to the papilla of Vater was found by endoscopy. The lesion bulged beneath the mucosa with a central depressed ulceration, which was the origin of the massive bleeding. Following blood transfusion the bleeding spontaneously stopped ().\nMagnetic resonance imaging (MRI) was remarkable for a homogenous tumor of the duodenum (). MRI and CT scans showed no metastases. The patient experienced another episode of bleeding for which a blood transfusion was performed due to a decreased hemoglobin level to 4g/dl. Fortunately the bleeding stopped again. Endoscopic ultrasonography showed a 12 x 10mm hypoechoic lesion that originated from the muscularis layer without any regional lymphadenopathy. The patient was diagnosed to have a duodenal GIST ( ).Surgery was recommended and a laparotomy was done. The submucosal tumor was located in the distal third portion of the duodenum, about 3 cm distal to the ampulla of Vater. No penetration of the pancreas or other adjacent organs was detected and there were no suspicious lymph nodes. The tumor was managed by a partial resection of the distal third and fourth portion of the duodenum with a 1cm safe margin on each side and an end-to-end anastomosis. His postoperative course passed without any problem and the patient was discharged on the fifth day after the operation. The diameter of the operated tumor was 3 cm (). Histopathology showed a GIST with a typical spindle tumor cell structure (). The overlying duodenal mucosa was ulcerated. The tumor had a thin fibrous capsule that reached the muscularis mucosae, but did not penetrate it. The tumor had a moderately malignant potential according to tumor grading and the excised margin was tumor-free. Immunohistochemistry was strongly positive for C- KIT and CD34 and DOG-1 and KI67(the pathologic tumor mitotic labeling index which expression has positive correlation to tumor size) =8% , while desmin, smooth muscle, HH8, EMA and beta-catenin were negative. Mitotic activity was less than 5 mitoses/10 high power fields (). No formal lymph node dissection was done, and as it was expected no lymph nodes were noticed in the resected specimen. The tumor diameter and low proliferative activity revealed a low risk for malignancy. |
We present the anaesthetic management of a 34-year-old gravida III, para 1 woman who was 34 weeks pregnant and who presented to a University Hospital setting for caesarean delivery. She was recently diagnosed with pulmonary arterial hypertension (PAH) and atrial septal defect (ASD). Her foetus was also diagnosed on a prenatal ultrasound as having an ASD. She was also suffering from gestational diabetes. Her clinical history included dyspnoea at rest and orthopnoea requiring two pillows whilst sleeping. She had a severely restricted functional capacity. She had a previous uneventful caesarean section 4 years prior as well as a miscarriage in the first trimester 3 years prior. She admitted that her symptoms were much worse in this pregnancy. Her physical examination revealed a pansystolic murmur in the left apex. An echocardiogram revealed a moderate sized ASD with severe PAH, moderate pulmonary and tricuspid regurgitation and enlarged right heart. A cardiology consultation recommended placing her on oral furosemide, aspirin and potassium supplements.\nAfter counselling the patient and her family pre-operatively in consultation with the obstetrician, the patient was advised regional anaesthesia for the delivery. On the day of the caesarean delivery, after routine monitors were placed in the operating room, a radial arterial line was placed for beat-to-beat blood pressure monitoring. Her baseline saturation as revealed by the use of a pulse oximeter was 89% to 95% on facemask oxygen. She was then placed in a sitting position where a combined spinal epidural technique was used to deliver a slow graded spinal with 1 cc 0.5% bupivacaine and 20 mcg of fentanyl with a 27-gauge spinal needle. She was then placed in a semi-sitting position at 45° propped up on pillows as much as her orthopnoea would allow. Another 2 cc of 0.25% bupivacaine was administered via the epidural catheter to establish a block up to T4 level. A strong motor block was accomplished. Systemic blood pressures were supported by boluses of phenylephrine. Caesarean section was then performed without delay in the semi-recumbent position without event and the patient remained comfortable. A pulmonary artery (PA) catheter was floated during surgery to reveal PA pressures of 60 to 70 systolic. After delivery of the baby, the patient was nebulised with 1 cc of prostacycline (PGE1) and 4 cc of normal saline via a facemask for 30 minutes. Her arterial saturations improved to 99% and PA pressures reduced to 30 to 40 systolic. Systemic blood pressures were stable. The entire procedure lasted 1.2 hours with no untoward event and both mother and baby remained well post-operatively. She was monitored in the cardiac care unit for 24 hours and later sent to the ward. She was discharged home on day seven with no problems. She had refused a tubal ligation. |
A 4-year-old girl was previously diagnosed with asplenia, single right ventricle, and supracardiac TAPVC. She underwent pulmonary artery banding at the age of 1 month, followed by a bidirectional Glenn procedure and TAPVC repair at the age of 5 months. She did not demonstrate symptoms of PVO, and there was no evidence of delay in the excretion of contrast media in cardiac catheter examination before Fontan procedure. Extracardiac Fontan palliation was subsequently performed at the age of 19 months. At the age of 3 years, although right lower PVO occurred because of the compression of the vertebra, she did not demonstrate symptoms of PVO (). At the age of 4 years, she underwent a cardiac catheterization to evaluate her hemodynamic parameters after Fontan procedure (). She was taking oral aspirin, warfarin, and enalapril. After a routine hemodynamic assessment, NO and oxygen tests were performed. A pigtail catheter was placed in the single ventricle, and a wedge catheter was positioned in the pulmonary artery. We performed the pulmonary vasodilator examination in the same way as when doing the examination in patients with pulmonary hypertension []. Subsequently, 20 ppm NO was administered via face mask. After 5 minutes of NO administration, her hemodynamic parameters were measured. Following a washout period of 5 minutes, 100% oxygen was administered, and after 5 minutes of oxygen administration, her hemodynamic parameters were again measured. To measure the pulmonary arterial wedge pressure and pulmonary arterial pressure accurately, the waveform was monitored carefully (Figures and ). After the administration of NO, the single-ventricle end-diastolic pressure, bilateral mean pulmonary arterial pressure, and cardiac index did not change. Oxygen saturation did not change at 95%, and pulmonary resistance index decreased from 2.1 to 1.0 Um2. However, the right lower pulmonary arterial wedge pressure increased from 8 to 12 mmHg, and the left lower pulmonary arterial wedge pressure increased from 7 to 9 mmHg. The cardiac index remained almost the same. Similarly, following the administration of oxygen, the single-ventricle end-diastolic pressure did not change; however, the right lower pulmonary arterial wedge pressure increased from 8 to 14 mmHg and the left lower pulmonary arterial wedge pressure increased from 7 to 12 mmHg. The bilateral mean pulmonary arterial pressure increased from 13 to 15 mmHg. Although angiography was performed after the inhalation of NO and oxygen, there was no evidence of left pulmonary venous obstruction or delay in the excretion of contrast media (Figures and ). A systemic-to-pulmonary shunt was also nonexistent. On echocardiography, there was no acceleration of blood flow at the left pulmonary vein or surgical anastomosis between the pulmonary venous confluence and the atrium. There was also no stenosis of the atrioventricular valve. Despite the inhalation of NO and oxygen, there was no acceleration of blood flow, and stenosis was not identified at the surgical anastomosis between the pulmonary venous confluence and the atrium (). |
Case 2 concerns a 57-year-old male, with no systemic diseases. He came to our observation in November 2019, to carry out an orthodontic treatment to improve the esthetic appearance of his smile. He showed a good oral hygiene and periodontal condition. Intra-oral evaluation showed a reduction of the transverse diameters, both in the upper and lower dental arches, and a lack of space for the tooth 4.5 in the lower arch ( and ). It was planned to re-establish elements 1.6 and 3.6 after orthodontic therapy in order to reach the first molar class. The most important problem for the patient was related to his smile esthetics and concerned the crossbite of the tooth 2.2.\nHis specific request was to obtain a noticeable improvement in his smile as soon as possible, with the resolution of the anterior crossbite. It was decided to use aligners to obtain esthetic and functional goals.\nIn the first phase, the patient had to wear 23 aligners with a 7-day aligner protocol. The choice to change aligners every 7 days in an adult patient is strongly related to compliance, and requests excellent collaboration by the patient in following the orthodontist prescriptions, without which the clinician would have to significantly extend the time of treatment. In this case, the DM system allowed to strictly follow patient compliance and monitor the resolution of the anterior cross that could be an insidious problem if not carefully monitored. In the present case, the No Go notification, in fact, was often linked to the complexity of the teeth movements, which could not be monitored without the DM, as some aligners required more time to obtain the desired result. The DM system allowed to obtain the proper planned results and allowed to avoid interruptions.\nThe patient reached good teeth alignment in 12 months. The crossbite on 2.2 was treated, reaching an ideal alignment. Molar and canine class I was reached, the midline was centered and the crowding was significantly improved. During his treatment, the patient received almost all “GO” signals (), which means that he showed an excellent compliance and confidence with the DM system. Monitoring was made active until all clinical goals were achieved. It was, therefore, suspended only while waiting for the new aligners. |
A six years old female child weighing 12 kg, admitted with history of gradual abdominal distension that was noticed by the mother for the last 2 years but did not seek any medical advice as there were no other associated complaints. With an increase of abdominal girth and vague abdominal pain, parents took the child to a nearby general practitioner who advised ultrasound and referred the child to our facility. On examination child appeared comfortable with abdominal fullness. Abdominal examination did not reveal a distinct mass though vague fullness was present oriented more in vertical direction. There was a definite feel of fluid thrill on palpation.\nUltrasound done previously showed cystic mass in abdomen. With female gender a differential diagnosis included ovarian cyst in addition to mesenteric and omental cyst. CT scan abdomen was advised. This showed a large cystic mass occupying almost whole of the abdomen and located under anterior abdominal wall with viscera pushed posteriorly (Fig. 1,2). A diagnosis of omental cyst was made at this stage.\nLaparotomy was performed. On opening peritoneum a huge lymphatic cyst was found (Fig. 3). It was delivered out with difficulty and that too after partially evacuating it. More than 1500 ml of milky fluid was drained out. The anatomy was then identified more clearly. It was found between leaves of transverse colon mesentery and extending into its root (Fig. 4). The redundant leaves of mesentery were excised without jeopardizing blood supply of colon and left open so as to prevent re-accumulation of fluid. Drain was kept and wound closed.\nPost-operative course was uneventful and patient discharged on 4th day. Biopsy was reported as consistent with mesenteric cyst. Parents were counseled again as to possible recurrence of the lesion and a regular follow up was planned. At three months follow up child is well. On ultrasound a small hypoechoic area of 4cm x 4cm was noted in mid abdomen. A repeat ultrasound after a month is advised to note the progress of the lesion. |
The first-trimester ultrasound for a pregnant 28-year-old woman revealed cystic fetal hygroma, which resolved spontaneously by the 20th gestational week (). Placental villous sampling revealed a normal male karyotype (46, XY), and tests for congenital viral infection were all negative. The fetal heart seemed normal, but the pathological flow of the venous duct was noticeable at the 20th week of gestation, with reversed a-wave during atrial contraction (). Later in gestation this finding also normalized. The child was born at 39 + 4 weeks of gestation, weighing 4385 g. There were no dysmorphic features; only the head circumference was +3.4 standard deviation compared with national references. He needed supplemental oxygen for a few hours after delivery and thereafter was in good condition. No cardiac murmur was audible. The electrocardiogram and the chest X-ray were normal.\nBecause of the hygroma detected by prenatal ultrasound, a transthoracic echocardiography was performed at the age of five days. It revealed normal structure and function of the heart except that neither left nor right superior caval veins existed. Instead, a venous structure was draining from the upper trunk behind the heart and joining the exceptionally broad inferior vena cava (IVC) that was connected to the right atrium (). The computerized tomography (CT) of the chest and abdomen ascertained five days later the anatomy; there was no SVC, and the blood from the head and the upper limbs drained into the right atrium through a venous plexus connected to the IVC (). CT scanning was chosen as the imagining modality because of a relatively short imaging time to be performed under light sedation without need for intubation anesthesia.\nThe boy had suffered from continuous wheezing since the age of one month, and symptoms worsened during respiratory infections. Because respiratory symptoms continued despite inhaled bronchodilators and corticosteroids, trachea compression was suspected, and at the age of eight months, the magnetic resonance angiography (MRA) of the thorax and abdomen was performed. The MRA confirmed the total absence of a SVC. Blood from the right arm and the right side of the head drained into the azygos vein, and blood from the left arm and the left side of the head drained into the hemiazygos vein. The azygos and the hemiazygos veins were fused below the level of the trachea bifurcation, and this vein formed a loop beneath the diaphragm joining the prominent IVC at the level of the kidneys, but both renal veins drained into the IVC above the conjunction (). All other vessels were normal. No structures were compressing the trachea. Ultrasound of the upper abdomen was performed at the age of one year, showing no signs of portal hypertension.\nWe performed a number of genetic tests to exclude genetic syndromes connecting total absence of the SVC with large head circumference and the fetal cystic hygroma. The child had a normal male karyotype (46, the XY), and tests for CATCH 22 syndrome, Sotos syndrome, and Prader-Willi syndrome were all negative. |
A 34-year-old male patient was admitted for an occipital headache that had started 1 month prior to his visit. He had no history of head trauma, injury to the spine or dura puncture. The headache was postural in nature because the headache occurred when he stood up or sat, and it subsided when he lay down. The character of the headache was a dull, continuous pain in the occipital area with some radiating pain to the parietal and frontal areas. Visual analog scale (VAS) score was 8-9 points and dizziness was accompanied when standing or sitting. However, when he lay down, the VAS score decreased to 1-2 points. Physical and neurological examinations were performed on the day of admission and no abnormal findings were observed. Brain magnetic resonance imaging showed no abnormal findings and laboratory data on the patient were also within normal limits. Radionuclide cisternography was checked and it showed possible cerebrospinal fluid leakage at the cervicothoracic junction level () and the patient was diagnosed with spontaneous intracranial hypotension. Conservative management was administered including hydration, bed rest, and NSAIDs. Yet, the symptom persisted and the patient was referred to the pain clinic for an epidural blood patch. The patient was 175.2 cm high and his body weight was 77 kg. His occupation was aquaculture, breeding abalone. The patient was not obese, but he had a relatively well-developed musculature. Upon entering the operation room, the patient was placed in the prone position on the C-arm table. Both arms of the patient were placed over his head. The lower cervical area and the upper thoracic area were prepared and the skin was anesthetized with a local anesthetic agent. A modified 18G Tuohy needle was inserted at the C7-T1 intervertebral space and it was advanced at the anteroposterior (AP) view. For further advancement and visual identification of the epidural space, the C-arm was rotated to the lateral plane. The patient had very well developed shoulder muscles; therefore, the true lateral view image of the C7 and T1 vertebrae was difficult to obtain due to the superimposition of the shoulder muscles and bones (). The optimal oblique view provided an increasingly more distinct image of the cervicothoracic junction and the needle was further advanced accompanied by the LOR technique and the imaging of the intermittent AP plane view (). To obtain sufficient visualization, the C-arm unit was rotated in the AP/lateral plane until a perpendicular view of the target level lamina was achieved. The laminar was visualized as an enface image of a hollow tube (). A hollow tube means the cross-sectional view of the target laminar as the perpendicular view of the target level when the target laminar is parallel with X-ray beam. The angle of the oblique position of the C-arm unit was calculated in reference to the cervical CT findings (). As the needle entered the interlaminar opening, radiocontrast dye was administered. The AP view along with the oblique view was acquired to confirm the positioning of the needle tip in the epidural space () and then 8ml of autologous blood was injected. On rounds the next day, the patient reported a pain score of 1/10 on the VAS. He was discharged 3 days after the procedure without any remaining symptoms. |
A 43-year-old previously healthy man, a physician, living in a city of about 150,000 inhabitants, began to use a lightweight motorbike to commute to work, a distance of about 10 km, in heavy traffic in the middle of August 2006. He had previously been travelling in a car fitted with an air pollution filter, and had experienced no previous heart symptoms. He also walked or jogged about 6 km four to five times a week with no problems and was not on any medication. He felt relaxed and did not experience stress while riding the motorbike in heavy traffic. There were numerous traffic lights on his journey to work, which meant that he was forced to stop behind buses and trucks on several occasions where he experienced a strong smell of exhaust fumes.\nAfter commuting to and from work by motorbike for about 2 weeks he began experiencing cardiac extrasystoles, something not previously experienced; on one occasion he was unable to sleep due to palpitations. He sought help and had an electrocardiogram (ECG) the following morning, which showed PVCs in bigeminy. The patient had also sinus tachycardia with a heart rate of about 110 beats per minute.\nThe patient was admitted to the cardiac intensive care unit and was examined using echocardiography, which was found to be normal, and there were no signs of false tendons. No ischaemia was seen on ECG and there were no signs of infarction. The frequency of PVCs began to decrease about 8 hours after admission. Blood tests showed no indications of infarction or infection, his blood glucose was normal and his lipid status and thyroid status were within normal limits. The patient had no fever. During the night and the next morning only a few PVCs and some premature atrial complexes were observed and the patient was discharged home. The diagnosis was given as myocarditis, although this diagnosis was uncertain.\nThe patient rested for 2 weeks with no further symptoms before returning to work. For the first few weeks he drove his car to work, but then began to use his motorbike again. Having used it for a few weeks on the same route he again began to experience extrasystoles and therefore contacted his physician, who recommended an exercise test and Holter ECG.\nIn the few days before the Holter ECG was applied the patient refrained from using his motorbike and began to feel better. Only a few PVCs and premature atrial complexes were found during 24 hours of Holter monitoring. The heart rate variability (HRV) showed a pattern with a somewhat high low-frequency to high-frequency ratio. An exercise test was carried out and the patient performed well, with no chest pain, arrhythmias or signs of ischaemia.\nThe patient began to believe that there was an association between using his motorbike and his symptoms and decided to stop using it. Since then no symptoms, apart from an occasional single extrasystole, have been noted by the patient. |
A 3-year-old Middle Eastern boy presented with a defect in the midline of his neck. He was born at full term by normal vaginal delivery and had no significance in his past medical history. There was no family history of congenital defects or consanguinity. The anomaly was located in the ventral midline of his neck (Fig. ). The superior aspect was composed of a skin tag leading to a short mucosa-like raw surface. Inferiorly, there was a sinus present with a greenish, thick residue occluding the opening. There was no contracture of the neck. He did not appear to be troubled by the lesion and a full examination was otherwise normal, except for adenoidal hypertrophy.\nHe had an MRI done elsewhere, indicating a soft tissue mass without any fistula tract. Despite contrast material being injected through the opening at the caudal end of the lesion, the diagnosis of MCC was established. No evidence of any other neck anomaly was found (Fig. ). The sinus, less than 1 cm in length, was found to extend caudally to the suprasternal notch. There were no attachments to underlying structures.\nA surgical removal and immediate closure with multiple Z-plasties were performed. Surgical removal was done with an incision 1–2 mm from the periphery of the lesion, deepened down to the supraplatysmal plane (Fig. ). During the surgery, the sinus at the caudal end of the lesion was probed and followed caudally until it ended, which was found to be approximately 2 cm long. This underdeveloped fistula tract ended right above the thymus gland. The cranial end of the defect had a fibrous band extending up to the mandible and this band was resected together with the cervical lesion. The midline lesion was found to be superficial and hence the excision was done at the subdermal level. A double Z-plasty was found to be sufficient for the closure. Closure was done with 5–0 vicryl interrupted sutures at the subcutaneous level and 6–0 rapid vicryl interrupted sutures for skin closure (Fig. ).\nA pathological examination of the specimen confirmed our clinical diagnosis. The findings were consistent with stratified squamous epithelial cells covering the cleft with few adnexial structures at the dermal level (Fig. ).\nOne month follow-up examination revealed an uneventful healing period, with redness along the incision scar and some nodularities, which were most probably due to the subcutaneous suture material. He was able to move his head in all directions without any restriction or pain (Fig. ).\nA 14-month follow-up examination showed an acceptable level of scarring causing no restriction of neck movements (Figs. and ). |
A 63-year-old male patient (180 cm, 75 kg, retired office worker, Korean) was admitted with the chief complaint of necrosis of the left thumb. He was healthy and a non-smoker with no underlying disease, including vascular disease, diabetes, or hypertension and family history. One week before admission, he visited a private clinic because of a cold, and received an injection of diclofenac sodium (OS-beta, Unimed®) 90 mg in the left wrist. He developed numbness and severe pain in the distal part of the wrist immediately upon receiving the injection, as well as hypesthesia in the thumb and index finger after several hours. On the following day, he developed swelling and cyanosis of the thumb and index finger. Necrosis of the distal end of the thumb started developing from the third day after the injection. Subsequent ultrasonography at another hospital indicated reduced blood flow to all fingers of the left hand and no measurable blood flow in the left thumb. Consequently, the patient was prescribed beraprost 40 mg twice a day. Even though he was taking the medication, his symptoms and necrosis worsened, and he visited our hospital after becoming aware of the possibility of needing an amputation. At the time of admission to our hospital, necrosis from the interphalangeal joint to the distal end on the left thumb was observed and an injection mark was visible in the proximal portion of the radial styloid process (). But there was no abnormality in the patient’s laboratory data. Strong pulse was palpable in the proximal portion of the radial styloid process of both wrists, but not where the radial artery is generally located. Variation in the superficial dorsal antebrachial artery was identified on angiographic CT (). After confirming the boundary of the necrotic area, the proximal phalanx was amputated. Thumb reconstruction was not performed because the patient chose not to undergo the procedure.\nWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. |
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 45-year-old woman was referred to the Emergency Unit by the cardiologist for management and investigation of symptomatic severe hypertension. At admission, blood pressure was high at 190/130 mmHg. Heart rate was normal at 78 bpm. The clinical examination was unremarkable. There was no evidence of aortic dissection and the patient was transferred to the Intensive Care Unit for blood pressure stabilization.\nPrior to admission, the patient was seen for the first time by cardiologist because she suffered from symptomatic hypertension with headaches, scotoma, tinnitus, epistaxis, paresthesia in the upper limbs, and dizziness lasting for 4 months. The episodes occurred several times per month but were more frequent of late and tended to happen every 2 days, lasting from a few minutes to an hour. The patient felt well between those episodes except for fatigue. She had been taking a combined antihypertensive drug (angiotensin-conversion enzyme inhibitor with diuretics) for 3 days prescribed by her general practitioner.\nDiagnosis of hypertension was established by her GP, confirmed by blood pressure self-measurement, which showed systolic pressure up to 180 mmHg and diastolic pressure up to 80 mmHg. The patient also had palpitations and tachycardia up to 147 per minute.\nThe patient had no major medical history, although she had depression when her first husband died from a car accident 20 years ago, leaving her in charge of a small child. She has now remarried and had 2 other children. She explained that her son from her first husband had psychological issues and drinking addiction; when drunk, he could be verbally and physically violent towards her. She confessed that her son tried to stab her 4 months ago and went to jail after that event. She had recently started seeing him again but was very anxious during their meetings. She did not drink alcohol but usually smoked a few cigarettes on social occasions. She did not use illicit drugs and did not drink coffee regularly.\nBiological results were strictly normal. There was no renal impairment. Hormone determination showed no evidence for secondary hypertension causes such as hypercorticism, hyperthyroidism, hyperaldosteronism, carcinoid tumour, or pheochromocytoma (). Plasmatic adrenaline and noradrenaline levels were within the normal range but urinary vanillylmandelic acid and urinary normetanephrine levels were slightly high (with, resp., 29.1 mg/24 h (1.8–6.7) and 289 micrograms/g creatinine (46–256)). Urinary catecholamine tests were repeated a few days thereafter and returned to normal.\nCardiac assessment by echocardiography and electrocardiogram was normal; there was no sign of hypertrophy or cavity dilatation, and cardiac output was normal. Cerebral scan revealed no lesion.\nAn abdominal CT scan was performed and showed no renal artery stenosis or adrenal mass.\nClinical evolution was satisfactory: blood pressure was well controlled by intravenous nicardipine in the first place and then by oral antihypertensive drugs afterwards (ACE inhibitor associated with calcium antagonist). Headaches were treated with simple painkillers. The patient was transferred to the Internal Medicine ward after 5 days spent in the ICU.\nFundoscopic examination of the eye revealed no retinopathy. Magnetic resonance imaging of the brain was normal. 123MIBG-scintigraphy was performed and ruled out the existence of adrenal or ectopic secreting mass.\nDuring hospitalization, we observed recurring paroxysmal hypertension crises at 210/120 mmHg despite the treatment. Beta-blockers and diuretics were added to the initial treatment but had little effect. The patient had hypertensive peaks at 240/150 mmHg and subsequently developed a seizure due to a hypertensive encephalopathy; she was readmitted in the ICU for 5 days. It must be noted that there was no orthostatic hypotension.\nAfter excluding every cause of secondary hypertension, pseudopheochromocytoma was the most likely diagnosis for paroxysmal hypertension without evidence of catecholamine excess or organ damage and often appears with an underlying psychological context. Emotional instability can trigger hypertension peaks, which mimic clinical manifestations of pheochromocytoma, even though patients are not aware of their psychological issues.\nAdequate treatment was started with alpha- and beta-blockers, combined with anxiolytics and psychological support. Hypertensive crises rapidly resolved after several days and the patient was discharged after normalization of blood pressure.\nTwo weeks later, the patient was readmitted in the ICU for tonic-clonic seizures with loss of consciousness. At admission, Glasgow Coma Scale was assessed at 3/15 and systolic blood pressure was of 220 mmHg. Electroencephalogram and cerebral scan were normal. Artificial ventilation was needed for a few hours. The patient recovered quickly and was transferred the day after to the General Internal Medicine Unit. The patient recognized afterwards that she had not taken the medication properly at home. Importance of treatment and psychological follow-up was explained again to the patient before discharge. She was seen at medical visit 3 weeks after hospitalization: the patient is now under a psychologist's care, she has no symptoms anymore, and blood pressure is within normal range, which allows progressive decrease of antihypertensive drug doses. |
A 71-year-old man was referred to our department complaining of dyspnea, hypoventilation and dysphonia, determined by swelling in the neck region and related to a considerable increase in size of the thyroid gland.\nOn clinical examination, the thyroid gland appeared firm during the acts of deglutition. The patient reported that he had a goiter for more than 20 years and he had never undergone any drug therapy.\nAn ultrasound examination dating back to 1997 documented a complete subversion of the echotexture of the whole gland and the presence of a large nodule in the right lobe displaying a complex echotexture. A further ecography in 2000 documented an increase in volume of the thyroid, which was also the cause of the right carotid bulb dislocation.\nLaboratory investigations revealed significantly elevated thyroglobulin values. A preoperative fine needle aspiration was not significant; it consisted of an acellular smear within a background of inflammatory and necrotic cells without any cytologic specification.\nConsequently, we decided not to repeat this procedure because of the worsening of the patient’s dyspnea, for which a surgical management for liberation of the airways was planned.\nA total thyroidectomy was performed. Although the surgical operation was expected to be very complex, it was performed in a completely linear way. The left lobe was easily separable from the surrounding tissue; it appeared to be in the throes of a nodular transformation. The right lobe appeared uniformly in a nodular transformation and it penetrated the upper part of the neck, adhering to the vessels, from which, however, it was easily dissociated. Lymph nodes were not visible. However, surgical times were also lower than expected, particularly for the removal of the right half, which was relatively easy, and the mass appeared well encapsulated and demarcated (Figure ).\nThe specimen was sent to surgical pathology for definitive diagnosis. The tissue samples were fixed in formalin, then routinely processed and embedded in paraffin. The sections were stained with hematoxylin and eosin. Additional 5-μm sections were cut and subjected to immunohistochemical studies using antibodies to the following antigens: CD34, CD31, factor VIII-related antigen, pan-cytokeratin (Pan-CK) and thyroglobulin. Grossly, the right thyroid lobe measured 10 × 8.5 × 6 cm, the left lobe was 5 × 4 × 1.5 cm and the pyramidal lobe was 4 × 2 × 1 cm in size. The right thyroid lobe was totally occupied by a well circumscribed nodule macroscopically confined within the capsule. The nodule measured 9 × 5 cm and, on the cut sections, appeared cystic and hemorrhagic, with large necrotic tissue areas (Figure ). The tumor was extensively sampled. On histological examination, the periphery of the lesion showed epithelioid areas that were made up of large rounded cells of relatively high nuclear grade, with eosinophilic cytoplasm and prominent nucleoli arranged in rudimentary vascular channels. These neoplastic channels were irregular in shape, and they were lined by a single layer of malignant endothelium forming intraluminal papillary projections (Figure ). An extensive central area of necrosis and hemorrhages was a characteristic feature of the lesion. The capsular surface was not involved with the tumor and a rim of residual thyroid tissue was observed in some peripheral areas. Immunohistochemically, neoplastic cells were strongly positive for CD31, CD34, and factor VIII-related antigen, showing evidence of their endothelial differentiation (Figure ). Diagnosis of this condition can be difficult as the histological features may mimic other malignant vascular lesions. In view of the clinical history and morphological and immunohistochemical findings, a diagnosis of primary angiosarcoma of the thyroid gland was made.\nAs regards adjuvant therapy, our patient has not been subjected to any kind of special treatment because, even today, there are no guidelines and there are various schools of thought as to the best treatment options.\nThe prognosis was not favorable. The postoperative course was not simple: it was decided to admit the patient to our intensive coronary unit for precautionary reasons. After 3 days, due to an atelectasis of the left lung, intubation and subsequently tracheostomy were needed. Breathing difficulties continued for a long time (about 60 days after surgery). Our patient was monitored and follow-up was started but it was too short to be meaningful because unfortunately, our patient died about 3 months later as a result of of cardiac and respiratory complications related to his oncologic condition. |
A 67-year-old man visited the emergency department of our hospital due to sudden paraplegia of both lower extremities caused immediately after slip down. On presentation to the department, both his lower limbs were observed to be almost paralyzed, with a motor grade of 2 or lower in both limbs. This paralysis showed a gradual aggravation. The patient had a history of renal cell carcinoma diagnosed 7 years prior, and achieved remission without any recurrence after total nephrectomy and adjuvant chemotherapy. He was also diagnosed with papillary thyroid carcinoma 5 years ago, and yet again achieved remission after surgical treatment. The patient signed an informed consent statement, and the study was approved by the Institutional Review Board of the Yeungnam University Medical Center.\nThe plain radiograph revealed the collapse of the T12 vertebral body. CT showed an acute burst fracture at the T12 vertebral body with an osteolytic mass-like lesion within the vertebral body and pedicle, causing severe encroachment of the spinal canal (Fig. ). Magnetic resonance imaging (MRI) revealed a bulging posterior cortex, with an acute fracture of the vertebral body and severe compression of the spinal cord (Fig. ). Considering his medical history and the MRI findings, a pathologic fracture with a tumorous condition was suspected. Therefore, the evaluation of the malignant potential and metastasis in the remote area was necessary. Hence, 18FDG PET/CT was performed, and 18FDG uptake at the T12 level was measured. A maximum standardized uptake value (maxSUV) of 1.7 was noted, with a central FDG defect on the vertebral body (Fig. ); this was interpreted as a benign fracture by a senior radiologist. Additionally, there was no positive uptake in the other body parts on PET/CT. Although there was a discrepancy between the interpretation of the spine fracture lesion on MRI and PET/CT, the patient required emergent surgical treatment owing to acute paraplegia caused by spinal cord compression, and we thus planned an initial surgery for the main purpose of cord decompression, temporary stabilization, and tissue biopsy. The surgical intervention was as follows. First, we performed T11-12 posterior laminectomy for the spinal cord decompression, followed by T9-L2 posterior instrumentation without a bone graft. Finally, tissue biopsy was obtained at the T12 pedicle and vertebral body. Histological examination confirmed the presence of a malignant solitary bone plasmacytoma (SBP) (Fig. ). Seven days later, a definite surgery with pedicle screw fixation and posterolateral bone graft from T8 to L2 without vertebral body corpectomy was performed.\nImmediately after the initial surgery, the patient's lower extremity motor function showed gradual improvement. After the surgery, the patient wore a thoracolumbar rigid brace for 2 months, and underwent continuous gait rehabilitation. Three weeks postoperatively, the motor function in his lower extremities had recovered sufficiently, and ambulation was possible with the assistance of a cane. Four weeks after the definite surgery, the patient underwent radiation therapy for 2 months. One year postoperatively, spine radiographs showed that the surgical segment had healed fully, and spine MRI revealed complete decompression of the spinal cord with no evidence of local recurrence (Fig. ). |
A 3-year-old Middle Eastern boy presented with a defect in the midline of his neck. He was born at full term by normal vaginal delivery and had no significance in his past medical history. There was no family history of congenital defects or consanguinity. The anomaly was located in the ventral midline of his neck (Fig. ). The superior aspect was composed of a skin tag leading to a short mucosa-like raw surface. Inferiorly, there was a sinus present with a greenish, thick residue occluding the opening. There was no contracture of the neck. He did not appear to be troubled by the lesion and a full examination was otherwise normal, except for adenoidal hypertrophy.\nHe had an MRI done elsewhere, indicating a soft tissue mass without any fistula tract. Despite contrast material being injected through the opening at the caudal end of the lesion, the diagnosis of MCC was established. No evidence of any other neck anomaly was found (Fig. ). The sinus, less than 1 cm in length, was found to extend caudally to the suprasternal notch. There were no attachments to underlying structures.\nA surgical removal and immediate closure with multiple Z-plasties were performed. Surgical removal was done with an incision 1–2 mm from the periphery of the lesion, deepened down to the supraplatysmal plane (Fig. ). During the surgery, the sinus at the caudal end of the lesion was probed and followed caudally until it ended, which was found to be approximately 2 cm long. This underdeveloped fistula tract ended right above the thymus gland. The cranial end of the defect had a fibrous band extending up to the mandible and this band was resected together with the cervical lesion. The midline lesion was found to be superficial and hence the excision was done at the subdermal level. A double Z-plasty was found to be sufficient for the closure. Closure was done with 5–0 vicryl interrupted sutures at the subcutaneous level and 6–0 rapid vicryl interrupted sutures for skin closure (Fig. ).\nA pathological examination of the specimen confirmed our clinical diagnosis. The findings were consistent with stratified squamous epithelial cells covering the cleft with few adnexial structures at the dermal level (Fig. ).\nOne month follow-up examination revealed an uneventful healing period, with redness along the incision scar and some nodularities, which were most probably due to the subcutaneous suture material. He was able to move his head in all directions without any restriction or pain (Fig. ).\nA 14-month follow-up examination showed an acceptable level of scarring causing no restriction of neck movements (Figs. and ). |
A 42-year-old Korean woman with low back pain, general weakness, loss of appetite, and indigestion for 3 months presented to the Department of Family Medicine, Dongsan Medical Center, Daegu, Korea via the outpatient clinic for evaluation and conservative management. The patient has been followed up on for hypertension, dyslipidemia, and osteogenesis imperfecta for 8 years.\nThe patient had been treated with monthly intravenous administration of pamidronate 15 mg for osteoporosis since the dual-energy X-ray absorptiometry had demonstrated a T score of -2.93 8 years ago, but there was no improvement in bone mass density. The patient has had percutaneous vertebroplasty for a T11 compression fracture 6 years ago, but her low back pain has continued. The patient had presented to the orthopedic outpatient clinic with aggravation of low back pain 4 years ago, in which she was diagnosed with osteogenesis imperfecta and had an magnetic resonance imaging (MRI) demonstrating a T11 compression fracture with thoracolumbar kyphotic deformity. One year ago, the patient had kyphosis correction with autogenous bone grafting for continued low back pain and 30 degrees kyphosis. A relief in symptoms was reported for some time thereafter, but her symptoms worsened for the past 3 months, requiring conservative treatment including pain medication and physical therapy.\nThe patient has been taking angiotensin receptor blockers and statins daily for 4 years for hypertension and hyperlipidemia with intermittent use of zolpidem for insomnia. Her daughter and son were diagnosed with osteogenesis imperfecta as well and have been followed up at pediatrics. Her mother has a history of cerebrovascular disease.\nThe laboratory data upon admission were within normal limits. Plain radiograph of the pelvis showed no change from previous testing. Thoracic MRI demonstrated no significant changes other than improvement in kyphosis at the T10-11 level from the previous surgery.\nThe patient's general weakness, depressed mood, insomnia and decreased appetite have been improving with the management of major depressive disorder which includes emotional support and medical management using mirtazapine 15 mg daily. However, the patient was complaining of aggravated pain on the left posterior iliac crest area, rating it as an 8/10 on the visual analogue scale (VAS).\nOn physical examination, she exhibited local hyperesthesia and tenderness on the skin over the left posterior iliac crest compared to the right side when a fold of the skin and subcutaneous tissue was taken and rolled. Tenderness upon palpation of spinous processes and the facet joint of the thoracolumbar junction was also observed. Based on these typical findings of physical examination of the posterior iliac crest and nonspecific findings of imaging studies, the patient was diagnosed with thoracolumbar junction syndrome.\nThe patient could not benefit from facet joint injection which was tried in cooperation with the pain clinic at our facility on the 4th day of admission. The continuation and severity of the symptoms prompted the decision to proceed with epidural nerve block using triamcinolone and 0.5% mepivacaine. The patient reported an improvement in pain, reporting a 4.5/10 on the VAS. On the 8th day of admission, a lumbar sympathetic nerve block was performed with 0.5% mepivacaine upon patient's complaining of increased pain to 5.5/10 on the VAS. The patient reported a reduction in pain, reporting a 2/10 on VAS thereafter. The patient's gastrointestinal symptoms including bloating and lower abdominal pain, also improved after epidural block, suggesting that the symptoms were also functional disabilities accompanied by throcolumbar junction syndrome. The patient was discharged on the 11th day of admission with improved clinical symptoms and instructed to follow-up via the outpatient clinic. |
A 35 years-old woman was admitted to local hospital complained of dyspnea, cough and hemoptosis. A Chest X-ray showed the presence of massive left pleural effusion. Thus, she referred to our unit for the treatment. A chest computed tomography (CT) scan confirmed the presence of pleural effusion accompanied by an area of consolidation. Pleural puncture undoubtedly revealed hemothorax. A tube thoracostomy yielded hemothorax to the amount of 1100 ml. The clinical condition of patients was stable and all laboratory values were within normal. A repeated CT scan performed three days after the procedure, confirmed the presence of area of consolidation in lower left lobe and the presence of an hilar nodule (size 3 mm) not been reported before (Figure ). Bronchoscopy showed no endoluminal lesion and the pathological results from bronchoalveolar lavage showed the presence of inflammatory cells in absence of malignant cells [,]. Then a fine needle biopsy CT-guided was attended but the results was inconclusive for a definitive diagnosis. Arteriography diagnosed the mass located in lower lobe to be a sequestration. Thus, our strategy was to attend an exploratory thoracotomy. The sequestration was successfully resected with partial resection of the diaphragm. Then the nodule was biopsied and the intraoperative diagnosis was positive for malignancy, possibly a sarcoma, whereas a conclusive diagnosis on frozen sections specimen was not possible. The tumor invaded the main trunk of left pulmonary artery, thus contraindicated a bronchoplastic procedure. A pneumonectomy was attended in a standard manner. A chest drainage was left in the chest, and removed two days after. For postoperative pain control, a patient controlled analgesia was used for the first two days []. Pathologic examinations revealed the sequestration to be an infarcted extralobar sequestration (ELS). Small elastic arteries were identified within the sequestration. The final diagnosis of the tumor was primary fibrosarcoma of the lung according to the pathological and immunostaining results as reported in Figures . And . The postoperative course was unremarkable, and the patient was discharged on postoperative day 11. |
A 51-year-old female referred to our department with the complaint of pain and swelling in the left mandibular region since two years. During systemic history, patient revealed low back pain, hypertension and diabetic mellitus Type 2 since 10-11 years. She underwent surgery of the maxillary sinus region which as per her previous records was treated with FESS (functional endoscopic sinus surgery), left conchaplasty with widening of maxillary sinus. The biopsied tissue of the ophthalmic and maxillary region showed inflammatory cells and was not suggestive of any malignancy. During course of time patient underwent root canal treatments of mandibular molars, premolars and incisors for her dental pain. However, the pain did not subside and patient referred to our department. On examination pain was mild, dull, and localized in nature. The family history of the patient was not contributory. Physical examination showed facial asymmetry attributable to diffuse swelling of the left mandibular region. Mouth opening and sensation over the distribution of the left inferior alveolar nerve was normal. Intraorally, the alveolar ridge posterior to the right first molar was covered with intact, normal-appearing mucosa. No teeth showed mobility or pain on percussion. There was no cervical or axillary lymphadenopathy. A two-year-old panoramic radiograph [] showed an ill-defined osteolytic lesion in the left posterior mandibular body, with involvement of the apices of both the first molar and the second molar and in the anterior part of the mandible involving the incisors and premolars of the left side of the mandible. However, a recent panoramic radiograph showed massive increase of erosion in the posterior and anterior part of the mandible [].\nBecause the clinical and radiographic findings led to suspicion of a malignancy, surgical intervention with biopsy of the lesion was planned and performed. The specimen, which was friable and resembled granulation tissue, showed a proliferation of histiocytic cells and an infiltration of eosinophils and neutrophils on microscopic examination. Soft-tissue fragments permeated by hematopoietic cells and predominantly mononuclear cells with clefted nuclei and granular cytoplasm were seen admixed with eosinophils, neutrophils and lymphocytes []. Immunohistochemical staining showed that the histiocytic cells were positive for the CD 68, CD1a, S-100 protein [Figures –], and Myeloperoxidaes were positive in the surrounding granulocytes. The CD 45 was also positive in lymphocytes [].\nThese features were consistent with a diagnosis of eosinophilic granuloma. To evaluate the possibility of systemic histiocytosis X, a radiographic skeletal survey and a visceral ultrasound was performed. These examinations detected no other lesions except a few changes in sacroiliac joint. The results of laboratory tests, consisting of blood and serum biochemical studies, were within normal ranges except there was a significant increase in ESR observed. A chest radiograph did not show any significant abnormality. Consequently, the mandibular lesion was diagnosed as eosinophilic granuloma. After three weeks of surgery the mandibular swelling decreased rapidly, and there was marked improvement in the facial asymmetry. Patient reported again after one year to us with a pain in the right mandibular posterior region. Computed tomography (CT) scans showed a destructive bony lesion extending from the mesial side of the right first premolar to the distal side of the second premolar []. A separate well-defined new radiolucent lesion was observed distal to the left mandibular first molar [].\nSecond surgery with curettage of the lesion was done along with biweekly intralesional 40 mg injections of methylprednisolone in the posterior lesion for the next eight weeks. The patient was also given systemic steroid Defcort 6 mg (Deflazacortil, Mehius India) per day for 30 days in a tapering manner along with surgical curettage. The patient was evaluated after every six months for the next two years. Patient was free of symptoms and signs and her radiographs revealed healed lesions in the anterior and posterior part of the mandible []. |
A 30-year-old male with a traumatic brain injury following assault status-post debridement and elevation of a depressed skull fracture was discharged home several weeks postoperatively. His preoperative CT scan is shown in Figure , and his postoperative CT shown in Figure .\nHis mental status at this point stabilized revealing a flat affect, slow verbal responses, and decreased overall cognitive abilities. He had no deficits on gross motor examination. After several weeks of weekly physical therapy and stable cognitive status, he was brought to the hospital again with encephalopathy and confusion. The patient was afebrile and did not have an elevated white blood cell count. He did not have positive blood cultures, consolidation on chest radiograph, a urinary tract infection, or any other typical postoperative or nosocomial infectious process to explain the change in mental status. MRI could not be obtained because of previous eye shrapnel. At this point, a CT scan of the head with contrast was obtained revealing an enhancing ring-shaped lesion in the right frontal lobe consistent with a brain abscess as shown in Figure .\nThe patient was taken to the operating room for image-guided excisional biopsy of the lesion. Surgery was uneventful with gross total resection of the lesion. The patient had no new neurological deficits postoperatively, and his mental status did improve.\nPathological examination of the specimen revealed mucormycosis. Specifically, the histology revealed abscess formation with polymorphonuclear cells and necrosis surrounded by granulation tissue and fibrin deposition. Also within the abscess were nonseptate fungal hyphae. The irregular width and right-angle branching pattern are characteristic of zygomycetes. The organisms were readily demonstrated in the areas of necrosis with hematoxylin and eosin staining as shown in Figures -.\nHis immediate postoperative CT is shown in Figure , and his clinical follow-up CT after amphotericin therapy is shown in Figure showing abscess resolution.\nInformed patient consent for treatment was obtained from the patient's family. No identifying patient information is included in this report. |
A 25-year-old lady with no significant medical history including allergic diseases such as bronchial asthma was admitted to a tertiary care hospital of South India because of recalcitrant erosive lesions on her oral mucosa and lip that had begun 3 months earlier. The patient was treated for Steven Johnson syndrome in a private hospital with steroids prior to the admission. On admission, there were extensive erosions in the oral mucosa and tongue with thick hemorrhagic crusts on the lip [] and erosive lesions over labia majora. Cutaneous and conjunctival lesions were not evident at that point of time. Histological examination of a biopsy taken from a violaceous, indurated lesion of the lower lip showed a band-like infiltrate of lymphocytes and histiocytes throughout the papillary dermis, hydropic degeneration of basal keratinocytes, and necrotic keratinocytes within the hypertrophic epidermis. Skin biopsy was suggestive of interface dermatitis suggestive of pemphigus vulgaris []. Anti Nuclear Antibody was negative. HIV was non-reactive by ELISA. Biopsy from un-involved buccal mucosa for direct immunofluorescence was negative for antibodies. During hospital stay, she developed respiratory paralysis and thus need ventilator support. Electrolytes and thyroid profile were normal. Workup for respiratory weakness with limb weakness with preserved deep tendon reflexes was done with neostigmine test. Positive response to the test was suggestive of myasthenia gravis; hence, pyridostigmine and steroids were started with which she was off ventilator in next 48 hours. Ultrasound abdomen and subsequently computed tomography (CT) imaging of the abdomen done revealed a solid tumor of 8.5 × 4 × 5.5 cm of size in right paraspinal area near the hilum of right kidney []. Workup for pheochromocytoma prior to surgery was done which showed normal urinary metanephrins. Physical examination revealed slightly decreased breath sounds in both lungs with no crackles. Mild hyperinflation without infiltrates was visible on chest radiographs, but conventional CT of the chest showed no remarkable abnormalities. She underwent surgery for the retroperitoneal tumor and highly vascular tumor of 8 × 6 × 5 cm was removed without any intraoperative and post-operative complications. Histopathology revealed Castleman's disease of hyaline vascular variety [Figures -]. Skin lesions improved at the end of 2 weeks post-operatively [] and she was discharged with an advise to tapper her steroids and to continue pyridostigmine for myasthenia gravis. |
A 23-year-old Caucasian female patient was admitted to the Department of Neurology at the end of September due to hands tremor and paresthesia extending to forearms, without the complaint of upper limb weakness. Another major symptom was severe pain in the mid-cervical region. Moreover, the patient suffered from episodes of nausea, vertigo in the period from May to September. During that period the patient also experienced transient episodes of diplopia on distance fixation. Most of the listed symptoms disappeared or decreased their intensity in September except for the limb tremor, episodes of pain in the cervical region, and diplopia.\nThe medical interview revealed a 2-day episode of fever in May. At that time, the patient could have been exposed to a tick bite in the forest endemic region. However, the tick bite was not remembered. The patient family history was negative for neurological or other chronic familial diseases. She was not taking any medications permanently and did not smoke cigarettes nor consume alcohol or drugs. There was no history of trauma, infections, intoxication and the patient was otherwise in good health. Apart from that, the review of the patient’s systems was negative.\nOn neurological examination, the muscle strength in the upper right limb was slightly reduced (grade 4 in Lovett scale) in comparison to the left limb. The muscle tone of the lower and upper extremities was at a normal range. Symmetrical intention tremor was observed in her hands, extending periodically to forearms and arms. Normal deep tendon reflexes occurred symmetrically in both upper and lower limbs. The patient’s movements were coherent. The sensory examination did not reveal skin hyperaesthesia in the upper nor lower extremities or spinal tenderness. The sensation was normal in the upper and lower extremities. There were no signs of cranial nerve impairment. The patient was conscious without signs of any psychological or mood disorders.\nThe patient underwent a comprehensive ophthalmological examination during hospitalization. Her best-corrected visual acuity was measured at 20/20 in both eyes. Pupils were equal, round, and reactive to light. Intraocular pressure was 18 mmHg in both eyes. No aberrations were observed in the anterior segments of the eyes. Besides the fact that the patient complained of transient episodes of diplopia on distance fixation, during the examination the extraocular muscle movements were normal. The fundoscopic examination showed bilateral papilloedema. Blurred optic margins and several flame-like peripapillary hemorrhages were observed in both eyes. The foveal reflex was normal. Optical coherence tomography (OCT) testing showed bilateral diffuse thickening of the retinal fiber nerve layer (RNFL) in all quadrants. The average RFNL was 297 μm in the right eye and 291 μm in the left eye (Fig. ). The retinal architecture was normal. Automated perimetry visual field test demonstrated no defects.\nNerve conduction study (NCS) was performed for a better evaluation of the cause of the limb numbness and tremor. A Median nerve motor NCS revealed an abnormal reduction of compound muscle action potential (CMAP) in the right median nerve compared to the left median nerve. Reduced amplitude of CMAP was also detected in both peroneal nerves. The reduction of CMAP was more severe in the right peroneal nerve. After supramaximal stimulation F - waves were recorded from median nerves. Decreased F - wave persistence(45%) was observed in the right median nerve. In both peroneal nerves, the absence of F - waves were found. During the orthodromic sensory study, a decreased conduction velocity was observed in the right median nerve and both sural nerves. Based on evidence from an NCS, radiculopathy of nerve roots of both peroneal nerves and the right median nerve was diagnosed. Furthermore, sensory neuropathy of both sural nerves and the right median nerve was also detected.\nRoutine blood tests were in the normal range. CRP, ESR, and TSH were within physiological limits. VDRL, HIV, EBV, HCV/HBV, HSV, CMV were negative. The patient was AQP − 4 - IgG negative. The ANA test was negative. Vitamin B12 level was in the normal range. High titers of Bd IgM and IgG antibodies were detected in serum using ELISA method. The results were confirmed by Anti Borellial IgG and IgM antibodies detection by western blot method (Table ).\nMRI of the cervical spine was obtained to determine the nature of the patient’s tremor and pain in the cervical region. MRI images showed longitudinally extensive (> 3 segments) enlargement of the spinal cord mostly visible from C3 to C6/C7 level. T2 and STIR-weighted images demonstrated a hyperintense, spindle-like lesion in the central part of the spinal cord extending from C1 to C6/C7 without enhancement in the post-contrast image. CSF reservoirs were constructed. Contrast-enhanced T1 images revealed signal amplification in the meninges (Fig. ). The MRI of the optic nerve disclosed bilateral protrusion of the optic nerve heads, slight vertical tortuosity of both optic nerves, and bilateral hyperintense perioptic nerve sheath in T2 images (Fig. ). Brain MRI showed an empty sella turcica sign. Together these signs could indicate elevated intracranial pressure.\nAfter the analysis of MRI images, the patient had a lumbar puncture performed. CSF findings included lymphocytic pleocytosis, increased level of protein, and albumin. Anti - Bb IgM and IgG antibodies were detected in CSF using Western Blotting. The titers of anti -Bb IgM and IgG antibodies were significantly increased. Bb - specific antibody (AI) index was elevated indicating the intrathecal production of antibodies (Table ).\nThe patient met the EFNS criteria for definite LNB [] and the diagnosis was SaTM due to Bb infection. She received a 28-day course of ceftriaxone (2 g/day intravenously). After the period of antibiotic administration, the symptoms subsided and the patient was discharged from the hospital. The patient’s CSF findings, including pleocytosis, the levels of albumin and protein normalized. Bilateral swelling of optic discs decreased. Post-treatment MRI images showed no abnormalities in the spinal cord and meninges (Fig. ). All other symptoms had subsided except for minor tremors in the left hand, which vanished one month later. The patient was monitored during regular follow - up visits for one year. Six months after the antibiotic treatment the patient’s anti C6 antibody titer decreased by 11 - fold indicating the effectiveness of antibiotic treatment [] (Table ). During follow -up visits no additional aberrations were found in MRI scans. In one year follow up a gradual decrease in swelling of RLNS was observed leading to optic atrophy in superior and nasal quadrants of the right eye and in the superior quadrant of the left eye (Fig. ). |
A 4-year-old boy was referred to the emergency department with mild abdominal pain and an incidental radiological finding of a radiopaque object in the abdomen. The patient was stable without vomiting or abdominal distension. Physical examination revealed mild tenderness of the lower abdomen without peritoneal irritation. There were no fever or blood from the rectum, laboratory blood tests were normal, and no nutrition-related issues emerged during this period.\nThe patient was admitted for observation. During the next 2 days, he was free of pain and could feed and evacuate without difficulty. Follow-up abdominal radiography showed the object still in the lower abdomen. Based on the good clinical status, the child was discharged home, and the parents were instructed to observe the stools and to refer to their pediatrician in case of any new sign noticed.\nA month later the boy returned complaining about recurrence of abdominal pain. Abdominal radiography still showed the same object image. The mother who did not follow the medical instructions on a daily basis presumed that the item had been evacuated and that there was nothing to worry about.\nThe presence of a radiopaque foreign body in the intestine for a long period and the recurrent abdominal pain resulted in the decision of exploratory laparotomy. No contrast radiological study was performed before operation as clinical, plain radiography, and history criteria were considered indicative for laparotomy. During the procedure, two intestinal loops (the 1st of the ileum, 1 m from the ileocecal valve and the 2nd of the jejunum, approximately 40 cm from the Treitz ligament) were found adhered together [], with the presence of two fistulas between them []. The implicated item was not single but consisted of 14 small cone-shaped magnets, removed through an enterotomy. Double enterectomy and end-to-end anastomosis followed.\nThe patient's postoperative course was uneventful and he was discharged home on the 5th postoperative day. Both parents recognized the removed particles as elements of a refrigerator magnetic ornament in the home of a relative that they had visited 10 months ago. The mechanism of the complication was that of enteric mural ischemia and necrosis. The parts in the jejunum and the parts in the ileum were attracted together, and a permanent pressure was applied to the bowel between them until it gave its place to the two fistulas. |
An 18-year-old female patient reported to the Department of Prosthodontics for prosthetic rehabilitation of her lost left eye. On eliciting history, it was found that the patient had sustained a shrapnel injury to her left eye, which necessitated a surgical evisceration of the eye. Clinical examination revealed a completely healed left eye socket. Her right eye had normal vision. The patient had no other relevant medical history [].\nA custom ocular tray was made by pouring autopolymerizing resin into an alginate mold made with a stock ocular prosthesis. Perforations were made in the custom ocular tray to aid in retention of the impression material, and a tunnel was cut out at the center of the custom tray to which a disposable impression tip was attached to deliver the impression material[] The impression was made by injecting light bodied addition silicone material (Aquasil Dentsply) through the prepared tunnel[] []. The patient was asked to move her eyes in all directions to facilitate flow of impression material into all aspects of the socket. Then, the patient was asked to look directly at a fixed point six feet away at the level of eye allowing impression of the site with the muscles in neutral gaze position The impression was invested first in dental stone till the height of contour and when set a second pour to create a two piece split cast mold[] [] A wax conformer was fabricated by pouring molten baseplate wax into the two pieces split cast, after which it was retrieved and the sharp edges were removed.[] The rubber stopper from a plunger tip of a tuberculin syringe was used as a removable cap which was fitted into an opening made in the posterosuperior aspect of the wax conformer A bevel was placed around the margins of the cap to help in easy removal and placement []. The wax conformer was then adjusted for the satisfactory fit, contours, and comfort An iris disk cut out from a stock eye was attached to the wax conformer using a transparent grid[] [] A needle cap was attached with cyanoacrylate adhesive to the iris disk []: To assess orientation of visual axis To stabilize and secure the iris disk during dewaxing and packing. A wire was attached to the rubber cap so that the rubber cap was retained in the same position during dewaxing and packing [] The prosthesis was invested in a dental flask. Upon separation of the flask after dewaxing, the rubber cap was retained in position by the attached wire and iris disk was retained in position by the needle cap which was attached to it [Figures and ] A mixture of clear heat cure acrylic resin and zinc oxide eugenol was packed to achieve a white scleral color.[] Lost salt technique was used to create a reservoir for the lubricant in the superior aspect of body of the ocular prosthesis[] [] A modified curing protocol (reverse curing cycle) was followed to minimize the monomer content of acrylic eye.[] In this technique, the flask was placed in water at 95°C × 20 min and thereafter in boiling water for additional 20 min The ocular prosthesis was acrylized, retrieved, and finished. All residual salt crystals were flushed out through the opening for the removable cap The prosthesis was tried to check for the extent, fit, comfort, and iris position. Characterization of the scleral part of the prosthesis was done with the help of (SR Adoro) light cure stains and (Targis Power) light curing unit so as to match the natural eye. Optiglaze protective coating agent (GC America) was applied to protect the characterization [] A 0.5 mm diameter exit hole for the lubricant was created on the anterior surface of the ocular prosthesis into the limbus with the help of a suitable bur which connected the reservoir containing the lubricant The prosthesis was disinfected in cidex :2% glutaraldehyde cidex (surgikos, Johnson & Johnson co.), and it was delivered to the patient with instructions as to how to load the lubricant (carboxymethylcellulose eye drops IP 0.5%, extralube).[] [Figures –]. The removable cap is to be replaced if there is deformation or tear such that it does not fit into the access passage or there is a leakage of lubricant. Patient was instructed to clean the prosthesis with ophthalmic irrigation solution.[] The chamber was cleaned by removing the removable cap and injecting ophthalmic irrigation solution through a syringe Patient was followed up after 24 h, 1 week, 1 month, 3 months, and then every 6 months. The removable cap was replaced after 6 months due to deformation. |
A 22-year-old male patient reported to the prosthodontic department with a defective right hand finger which was amputated in an industrial accident 3 years back. Since surgical reconstruction was not possible, the site was covered with a skin flap at that time and the healing was uneventful []. As the patient was a dental assistant, his job mainly involved the use of the right hand, especially the index finger which was used for writing and handling dental materials and so wanted to rehabilitate the defect with a retentive prosthesis.\nPhysical examination of the hand showed that the patient's index finger was amputated at the level of the distal phalange, but the joint was preserved and functional.\nConventional acrylic resin finger prosthesis was fabricated for knowing the acceptance and adaptability level of the patient to an artificial prosthesis. The acceptance was satisfactory, but patient was disappointed with the poor retention of the same. Multiple treatment options were discussed with the patient and patient showed willingness toward the osseointegrated finger prosthesis fabrication.\nA radiographic analysis of the residual finger was done, palmar, and lateral views were made to evaluate the skeleton's bone density and dimensions. Routine blood investigations were carried out. The case was discussed with relevant medical specialty surgeons and oral and maxillofacial surgeon.\nSince the case was done for the first time by the surgeon and prosthodontist, a cadaver study was planned and carried out successfully.\nAn implant retained finger prosthesis was finalized and it was decided to be done using a two stage surgery technique which is considered as the standard protocol.[] An informed consent was obtained from the patient. Prophylactic antibiotics were prescribed.\nThe surgical procedures were performed in the dental implant operatory of the department, under strict asepsis.\nRoutine presurgical scrubbing was carried out and the area was isolated. Then, the Right index finger's digital nerve was anaesthetized with 2% lignocaine without epinephrine and hemostasis was obtained using a tourniquet at 250 mmHg. The right hand was kept on a flat platform. Skin incision was made at the implant site and a skin flap was elevated. The osteotomy was started with a 2 mm pilot drill, the position and the angulation of the osteotomy was guided by radiovisiography (RVG) []. The bone density was observed as Type IV according to Lekholm and Zarb classification.[] Sequential drilling was done to insert a 3.5 mm (diameter) × 11.5 mm (length) Adin Touareg dental implant (Afula, Israel). The osteotomy site was irrigated with copious amount of saline and betadine. The implant was manually inserted using a hand wrench with 30 N torque. A cover screw was placed and the flap was repositioned using nylon sutures []. RVG was taken from various angles to verify the position of the implant and a pressure dressing was given and was changed once in 3 days. The patient was also asked to care for the wound. The healing was uneventful and on the 10th day the sutures were removed. The superficial skin layer was found to be necrotized and the color of the skin had darkened, careful debridement was carried out and the issue was resolved.\nAt 5th month follow-up, the radiographs revealed a fine degree of osseous integration of the implant and the absence of infection and other complications.\nA second stage surgery was planned after 5 months. The soft tissue covering the implant was measured and was found to be 5 mm, hence to obtain an ideal soft tissue cover the sub mucosal tissue was scooped out using a tissue curette. By reducing the distance between the implant platform and the prosthesis the leverage forces on the implant fixture can be reduced. The possibilities of secondary infections can also be controlled by limiting the excessive soft tissue thickness around the abutment.[] A healing collar (3 mm) was attached to the implant and sutures were given []. The patient was recalled for the impression procedures after 2 weeks. The healing collar was replaced with an open tray impression coping. The impression was made using polyether impression material (Impregum, 3M, St. Paul, USA) by using a custom impression tray which was earlier fabricated using a cylindrical measuring jar. A cast was obtained with type 4 die stone with a soft tissue simulator at the collar region.\nThe open tray transfer coping was modified to be used as a custom abutment. Self-cure clear acrylic was molded into a ribbed form along the sides of the coping converting it to a retentive abutment for the silicone prosthesis []. A full anatomy index finger was sculpted using modeling wax and a wax trial was carried out to ensure the angulations and appearance was life-like. The pattern was invested in a dental flask and kept in a dewaxing unit to eliminate the wax. The mold space was then filled with medical grade silicone with intrinsic stains (M72 Full Prosthetics Starter Kit, Technovent Ltd., South Wales, UK) to simulate the exact color of the patient's skin. The silicone was cured at room temperature according to the manufacturer's instructions. An acrylic nail was fabricated using self-cure acrylic resin, by incorporating intrinsic stains. The nail was attached to the prosthesis using adhesive primer (G611 Platinum Primer-Technovent Ltd, South Wales, UK). The finished and polished prosthesis was gently pushed over the ribbed area of the custom abutment and it exhibited good retentive ability. The insertion and removal of the prosthesis was easy and patient was satisfied with the function of the prosthesis. The patient could hold a pen and write immediately after insertion []. Instructions were given on the maintenance of the prosthesis as well as the peri implant area.\nPatient was asked to wash the area with Luke warm water and clean the area with a soft dental brush. Since the prosthesis is subjected to wear and tear, it has to be reviewed regularly and if needed to be refabricated. The mold was retained in the dental flask for further remaking.\nPatient reported for review after 1 month and the site was examined in detail, no postoperative infections were observed and the bone loss was within the acceptable limits. The patient was able to do his day today work and social activities with confidence. |
A 33-year-old woman presented with a 2-month history of mild pain in the lower left posterior jaw. She had no history of surgery or trauma to the mandible. Panoramic radiography at another hospital showed a large hypointense lesion with an irregular edge in the lower left posterior jaw, and examination of a biopsy specimen indicated a low-grade MEC in the mandible.\nClinical examination revealed no swelling of the left mandible or difficulty chewing. The only abnormality was swollen gums in the left retromolar area and mandibular ramus. The superficial mucosa was intact with no obvious tenderness. Non-swollen lymph nodes were found in the submental and submandibular regions. Panoramic radiography in our hospital showed that the large hypointense lesion in the left retromolar area and mandibular ramus and the distal root of tooth 37 had been absorbed (Fig. ). Computed tomography (CT) showed that the left mandibular bone was not dilated, and a 24 × 17.5 × 43 mm cystic space-occupying lesion was present in the ascending branch of the left mandible (Fig. ). The digital information of the CT examination was collected. A three-dimensional digital model was then established based on this information, and we planned partial mandibular resection with placement of a microvascular fibula myocutaneous flap to reconstruct the shape of the mandible and a free fibula flap to restore the height of the mandible. These flaps were used not only to restore the maxillofacial profile but also to provide a possibility for later dental implantation. The range of resection and the reconstruction of the length and angle of the fibula were pre-designed with reference to the three-dimensional model (Fig. ).\nThe patient underwent radical tumor resection under the assistance of the digital design and ipsilateral functional neck dissection through a standard transcervical approach with lip splitting. Intraoperatively, the surgical margins were located at the distal part of the condyle and the left mandibular lateral incisors. No bone erosion or destruction was present at the margins. The shaped pedicled fibular myocutaneous flap and the free fibula flap were used to reconstruct the mandible with small plates and screws. The ipsilateral submandibular gland and cervical lymph nodes were completely excised, and the operation areas were closed eventually.\nThe main body of the lesion was located in the inflated part of the jaw. Routine postoperative pathological examination revealed that the specimen was cystic structure and lined by myxoid cells, high columnar cells, and squamous epithelial cells. The diagnosis of low-grade IMC was confirmed based on histopathology and imaging. The histopathological features showed only reactive hyperplasia of lymph nodes; no lymph node metastasis was found in the left cervical lymph node specimens. Therefore, the patient did not undergo postoperative adjuvant treatment. Meanwhile, immunohistochemistry results showed positive results for ck7, 18 and mucin (Fig. ).\nPostoperative imaging showed that the height of the mandible and the symmetry of the mandible were satisfactory (Fig. ). The patient was also satisfied with her appearance. Healing of the microvascular and free fibula flaps during the long-term follow-up would allow for the performance of secondary operations. The patient has been on regular follow-up for >8 months without any evidence of recurrence. Ethics approval was not required for this paper as it is a case report. Informed consent was obtained from the patient for publication of this case report and accompanying images. |
A 61-year-old woman with liver failure secondary to autoimmune hepatitis was transferred to our facility owing to acute onset of epigastric pain, melanotic stools, and hypotension. Computed tomography of the abdomen and pelvis showed free intraperitoneal air as well as free fluid anterior to the stomach. Emergency laparotomy was performed and found both an anterior and a posterior antral ulcer. The patient underwent an antrectomy with Billroth II reconstruction. During the procedure, 3 L of bile-stained peritoneal fluid were evacuated. Three closed suction drains were left in place to drain the duodenal area, and the abdominal fascia was closed with a combination of running and interrupted sutures. The skin was closed with skin staples.\nThe patient initially did well, and 2 of the 3 drains, which were draining approximately 300 mL each day, were discontinued on postoperative days 3 and 5, respectively. However, the only remaining drain subsequently increased in output to more than 1 L daily. On postoperative day 7, large amounts of serous fluid started to leak from the midline incision site. The drainage measured more than 3 L on postoperative day 8. Over the next 4 days, the drain output decreased to less than 100 mL daily, and the drain was discontinued. Owing to continued leakage of ascites from the midline abdominal wound, a wound manager device was placed to control the leakage (Fig ).\nMeanwhile, a regimen of spironolactone and furosemide was started in order to control the ascites medically, but the fluid drainage persisted. Concurrently, the patient was started on concentrated nutritional supplementation. On postoperative day 12, a VAC dressing was placed over the wound in an attempt to control the ascitic fluid leak (Figs –). The VAC drained 1 L of serous fluid during the first 24 hours. However, there was minimal VAC drainage thereafter. Fifteen days following the operation, the patient was discharged to home. Outpatient nursing care was provided to help manage VAC dressing changes at home. The patient's medical management of ascites consisted of a continued regimen of spironolactone. She was doing well at the 2-month follow-up visit, with no evidence of any recurrent drainage of ascites. |
In October 2000, a 57-year-old Caucasian woman was diagnosed with breast carcinoma following mammogram screening. She had a wide local excision of the left breast and axillary node sampling. Histology was reported as T1N0 grade 1 invasive ductal carcinoma with clear resection margins. She was treated with tamoxifen 20 mg daily and commenced on adjuvant radiotherapy to the left breast and axilla. The radiotherapy dose was 40 Gy in 15 fractions using medial and lateral tangential fields of 5 MV photons followed by 5 Gy in two fractions of 10 MeV electron boost to the tumour bed.\nAt the end of her radiotherapy treatment the patient developed acute radiotherapy reaction in the left inframammary fold consisting of mild moist desquamation that subsequently resolved. On clinic review nine months later, she noticed a spontaneous, painful and discoloured swelling of the left breast (Figure , left panel). This was initially diagnosed as cellulitis and treated with antibiotics, but as there was no improvement, a fine-needle aspiration was carried out which showed no recurrence of the breast cancer.\nShe was referred to a rheumatologist and dermatologist. She was screened for systemic collagen disease and fungal infection. By then, the abnormal area had extended further to the axilla and medial aspect of the left upper arm. A review of the breast radiotherapy plans and delivery did not reveal any incorrect delivery or unexpected high subcutaneous dose.\nSubsequent breast biopsies confirmed RIM of the breast. The histology showed intact epidermis but the papillary dermis had a patchy perivascular lymphocytic infiltrate. The most striking changes were in the reticular dermis where the collagen bundles appeared thickened with increased eosinophilia, accompanied by a moderate amount of chronic inflammatory cell infiltrate consisting of lymphocytes predominantly, plasma cells and histiocytes (Figure ).\nVarious treatments including topical and oral steroids and oral psoralen ultraviolet-A (PUVA) therapy did not improve the appearance of the breast. Paracetamol and amitriptyline were used to control her breast pain. The patient was referred to a plastic surgeon but she declined any reconstructive surgery.\nThe photographs in Figure show the changes in the left breast over time. The initial appearance was of swelling, erythema and bruising (Figure , left panel). It reduced in size and became harder with skin telangiectasia over one year (Figure , middle panel) and 3 and a half years post-radiotherapy (Figure , right panel). On her clinical review 6 and a half years post-radiotherapy, she remained free from recurrence and the breast appearance did not deteriorate any further. |
A 92-year-old woman presented to the emergency room with acute onset of right upper quadrant pain, nausea, and vomiting. She was previously in her usual state of health with minimal medical or surgical comorbidities with the exception of a minor weight loss. Her past medical history is significant for gastroesophageal reflux, history of peptic ulcer disease, and osteoarthritis. She has had cataract surgery in the past in addition to colonic polypectomy for benign polyps a few years prior to her presentation. Her family history was significant for uterine cancer in her mother, without known genetic predisposition. On physical examination, she was hemodynamically normal and the only pertinent finding was tenderness to palpation in her right upper and lower abdominal quadrants. All blood tests were within normal limits including a white blood cell count and liver function tests. A right upper quadrant ultrasound demonstrated gallbladder distention with mild gallbladder wall thickening, but no evidence of gallstones, sludge, or pericholecystic fluid. A computed tomography (CT) scan demonstrated a markedly dilated extrahepatic biliary ductal system (intrapancreatic common bile duct > 2.5 cm) and a markedly distended gallbladder (). The patient was admitted to the hospital for treatment of acute cholecystitis including bowel rest and antibiotics. Given the marked dilation of the intra- and extrahepatic bile ducts an obstructing mass at the head of the pancreas or the distal bile duct had to be ruled out. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a distended gallbladder with wall thickening, edema, and pericholecystic fluid confirming acalculous cholecystitis, with a mention of focal narrowing and wall thickening of the cystic duct. The extrahepatic bile duct had a fusiform dilation measuring 27 mm in the largest dimension (). Endoscopic retrograde cholangiopancreatography (ERCP) and an endoscopic ultrasound (EUS) failed to show a pancreatic head mass or distal common bile duct stricture; however the cystic duct did not opacify, suggesting an obstruction in the absence of gallstones. The patient's clinical status did not improve during a short period of observation; she developed increasing abdominal pain and leukocytosis to 13.5 e3/μL. After reviewing of previous CT scans spanning several years, the gallbladder was noted to be located in several different locations adding suspicion for gallbladder torsion to the differential diagnosis (). The patient was consented for open cholecystectomy due to the extremely large size of her gallbladder, her concomitant small body habitus, and a relative delay in diagnosis.\nAt laparotomy, a gangrenous, necrotic gallbladder was identified in the right lower quadrant and was nonadherent to the liver bed. The gallbladder was completely torsed (360 degrees) around the cystic duct and cystic artery. The gallbladder was so mobile that it could be brought out onto the abdominal wall and detorsed; a blood clot was visible in the gallbladder mesentery at the point of torsion. The gallbladder was readily removed following simple ligation of the cystic artery and duct (). The choledochal cyst was not addressed given her advanced age and lack of malignancy seen on axial imaging, ERCP, and EUS. Inspection of the specimen revealed significant gallbladder wall thickening and absence of gallstones (). The patient recovered without major events and was discharged to a rehabilitation facility on postoperative day four. Final pathology revealed severe acute cholecystitis with transmural necrosis and acute serositis. |
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 patient with a history of appendectomy and cholecystectomy was diagnosed with hypertension and diabetes mellitus. She was referred to an outpatient clinic with a complaint of a 3 × 4 cm mass that had been located in the right parotid region for eight months and recently grew rapidly to cause total facial nerve palsy. The mass was mobile, and the patient did not report pain. The patient's computed tomography (CT) indicated a lobular-contoured, 4 × 2.5 cm solid mass lesion with heterogeneous contrast enhancement in the anterior lobe of the right parotid gland (). A fine needle aspiration biopsy revealed a malignancy of an unknown type. Neither physical and endoscopic examinations nor positron emission tomography-computed tomography (PET-CT) checks succeeded in establishing the primary origin of the malignancy.\nHowever, an elevated skin flap revealed a pigmented lesion that had infiltrated the superficial parotid gland. Following a frozen-section examination, the patient was diagnosed with melanoma. We observed the temporozygomatic and buccal branches of the facial nerve penetrating a 5 × 6 cm mass originating from the superficial lobe of the parotid gland (). We then performed a total parotidectomy operation in which we resected the temporozygomatic and buccal branches and dissected the deep lobe. The results of an immunohistochemical analysis found the melanoma to be HMB-45 positive, S100 positive, Melan-A positive, and PanCK negative. These findings verified the malignant melanoma diagnosis (Figures , , , and ).\nNo primary origin of the melanoma was detected in the head, the neck, or any other region during the patient's postoperative dermatology consultation. Considering the possibility that the primary metastatic malignant melanoma might have regressed, we decided to check the patient's earlier photographs. Upon examination of photographs that were taken five to six years ago, we detected a 3 × 3 cm hyperpigmented lesion in the right facial region (Figures and ). The patient reported that the lesion gradually disappeared spontaneously. We considered the possibility that the metastatic malignant melanoma's primary tumor was likely to have regressed at a later time. |
A 29-year-old male patient who complained of pain and swelling around the popliteal area and symptoms of common peroneal nerve palsy in the right lower leg was referred to our service. The patient had a medical history of re-revision of ACL reconstruction using a transtibial technique for femoral tunnel in the right knee 6 weeks ago in another hospital. The initial ACL reconstruction was performed 9 years ago with an Achilles tendon allograft after the patient had injured his knee during a soccer game. Revision was performed four years ago with an Achilles tendon allograft under the diagnosis of re-ruptured ACL that occurred during a basketball game. The patient's past history revealed popliteal fossa pain that started from the night of the 3rd operation (re-revision ACL reconstruction). The pain became aggravated on the 2nd postoperative day, sudden swelling of the popliteal fossa was noted and symptoms of common peroneal nerve palsy developed. The surgeon who had performed the re-revision surgery could palpate the dorsalis pedis and posterior tibial arterial pulses and concluded that the patient had intact circulation and that the paralysis could be the result of inadequately long post-operative leg splinting. The patient was required to rest for 6 weeks. With no sign of pain and swelling subsiding, the patient was referred to our hospital.\nOn arrival, the dorsalis pedis and posterior tibia arterial pulses were palpated. Vital signs, including blood pressure, were within normal limits, and the results of blood gas analysis were normal. Dorsiflexion power of the right ankle was observed as grade 1-2 with 80% sensory loss compared to the contralateral limb. Ankle brachial index and toe pressure were not measured before surgery. Magnetic resonance imaging (MRI) and computed tomographic (CT) angiography were performed for evaluation.\nMRI findings showed abundant hematoma in the popliteal fossa and CT angiogram showed pseudoaneurysm of the popliteal artery and leakage of administered dye at the level just superior to the medial and lateral superior genicular artery (). From the MRI scan, the authors observed a trace of drilling track, presumably for Rigidfix insertion, which extended from anterior to posterior. The distal end of the drilling track was at the site of popliteal injury (). We believe that this drilling may have caused the arterial injury.\nSymptoms similar to those of compartment syndrome, such as swelling, pain of the lower limb, and common peroneal nerve palsy and abundant hematoma on MR images are the reasons why we decided that decompression and exploration are required based on the result from the medical check-up.\nEmergency surgical exploration was performed in the prone position through an S popliteal incision. Intraoperative findings revealed a hematoma measuring 8×8 cm around the popliteal artery, which showed abundant adhesion with adjacent soft tissue and muscles. Segmental arterial injury was observed just superior to the level of the medial and lateral superior genicular artery.\nMicroscopic evaluation showed evidence of two perforating injuries and one peripheral injury (). A greater saphenous vein autograft was harvested from the ipsilateral limb and a re-anastomosis procedure was performed ().\nAspirin (Bayer, Leverkusen, Germany) and Cilostazol (Pletaal; Otsuka, Tokyo, Japan) were administered for postoperative thrombo-prophylaxis. Ankle brachial index and toe pressure, compared to the contralateral limb, showed normal results on the third day after arterial re-anastomosis surgery. Follow-up CT angiograms obtained on the first postoperative day () showed intact circulations. Then, the patient was transferred to another hospital on patient demand.\nSwelling and pain around the popliteal fossa were completely resolved and range of knee motion was restored three months after arterial re-anastomosis. However, the common peroneal nerve palsy detected by advanced Tinel's sign was partially improved and dorsiflexion power of the right ankle was still not improved. |
A 60-year-old female patient was presented with swelling in front of the neck since 12 yrs, initially small in size started in thyroid region and gradually increased to present size (25 × 15 cm) with watery discharge form swelling of 6 months duration ().\nOn examination there were multiple cystic swellings extending from thyroid cartilage to mid sternum. There were about 12–15 cysts with features of intercommunication. The whole swelling moved with deglutition and there was no independent mobility of cysts. A sinus was present on right side of neck with active serous discharge (). Cervical lymph nodes were not enlarged. On indirect laryngoscopy, no abnormality was detected. Thyroid profile was within normal limits. Neck and chest X-ray showed increased soft tissue density seen in neck region extending up to upper sternal region and indenting trachea. Fine Needle Aspiration Cytology of the swelling showed features suggestive of nodular goitre. Ultrasound of the neck showed multiple anechoic areas with areas of calcification and internal septae in the neck extending from carotid level to midsternal level. Lesion seemed to be arising from thyroid tissue showing minimal vascularity suggestive of multicystic goitre or lymphangioma. On computer tomography there were multiple fluid attenuation coalescent cystic lesions in subcutaneous plane of neck and proximal thorax. There were no inhomogenous enhancing areas within the cyst. Thyroid gland could not be visualized seperately from cysts. There was no infiltration of surrounding structures or lymphadenopathy. The cystic lesions seem to be arising from thyroid gland and only part of left lobe of thyroid was visible (). Patient was subjected for surgery. Under general anesthesia Kocher's horizontal incision taken over the swelling and in middle incision extended vertically downwards over right breast as T incision and flaps raised. Fluid in cyst was clear light brown color. Some cysts were intercommunicated and cysts were found arising from right lobe and isthmus of thyroid (). On the right side cysts were adherent to internal jugular vein [IJV] () and common carotid artery (). Internal jugular vein was ligated and divided. Cysts were separated from right carotid artery. Total thyroidectomy done along with excision of all cysts and skin around sinus. Postoperative period was uneventful (). On histopathological examination of specimen papillary carcinoma of thyroid was found and sinus tract was free of tumor cells. Patient underwent an radioactive iodine ablative postoperatively and is on suppressive dose of thyroxine since then. |
A 56 year old male patient was admitted to our clinic with complaints of shortness of breath ongoing for three months. He reported that the severity and frequency of his complaints had increased recently. On admission, the patient was orthopneic and dyspneic and described a feeling of constriction in the chest. He had no other atherosclerotic risk factors except for tobacco abuse. On physical examination, blood pressure was 90/70 mmHg and pulse was 130/min. Bilateral crepitant rales were heard along the lungs. The patient had 1 + edema in both legs. Cardiac oscultation revealed 1/4 diastolic rulman and a 2/6 systolic murmur at the apex and at the mitral focus. Electrocardiography (ECG) revealed T wave negativity on chest derivations C4-6. A venous blood sample showed hypercholesterolemia and a sedimentation rate of 81 mm/hour. Based on these findings, transthoracic echocardiography was performed and revealed a 44 x 31 mm mass in the left atrium. The mass was arising from the atrial side of the anterior mitral valve and was moving in and out of the left ventricle with each cardiac cycle and causing obstruction of the mitral valve (). Global systolic function was normal. Both atria were enlarged and pulmonary artery systolic pressure was 48 mmHg. Surgical removal of the mass was decided due to the size of the mass, stenosis in the left ventricular inflow tract and high risk for thromboembolism and sudden death. Based on the patient’s complaints, risk factors and ischemic ECG findings, preoperative coronary angiography was decided. Coronary angiography showed critical stenosis of the left anterior descending artery (LAD) and circumflex artery (LCx) and noncritical stenosis of the right coronary artery (RCA) (). Coronary angiography showed no findings suggestive of tumor vascularity. Ventriculography was not performed due to the potential risk of embolism. The patient was advised to undergo surgery for the resection of the left atrial mass and coronary bypass surgery. The mass arising from the mitral valve was resected and LIMA-LAD and SVG-OM1 bypass grafting was performed. The pathology report was consistent with myxoma. An echocardiography, performed at follow-up examination 2 months postoperatively, revealed no evidence of residual mass. Minimal mitral regurgitation was present. Pulmonary artery systolic pressure decreased to 38 mmHg. The patient had no complaints and his functional capacity was NYHA class 1-2. His ECG was completely normal. |
Patient 2 (40–45 years old) presented with severe agitation. He was threatening, screaming, scratching, and spitting, and refused a conversation. He thus showed a similar clinical picture as patient 1 but also appeared to experience auditory hallucinations and to actively talk to them. Patient 2 was in a state of poor hygiene. Taking into consideration his manner of response, one could assume that patient 2 has experienced psychiatric treatment in the past. When the nurse asked him if he had any experience with psychiatric medication, he yelled at her and clarified his wish to refuse haloperidol. He seemed to feel especially threatened by the police and the psychiatric staff, not only due to psychotic symptoms but also due to previous aversive experiences with psychiatric treatment. Once again, the staff members involved in the situation discussed the clinical case in a multiprofessional setting and weighed out every possible option. The team suspected that patient 2 suffered from an acute exacerbation of a disorder that persisted for a longer period of time or a psychotic relapse. In this case, the team decided that patient 2—due to his previous aversive experiences—would have extraordinarily suffered from compulsory treatment, which may exacerbate previous traumatic experiences. Also, he calmed down a bit when given a space to withdraw and did not immediately endanger himself or others; however, he remained tense for several days and threw objects whenever members of staff tried to engage him in a conversation or offered oral medication. When left alone, he did not appear aggressive or present improper handling, showed a regular food intake, and welcomed the possibility to smoke. Somewhat later, he was seeking a medical consultation and expressed the need for a low-dosage medication. To this day, 6 years later, he regularly receives outpatient care and short-term crisis intervention treatment on a psychiatric ward, although he has felt threatened and deprived of his identity by the state and the psychiatric system of another city for more than 25 years. |
A 33-year-old white woman presented with a history of left-sided TMD. The dysfunction initiated when she was tackled during a football game when she was approximately 13 years of age. Symptoms originally presented as an asymptomatic click, which became painful and progressively deteriorated, eventually resulting in a sustained period where she was unable to attain full opening. She presented with an anterior disc derangement with reduction typically occurring early in the morning. It was postulated that she was bruxing at night, causing the derangement. She continued to function relatively well during the course of the day, which was somewhat atypical given the pathology present.\nShe attended a course of physical therapy, which provided short-term benefit, but returned 20 months later with more frequent clicking, pain, and an inability to self-manage following dental procedures. The procedures were for fillings, occurring 2 weeks apart prior to her return. She reported initial swelling in her left jaw, slurring of words due to swelling, and inability to open her mouth. The slurring resolved over the first 24 hours; however, she reported the onset of headaches into the left temporal and suboccipital region the next day. Ibuprofen was used for symptom management. She reported that her left TMJ “popped” 3 days later. She reported severe pain with the reduction; however, there was improvement in movement and pain.\nThis individual was now presenting with progressive disc derangement tendencies with likely further development of posterior ligament insufficiency. She also appeared to be developing degenerative changes in this joint with progressively increasing pain and movement loss. Range of motion was limited to 25 mm of opening (defined as maximal opening of incisor distance), 1 to 2 mm protrusion, 7 mm left deviation, and 7 mm right deviation with left TMJ pain reported. There was no deviation of her jaw with opening. Significant capsular stiffness was noted with all TMJ mobilizations. There was increased tone of her masseter (left > right) and lateral pterygoid (left > right). Scalenes, upper trapezius, and levator scapulae musculature (left) demonstrated increased tone with decreased length. Isometric resisted testing of all jaw muscles aggravated her left TMJ. A cervical scan demonstrated C2/3 hypomobility with flexion and extension, with normal craniovertebral (CV) ligament and vertebrobasilar artery (VBA) stress testing.\nFollowing her second course of manual treatment, she presented with full range of motion of her TMJ, and improvement in myofascial tone. Her cervical dysfunction resolved. However, she continued to have increased frequency of clicking in her left TMJ, occasionally leading to the onset of pain. Despite improvement in range of motion and mechanics, she continued to present with a reduction click at end range of opening. The crisp and loud nature of the reduction click indicated a viable posterior ligament and reduction of the anterior displaced disc. Various options were discussed, including intermittent treatment for derangements, which had been successful in the past, or referral to an oral surgeon for consideration of disc resection and/or arthrocentesis. She was not an exceptionally good candidate for arthrocentesis as she was not fibrosed at the present time, had excellent mobility, and had a disc derangement with reduction. She was a candidate for PRP therapy, although the potential fibrosis of the posterior ligament and the viability was suspect. Due to the question of the viability of the ligament, she was educated and given 20% odds of success, but wished to proceed.\nFollowing her initial assessment, she attended a course of five treatment sessions approximately once weekly (Additional file : Physical Therapy Protocol). Following this course of treatment, she presented with full opening and full movement in all planes. There was no deviation of her mandible. The accessory movements of her TMJ did not indicate any derangement of the intra-articular disc. She was asymptomatic and fully functioning. The situation had resolved to its status prior to her acute crisis with an early morning click followed by a relatively asymptomatic day.\nThe options of management were discussed with our patient, which could have included intermittent physical therapy during crisis or PRP injection. The posterior ligament was still healthy enough to consider a distractive splint with PRP injection of the posterior ligament to induce another degree of fibrosis. However, this would require a significantly large occlusal splint that most would find quite bothersome. After considerable discussion, it was decided that she could function well enough with intermittent treatment. She was discharged with the advice to be in contact for intermittent physical therapy, as it would be likely that she would have intermittent derangement and she should seek early rather than later care.\nFor the second course of treatment, she received three additional physical therapy treatment sessions, consisting of biomechanical optimization of her cervical spine and TMJ, leaving her again with full range of motion of her TMJ, and improvement in myofascial tone. Her cervical dysfunction resolved. However, she continued to have increased frequency of clicking in her left TMJ, occasionally leading to the onset of pain. She opted for PRP injection, and given that there was no guiding protocol relative to splinting, we planned to use a large plastic athletic splint Brain-Pad LoPro Double Laminated Strap/Strapless Combo in one Adult Mouthguard (Fig. ) to keep the disc in a reduced position at 15 mm of opening for 24 hours a day. The exception was for dental care, which would be done with the mouth in a fully open position, avoiding closure. The immobilization period was for 3 weeks, followed by a gradual weaning period with reduced posterior support (Fig. ) for an additional 5 weeks.\nThe PRP injection procedure was performed by a chronic pain specialist, with the assistance of a physical therapist and nurse. Sixty ml of whole blood was withdrawn from the antebrachial area. The Magellan centrifuge (Arteriocyte Medical Systems, Hopkinton, MA, USA) was used to obtain a total of 4 ml of PRP. Acetaminophen 1000 mg and 50 mg of tramadol were provided as pre-procedure analgesics.\nThe physical therapist present assisted in examination and localizing the site of injection based on anatomic landmarks and tenderness. The physical therapist manually reduced the anterior disc derangement with a combination of distraction and anterior glide until the mandibular condyle was under the anteriorly displaced disc. This was maintained through the injection process by compression under the angle of the mandible, squeezing the disc condyle relationship to the eminence. The skin and superficial tissues were anesthetized with 1% lidocaine. Ultrasound guidance was used to introduce the PRP into the center of the temporal fossa and distribute the PRP at angles centrally, posteriorly, and anteriorly into the posterior ligament. A total of 3 ml of PRP was injected into the involved structures with a 27 gauge, 1.5 inch needle. Without closing the mouth, the splint was put in place. Our patient was advised to keep the appliance in 24 hours a day for 3 weeks, with the exception of dental care which was to be done with the mouth in a fully open position, avoiding closure. She was instructed to use a liquid diet, as well as concepts of appropriate nutrition and oral hygiene. To maximize benefits, she was given advice about PRP injection rehabilitation. Post-injection pain over the next few days was treated with acetaminophen or tramadol, with avoidance of anti-inflammatories for 4 weeks.\nShe was followed up by a physical therapist at 3 weeks, 8 weeks, and 6 months post-injection. Follow-up procedures and outcomes are outlined in Fig. . |
An 8-year-old female patient came to the clinic with her parent having fractured her mandibular left incisors (teeth number 31 and 32) the previous day (). The fractured fragments of both teeth were kept in a small container and immersed in tap water. The patient was playing with a toy when it slipped and hit and fractured her teeth. Clinical examination revealed that both teeth had an Ellis fracture class II, which meant that there was an extended crown fracture with dentin involvement but without pulp exposure (). There were oblique fractures extending mesiodistally and involving the incisal and middle third of tooth number 31 while the fracture of tooth number 32 also involved the cervical third. Both teeth were already covered with glass ionomer cement temporary fillings which were placed within 2 hours after the trauma by a general dentist who advised them to keep the fractured fragments and present them to a specialist to reattach them (). Gingival and periodontal tissues surrounding both teeth were healthy and unremarkable. The patient was not experiencing any pain related to either tooth. Vitality test using cold test revealed normal response while percussion tests were normal and unremarkable.\nPeriapical radiographs were taken for both teeth. There was no evidence of pulpal involvement in either tooth and no periapical radiolucency noticed.\nBoth fractured fragments were cleaned with prophylactic paste and kept aside (). After removal of the temporary fillings on both teeth using a low-speed round-head bur, the fractured fragments were tried on to check if there were any missing pieces from either tooth and to determine which piece belonged to which tooth. Both fragments fit perfectly and there were no chipping or missing small fractured pieces. Each fractured fragment was identified and coupled to its fractured counterpart. Shade was determined to be A2 using classic Vita shade guide.\nBoth fractured teeth received a circumferential bevel which encompassed the whole fractured tooth and it was 1.5 mm wide and 0.5 mm in depth (). The width of the bevel was limited to 1.5 mm to keep the bevel away from the gingiva by 1 mm. A straight diamond bur was used to this effect.\nBoth fragments also received a similar circumferential bevel which encompassed the whole fractured piece and it was 3 mm in width and 0.5 in depth (). Both fragments were then acid-etched for 20 seconds on the exterior surfaces (labial, lingual, mesial, and distal) and 15 seconds on the interior surfaces where dentin was involved using 35% phosphoric acid. Both were then rinsed thoroughly and then dried for 5 seconds each, and then kept separate.\nAfter isolating the field, both fractured teeth were acid-etched for 20 seconds on the exterior enamel surfaces and 15 seconds on the interior dentin surfaces using 35% phosphoric acid. Both teeth were rinsed thoroughly for 10 seconds and then dried for 5 seconds, keeping dentin moist and enamel dry. Adhesive layers were then placed using Single Bond Universal Adhesive (3M/ESPE, St Paul, MN, USA) according to manufacturer’s instructions, after which it was light cured with an LED curing light for 10 seconds (Elipar™; 3M/ESPE).\nEnamel shade of A2 Filtek Z350 XT Flowable Restorative (3M/ESPE) composite was used. It was placed on top of one fractured tooth, and then the fractured fragment was pressed in place. Excess flowable composite was removed with an applicator tip and the cementation was finalized with light curing for 20 seconds labially and lingually. The same procedure was done for the other tooth. After cementing both pieces with the flowable composite, enamel shade of A2 Filtek Z350 XT Universal Restorative was placed labially and lingually to cover the fractured lines and the bevels surrounding them. After light curing both, the placed composite was finished and polished using an Astropol® finishing and polishing kit (Ivoclar Vivadent, Schaan, Liechtenstein) (). Finally, a solid gold chain retainer (Ortho FlexTech Dental Retention System; Reliance Orthodontic Products, Inc., Itasca, IL, USA) was bonded to the lingual aspect of teeth number 32, 31, and 41 for extra means of retention.\nThe patient was recalled after 8 months to follow up both teeth. Clinical examination revealed excellent composite restorations covering the fracture lines (). Some plaque accumulation was noticed against the palatal surfaces of bonded teeth with mild gingival inflammation (). Both teeth responded normally to cold test and there were negative percussion responses. Radiographic examination of periapical X-rays revealed normal and unremarkable bone tissue surrounding both teeth (). |
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. |
An 80-year-old man with history of grade 1 follicular lymphoma since 2013 with no indication for therapy being followed by oncology for clinical surveillance presented with worsening shortness of breath and hemoptysis. Physical exam was unremarkable, and lab workup showed chronic anemia. Computerized tomography (CT) imaging of the chest showed an enlarging 2.0 cm density in the posterior right upper lobe of lung (RUL) as well as scattered pulmonary nodules in the RUL. With his extensive history of smoking, he underwent bronchoscopy with endobronchial ultrasound-guided biopsy (EBUS) of mediastinal lymphadenopathy. Bronchoscopy revealed lung mass with endobronchial lesions and mediastinal lymphadenopathy. Although clinically on bronchoscopy it appeared to be cancer, biopsy was negative. He subsequently was sent to interventional radiology for biopsy of an RUL spiculated mass, which again was negative for cancer. Needle biopsy sections of lungs were suggestive of organizing pneumonia.\nWith clinically suspected cancer and two separate negative biopsies, we decided to proceed with positron emission tomography (PET) scan to reassess approaches for tissue biopsy. Meanwhile patient was started on antibiotics with which he had significant improvement clinically and his shortness of breath and mucus production got better. Patient had PET scan that showed extensive mediastinal lymphadenopathy throughout the right mediastinum and LA which could probably correspond to patient’s known lymphoma ( and ) as his biopsied right spiculated lung mass did not appear to be growing and had less impressive uptake. Patient was recommended to have repeat EBUS; however, he refused to undergo any further procedures or biopsies.\nThree months later, patient underwent repeat chest CT with contrast that showed right hilar and mediastinal mass measuring 7 cm in size with involvement of right and left brachiocephalic veins, SVC and a large tumor thrombus in the LA (). He had transthoracic echocardiogram done that showed large left atrial mass 3.8 × 3.2 cm lying in the base of the LA extending into the main body of the LA ( and ). Patient eventually decided to have repeat bronchoscopy with EBUS to biopsy the mediastinal mass before chemotherapy could be considered. He was also started on radiation therapy after biopsy performed with his SVC syndrome. Because of SVC narrowing and possible complete obstruction with collateralization, he also underwent SVC stent placement as well (). His biopsy results came back showing squamous cell carcinoma (SCC) of lung. Patient then underwent combined chemotherapy with platinum-based agents for lung cancer and radiation therapy. Patient had repeat echocardiogram done 6 weeks later that showed the large mass in the LA was no longer visualized (). On his repeat chest CT, there was significant decrease in right mediastinal mass and left atrial mass (). Patient underwent systemic chemotherapy, improved clinically over long-term follow-up and is under oncological surveillance. |
A 50 year old male presented with abnormal movements in the form of jerky movements of all four limbs associated with tongue bite and urinary incontinence. These abnormal movements were episodic and each episode lasted for 3-4 minutes and was followed by clouding of consciousness for few minutes. The patient started to experience these seizure episodes when he was 25 years of age, the frequency of seizures was initially one to two episodes in 5-6 months. But since last one month the frequency had markedly increased and patient was having convulsions on almost daily basis. Patient was prescribed phenytoin tablets by local practitioner in dose of 300 mg/day but the seizures were not controlled. Patient also developed tremors of both the hands since last 2 months, tremors were more in the left hand as compared to right and they were more prominent at rest.\nOn examination there was painful spasm of hand on inflating sphygmomanometer cuff above systolic blood pressure (i.e. Trousseau's sign was positive), he was fully conscious well oriented, appearance and behavior were normal, there were no hallucination and delusions and his memory and speech were normal, all the cranial nerves were intact, coarse pill rolling type of tremors were present at rest in both the hands but more in left hand as compared to right hand. Cog wheel rigidity was present in both the upper limbs, power was normal in all four limbs and sensations were intact.\nNo scar on the neck to suggest any previous neck surgery was seen, there was no candidiasis or vitiligo neither there was any hearing loss. However cataracts were present in both the eyes.\nOn investigation his haemoglobin was 13.2 gm/dl, total leucocyte count 9400/μL, differential leucocyte count showed 76% neutrophils and 24% lymphocytes. Blood sugar 90 mg%, blood urea 27 mg% and serum creatinine 0.8 mg%. Alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase and serum bilirubin were all with in normal range. His serum albumin was 4.0 gm/dl. Serum electrolytes were sodium 136 meq/L, potassium 4.2 meq/L, calcium 6.11 mg/dl (normal range 8.0-10.4 mg/dl), ionized calcium 3.0 mg/dl (normal range 4.6-5.4 mg/dl), serum phosphate 5.7 mg/dl (normal range 2.5-4.5 mg/ dl) and serum magnesium was 2.12 mg/dl (normal range 1.3-2.5 mg/dl). His parathormone level was 3.6 pg/ml (normal range 15-68 pg/ml). CT scan of the brain revealed bilaterally symmetrical hyperdense lesions with CT value of calcification in basal ganglia, thalami, white matter of cerebellar hemispheres and subcortical white matter of bilateral frontal and parietal lobes [Figures and ].\nOn the basis of seizures, extrapyramidal features, bilateral cataracts, positive Trousseau's sign, hypocalcemia, high phosphate levels and low PTH levels our patient was diagnosed as a case of hypoparathyroidism with extrapyramidal features and seizures due to hypocalcemia.\nCalcitriol 0.5 μg/day and calcium 1 gm/day was started. Patient's calcium levels returned to normal range with this treatment. Although antiepileptic drugs were not indicated in this patient but we put him on sodium valproate 500 mg twice daily with the aim to withdraw the drug slowly, this was done as the patient was taking phenytoin tablets for a very long duration. With the normalization of serum calcium patient became seizure free and the parkinsonian features (tremors and cog wheel rigidity) also improved remarkably, patient was not prescribed any anti-parkinsonian drug for control of extrapyramidal features. Patient is in follow up for the last four months and did not have even a single seizure episode. |
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. |
Here, we present a case of a 55-year-old Caucasian female with a history of substance use disorder and a comorbid bipolar disorder, who presented to the local general hospital with a history of the fragmentation of a single personality into different personalities under emotional stress and under the influence of a drug. Multiple aspects of her personalities were reported, including the following: a personality of a seven-year-old child, a personality that would behave as a teenager, and another that acted like a male person in addition to her normal 55-year-old personality. She reported that she had been constantly dominated by her alternate personalities and became aware of their existence when people around her informed her, usually after a situation ended. She reported that stressful situations and substance abuse could aggravate the fragmentation of her personality. This was found to be mostly an involuntary phenomenon with seldom memory of the event.\nWhile transitioning between these personalities, she was found to be violent even to people who were close to her. This could range from being suicidal to homicidal for which she was arrested twice in the past. She had to be isolated and restrained by being locked in a room and calling the police. As a result, she was hospitalized in a mental institution for a significant period at least two to three times in the past. Under the influence of stress or substances like marijuana or cocaine, her personality would split into various personalities. These states were very different from one another in terms of age or gender.\nOne of her alternate personalities behaved as a seven-year-old child and would show the same interests and choices that included becoming moody or a self-arrogant personality. While in these states, she could hurt herself or had weeping spells if her wants were not met.\nAnother personality acted as a teenager with some sharp choices and dressing. Increase in substance abuse, alcohol use, and smoking would lead to multiple cases of fights or homicidal attacks, with some incidents of self-harming events. Multiple scars were found on the dorsal side of her right hand. Her speech was found to be pressured and she would repeat the same words/ conversations.\nThe next personality was diagnosed to be a temporary transition to the opposite gender (a male). There was a change in voice and behavior. This included male dressing, language, a perception of male body parts, choices of friends, and attraction towards females, including sexual behavior.\nThe normal state of a 55-year aged female was the default personality that made her feel most comfortable. She reported that she had anxiety during a personality state transition, as it could occur at any time, and involuntarily, but mostly in stressful situations and during substance abuse. More violent and harmful events were reported when someone tried to meet the patient alone rather than in a group.\nThe treatment included psychotherapy with cognitive behavioral therapy addressing stress and substance use disorder. The psychotherapeutic treatment lasted for at least six months. The dual treatment of drug therapy was also involved to calm her down. The patient was prescribed escitalopram to reduce her anxiety symptoms. She believed that the anxiety pills were really helpful. After six months, the patient's condition was not drastically different. However, she believed her stress was getting better. The patient was further followed up for the next one year and the treatment continues to date. |
A 55-year-old woman with a known history of osteoarthritis who has undergone right total knee arthroplasty in another clinic four months ago was referred to our hospital. She was unable to walk due to limitation of her knee motion with persistent pain unresolved despite postoperative intense physical therapy and exercise program. The physical examination of the patient demonstrated insignificant swelling but no effusion in her knee, and the active range of motion was 70° of flexion and 10° of extension deficit. Her neurovascular examination was normal. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 38 and visual analogue scale score (VAS) was 8 (0 best, 10 worst). There were no signs of infection clinically, and serum laboratory analyses were within reference values. From her hospital track records, it was learned that mobile insert CR-designed TKA (NexGen, Warsaw, IN) was implanted without surgical difficulty. Her radiographs showed that the femoral and tibial components were properly implanted with slight varus thrust, and the alignment patella was adequate (). Reflex sympathetic dystrophy was thought to be unlikely and computerized tomography (CT) of the components to examine rotational alignment of the components showed insignificant findings.\nExamination of range of motion under anesthesia revealed improvement of flexion to 90° but 10° of extension deficit remained the same. Revision of the components was planned to correct flexion and extension gap imbalance and for secondary patellar resurfacing. However, intraoperatively, a large cement part extruded into intercondylar notch impinging PCL and limiting terminal extension was detected and removed (). Following removal of the cement, polyethylene insert exchanged with the same size and thickness, and secondary patellar resurfacing was also performed though the patellar cartilage was uniform and congruent.\nHer postoperative course was steady after the surgery. The patient allowed weight bearing, and passive and active ROM exercises were begun immediately in early postoperative period. Flexion angle of 90 degrees was achieved at 3rd postoperative day and she was discharged from hospital with a VAS score of 4. At second year follow-up examination WOMAC score was 87, and she was pain-free walking without crutches and climbing stairs. The ROM was 0°–100° of flexion. |
A 32-year-old primigravida presented at 21 weeks of pregnancy for investigation of left pelvic pain. She had no prior history of endometriosis. An early transvaginal ultrasound in first trimester did not report any adnexal masses. Transvaginal ultrasound revealed a large 9 cm left ovarian mass that was multiloculated with nodule thickening of septas and of the wall with a positive Doppler flow inside. The CA 125 assay was 50 IU/L. A diagnostic laparoscopy was proposed to the patient due to the concern of possible borderline or even malignant tumor, but she declined this procedure. At 24 weeks, a Magnetic Resonance Imaging (MRI) without contrast was performed as the patient refused gadolinium injection. The heterogeneous mass had not increased in size (7.7 cm). The solid component exhibited an intermediate T2 weighted signal and a high diffusion-weighted imaging (DWI) signal, suggesting the possibility of a borderline component (). There was no ascites, peritoneal carcinomatosis, lymphadenopathy, nor any signs of compression. CA 125 and MRI remained unchanged at 28 weeks.\nGiven the absence of symptomatology and the stable imaging, the pregnancy was prolonged until an acceptable level of prematurity, as recommended by the French national multidisciplinary network for the management of pregnancy-associated cancers. Corticosteroids for accelerating fetal lung maturation were administrated at 29 and 33 weeks in case of acute complications requiring immediate preterm birth. The follow-up of pregnancy was uneventful until 35 weeks.\nA planned caesarean section was performed at 35 weeks and this resulted in the birth of a healthy baby girl weighing 2100 g, with Apgar 10 at 1 and 5 minutes. At laparotomy, the left ovarian tumor measured 9 cm in diameter and had an irregular white surface covered by red punctations. Focal zones of the cortical surface had partially ruptured and small cysts containing clear yellow fluid were observed under the cortex of the ovarian tumor. The peritoneal surfaces of the uterus, the bowels, and the pouch of Douglas were also covered by reddish punctations and flames. The right ovary was 3 cm in diameter and carried a small simple cyst of 2 cm. A left salpingo-oophorectomy was performed. Multiple peritoneal biopsies were carried out, as well as the removal of the right ovarian cyst. Her postoperative course was unremarkable.\nMacroscopic examination of the left adnexal mass revealed a mixed ovarian tumor with solid and cystic components and vegetations inside and outside the cyst measuring up to 5 mm in height. On sectioning, pale yellow fluid was present. Frozen section showed a nonepithelial lesion, with no evidence of malignancy, and the overall appearance resembled a functional ovarian cyst. The final microscopic histological examination of the left ovarian tumor showed a lesion consisting of luteinized cells, with a large eosinophilic granular cytoplasm and rounded nucleus cells, sitting in an edematous stroma (). The papillary excrescences consisted only of dense fibrous tissue. There was no sign of endometriosis nor malignancy. Similar lesions were found on the peritoneal biopsies, the right ovarian cyst, and the peritoneal cytology. Immunohistochemical analysis showed strong positivity with progesterone receptors and negativity for mesothelial markers (calretinin and WT1). These findings supported the diagnosis of peritoneal and ovarian deciduosis. |
A 48 year old Englishman presented in our hospital with a steel ring constricting his external genitalia that he could not remove. The ring had been placed for enhancement of sexual performance 48 hours ago. He complained of pain and swelling on his external genitalia but he did not report any difficulty in passing urine. On clinical examination he had normal vital signs and there was marked local oedema with ulceration and pus at the pressure points (figure ). Attempts to remove it with lubrication, compression or cutting devices from the department of orthopaedics were unsuccessful. Further attempts to cut it with the biggest bold cutters that were available in the market failed again. The patient was taken to the operating theatre and under general anaesthesia the ring was cut along two sides with the help of an angle grinder that was supplied by our hospital's department of engineering (figure ). To avoid burns from the sparks and excessive heating, the penis was isolated with pieces of tinfoil between the ring and the skin and pouring cold normal saline on the field. The ring was successfully removed and the patient was started on intravenous antibiotics. 24 hours later the oedema had subsided and the patient was discharged.\nA great variety of metallic and non-metallic rings causing constriction the external genitalia has been described in literature []. The type of the foreign body differs in relation to age. In newborns and children penile strangulation with air or elastic rings has been described. The insertion of these rings may be accidental or intentional from the patient, a sibling or the parent [,]. In adults various objects like wedding rings, metal plumbing cuffs, bull rings, bottle necks etc have been used []. In adolescents it is usually the result of curiosity or masturbation while in adults the reason is to enhance sexual pleasure, autoerotism or as a result of a psychiatric disorder.\nInsertion of constricting rings in the flaccid or semi erect penis may result to inability in removing them after erection. The object has been placed a few hours up to 3–4 days before seeking medical help and the patients have usually attempted unsuccessfully to remove the object themselves [,].\nIn children the strangulation may be easily overlooked as an erosion or eczema. A high level of suspicion is required from the clinician to avoid missing it.\nWithin a few hours of obstruction of the blood supply, as stagnation of blood becomes more prominent, oedema and haemorrhage occur, causing a swelling of the affected part. Metallic rings usually cause less injury than non-metallic rings []. Delayed removal may lead to necrosis, fistula, sepsis and penile amputation [].\nVarious procedures depending on the constricting object have been described for removal. These include the common metal ring cutter, cutting tang, metal saw, Dremel Moto-Tool Kit, Anspach cement eater, high speed drill, string method, and "wrapping" by package cord [].\nUsually removal is accomplished under general anaesthesia. The urologist must remove the ring with great care to avoid iatrogenic injury to the external genitalia. It should also be kept in mind that removal of these objects may be challenging and require equipment that is not directly available in the urology department. |
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 13-year-old female child of non-consanguineous parents, youngest of siblings [Figure and ] reported to our department with a complaint of painless, progressive and bilateral enlargement of lower face and jaws. There was no history of similar disease in any of the siblings and parents of the affected child.\nThe history of present illness revealed that the patient had been born as a full-term normal baby and showed no abnormalities until about the age of 2 years, but later bilateral symmetrical prominence of lower face was seen. This enlargement had stopped at age of two and half years and remained the same in size for the subsequent years. Since 3-4 months her parents observed that it gradually increased to present size. On physical examination it was seen that patient was well built, active and mentally alert. No abnormality was found on clinical examination of the chest, abdomen, cardiovascular and central nervous system. No cutaneous pigmentation or other congenital abnormality was present and there was no evidence of endocrinal disturbance.\nExtraoral examination revealed normal expression and color of the face with no ophthalmic abnormality. Diffuse enlargement on both right and left side of face extending till the inferior border and angle of mandible region bilaterally was noticed. It was roughly round in shape and hard in consistency with ill-defined margins. The swelling was fixed with no secondary changes. Swelling on the right side was slightly larger as compared with left [Figure and ]. On palpation, temperature of the overlying skin was normal and no tenderness was elicited. Submandibular lymph node was palpable on right side, single in number, measuring approximately 1 cm in diameter, firm in consistency, non-tender and mobile in nature.\nIntraoral examination revealed that patient was in permanent dentition stage with absence of mandibular left second permanent molar. There was no disturbance in occlusion or shift in midline [Figure and ]. Based on history and clinical examination, a provisional diagnosis of cherubism was given, with the differential diagnosis of mumps, fibrous dysplasia, bilateral masseter dystrophy, central giant cell granuloma, infantile cortical hyperostosis and human immunodeficiency virus parotitis. To differentiate from the various disorders, blood, radiographic, histopathologic investigations and computed tomography (CT) scan was performed.\nSerum alkaline phosphatase, serum glutamic oxaloacetic transaminase (SGOT) (17 IU/l), serum glutamic-pyruvic transaminase (SGPT) (20 IU/l), calcium (8.6 mg/dl) and phosphorus level assessment (5.40 mg/dl) were conducted and all were within the normal range except serum alkaline phosphatase levels (260 IU/l), which was found to be highly raised.\nPanoramic radiograph revealed diffuse multiple cystic areas involving body, ramus, angle and coronoid process of the mandible bilaterally. The tooth bud of mandibular left second permanent molar was seen floating in multilocular radiolucent areas conferring so called ‘floating tooth’ appearance [].\nA posterioanterior view of skull revealed multilocular radiolucency extending bilaterally on both sides of mandible [].\nTo confirm radiographic findings, CT was performed on Siemens Sensation 40 slice modified discrete cosine transform (MDCT) using 50 ml of intravenous (IV) contrast. The sections of 0.6 mm thickness were obtained and reconstructed at 1.0 and 3.0 mm thickness. There was evidence of bilaterally symmetrical osseous expansile lesions involving body, angle and rami. It revealed bone remodeling, cortical thinning, multilocular contour with coarse trabecular pattern. Multiple cystic/lucent areas were seen within the lesion, which contains low attenuation materials [Figure –].\nCT-axial and coronal contrast images showed symmetric expansion of the mandible with “ground glass” appearance.\nDifferent CT-Axial sections from symphysis region, body, ramus and angle of mandible were taken [Figure –]. The multilocular radiolucency was found to be gradually increasing in size from body to angle of mandible.\nHistopathological examination revealed multinucleated giant cells (up to 10 nuclei) with interlacing bundles and whorls of spindle cells and moderate vascular stroma. It also showed an eosinophilic perivascular cuffing of collagen [Figure and ].\nA similarity with central giant cell lesions and hyperparathyroidism was found to be present in the histological findings. In cherubism, multinucleated giant cells are found scattered throughout collagenous and vascularized fibrous connective tissue. There was presence of dense connective tissue that is highly or poorly cellularized, with a smaller or larger number of collagen fibers, depending on the progression of the lesion.\nFurthermore, central giant cell lesion can be excluded on the basis of clinical background, as it is not bilateral in nature and does not regress in adulthood. It can be distinguished by radiological findings as most lesions are unilocular in nature.\nHyperparathyroidism can be excluded on the basis of laboratory tests as serum calcium and parathyroid hormone (PTH) levels are found to be increased and phosphorus levels are found to be normal or reduced. In present case, laboratory investigations showed normal calcium and phosphorus level with increased levels of alkaline phosphatase. |
In January 2013, a 73-year-old man presented to the Department of Oral and Maxillofacial Surgery, complaining of a painful mass in the mandible on the right side. He had also a history of deep neck pain for 3 months, but it had been disregarded. A review of patient's medical history revealed that he had an acute myocardial infarction 2 years before, which was treated by percutaneous coronary angioplasty. The patient had a 30-year history of cigarette smoking and opium use. Physical examination showed a firm, well-defined swelling measuring about 3 × 3 cm in the body of the mandible on the right side. The skin over the mass was normal in color and texture. No palpable submandibular and cervical lymph node was evident. Intraoral examination showed that the involved mandibular area was edentulous and the mucosa over the mass was intact.\nAn orthopantomogram radiograph demonstrated an ill-defined radiolucent lesion in the body of the mandible causing pathologic fracture of the involved bone [].\nThe results of laboratory tests were normal with the exception of prostate-specific antigen (PSA) level which was 52 ng/ml.\nIntraorally, an incisional biopsy was performed under local anesthesia. Histological sections stained with hematoxylin and eosin revealed a metastatic tumor of epithelial origin; however, it was unclear from which primary site the metastasis occurred. Histologically, the neoplastic cells arranged in glandular patterns had low mitotic index and were composed of round hyperchromatic nuclei and acidophilic cytoplasm [].\nBecause of concern over raised PSA level and high suspicion of prostate malignancy, the patient was referred to an urologist for further evaluation. In pelvic ultrasonography, a significantly enlarged prostate was observed. A biopsy of the prostate was done; the histopathological examination was consistent with prostatic adenocarcinoma. Whole body skeletal survey using bone scintigraphy revealed a bone lesion of the right mandible plus a destructive lesion in the cervical vertebrae. Subsequently, additional metastatic work-up including neck, chest, abdomen and pelvis computed tomography (CT) scan was performed. CT scan of the cervical area revealed a mass, measuring 4 cm in diameter, in the right thyroid lobe causing severe destruction of the adjacent vertebrae and extending into the vertebral canal []. CT scan of the chest showed multiple nodules up to 15 mm in both pulmonary fields. CT scans of the abdomen and pelvis were normal with the exception of an enlarged prostate.\nThe differential diagnosis for the mandibular lesion included metastatic prostate adenocarcinoma, metastatic thyroid carcinoma and metastatic pulmonary adenocarcinoma. To differentiate between these three lesions, immunohistochemical study with a panel of antibodies including PSA, thyroid transcription factor 1 (TTF-1) and thyroglobulin was performed and showed a positive staining for TTF-1 and thyroglobulin and a negative staining for PSA []. Thus, a final diagnosis of mandibular metastasis of thyroid carcinoma was established. The patient was referred to the oncology unit for further management. Because of the widespread metastases, the treatment was limited to palliation. |
A 52-year-old female patient came to our private practice with a complaint of pain in the left lower jaw and teeth. On examination she revealed the presence of a large disto-occlusal carious lesion on the left lower second molar which was tender on percussion. This was indicative of periapical periodontitis of the above mentioned tooth. A routine orthopantomogram was suggested to assess the extent of the carious lesion and assess the general dental status of the patient.\nOrthopantomogram revealed the presence of bilateral radiolucencies with clearly defined borders in the periradicular region of the mandibular third molars, which were roughly 3 × 2 cm in dimensions []. The radiolucencies involved the interdental and interradicular spaces of the mandibular second and third molars with no resorption of involved roots. There was no evidence of cortical expansion clinically and hence was not investigated by imaging. The radiograph also confirmed the presence of a disto-occlusal carious lesion of the left mandibular second molar with involvement of the pulp and periapical region.\nA fine-needle aspiration was performed for the patient, which provided a negative yield on both the sides and the patient was planned for enucleation under procedural sedation. The second and third molars were extracted bilaterally which gave adequate exposure to the cystic cavity. Intraoperative examination of the cystic cavity revealed empty spaces with no lining []. A provisional clinical diagnosis of traumatic bone cyst was made and the lesion was thoroughly curetted to induce fresh bleeding. The curetted material with a small bone specimen and extracted teeth were submitted for histopathological examination. The wound was closed primarily with absorbable sutures.\nVery less amount of tissue were available for the microscopic study. Histopathological examination of sections stained with hematoxylin and eosin showed cystic cavity with hemorrhagic lining and bone suggestive of solitary or traumatic bone cyst (SBC) [].\nThe specimen demonstrated the presence of bony trabeculae exhibiting reversal lines, thin fibrous connective tissue and extravasated red blood cells (RBCs) suggestive of normal bony wall. No cystic lining epithelium was evidenced in the section which is characteristic of solitary bony cyst.\nThe patient was followed-up for a period of 3 years with a radiograph taken once a year. The orthopantomogram taken after 3 years of surgery, revealed complete resolution of the lesions bilaterally with good bone regeneration and obliteration of the cystic spaces []. |
A 65-year-old man presented with the complaint of difficulty with chewing, recurrent pain from various regions of the mouth, and poor aesthetics of the teeth. The man’s medical history was clear. Clinical and radiographic examinations yielded the following findings: only the anterior teeth were in occlusion, and the occlusal vertical dimension was reduced (). The mandibular anterior teeth had severe tooth wear and were non-vital (). Multiple carious teeth, retained roots, over-contoured and splinted metal-ceramic crowns, and multiple missing teeth were found on the maxillary arch (), whereas multiple missing teeth and teeth with severe wear were found on the mandibular arch (). The radiographic examination showed caries on the teeth of both arches, as well as periodontal disease with generalized moderate to severe horizontal bone loss (). Periapical radiolucencies were observed on the retained roots of the maxillary arch and on the anterior teeth of the mandibular arch. The treatment plan was developed with the objective of restoring his oral health by controlling his periodontal disease, eradicating caries, and restoring his chewing function and aesthetics with removable dentures.\nThe patient was informed of the findings, and a treatment plan was formulated following a thorough discussion. The treatment began with oral hygiene instructions and scaling. Caries on the right mandibular first molar and the right mandibular second premolar was restored. In addition, the splinted maxillary anterior crowns were sectioned and replaced with temporary resin crowns. Furthermore, the teeth from the left maxillary lateral incisor to the second molar were extracted due to considerable periodontal attachment loss or severe caries. Clearance of the maxillary arch followed by a maxillary complete denture was planned as well. In view of the patient’s desire to avoid a period of complete maxillary edentulism without replacement, an immediate maxillary complete denture was determined to be the best approach. Further treatment to the mandibular arch included the extractions of mandibular incisors, root canal treatment of the right mandibular first molar, and crowning of the right mandibular first molar and the left mandibular first premolar, as well as the provision of a mandibular partial denture.\nRapid alveolar bone resorption occurs in the first three months after tooth extraction. Immediate complete maxillary denture construction therefore began about four months after the left maxillary lateral incisor to the second molar were extracted, when the bone resorption in this region had slowed down. Delaying the commencement of denture construction also allowed the posterior sockets to heal without functional loading. Maxillary and mandibular study impressions were then taken. In addition, spaced and perforated maxillary () and mandibular () custom trays for irreversible hydrocolloid impressions were constructed. A space of about 3 mm should be allowed for an irreversible hydrocolloid; otherwise, the material could be torn when an undercut is present. Next, the trays were perforated to improve the tray’s retention of the material. The maxillary working impression recorded the entire denture-bearing area, which the buccal sulcus bordered anteriorly and laterally, and the vibrating line posteriorly (). An accurate impression of the remaining teeth was essential for future model trimming and for copying their position and desirable characteristics to the immediate denture. A mandibular study impression was also taken ().\nSelf-cured acrylic temporary base was fabricated with a wax occlusal rim for its minimal distortion (). Stainless steel clasps were incorporated into the mandibular base for retention (). The fit and retention of the base was verified clinically. Standard clinical procedures for adjusting the wax occlusal rims, establishing and recording the jaw relations and facebow records were followed. The shade and mould of the denture teeth to be used were also selected.\nThe waxed-up denture was tried in the mouth. The vertical and horizontal jaw relations, and appearance were verified and approved by the patient. ().\nThe maxillary teeth on the model were removed, and the surrounding area was trimmed (). The artificial teeth replacing the teeth to be extracted were set, and the labial flange was added. The denture was then processed. The aim of the trimming was to produce a good approximation of the fitting surface of the denture base to the shape of the ridge immediately after extraction. The situation involving the presence of undercut to prevent the extension of the labial flange to the functional sulcus reflection point will be further discussed. The dentist, not the technician, should trim the cast in this situation because the experience of cast trimming can assist the dentist in performing surgery.\nLocal anaesthesia was administrated to the remaining maxillary teeth via buccal and palatal infiltration. The replacement of the splinted metal-ceramic crowns with the splinted temporary resin crowns (cemented with temporary cement) allowed for the easy removal of the crowns. The teeth were then extracted. Finger pressure was applied to the labial and palatal plates to help haemostasis. After it was confirmed that the denture could be fitted, sutures were placed in the interdental areas so that they laid over interdental bone instead of the sockets. In this situation, the sutures should not be under tension (). Pressure-indicating paste was then applied to the fitting surface and border to identify the area with excessive pressure (), and the denture was adjusted accordingly. The extension of the denture border was also checked. After the necessary adjustments had been made, the denture was delivered to the patient ().\nFollowing the delivery of the immediate complete denture, detailed post-operative instructions were given to the patient. In addition to receiving instructions regarding post-extraction management, the patient was asked to return for a review appointment the following day. Prior to that, the denture should not be removed. At the 24-hour appointment, the patient was asked whether he had any complaint regarding the extraction sites and the denture. Sign of soft tissue trauma stemming from the denture was checked. Special attention was paid to the region corresponding to the trimmed area of the working model because remodelling of the alveolar ridge was unpredictable after teeth extractions. The region would be under excessive pressure if it had been over-trimmed. The denture had to be adjusted accordingly. Instructions regarding the insertion and removal of the denture, as well as instructions regarding denture hygiene was given. The patient was reviewed one week post-extraction to have the sutures removed. Thereafter, the patient was reviewed weekly for a few more times until no new problem was detected. The patient was reminded to visit the dentist promptly if any problem arose.\nFurther treatment items include the extractions of the mandibular incisors, the root canal treatment of the right mandibular first molar, and the crowning of the right mandibular first molar and the left mandibular first premolar, as well as the provision of a mandibular partial denture (). These procedures were completed uneventfully. The patient was satisfied with the treatment and had no problem with the maxillary complete denture and the mandibular partial denture ().\nDuring the 10-year follow-up period, the fit and occlusion of both the maxillary complete conventional immediate denture () and the mandibular removable partial denture () as well as the oral hygiene were maintained as needed. His oral hygiene was satisfactory, and no caries was found (). This ensured patient's satisfaction in terms of aesthetics, function and comfort (). |
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. |
A 20-year-old G2P1 pregnant female at 22 weeks from her last menstrual period presents to the emergency department as a transfer patient from an outside hospital. She was evaluated for two days of progressively worse shortness of breath. The major concern at the outside hospital was a pulmonary embolism. They performed a chest CT scan that was reported as inconclusive for pulmonary embolism secondary to poor quality, and thus she was transferred for further evaluation of pulmonary embolism.\nUpon arrival to the ED, the patient denied any personal or family history of DVT, pulmonary embolism, or clotting disorders. Her only identifiable risk factor for pulmonary embolism was her pregnancy. On physical examination the patient was well appearing and oriented to person, place, and time. She was clearly tachypneic with a heart rate of 120–140 s bpm. The rest of her vital signs and physical examination were normal. An EKG was performed in the emergency department which showed sinus tachycardia without S1Q3T3 sign.\nUltrasound evaluation in the emergency department was performed with the focus on evaluation of pulmonary embolism. A 2–4 MHz phased-array probe was used to perform the echocardiogram. A subxiphoid view of the heart was performed, and no pericardial effusion or wall motion abnormalities were noted. The IVC diameter was not dilated and had normal variation with respirations (). A parasternal short axis view at the level of the pulmonary artery was performed and did not show any free-floating thrombus in either the right heart or pulmonary artery. The parasternal short axis view at the level of the papillary muscles did not show any flattening or bowing of the intraventricular septum into the left ventricle. No right ventricular dilation was noted (). In total, besides the tachycardia there were no other findings concerning pulmonary embolism on ultrasound. CT chest for pulmonary embolism was repeated and this time an adequate quality film was obtained and was negative for pulmonary embolism.\nUpon further history taking, the patient admitted to be ingesting 1-2 tablets of aspirin every 4 hours on a regular basis for tooth pain. Her arterial blood gas showed a mixed metabolic acidosis and respiratory alkalosis. The history and lab work raised high suspicion for salicylate intoxication and thus a salicylate level was drawn. The salicylate level came back elevated, and the patient was diagnosed with salicylate toxicity. She was admitted and treated appropriately. She was discharged 4 days later in stable condition. |
A 27-year-old male patient complained of painless swelling in relation to left lower mandibular posterior region. Past medical, dental and family history of the patient was unremarkable. There was no history of trauma or pus discharge. Extra-oral examination revealed facial asymmetry due to swelling on the left side of the face extending anteroposteriorly from 3 cm anterior to the ear till the corner of mouth and superior-inferiorly, extended from infraorbital margin to inferior border of mandible. Clinical examination revealed firm to bony hard swelling in the left mandibular region with normal overlying skin. Intra-oral examination revealed obliteration of buccal sulcus in the region of 34, 35, 37 as seen in . Orthopantomograph as observed in revealed multiple multilocular radiolucencies in the left side of mandibular body and ramus area involving coronoid and condylar process. There was thinning of inferior border of mandible. Posterior border of ramus and right side of mandible appeared normal. Coronal slice of computed tomography (CT) scan showed expansion of medial and lateral border of the left side of ramus with thick and curved bony septa and homogenous density []. Axial slice CT at level of mandible showed soft tissue mass in left side of mandible with complete destruction of buccal and lingual plates and remnant of bone within mass extending into adjacent soft tissue with loss of flat plane []. From these clinical and radiographic findings, differential diagnoses of ameloblastoma or odontogenic keratocyst were considered. Fine needle aspiration was carried out, but it did not yield any fluid.\nTo obtain a specific diagnosis, an incisional biopsy was done. H and E stained sections showed lesional tissue composed of nests of uniform basaloid cells. No stellate reticulum was seen in the central portion of the nests. The peripheral cells were cuboidal to short columnar with reversal of polarity. Fibrous septa divided the lesional tissue giving it a lobular pattern []. Based on the available supporting evidence, final diagnosis of basal cell Ameloblastoma was given.\nUnder general anesthesia, tumor mass was exposed buccally and lingually and osteotomy cut was placed and completed buccally and lingually and tumor mass was excised with bone margin of 1.5 cm and also by encompassing surrounding healthy soft tissue. Free fibula osteocutaneous graft of 16 × 4.5 × 3 cm in dimension was harvested from right leg along with peroneal artery and vessels. Antibiotics, analgesics and antiinflammatory drugs were given postoperatively. Histopathological examination of excised specimen reconfirmed the initial diagnosis. Surgical wound healed uneventfully, and sutures were removed on 10th postoperative day. The postoperative recovery of the patient was uneventful and followed-up of 2 years revealed no evidence of recurrence. |
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 47-year-old woman came to our hospital because of painful swelling of her left breast. She had been suffering from bilateral breast swelling for the previous three months. She also complained of associated bilateral mastalgia for the previous 10 days. On examination, both her breasts showed huge enlargement and the left breast was larger than the right breast. The periareolar skin of both breasts appeared tense, it had undergone erythematous change and the skin was warm to the touch. A discrete mass was not palpated because the abnormality was so large that nearly the entire breast was affected. The axillary lymph nodes were also not palpated. The patient had been diagnosed 15 years previously with diabetes mellitus and she was now blind due to the resulting diabetic retinopathy. The patient was premenopausal and she did not take oral contraceptives or hormonal medications.\nMammography revealed a bilateral, extremely dense, parenchymal pattern. Both breasts were enlarged, although the left breast was larger than the right breast. There was a reticular density surrounding the dense parenchyma and skin thickening without mammographic evidence of a mass. On sonography, skin thickening and low echoes similar to lobular thickening of the glandular layer were noted in both breasts, with the left breast being more prominent, although no discrete mass was detected (). The patient required hospital treatment because she was initially diagnosed with bilateral diffuse mastitis. After the administration of antibiotics for two days, she was discharged from the hospital as both her breast pain and swelling had subsided.\nHowever, six months later, the patient again complained of the same symptoms. Sonography revealed progression of the previous, lobular echo-like, parenchymal thickening and numerous conglomerations of tiny cysts, although there was no evidence of a mass (). We performed a 14G core biopsy to confirm the bilateral breast lesions, and PASH was diagnosed (). MRI was performed to evaluate the exact extent of the breast lesion. There were high-signal spaces between the diffuse, nodular low signals on the T2WIs. After contrast (Gadopentetate dimeglumine) infusion, this diffuse, nodular signal showed homogeneous enhancement. All of the abnormal signals were seen in the entire area of both breasts, although the signals were more prominent in the left breast (). The patient subsequently underwent left breast reduction mammoplasty in an attempt to alleviate her symptoms and to correct the breast asymmetry. |
The reporting of this study conforms to the CARE guidelines.
A 70-year-old woman with no history of any cardiac disease was admitted to the local Department of Cardiology with chest pain. Upon admission, an electrocardiogram showed a discrete elevation of the ST segment in the lateral wall of the left ventricle (1 mm). Coronary angiography was immediately performed owing to the electrocardiographic findings and symptoms. During angiography, a saccular aneurysm 22 × 18 mm in diameter, which was connected to the left anterior descending artery by a narrow neck, was found. Tortuous aberrant vessels originated from this aneurysm. These vessels supplied another smaller aneurysm of 11 × 13 mm, which subsequently drained into the pulmonary artery. Another aberrant vessel, which originated from the ostial part of the right coronary artery, was found, and this terminated in the aneurysm. Coronary artery blood flow was not limited, and no coronary artery stenosis was found (, ). The chest pain subsided after administration of nitrates during angiography. Echocardiography showed normal kinetics of the left ventricle and no valvular malfunction.
To further examine the aneurysms, computed tomography coronary angiography with three-dimensional reconstruction was performed (). The diagnosis of coronary artery aneurysms was confirmed, and an intra-aneurysmal adherent thrombus was found. The serum cardiac high-sensitivity troponin T level was not increased. Surgical treatment was performed because of the complexity of the findings. The patient underwent a cardiac surgical procedure using a heart-lung machine with cardiac arrest. The adhering thrombus was removed after the aneurysms had been opened (). The aberrant supplying arteries were ligated and the fistula to the pulmonary artery was treated by a direct suture. The aneurysmal sacs were then sutured ().
The histological findings in our case showed degenerative changes with fibrosis, thinning, and focal hemorrhage in the tunica muscularis. Fibrotic changes and atheromatic plaques with foamy histiocytes in the tunica intima were also found. Some of the plaques were calcified and partially dissected with fresh thrombus formation. |
A 14-year-old girl presented to our hospital because of deformity and painful functional limitation of her right forearm that had been developing over many years. The right wrist pain had started when she was 5 years old. She had since experienced progressive deformity and functional loss that prevented her from performing sports activities and activities of daily life. The patient was a left-handed junior high school student who had played tennis 6 days per week for 2 years, and had occasionally played basketball for about 8 years. She had no history of trauma to the right wrist, including physeal fracture or bone bruising. She had a systemic history of vascular purpura at 6 years old and absence epilepsy at 12 years old; she had been taking antiepileptic medication (sodium valproate), but not corticosteroids.\nPhysical examination showed mild swelling of the dorsum of the right wrist and dorsal protrusion of the distal ulna compared with the contralateral wrist, with the appearance resembling a Madelung-like deformity. The right wrist was able to achieve extension of 90° and flexion of 65°, and the right forearm had a full range of rotation. The right wrist had 97% range of motion compared with the contralateral wrist. Plain radiographs showed angulation of the distal radius and early closure of the physis of the distal radius, resulting in the ulnar length discrepancy (Fig. A and B). The ulnar inclination, volar tilt of the distal radius, and ulnar variance of the affected wrist vs the contralateral wrist were 10° vs 28°, 35° vs 12°, and +12 mm vs 0 mm, respectively. Three-dimensional computed tomography revealed volar angulation of the distal radius, dorsal protrusion of the distal ulna and radius, and a radioulnar length discrepancy (Fig. A–D). Six months after the initial visit to our hospital, the patient provided written informed consent for surgery and for the publication of her anonymized images in this case report.\nTo eliminate the deformity and to achieve painless functional recovery of the wrist, the patient underwent opening wedge osteotomy of the distal radius with an iliac bone graft followed by distal ulnar shortening osteotomy. Briefly, the patient was placed in the supine position with the affected limb positioned to expose the surgical site, and an air tourniquet was applied. The distal radius deformity was treated via opening wedge osteotomy with an iliac bone graft and internal fixation with a volar locking plate. The distal radius was explored through a radial longitudinal incision above the flexor carpi radialis, with the flexor tendon retracted to the ulnar side. The flexor pollicis longus was exposed and retracted radially to expose the pronator quadratus. The pronator quadratus was divided and elevated to reveal the deformation site. At 1 cm distal to the distal end of the radius, opening wedge osteotomy was carried out to adjust the volar tilt and length of the radius. A block of iliac bone was harvested and shaped to fit the radial defect, followed by fixation with a volar locking plate. Subsequently, distal ulnar shortening osteotomy was carried out at 5 cm distal to the distal end of the ulna, followed by fixation with a locking plate. Postoperative radiographs showed that the radiocarpal and distal radioulnar joints were well aligned. The angle of radial inclination, volar tilt, and ulnar variance were 22°, 16°, and −6 mm, respectively (Fig. A and B).\nPostoperatively, a short-arm splint was applied for 4 weeks. Active range of motion exercises of the right wrist were permitted beginning the day after the removal of the splint. Surgical treatment resulted in pain relief, improvement of the mobility arc, full rotation of the forearm, and the resumption of the patient's regular activities within 3 months. A 6 months postoperatively, plain radiography showed complete union of both bones. Thus, a second surgery was performed to remove the plates and screws. Radiographs obtained at final follow-up showed good alignment of the distal radioulnar joint without any length discrepancy between the two forearm bones (Fig. A and B). The right ulna had gained about 1 cm of growth, but the growth plate of the distal ulna was closed at 1 year and 9 months postoperatively. The angle of radial inclination, volar tilt, and ulnar variance were 21°, 14°, and 0 mm. The right wrist showed extension of 90°, flexion of 70°, and a full range of forearm rotation. The range of motion of the right wrist was 100% compared with the contralateral wrist without pain. The grasp strength of the right hand was 18 kg, which was 82% compared with the dominant left hand. Although the right radius was 1 cm shorter than the unaffected side, the deformity of the wrist had been corrected, and the patient was satisfied with the outcome. |
A 13-year-old boy was referred to our tertiary young adult hip service by a Paediatric Orthopaedic Surgeon for evaluation of left groin pain and a decreased range of movement in the left hip. He was a keen rugby player and had experienced an avulsion fracture of the AIIS during a rugby game which was played without a warm up six months previously. MRI just after injury showed a single bony fragment measuring 12 mm × 4 mm × 12 mm at the rectus femoris origin of the AIIS and it was retracted inferiorly 3 cm, anteriorly 1 cm and laterally 0.5 cm. Conservative treatment was advised by the Paediatric Orthopaedic Surgeon and he was referred to a physiotherapist for mobilisation and subsequently muscle strengthening.\nFive months post-injury he was progressing well with the physiotherapy, although, he still felt a sharp pain in his left groin when running with a ball while playing rugby. Flexion was restricted to 70° and a decrease in internal rotation in comparison with the opposite side was observed while abduction, adduction, extension and external rotation were comparable to the other side. There was no significant tenderness and no bruise in the region of the groin, and no distal neurovascular deficit. Plain radiographs demonstrated hypertrophic calcification in the region of the rectus femoris avulsion, whilst the hip joints were normal in appearance. A CT scan showed well corticated heterotopic bone formation at the site, measuring approximately 3.5 cm at maximum diameter (). Motion analysis using the three-dimensional CT datasets clearly showed the impinging area especially in 70° of hip flexion.\nBoth conservative and surgical management were suggested and discussed with the patient and his parents. They chose to go ahead with surgery, as he could not play rugby well because of the pain and restricted range of movement. The patient wanted to play rugby at a fairly high level, hopefully nationally, in the future. At arthroscopy, he was found to have a well corticated large lesion of heterotopic ossification, and it was dissected carefully from the muscles (). Once the dissection was completed, it was extracted via an incision to deliver the lesion. A dynamic impingement test was performed on the table to ensure there was no residual impingement and the impingement lesion was resected with a 5.5 mm arthroscopic burr. A thorough washout was carried out before closure.\nThe patient was advised not to perform any rotational activities in deep flexion for six weeks postoperatively and to follow the 16-week post-operative rehabilitation protocol. He was also advised prophylaxis against heterotopic ossification. Eight weeks following the procedure, the wound had healed well and there were no obvious signs of complications such as infection or deep vein thrombosis. Along with this, he demonstrated a pain-free, fully functional range of movement in his left hip joint and was delighted with his progress. Plain radiographs showed no further signs of calcification (). He was advised to continue to attend physiotherapy for at least another eight weeks and to engage in more gentle sporting activities like cricket and basketball, which he had enjoyed before the injury. At the 1-year follow-up, he remains asymptomatic with a full range of movement in his hip and continues to play rugby at a high level. |
A 22-year-old unmarried female, with an uneventful birth and developmental history, without past and family history of any psychiatric or neurological illness, presented with an episodic illness of excessive sleep for past the six and a half years. The first episode started after a viral fever at 15 years of age. After a week of subsidence of fever, the first episode started abruptly with complaints of increased sleep, confusion, dream like state and irritability with intermittent irrelevant talks. She started sleeping more than her normal sleep. She would sleep for 16–18 hours in a day and would wake up for eating and natural calls. Sometimes she had to be awakened to have her meals. While eating, she would often eat more than her usual self. She could be arousable without difficulty but would prefer to go right back to sleep, would be irritable, and would not like to talk to anyone. The patient also complained that the things and the persons around her did not appear real to her. She would touch things to establish the reality. Her self-care also decreased and she was forced to take bath and change clothes. She also became fearful and would ask her mother to sleep with her. This was not present in premorbid state. She stopped going to the school. There was no significant personal or past history. Her menstrual history revealed irregular cycles and oligomenorrhea but this episode was not related to her menstrual period and had started around 10 days after her last menstrual cycle. A diagnosis of “Post viral depression” was made and she was started on multivitamins. This episode lasted for 13 days and there was complete spontaneous recovery. The patient had complete memory for the episode. In the next episode, 8 months later, a diagnosis of “Recurrent Depressive Disorder” was made and was started on sertraline 100 mg/day. In the next 2 years patient had 3 more episodes (8 and 3 months apart) each lasting for approximately 25 days, which occurred despite patient taking sertraline. During the fifth episode she got admitted and a diagnosis of “Periodic Hypersomnia” was made and started on methylphenidate upto 35 mg/day. This episode lasted for 35 days. During OPD follow-up, fluoxetine was added upto 40 mg/day. She remained symptom free for the next 2 years and did not follow-up. In the next 1 year she had 3 similar episodes (7 and 2 months apart) each being precipitated by sleep deprivation and lasting for approximately 15–20 days. She again got admitted during eight episode and a diagnosis of “Recurrent Hypersomnia” was made and she was restarted on methylphenidate, which was gradually increased to 25 mg/day. Her gynecological referral and investigations including serum prolactin, LH, FSH, and thyroid function test were normal. Her routine investigations including CBC, fasting blood sugar, KFT, urine R/M, and LFT were normal. Her ultrasonogram abdomen, MRI of the brain, and EEG were normal. This episode aborted in 12 days and she was continued on the same treatment. During few episodes in the past, the patient would eat excessively and also would talk regarding sex and on one occasion, started fondling with the genitalia of her cousin who had come. Following this she was symptom-free for 21 months though she underwent the treatment for 1 year only. The patient presented to us on the third day of ninth episode with similar symptoms. Outside the hypersomnia periods, she was asymptomatic. Patient did not cooperate for polysomnographic test, and hence, it could not be done. A diagnosis of Kleine-Levin Syndrome was made and she was started on modafinil 100 mg per day, which was increased to 200 mg/day on third day. She showed improvement in her symptoms from the fourth day of start of treatment and was subsequently discharged. She has been symptom-free after a total period of 2 years of regular follow-up on 100 mg of modafinil. |
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 23-year-old male professional hockey player suffered a fall on ice during a game, which resulted in a flexion-external rotation injury to his left lower extremity. At the time, he felt a pop and developed immediate onset of the left knee pain. Plain films and magnetic resonance imaging (MRI) revealed anterior dislocation of the proximal tibiofibular joint (). The patient had subsequent spontaneous reduction while entering a car the following day. 3 days after injury, the patient had persistent the left knee pain and difficulty with the range of motion to terminal flexion and extension and presented to clinic. At presentation, the patient was unable to comfortably bear weight on the extremity. On examination, he had tenderness to palpation at the fibular head but no tenderness over the ankle. His left knee had a range of motion comfortably from 10 to 90° and full strength in all muscle groups, as well as intact sensation in all nerve distributions in the lower extremity. Initially, the patient elected for nonoperative treatment and was advised to remain non- weight- bearing for 1week followed by a repeat MRI. This study revealed a small amount of lateral subluxation of the left fibular head. At this point, the patient had persistent pain and difficulty with extension, and so elected to undergo surgical treatment. 12 days after injury, the patient underwent ORIF of the proximal tibiofibular joint. The joint was noted to be resting in a laterally subluxed position. It was manually reducible but unstable (). A single 3.5 mm cortical lag screw was inserted from the fibula to the tibia parallel to the knee joint, after which the joint remained anatomically reduced. Postoperatively, the patient remained non-weight-bearing with passive range of motion limitations for 4 weeks, after which weight-bearing and active range of motion were allowed. At 8 weeks, his physical examination included minimal edema about the head of the fibula; active range of motion from 0° to 135° without pain and equal to the contralatera l side; and no instability or pain with stress applied to the syndesmosis. He resumed hockey practice after 8 weeks and resumed competition 3 months following the injury. At 5½ months, the patient had minimal leg pain only with push off and the screw was removed to allow for return of physiologic motion (). |
The patient is a 31-year-old male with a history of hypertension, hypothyroidism, and hyperlipidemia who initially presented to his primary care provider with fatigue and lethargy. He had no past surgical history and his family medical history was noncontributory. He was found to have severe hypothyroidism with a thyroid stimulating hormone level of greater than 100. He presented to the Emergency Department (ED) at an outside hospital for concerns of ongoing leg swelling, fatigue, and lethargy in conjunction with hypothyroidism. Upon admission to the ED, he was found to have a deep vein thrombosis (DVT) in the popliteal vein. He was then started on enoxaparin sodium 100 milligrams twice a day and was scheduled for a thyroid ultrasound. The thyroid ultrasound displayed multiple bilateral hypoechoic thyroid nodules with the largest 3.5 cm in diameter. He underwent FNAB of the dominant left and right nodules with 5 passes each, using a 22 gauge needle under ultrasound guidance.\nThe procedure was reported to have gone well; however, several hours later he developed anterior neck swelling and difficulty breathing. An ultrasound at that time confirmed an intrathyroidal hematoma with concern for arterial disruption. The patient was fiberoptically intubated at the outside hospital for airway protection and transferred to a tertiary care center. Upon admission, computed tomographic angiography of the neck displayed a large intrathyroidal hematoma with an arterial blush concerning for active hemorrhage (). Enoxaparin sodium was held at the time of his admission to the tertiary care center. Interventional radiology was consulted for possible embolization of the hemorrhaging vessel. The patient was found to have active bleeding from his left superior thyroid artery (), which was successfully embolized using n-butyl cyanoacrylate particles (). The patient was assessed for an endotracheal cuff leak the next day for possible extubation. Unfortunately, the patient did not have a leak and the hematoma was not noted to be reduced in size. He was then taken to the operating room the next day for evacuation of the intrathyroidal hematoma to expedite extubation.\nThe patient was then taken to the operating room the next day for evacuation of the intrathyroidal hematoma. A 4 centimeter transcervical incision was made over the lower anterior neck and exploration identified an organized intrathyroidal hematoma with no active bleeding. The hematoma was noted to be superficially involving the thyroid but it appeared viable and thyroidectomy was not deemed necessary. The neck was then copiously irrigated.\nA Jackson-Pratt drain was placed in the wound bed. Enoxaparin sodium was restarted on postoperative day one after his neck evacuation and the patient was extubated. The patient had no further shortness of breath. He was subsequently discharged on postoperative day two after an uneventful hospital stay. His Jackson-Pratt drain was removed in clinic on postoperative day five. His surgical incision appeared to be healing well and neck soft without reaccumulation of fluid. |
A 37-year-old male with no significant past medical history presented to the emergency room with a penetrating stab wound to zone one of the left neck. On arrival, the patient had a GCS of 15 and endorsed alcohol intoxication. Upon clinical exam, the wound measured about 3–4 cm with minimal bleeding and no expanding hematoma or other hard sign of vascular injury. Initial blood pressure showed 68/40 mmHg; following IV fluid resuscitation with normal saline and packed red blood cells, repeat blood pressure was 134/85 mmHg. The remaining vital signs were stable. The patient was intubated in the emergency department for airway protection and ATLS protocol was followed. An X-ray of the neck revealed left subcutaneous emphysema. Neck computed tomography angiography was performed to rule out vascular injury. It did reveal a possible right pulmonary laceration at the apex along with a trace right apical pneumothorax. Given the findings on the CTA, the patient was then taken to the OR for esophagography and bronchoscopy which revealed no acute injuries. A right chest tube was placed and monitored for drainage.\nOn a postoperative day (POD) 1 a repeat chest X-ray demonstrated bibasilar atelectasis; however, he was successfully extubated later that day. On POD 3, the patient became hypertensive and the right chest tube output developed a milky appearance with a total volume of 260 cc over 24 h. The specimen was sent for triglyceride analysis and confirmed diagnosis of chylothorax with a triglyceride level of 1106 mg/dl. Nutrition was consulted and recommended a low-fat diet of 20 g fat/day in addition to MCT Oil. Octreotide was added to his scheduled medications. Chest tube output increased to 340 cc on POD 4 and 700 cc on POD 5 before downtrending to 260 cc on POD 6. The drainage continually decreased in volume until POD 10 when output over 24 h was less 40 cc and the chest tube was successfully removed. On POD 10, the patient was discharged. |
A 32-year-old male visited our clinic with a major complaint of severe pain in the right knee that started to occur when he managed to stop running over the second base that he had run toward while playing baseball. The right leg that was planted on the second base at the time of injury produced a crackling sound when the knee was flexed with a valgus force applied and severe swelling of the right knee, range of motion (ROM) restriction due to pain, and approximately 40° of extension lag were present. Simple plain radiography showed patella alta on the lateral view (), but other abnormal findings, such as a fracture, were not observed. Magnetic resonance imaging (MRI) was performed to identify if there is an accompanying injury, which revealed a complete tear of the patellar tendon and complete tears of the ACL and the medial collateral ligament (MCL) at the femoral attachment sites, and increased signal intensity in the lateral meniscus led us to suspect an injury to the meniscus ().\nAt 6 days after injury, primary suture repair of the patellar tendon with ACL reconstruction was carried out. The patellar tendon repair preceded the ACL reconstruction. Initially, a 10cm longitudinal skin incision extending from the middle of the patella through the center of the patellar tendon to the tibial tuberosity was made to expose the ruptured patellar tendon. The patellar tendon was completely torn in the midsubstance, the torn end had a frayed mop-end appearance, and the tear extended to the medial retinaculum (). Taking consideration into the shape of the torn end and the distally narrowing anatomical shape of the patellar tendon, the torn end was longitudinally divided into three equal sections, and three core sutures of the patellar tendon were determined. The center of the distal end was repaired with a Fiberwire (Arthrex, Naples, FL, USA) suture using the Krackow method. Two longitudinal bone tunnels were created in the patella using a 2.0-mm Kirschner wire. A suture was passed through the tunnel and pullout repair with the proximal end was performed on the anterosuperior patella with the knee in 45° flexion. The proximal end was sutured with two Fiberwire sutures at medial 1/3 and lateral 1/3 points using the Krackow method. A bone tunnel parallel to the tibial tuberosity was created, through which the sutures were passed and pullout suture with the distal torn end was done. At the torn ends, end-to-end anastomosis was performed additionally (. Subsequently, an anterolateral portal, an anteromedial portal, and an accessory far medial portal for anatomical ACL reconstruction were created through the skin incision. An arthroscope was introduced into the joint. The presence of a transverse tear in the posterior horn of the lateral meniscus that was not clearly identifiable on MRI was confirmed. It was repaired using an all inside technique with two PDS (polydioxanone monofilament; Ethicon Inc., Somerville, NJ, USA) sutures. A complete tear of the ACL at the femoral attachment site was confirmed, and reconstruction was done using an Achilles tendon allograft to avoid a donor site injury (). For anatomical ACL reconstruction, a femoral tunnel was created at the center of the femoral attachment of the ACL using the transportal technique and a tibial tunnel was made at the center of the tibial attachment site using Pinn-ACL tibial guide (Linvatec, Largo, FL, USA). With the calcaneal fragment of the Achilles tendon allograft placed toward the femur, the graft was fixated to the femur using a metal interference screw and to the tibia using a bioabsorbable interference screw with the knee in 20° flexion, and a metal staple was used for additional fixation. Following ACL reconstruction, a primary suture for the medial retinaculum and the patellar tendon sheath was carried out. The complete tear of the MCL at the femoral attachment site was conservatively treated: after 2 weeks of splint immobilization, rehabilitation therapy was administered so that the range of flexion could be gradually increased.\nFor the 14 postoperative days, the patient was treated with compression dressing, application of ice, and elevation of the leg with a long leg splint applied, to reduce swelling. From day 1 after surgery, quadriceps strengthening exercises were recommended. From the second postoperative week, the long leg splint was replaced with a limited motion knee brace and the patient was encouraged to perform flexion exercises within pain-free ranges. The range of flexion was gradually increased to 30° at the 2nd postoperative week, to 60° at the 4th postoperative week, and to 90° at the 6th postoperative week. Weight bearing ambulation was not allowed until 6 weeks after surgery due to the meniscal repair.\nMRI scan at 6 month after surgery showed well-maintained continuity of the ACL and patellar tendon and no abnormal findings in other soft tissue, such as the meniscus (). At 1-year postoperative follow-up, 0°-140° of flexion was possible, and no changes were detected in the Lachman and pivot shift tests. The Lysholm score was satisfactorily high (94 points). Other than discomfort in the knee after long or knee-straining activities, no complication was reported. |
This is a 10-year-old female who first presented at age 4 days to Vanderbilt University Medical Center pediatric ophthalmology for bilateral congenital cataracts. She underwent cataract extraction and anterior vitrectomy at age 5 and 6 weeks. She required removal of reproliferation secondary membranous cataract in both eyes 2 months later. An additional two months later, she was referred to the glaucoma service for elevated IOP in the right eye (30 mm Hg). Examination under anesthesia revealed a hemangioma near her right eyebrow and a soft protuberance at her posterior scalp, IOPs in both eyes controlled on topical glaucoma medications required only in the right eye, bilateral multiple CHRPE (), and axial eye lengths indicating left eye microphthalmia. Her early secondary glaucoma/ocular hypertension subsequently required the addition of glaucoma medications to the left eye. Both eyes were then controlled with glaucoma medications until age 17 months at which time she underwent an anterior chamber Baerveldt shunt and complete pars plana vitrectomy in the left eye. The eye required additional steroids, vitrectomy, and membranectomy 5 and 21 months later. Subsequently, the IOP has remained controlled bilaterally on topical glaucoma medications.\nShe also had an atrial septal defect confirmed by ECHO at 1 month of age, and concern for possible Wolff-Parkinson-White (WPW) syndrome by the ECG per her local cardiologist's note.\nWhen she was 11 months of age, pediatric neurology evaluated the vascular lesion on the parietal scalp and estimated its size to be 5 × 6 cm and specifically hypothesized PHACE syndrome. Due to this finding, she underwent brain MRI/MRA at 12 months of age which showed a large enhancing lesion of the right parietal scalp measuring up to 3.9 × 2.3 cm axially, interpreted as a likely hemangioma (). There was an adjacent prominent intracranial draining vein in the right parietal region. A second smaller lesion was also present in the right frontal scalp with similar imaging characteristics. No intracranial abnormality was seen in association with the smaller lesion.\nAt 25 months, repeat imaging was performed, showing that the right parietal scalp mass contained multiple enhancing vessels with at least one feeding artery from the right external carotid artery. The right parietal lesion demonstrated diminished overall thickness measuring approximately 1.4 cm on the current exam compared to 2.2 cm in thickness on the prior exam. No communication with the intracranial vasculature was identified. The smaller lesion within the right frontal scalp was unchanged in size measuring approximately 1.2 cm in diameter. This lesion also demonstrated no definite communication with the intracranial vasculature. Imaging at this time also showed an aberrant right subclavian artery. The right external carotid artery supplied at least one arterial branch to the right parietal scalp mass, and all intracranial arteries were patent and without abnormality. Overall, these results showed that the right frontal and right parietal scalp lesions demonstrated no communication with the intracranial arterial system and a decreased size of the right parietal scalp lesion from previous imaging which may have represented early involution. She had appropriate growth, so endocrinopathies that may occur in PHACE were not suspected. She had no reported dental or hearing problems nor structural brain malformations.\nShe presented at age 9 years to the genetics clinic for confirmation of the probable diagnosis of PHACE syndrome. Due to these findings, a “definite diagnosis” of PHACE syndrome was given based on two forehead/scalp hemangiomas that grew rapidly as an infant and then resolved as well as history of an arterial anomaly (aberrant subclavian artery), cardiac defect, and eye anomalies (i.e., 4 of 5 major criteria for PHACE based on 2016 Journal of Pediatrics report by Garzon et al. on consensus diagnostic criteria []). During this appointment, it was noted that she had not had dental problems. The family history was notable for her mother having severe to profound congenital hearing loss diagnosed at six months of age and currently requiring hearing aids. Her father had a heart murmur in childhood. Her sister had childhood rheumatoid arthritis in the knee but was in remission.\nDuring regular follow-up, her glaucoma ophthalmologist (KMJ) noted that the ocular phenotype, including congenital cataracts, glaucoma, and bilateral CHRPE raised strong suspicion for oculofaciocardiodental syndrome (OFCD) based upon similarity to the phenotype of case 1. Her parents also reported that she had long roots of her teeth with one missing tooth and first primary tooth loss at 6-7 years of age (). Due to this important clinical observation and her cardiac history, genetic testing for this condition was performed, revealing a pathogenic monoallelic variant, c.2514del(G), p.Lys839Serfs∗17 consistent with X-linked OFCD. Her mother, father, and sister tested negative for the variant in DNA derived from peripheral blood lymphocytes.\nTo further analyze any molecular genetic studies of PHACE that might shed light on BCOR's candidacy for this diagnosis, we performed a gene set enrichment pathway analysis (GSEA) (GSEA—Broad Institute [, ], ) by adding BCOR to Sigel's (2018) gene list []. When BCOR is added among BRAF, GNA11, GNAQ, KRAS, MAP2K1, MTOR, NRAS, PIK3CA, PIK3R1, and RASA1, GSEA shows that BCOR overlaps significantly with other genes in the pathway of domain of “circulatory system development ().” |
A 78-year-old right-handed lady was referred to elective cardiac surgery department for coronary artery bypass graft (CABG) surgery. She was hospitalized for conducting the pre-operation investigations. On the second day of admission, she developed sudden onset weakness of left upper and lower limbs and dropping of left side of the face. She has had a past history of hypertension, which was controlled by taking 50 mg atenolol twice a day. She has had angina pectoris but not any history of myocardial infarction. According to her coronary angiography, she was candidate for CABG surgery due to coronary artery stenosis.\nThe vital signs at the onset of left side hemiparesis included pulse rate of 74/min with regular rhythm, respiratory rate of 16/min, blood pressure of 160/100 mm Hg and normal body temperature. Her baseline electrocardiogram showed evidences of left ventricular hypertrophy (LVH) and there was no evidence of acute cardiac ischemia.\nAxial brain computed tomography (CT) scan without contrast, which has been done after 30 minutes of hemiparesis, showed no evidence of hemorrhage, no new parenchymal hypodensity and no dense clot sign. Although, the brain CT scan showed an old stroke in left hemisphere which was not compatible with the symptoms of the patient. Due to acute left hemiparesis and no evidence of hemorrhage on brain CT scan, the diagnosis of ischemic stroke with unclear mechanism was made. The National Institutes of Health Stroke Scale (NIHSS) was 10 out of 42, composed of 2 score for partial paralysis of lower face, 3 score for left arm motor weakness, 3 score for left leg motor weakness, 1 score for sensory disturbances and 1 score for language problem. Next decision was to administer the intravenous thrombolytic. Intravenous rTPA was started after 120 minutes of the event onset. The bolus dosage of rTPA was 8 mg, followed by infusion of 58 mg in the next 60 minutes.\nApproximately three hours later, the patient complained of chest pain and palpitation. The immediate electrocardiogram (ECG) showed ST-segment elevations in the inferior leads (II, III, aVF), and ST-segment depressions in the anterolateral leads (I, aVL) (). The patient was emergently transferred to the cardiac catheterization laboratory for rescue percutaneous coronary intervention (PCI). On angiography, the occlusion of right coronary artery was detected. Thrombectomy via an aspiration catheter was performed and normal coronary blood flow was restored. Then PCI was conducted on right coronary artery and posterior descending artery bifurcation with two bare metal stents. After revascularization, the patient’s heart rhythm returned to normal sinus and hypotension was resolved. The brain CT scan was repeated and showed a new hypodensity in right parietal lobe. Brain MRI with diffusion-weighted sequence (DW) revealed a watershed ischemic infarction between anterior cerebral artery (ACA)-multiple correspondence analysis (MCA) and MCA-principal component analysis (PCA) territories in right side, which was hyposignal in equivalent Apparent Diffusion Coefficient (ADC) sequence that means an acute stroke occurred (). The echocardiography revealed a left-ventricular ejection fraction of 50% with inferior hypokinesia and without evidence of intracardiac thrombus or intracardiac right-to-left shunt. |
A 51-year-old female was brought to the hospital late in the evening with a history of loss of strength in the right side of the body for ½ h. The patient was roaming inside her house and suddenly knocked off her feet. She complained of loss of strength in the right side of her body along with a feeling of numbness in the affected limbs. There was no history of losing consciousness or seizure. There was no history of diabetes or hypertension. That was a stormy night with flashes of lightning and deafening thunderstorm striking every other minute and the monsoon had just arrived. A deep crack was noticed on one of the walls of the house due to the lightning strike, and pieces of broken window glass found scattered all over the room where the patient had the lightning injury.\nThe patient was conscious and could narrate her problems lucidly but appeared terrified. Her vitals were normal, and her oxygen saturation was 98% in the room air. She was afebrile, but the affected limbs felt cold. There were no external injuries or burns on her body. Examination of cardiovascular and respiratory systems was normal. Her peripheral pulses were felt equal and normal on either side. She was fully conscious and oriented with normal cranial nerves though there was a subjective feeling of numbness on the right side of the face. There was right hemiparesis with a power of 2/5 in her lower and upper limbs with hypotonia along with reduced deep tendon reflexes as compared to the left. The plantar reflex was flexor bilaterally. There was a marked impairment of all modalities of sensation on the affected right upper and lower limbs with a subjective feeling of numbness.\nHer hemoglobin was 10.5 g/dl; hemogram, metabolic parameters, serum electrolytes, and urine analysis were within normal limits. Her cardiac enzymes were within normal limits, and the electrocardiography showed normal sinus rhythm with no arrhythmia. The chest X-ray and computed tomography scan of the head were normal.\nThe patient was managed with 0.9% normal saline and parenteral betamethasone 4 mg 8th h along with ranitidine. The patient made a remarkable recovery over a period of 2–4 h. Her motor weakness disappeared completely with near-normal sensations, except minimal numbness on the affected side. However, she continued to have giddiness and vomited twice. The patient was discharged later after 2 days. A follow-up after a week revealed minimal residual giddiness and numbness in the limbs. |
A 12-year-old girl reported to the department of Pedodontics RDC Loni with a complaint of swelling in the lower front gum region since 3 months. Clinically there was an isolated gingival swelling in the lower left anterior region between central and lateral incisors (31 and 32). The swelling was red and shiny in appearance measuring about 2 × 1 cm in size extending from mesial surface of central incisor to the mesial half of canine on the labial side and was extending on the lingual side of incisors measuring 0.8 × 0.5 cm in size. Both the swellings were connected at the interdental area of central and lateral incisors [Figures and ]. On palpation the swelling was a pedunculated mass, soft and easily movable from the base. On probing gently, the lesion showed considerable amount of bleeding. Extraorally the face was asymmetrical with slight enlargement on the right side of the face. Remarkably the enlarged right half of the face was bluish red in color. There was a prominent scar on the right side of the face in upper buccal region []. Parents revealed a history of surgery 7 years ago for a red swelling in the scarred area.\nIntraorally right half of the mouth was markedly red affecting labial and buccal mucosa, buccal vestibule, floor of mouth, tongue and palate while left side did not show any abnormalities. Intraoral periapical radiographs of the 31, 32, and 33 region and OPG were advised to rule out any bony involvement. The radiographs did not reveal any significant problems except presence of initial bone loss from the interdental area of 31 and 32.\nSince the lesion had a pedunculated base with little bony involvement excisional biopsy was carried out carefully followed by bony curettage. The entire procedure was performed under local anesthesia. Histopathological examination of the excised mass showed numerous endothelium lined spaces, abundant fibroblasts, collagen fibers, and polymorphonuclear leucocytes revealing features of pyogenic granuloma []. At the end of 1 month, the lesion had uneventful healing []. Six-month follow-up was quite satisfactory and there was no evidence of any recurrence. During surgery and curettage the amount of bleeding was controllable and no additional steps were required to stop the bleeding. This could have been due to the presence of granuloma on the left side which was not affected by the vascular lesion. |
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. |
An 85-year-old woman with a past medical history of severe peripheral vascular disease and right below knee amputation presented to the emergency department with a 1-day history of non-positional dizziness and weakness. She denied any headache, neck pain, chest pain, trauma, or fever. Her ED vital signs were normal, and her ECG showed normal sinus rhythm with a heart rate of 91 bpm. Her physical examination was normal including a right below knee stump that was clean and dry. An MRI/MRA of the head and neck showed no new changes. The patient required intravenous access to work up her dizziness and weakness. The patient had multiple failed blind ED peripheral IV attempts performed in the past.\nAn ED bedside ultrasound guided antecubital brachial vein was cannulated on the first attempt using the long-axis approach (see video clips in Additional files , , and .). After applying an elastic tourniquet to the patients non-dominant left arm and applying ultrasound gel, a high frequency linear array probe was used to identify an antecubital vein that was the largest in diameter, at least 3 mm or greater in diameter and a vein as close as possible to the skin surface. An augmentation procedure was performed by squeezing the patient's forearm while sampling the vessel with color Doppler and pulse Doppler. The augmentation procedure with increased Doppler flow verified the selected vessel was a vein, since an arterial vessel would produce a pulsatile Doppler flow pattern (see video clip in Additional file .). The skin was prepped with alcohol swabs, the vein verified with augmentation again, and the probe, now covered with a thin sterile plastic film dressing, was placed in the nine o'clock position to view the antecubital brachial vein in short-axis, then the ultrasound probe was turned counter clockwise to the six o'clock position to position the vein in the long-axis position (Figure ). The ED physician held the vascular ultrasound probe while resting on the patient's bed to provide stability. A 20-gauge 2-in. catheter was placed under the long-axis of the probe and vein so that direct visualization of the needle tip and catheter inside the vessel could occur (Figures and ). The catheter was flushed with saline and secured. |
Fifty-nine-year-old woman presented to a pulmonary outpatient department for management of recurrent pneumonias due to bronchiectasis diagnosed two years ago. She was found to have on an average of four to five episodes of lower respiratory tract infections (LRTI) per year during the same period. She was apparently well until about two years ago when she started developing LRTI which was initially treated with various antibiotics including fluoroquinolones, beta-lactam antibiotics and macrolides at different walk-in clinics. Chest X-rays obtained before the presentation were normal. Computed tomography (CT) of the chest which was obtained at our hospital revealed right lower lobe focal cylindrical bronchiectasis. This was presumed to be post-infectious based on LRTI history. Frequency of LRTI increased from an average of two episodes in six months to three to four episodes in six months. Repeat sputum cultures grew pseudomonas aeruginosa every time. She was managed symptomatically with airways mucus clearance and fluoroquinolones as needed.\nHistory for pulmonary childhood infections, immunodeficiency, severe allergies and other risk factors for bronchiectasis was negative. Serum immunoglobulin G subgroups and immunoglobulin E levels were normal arguing against immunodeficiency and ABPA. Upon closer review of the computed tomography of the chest, a possible endobronchial lesion was noticed resembling a polyp of about half a centimeter in length (Figure ) at the right lower lobe posterior segment. Flexible bronchoscopy was performed revealing thick yellow-green secretions originating from the right lower lobe with an endobronchial lesion in the posterior segment at the same level as the CT scan abnormality. Cultures from the bronchoalveolar once again grew pseudomonas aeruginosa and pathology from the biopsy of the endobronchial mass revealed acute inflammation with predominant neutrophils which we related to ongoing infection. Over the next six months, the patient had three hospitalizations due to LRTI. Department of cardiothoracic surgery was consulted and the patient underwent a video-assisted thoracoscopic surgery and a right lower lobectomy was performed due to BSI of 15. The resected lobe was sent to a pathologist for histopathological analysis. An impacted 1.3 cm non-surgical plastic foreign body was discovered in the right lower bronchus by the pathologist during the gross examination of the specimen (Figures , ). The histology of the airway and lung parenchyma surrounding the foreign body showed chronic inflammation and reactive benign tissue growth. Post-operative recovery in the hospital lasted four days and was uneventful. The patient had no recollection of aspiration or choking in the past which could explain the foreign body, nor did she have risk factors for aspiration such as dementia, alcoholism, drug use, stroke, medications, etc. Subsequently, the patient has had no recurrence of infections in the one-year follow-up. |
A 70-year-old male had a rapidly growing mass on his right thigh, with no pain, redness, and swelling observed on the surface of the mass.\nThe patient had underlying chronic hepatitis B virus infection, and was diagnosed with HCC. He had received a liver transplant for primary liver cancer 6 years prior. He was admitted to the hospital after finding a rapidly growing mass on his right thigh.\nThe patient underwent a liver transplant for primary liver cancer 6 years prior.\nThe patient was retired, living with his son, and had no family history of hereditary disease.\nThe patient was hospitalized and his physical parameters were examined. The vital signs were as follows: Body temperature 36 °C, heart rate 85 beats/min, respiratory rate 16 breaths/min, blood pressure 130/85 mmHg, and oxygen saturation in room air 95%. There were no apparent signs of cranial nerve dysfunction. Muscle tone, strength, and deep tendon reflexes were normal in the upper extremities, while low in the inferior extremities with more on the right side. Abdominal cutaneous reflexes were normal. The remaining physical examination was unremarkable.\nAfter re-sectioning the right lateral femoral soft tissue mass, the patient was examined intraoperatively (right thigh mass) with a circumscribed mass of 5 cm × 3 cm × 2 cm. The findings revealed that small muscle tissue was attached to the surrounding mass, and a section of the mass was light brown, solid, and multinodular.\nDuring admission, physical examination showed an oval-shaped mass with a diameter of about 5 cm on the anterolateral part of the right thigh. It was hard to touch, had poor mobility, and was attached to the surrounding soft tissue. He had normal blood flow from the right lower limb with adequate movement; the skin temperature was normal, no abnormality was found in the sensory nerve examination, the physiological reflex was normal, and no abnormality was found in the rest of the review. The ultrasound examination revealed a mixed echo mass in the lateral soft tissue of the middle part of the right femur, with a size of approximately 5 cm × 2 cm × 3 cm, which had a clear boundary and regular shape. Figure presents an ultrasound image of the muscularis in the right thigh in which the blood flow is indicated with undefined boundaries. Figure depicts the arterial spectrum taken by color Doppler flow imaging. The ultrasound image showed that soft tissues covered the right side of the femur, the nature of which remains to be determined. Figure presents circular abnormal signals in the middle part of the right femur near the lateral soft tissue, accompanied by surrounding soft tissue edema by magnetic resonance imaging (MRI). The images showed heterogeneous iso-signal intensity on T1WI and heterogeneous hyper-intensity on T2WI compared to the surrounding muscles, which had signal inhomogeneity. The size was about 4.5 cm × 1.4 cm × 3.1 cm; the boundary was slightly blurred, and there were a few pieces of long T2 signal in the adjacent soft tissue (Figure and ). |
Here, we present a case of a 55-year-old Caucasian female with a history of substance use disorder and a comorbid bipolar disorder, who presented to the local general hospital with a history of the fragmentation of a single personality into different personalities under emotional stress and under the influence of a drug. Multiple aspects of her personalities were reported, including the following: a personality of a seven-year-old child, a personality that would behave as a teenager, and another that acted like a male person in addition to her normal 55-year-old personality. She reported that she had been constantly dominated by her alternate personalities and became aware of their existence when people around her informed her, usually after a situation ended. She reported that stressful situations and substance abuse could aggravate the fragmentation of her personality. This was found to be mostly an involuntary phenomenon with seldom memory of the event.\nWhile transitioning between these personalities, she was found to be violent even to people who were close to her. This could range from being suicidal to homicidal for which she was arrested twice in the past. She had to be isolated and restrained by being locked in a room and calling the police. As a result, she was hospitalized in a mental institution for a significant period at least two to three times in the past. Under the influence of stress or substances like marijuana or cocaine, her personality would split into various personalities. These states were very different from one another in terms of age or gender.\nOne of her alternate personalities behaved as a seven-year-old child and would show the same interests and choices that included becoming moody or a self-arrogant personality. While in these states, she could hurt herself or had weeping spells if her wants were not met.\nAnother personality acted as a teenager with some sharp choices and dressing. Increase in substance abuse, alcohol use, and smoking would lead to multiple cases of fights or homicidal attacks, with some incidents of self-harming events. Multiple scars were found on the dorsal side of her right hand. Her speech was found to be pressured and she would repeat the same words/ conversations.\nThe next personality was diagnosed to be a temporary transition to the opposite gender (a male). There was a change in voice and behavior. This included male dressing, language, a perception of male body parts, choices of friends, and attraction towards females, including sexual behavior.\nThe normal state of a 55-year aged female was the default personality that made her feel most comfortable. She reported that she had anxiety during a personality state transition, as it could occur at any time, and involuntarily, but mostly in stressful situations and during substance abuse. More violent and harmful events were reported when someone tried to meet the patient alone rather than in a group.\nThe treatment included psychotherapy with cognitive behavioral therapy addressing stress and substance use disorder. The psychotherapeutic treatment lasted for at least six months. The dual treatment of drug therapy was also involved to calm her down. The patient was prescribed escitalopram to reduce her anxiety symptoms. She believed that the anxiety pills were really helpful. After six months, the patient's condition was not drastically different. However, she believed her stress was getting better. The patient was further followed up for the next one year and the treatment continues to date. |
A 55-year-old Caucasian male presented with bilateral ulnar deviation of the fingers that could be corrected without pain (Figures and ). He first noticed the ulnar deviation in his early twenties. Initially he had no associated pain and he still had full function of his hands and therefore did not receive treatment. Three years prior to presentation he developed pain at the base of both thumbs and approximately 4 months priorly he began to have a significant increase in pain in his left 2nd and 3rd metacarpophalangeal (MCP) joints as well as in both 1st carpometacarpal (CMC) joints. He also began to notice some wasting in the muscles between his thumb and index fingers. As an active surgeon, he noted minor difficulty with some instrumentation such as hemostat use when in the OR. Symptomology was treated with over the counter anti-inflammatory medication.\nThe patient has two brothers (aged 54 and 53) that are affected, one brother that is not affected (age 45), and two sisters that are not affected. Both parents are deceased but the patient did not believe that they had any ulnar deviation of their fingers. The patient also has three children, none of which show hand abnormalities. By report, neither of the patient's affected brothers have any pain or other arthritic symptoms associated with their hands.\nOn physical exam bilateral adductor wasting was noted bilaterally with greater changes on the left hand. No symptoms of numbness in the ulnar nerve distribution were encountered. He has hyperextension of the PIP joints that is worse on the left side giving a mild swan neck impression of the digits. Light touch neurosensory was intact. He had a minor prominence at the right volar wrist that was clinically compatible with ganglion cyst formation secondary to CMC arthritis. CMC grinding was present bilaterally at the first metacarpal as well as bilateral enlargement of the first and second MCP with positive grind at the left 2nd MCP. He had a negative Wartenberg test and no interosseous wasting, and full extension was possible. Grip strength was R78 lbs and L62 lbs tested with dynamometer, while his pinch strength was R11 lbs and L8 lbs, respectively. No bands were palpable on the palm with extension and radial displacement of the fingers. No subluxation of the extensor tendon was noted.\nThe patient had no history of rheumatoid arthritis, rheumatic fever, or SLE. ESR was 1, uric acid was 6.0, C-reactive protein was 0.0, rheumatoid factor was <10, and he was negative for anti-nuclear antibody suggesting no rheumatoid arthritis or SLE. It was felt to be unlikely seronegative rheumatoid arthritis given his family history and the lack of other symptoms compatible with this disease process. The deformity was not present at birth and he had no other deformities as a child. The pain was isolated to the MP and CMC joints of his hands. Radiographs of his hands were done as seen in Figures and . The radiographs confirmed osteoarthritic changes of the left hand and wrist, worsening at the second MCP joint, the third MCP joint, and the scaphotrapezial joint. Spurs were present at the second metacarpal head as well as at the trapezium. The radiographs also confirmed osteoarthritic changes in the right hand with severe joint space narrowing at the scaphotrapezial and first CMC joint, along with minor joint space narrowing in the second and third MCP joints. |
Patient 2 (40–45 years old) presented with severe agitation. He was threatening, screaming, scratching, and spitting, and refused a conversation. He thus showed a similar clinical picture as patient 1 but also appeared to experience auditory hallucinations and to actively talk to them. Patient 2 was in a state of poor hygiene. Taking into consideration his manner of response, one could assume that patient 2 has experienced psychiatric treatment in the past. When the nurse asked him if he had any experience with psychiatric medication, he yelled at her and clarified his wish to refuse haloperidol. He seemed to feel especially threatened by the police and the psychiatric staff, not only due to psychotic symptoms but also due to previous aversive experiences with psychiatric treatment. Once again, the staff members involved in the situation discussed the clinical case in a multiprofessional setting and weighed out every possible option. The team suspected that patient 2 suffered from an acute exacerbation of a disorder that persisted for a longer period of time or a psychotic relapse. In this case, the team decided that patient 2—due to his previous aversive experiences—would have extraordinarily suffered from compulsory treatment, which may exacerbate previous traumatic experiences. Also, he calmed down a bit when given a space to withdraw and did not immediately endanger himself or others; however, he remained tense for several days and threw objects whenever members of staff tried to engage him in a conversation or offered oral medication. When left alone, he did not appear aggressive or present improper handling, showed a regular food intake, and welcomed the possibility to smoke. Somewhat later, he was seeking a medical consultation and expressed the need for a low-dosage medication. To this day, 6 years later, he regularly receives outpatient care and short-term crisis intervention treatment on a psychiatric ward, although he has felt threatened and deprived of his identity by the state and the psychiatric system of another city for more than 25 years. |
An 18-year-old man with history of end stage renal disease secondary to congenital renal agenesis presented to the Emergency Department with an acute onset of hemoptysis, back pain, and fever. He had undergone a cadaveric kidney transplant four months before at a different institution. The transplant was performed without any complications, and the patient had reportedly normal kidney function. He was taking cyclosporine, mycophenolate, and prednisone for maintenance immunosuppression. He was not on any antifungal prophylaxis. The patient was not residing in a house with routine expose to soil and livestock. He denied any weight loss or recent foreign travel. His laboratory values were significant for leukocytosis with a white blood cell count of 21,900/mm3 and elevated creatinine. His initial chest X-ray demonstrated a consolidation of the left lower lobe (). Further imaging on chest CT showed a left lower lobe cavitary lesion (). Sputum, bronchoalveolar lavage, and blood cultures were all negative for infectious etiology. His workup was additionally negative for any additional infectious etiology. His renal biopsy showed no evidence of rejection or active infection. He was initially started on broad-spectrum antibiotics and antifungals. His immunosuppressants were held.\nHe was taken for an open thoracotomy with a left lower lobectomy one week after initial presentation due to the critical nature of his illness. Intraoperatively, he was found to have a solitary consolidated fungal mass surrounded by an area of hemorrhagic necrosis (). Final pathology showed Rhizopus species (). Treatment was initiated with IV liposomal amphotericin B 50 mg daily.\nThe patient demonstrated overall clinical improvement. However, one week postoperatively, the patient developed a new consolidation of his left upper lobe on chest X-ray. Repeat chest CT demonstrated an empyema. The patient also had Rhizopus cultured from his surgical site. He remained febrile with significant leukocytosis. He was taken to the operating room for an evacuation of an empyema and debridement of soft tissue surrounding the incision (Figures and ).\nDespite aggressive surgical management of his recurrent disease, the patient continued to remain symptomatic. However, he had evidence of consolidations in both lungs (). It was then decided to add isavuconazonium (372 mg daily). The patient improved clinically, and he was discharged home 24 days after his initial presentation.\nThe patient was maintained on the regimen of amphotericin B (50 mg daily) and isavuconazonium (372 mg daily) after discharge. His follow-up chest X-ray 7 months after treatment showed no evidence of residual disease. His medications were discontinued at this time. To our knowledge, he has had no further issues. |
The patient was a 61-year-old male who was diagnosed with right temporoparietal GBM and treated with right temporoparietal resection and adjuvant chemo-radiation. Unfortunately, he developed recurrence of his tumor and was re-operated for recurrent tumor and ultimately started on avastin chemotherapy. During a routine follow-up magnetic resonance imaging, he was found to have a right middle cerebral artery pseudoaneurysm for which he required another craniotomy for definitive obliteration of the pseudoaneurysm. He then developed wound dehiscence with cerebrospinal fluid (CSF) leak, which was likely from a combination of steroid use, prior irradiation, multiple operations through the same incision, and avastin use – the latter, through its anti-angiogenic properties, is particularly harmful to healing incisions. He underwent wound debridement with the removal of his bone flap and previously placed titanium hardware and a titanium cranioplasty was done along with multiple layered scalp closure. He continued to have multiple episodes of CSF leak over next few months with elevated spinal fluid pressure on multiple lumbar punctures. Given the diminished wound leakage with lumbar drainage, a VP shunt was placed for definitive CSF diversion. He was discharged after uneventful recovery, but returned 5 days later with acute onset left sided weakness on his upper and lower extremity along with decreased sensation on the entire left side. A head computed tomography (CT) scan was obtained which revealed significant right-sided tension pneumocephalus beneath his craniotomy site. He was emergently operated on for right parietal craniotomy for the relief of his tension pneumocephalus. Intra-operatively, he was found to have frank wound dehiscence and his previous craniotomy wound was debrided and replaced with a new titanium implant measuring 6 cm × 6 cm. The overlying skin was closed with a running 5–0 prolene for watertight closure. He was discharged after resolution of his symptoms and uneventful recovery.\nHe continued to have a nonhealing portion in the central portion of his incision with a small opening which was being managed conservatively. Unfortunately, he presented again to the emergency room with left sided numbness and weakness with gait instability. A CT scan was done which demonstrated concern for acute pneumocephalus []. He was taken to the operating room for exploration and large scalp rotational flap based on the superficial temporal artery for definitive closure of another episode of wound dehiscence. However, while the patient was undergoing debridement and prior to entering his old resection cavity, he was receiving N2O as a part of his general anesthesia. At this point, his brain was noted to be incredibly tense which was significantly different from the start of the operation. His blood pressure was significantly elevated and his heart rate dropped to 40 s raising the concern of tension pneumocephalus and Cushing phenomenon. The N2O was immediately discontinued and emergently the old tumor cavity was entered with a curved snap followed by a forceful large “whooshing” sound, indicating escape of a large amount of trapped intracranial air (cerebral flatulence). Following this maneuver, his heart rate returned to the normal range and the vital signs were reversed from the Cushing phenomenon. The remainder portion of the surgery was uneventful and the wound was covered with superficial temporalis artery-based flap. N2O had been discontinued. The patient had an unremarkable postoperative recovery and discharged 5 days postoperatively. However, his tumor continued to progress resulting in worsening neurological dysfunction and he died 24 months later from progressive illness. |
A 44-year-old woman visited the Department of Conservative Dentistry because of tooth avulsion of the left maxillary central incisors after an injury caused by falling down one day before visiting the dental office. The patient brought the avulsed tooth wrapped in tissue paper. The tooth was totally dry. Clinical and radiographic examination revealed that tooth #21 was avulsed, and a blood clot was found in the alveolar socket (). Debridement of the contaminated root surfaces, endodontic treatment, and resin-wire splint were performed. At the 8-week recall, mobility of tooth #21 had increased and periapical radiographs revealed that there was an obvious radiolucent band around the root surface (). It was diagnosed as a failure of replantation on #21. The patient was referred to the Department of Prosthodontics for further treatment. However, the patient did not show up for 10 months for personal reasons.\nOne year after the trauma, the patient came to our department again for checkups. The patient was free of symptoms, and #21 was retained by a lingual fixed retainer, which was made at a local clinic. Clinical examination showed a gingival recession of about 4 mm on #21 and full probing depth around #21. Additionally, a black triangle was formed between #11 and #21 (). The patient complained about the conventional treatment options and refused both conventional fixed partial prosthesis and implant restoration. In case of treatment with conventional fixed partial prosthesis, excessive preparation of the adjacent tooth was necessary for crowding relief, and additional endodontic treatment was required. She refused this option because of the tooth preparation of the adjacent teeth. When we considered an implant, additional bone graft was necessary due to the loss of the buccal plate in the extraction socket area. In addition, she was anxious about implant treatment due to past experience during implant surgery on the left mandibular second molar. Also, due to crowding on the left maxillary lateral incisor, implant placement was particularly difficult. After discussing all treatment options with the patient, the FRC fixed partial prosthesis was chosen. An impression was made with alginate for the FRC fixed partial prosthesis fabrication. It was possible to avoid occlusal stress on restoration because the avulsed tooth was out of contact ().\nAfter local anesthetizing the area, the tooth was extracted. A piece of sterile gauze was gently packed into the extraction site to prevent bleeding. After hemostasis, the prefabricated temporary composite crown was held in position attached to the adjacent teeth with direct composite, and then, the interproximal gingival contour was reformed ().\nThirty minutes before the patient's next visit, a composite pontic was fabricated using nanofilled composite (Filtek Z350 XT, 3M ESPE, St Paul, MN, USA) to enhance the cohesion between the lab-fabricated pontic and the intraoral direct-filled composite. The fiber framework (FibreKor, Jeneric/Pentron Inc., Wallingford, CA, USA) was cut to the appropriate length and adapted to the abutment teeth and the pontic area. The framework was covered with a body layer of the pontic and light polymerized. The FRC framework was located in the palatal 1/3 area of #11 and #21, and in the buccal 1/3 area of #21 pontic ().\nWhen the patient arrived, the abutment teeth were anesthetized and the temporary composite crown was removed (). The abutment teeth were prepared using tapered diamond burs (835.31.009, Brasseler, Savannah, GA, USA). The preparations consisted of removing approximately 1.0 mm of the lingual surface of the abutment teeth to ensure adequate space for the placement of the fibers and composite resin. All margins were in enamel (). After the preparation, a 37% phosphoric acid gel (ETCH-37, Bisco Inc., Schaumburg, IL, USA) was applied to the enamel margin for 20 seconds. The etchant was thoroughly rinsed off and gently dried. Clearfil SE bond (Kuraray Medical Inc., Tokyo, Japan) was applied following the manufacturer's instructions, and a thin layer of flowable composite resin was placed on the prepared surfaces of the abutment teeth. The prefabricated FRC fixed partial prosthesis () was inserted in the cavity. Fiber was pressed into the unpolymerized flowable composite resin (Aelite Flow, Bisco Inc.) using a hand instrument and cured for 20 seconds. The exposed fiber surfaces on the abutment teeth were covered with Filtek Z350 XT and cured for 40 seconds (). Composite was added to the pontic in order to obtain a more natural shape and shade of the final restoration and to reinforce the connector area of the interproximal surface. Occlusal adjustment was made using articulating paper and diamond finishing burs, and surfaces were polished with Soflex (3M ESPE) ().\nAt the 1-year recall, the patient stated that she was satisfied with the appearance and function of the prosthesis. The pontic area and resin-bonded margins were clinically sound, and the abutment teeth were intact (). The pontic was in good condition, and the desired shade of the teeth had been maintained. |
A 40-year-old female admitted with complaint of shortness of breath for last 2-3 day, associated with cough and sputum streaking with blood for last around 15 days. She had pulmonary tuberculosis in the past and had destroyed lung on the right side with mediastinal shift []. On the left side, she was having pulmonary infiltrates, for which she was receiving antibiotics. Her condition further deteriorated to the point that the patient was intubated with an endotracheal tube (ETT) number eight and mechanically ventilated with sedation and paralysis.\nAfter a few hours of mechanical ventilation, her saturation began to drop, and blood pressure increased to more than 200 mmHg systolic with tachycardia. On realizing the problem that tidal volume is not being delivered, endotracheal suction was attempted. However, it was found that the suction catheter could not be passed as an obstruction was encountered. The tube was removed, and the patient was reintubated. On removing the tube, there was no blockage in the tube but now patient was reintubated with a seven number ETT. This was followed by delivery of set tidal volume and normalization of oxygen saturation and blood pressure.\nFurther into the patient's management, after a few hours, patient developed the same problem of worsening oxygen saturation with rise in blood pressure and tachycardia. Again, the delivered tidal volume was not adequate and less than the predetermined value. It was again not possible to introduce the suction catheter through the ETT. On looking specifically at airway pressure alarm limit nothing relevant found which could be the reason for failure to deliver predetermined tidal volume.\nNow, it was suspected that there could be impingement of ETT bevel on the tracheal wall after intubation due to the anatomical distortion of trachea. Gradual withdrawal of the ETT tip up to just below the vocal cords did not restore the ventilation. Therefore, another ETT was introduced with its bevel tip shortened. This was followed by adequate tidal volume delivery. |
A 79-year-old woman presented with a 4-month history of a painless swelling in the hard palate. The swelling had gradually increased in size over the last two months. The lesion had been examined by biopsy at another hospital, and diagnosed as a poorly differentiated squamous cell carcinoma. The biopsy specimen was reviewed at our hospital, and the tumor diagnosed as a poorly differentiated carcinoma.\nOral examination revealed a 3×4 cm firm, painless, submucosal mass located in the hard palate and overlying mucosa was ulcerated. There was no regional lymphadenopathy. The remainder of her physical examination was otherwise normal and laboratory studies showed no abnormalities. Magnetic resonance imaging of the head and neck region revealed a solid mass in the hard palate (). The tumor was removed using a transoral approach under general anesthesia. The lesion was mapped with an adequate margin of 1 cm and the incision included the periosteum. No invasion was seen on the periosteum and bone. The defect was covered with a dermal graft.\nThe postoperative course of the patient was uncomplicated, and she was discharged on the 12th postoperative day. Five months after the operation, the patient is well without evidence of recurrence or metastasis.\nMacroscopically, the tumor was 3×4 cm in size and unencapsulated. The overlying mucosa was ulcerated. The cut surface of the tumor was solid and tan-white, with punctate yellowish foci. Microscopically, the tumor was composed of a mixture of two distinct neoplastic cell populations. The predominant population was composed of large polyhedral cells with eosinophilic cytoplasm and eccentric, round nuclei (). The cells had a distinct plasmacytoid appearance. The nuclei were generally large, hyperchromatic and pleomorphic, and contained prominent nucleoli. The cells were arranged in either sheets or as loose aggregates lying in a myxoid matrix. The mitotic rate was 18 mitoses per 10 high power fields (HPFs) and atypical mitotic figures were also observed. The second population was seen in focal areas and consisted of spindle, fibroblast-like cells with elongated nuclei. The cells formed bundles and showed less pleomorphism than the plasmacytoid cells. There were small foci of necrosis. No perineural and vascular invasions were observed. Noncohesive, infiltrative single tumor cells were seen at the edge of the tumor (). The surgical margins were free of disease.\nThe tumor cells were strongly and diffusely positive for vimentin (Neomarkers, Fremont, CA, USA) and S-100 protein (Novocastra, Newcastle, UK) (). Large numbers of tumor cells were immunoreactive for cytokeratin (Neomarkers). Epithelial membrane antigen (Neomarkers), smooth muscle actin (Novocastra) and glial fibrillary acidic protein (Dako, Carpinteria, CA, USA) were also expressed focally. The tumor cells were negative for desmin (Novocastra) and HMB-45 (Neomarkers). The Ki-67 (using the mAb MIB-1, Novocastra) labeling index was 17%. |
A 13-year-old boy was referred to our tertiary young adult hip service by a Paediatric Orthopaedic Surgeon for evaluation of left groin pain and a decreased range of movement in the left hip. He was a keen rugby player and had experienced an avulsion fracture of the AIIS during a rugby game which was played without a warm up six months previously. MRI just after injury showed a single bony fragment measuring 12 mm × 4 mm × 12 mm at the rectus femoris origin of the AIIS and it was retracted inferiorly 3 cm, anteriorly 1 cm and laterally 0.5 cm. Conservative treatment was advised by the Paediatric Orthopaedic Surgeon and he was referred to a physiotherapist for mobilisation and subsequently muscle strengthening.\nFive months post-injury he was progressing well with the physiotherapy, although, he still felt a sharp pain in his left groin when running with a ball while playing rugby. Flexion was restricted to 70° and a decrease in internal rotation in comparison with the opposite side was observed while abduction, adduction, extension and external rotation were comparable to the other side. There was no significant tenderness and no bruise in the region of the groin, and no distal neurovascular deficit. Plain radiographs demonstrated hypertrophic calcification in the region of the rectus femoris avulsion, whilst the hip joints were normal in appearance. A CT scan showed well corticated heterotopic bone formation at the site, measuring approximately 3.5 cm at maximum diameter (). Motion analysis using the three-dimensional CT datasets clearly showed the impinging area especially in 70° of hip flexion.\nBoth conservative and surgical management were suggested and discussed with the patient and his parents. They chose to go ahead with surgery, as he could not play rugby well because of the pain and restricted range of movement. The patient wanted to play rugby at a fairly high level, hopefully nationally, in the future. At arthroscopy, he was found to have a well corticated large lesion of heterotopic ossification, and it was dissected carefully from the muscles (). Once the dissection was completed, it was extracted via an incision to deliver the lesion. A dynamic impingement test was performed on the table to ensure there was no residual impingement and the impingement lesion was resected with a 5.5 mm arthroscopic burr. A thorough washout was carried out before closure.\nThe patient was advised not to perform any rotational activities in deep flexion for six weeks postoperatively and to follow the 16-week post-operative rehabilitation protocol. He was also advised prophylaxis against heterotopic ossification. Eight weeks following the procedure, the wound had healed well and there were no obvious signs of complications such as infection or deep vein thrombosis. Along with this, he demonstrated a pain-free, fully functional range of movement in his left hip joint and was delighted with his progress. Plain radiographs showed no further signs of calcification (). He was advised to continue to attend physiotherapy for at least another eight weeks and to engage in more gentle sporting activities like cricket and basketball, which he had enjoyed before the injury. At the 1-year follow-up, he remains asymptomatic with a full range of movement in his hip and continues to play rugby at a high level. |
A 74-year-old Albanian man from Kosovo presented to our cardiology department because of unstable angina. The associated risk factors included diabetes, tobacco smoking, and hypercholesterolemia. Four months earlier, he had experienced a lateral wall myocardial infarction which was not treated percutaneously because he was admitted 3 days after the onset of myocardial infarction. His left ventricular ejection fraction was 52 %. He underwent coronary angiography. We were unable to selectively cannulate his left coronary artery, and a nonselective injection disclosed no coronary artery arising from the left coronary sinus. On selective injection of his right coronary sinus, all three coronary arteries originated from a single ostium in the right coronary sinus. Close to the right coronary ostium originated an aberrant large vessel (Fig. ) which coursed transversely and anterior to the right ventricular outflow tract (Fig. ), from which the left anterior descending artery arose and coursed to the anterior interventricular groove continuing distally and proximally as a normal left anterior descending artery, it had the shape of a “T-vessel”, presenting a critical stenosis at the bifurcation of the first diagonal artery (Fig. ). Another aberrant vessel arose at the mid portion of his right coronary artery, coursed to the left, behind the aorta, and in front of the atria to reach the atrioventricular groove on the left and then travelled the normal course with an important obtuse marginal artery (Figs. and ) presenting a critical proximal stenosis. His right coronary artery followed a normal course presenting a critical stenosis at the origin of the posterior descending artery (Fig. ).\nHe underwent coronary artery bypass grafting. His heart was arrested employing intermittent anterior cold blood cardioplegia. The aortic cross clamping time was 57 minutes and extracorporeal circulation was 70 minutes. Intraoperatively the aberrant vessel from which the left anterior descending artery originated was easily found (Fig. ). The coronary revascularization consisted in left internal mammary artery anastomosed to the left anterior descending artery, and vein graft to the first diagonal artery, obtuse marginal artery and posterior descending artery (Fig. ). His postoperative course was uneventful. |
A healthy 7-year-old boy was referred from the dental emergency department to the pediatric dentistry department in the Dental School of Casablanca.\nClinical examination revealed that the child has a flexible splint on maxillary teeth and a coronal restoration with a glass ionomer on 11. Radiographic examination showed incomplete root formation of both central incisors (Nolla's stage 8: short root with thin walls) ().\nBased on the emergency file, it was found that the boy fell at school three weeks ago. Clinical examination revealed that 11 had a lateral luxation with an uncomplicated crown fracture and 21 had a subluxation. Emergency treatment was carried out on the same day and consisted of reattaching the tooth fragment, repositioning 11 with a gentle digital pressure, and stabilizing it with a flexible splint. One week after trauma, the patient presented with intraoral swelling on 11 revealing necrosis. Consequently, an endodontic treatment was performed and the root canal was instrumented using hand files with gentle irrigation using 0.5% sodium hypochlorite. Calcium hydroxide was placed as intracanal medication. The access cavity was sealed with glass ionomer cement.\nFor this purpose, the apexification technique using calcium hydroxide has been initiated on 11. The calcium hydroxide was renewed once resorbed. A regular clinical and radiological follow-up was carried out to check the vitality of 21 ().\n6 months after the beginning of the treatment of 11, a radiolucent lesion in the periapical region was detected on 21 (). The negative response to the cold test confirms a pulp necrosis. Considering the immaturity of the tooth and the thinness of the root and after obtaining parental consent, the optimal treatment option was revascularization.\nAn access cavity was made under a dental dam. Once the canal orifice was well cleared, gentle root canal irrigation was performed with 2% sodium hypochlorite followed by irrigation with saline solution. Subsequently, the root canal was dried with large paper points until they were removed without evidence of fluids and filled with calcium hydroxide used as intracanal medication. A temporary restoration using a glass ionomer was placed.\nThe patient was recalled 4 weeks after the first appointment. The tooth was clinically and radiologically asymptomatic. In the second session, the tooth was anaesthetized, accessed, and irrigated gently with 2% sodium hypochlorite followed by saline solution to remove calcium hydroxide. The bleeding was induced with manual K files introduced into the root canal and placed at 2 mm beyond the working length. Once the blood clot was formed, MTA was placed in the cervical third of the root canal (). The access cavity was sealed with a glass ionomer.\nThree months after performing revascularization treatment, visible root edification was observed (). The 6-month follow-up showed an important thickening of the root with calcification of the canal. Concerning 11, a renewal of the calcium hydroxide was carried out once the material has been absorbed ().\nAfter 24 months of apexification treatment on 11, we noticed the formation of an apical barrier which was easily crossable with a file (). To solve that problem, the apical third was sealed using MTA and then the coronal two-third with warm gutta-percha. Concerning 21, the canal was almost completely obliterated with an extension of the root (). |
A 47-year-old male presented following acute onset right upper limb weakness and expressive dysphasia. The past medical history included well controlled epilepsy and hypertension. There was no history of diabetes mellitus, hypertension or previous smoking. Urgent CT angiography of the head and neck demonstrated a distal left MCA embolic stroke. Transthoracic echocardiography demonstrated left ventricular dilatation with severe systolic dysfunction (left ventricular ejection fraction [LVEF] 25%). Mobile thrombus was noted at the apex of the left ventricle, measuring 14 × 12 mm (Fig. ). The aortic valve was bicuspid with moderate stenosis and mild valvular regurgitation. The ascending aorta was mildly dilated at less than 40 mm. Subsequent cerebral MR imaging confirmed a left frontal lobe cortical infarct with evidence of focal haemorrhagic transformation and evidence of previous infarction in the MCA territory. The patient was commenced on apixaban and therapy (Bisoprolol and Ramipril) for left ventricular systolic dysfunction. Subsequent angiography demonstrated a significant (80%) proximal LAD stenosis, proximal 90% stenosis of a small non dominant circumflex and 80% stenosis of a large ramus intermediate.\nGiven the mobile nature of the LV thrombus and the history of stroke, the patient underwent early surgery to reduce the risk of further embolic episodes. The patient proceeded to coronary artery bypass grafting, mechanical aortic valve replacement and resection of the left ventricular thrombus. A repeat CT head scan performed prior to surgery (12 days following the infarction), demonstrated the frontal lobe infarct with no evidence of further haemorrhagic transformation. Apixaban was discontinued and the patient commenced on intravenous heparin in preparation for surgery.\nThe patient underwent surgery via median sternotomy and the left internal mammary artery (LIMA) was harvested as an in-situ pedicle graft. The left radial was harvested as a free graft. Systemic heparinisation commenced and cardiopulmonary bypass was instituted with bi-caval and distal ascending aortic cannulation. The left ventricle was vented via the right superior pulmonary vein. The aorta was cross clamped and the heart arrested via anterograde and retrograde cold blood cardioplegia. This was repeated at regular intervals to provide myocardial protection.\nIntra operative transesophageal echocardiography confirmed a bicuspid aortic valve with moderate aortic stenosis, severe left ventricular dysfunction and apical left ventricular thrombus with a mobile component (Fig. ). The aorta was opened in a transverse fashion and the native aortic valve was excised and the annulus decalcified. A 5 mm zero degree Olympus® Videoscope was introduced into the left ventricle with excellent visibility of the left ventricular thrombus assisted by venting of the left ventricle (Fig. ). With visualisation of the apex under the 5 mm camera, the thrombi were removed using a single shaft grasper and rongeur (Fig. ). All fresh thrombi were removed, and a fine tipped suction catheter aided in removal of residual thrombus (Figs. and ). One component of the apical thrombus was firmly embedded within the trabeculae and was not removed as it was felt unlikely to pose an embolic threat (Fig. ). The left anterior descending artery was bypassed with the LIMA, and the radial artery conduit was used to bypass the ramus branch. The aortic valve was replaced with a 25 mm St Jude mechanical prosthesis and the aortotomy closed. The patient was weaned off cardiopulmonary bypass on first attempt with inotropic support. The patient was discharged day 7 with no complications and maintained on warfarin (target INR of 2 to 3). The LVEF on echocardiography was 45% on discharge.\nOn review six weeks following surgery there was no evidence of left ventricular thrombus. The aortic valve appeared well seated and there was mild paravalvular aortic regurgitation. There was no residual sequelae from his previous stroke. |
A 51-year-old woman presented to her general practitioner with a 2-week history of a painful left breast lump. She denied any history of trauma. Her past medical history included ischemic heart disease, myocardial infarction, type 2 diabetes, dyslipidemia, hypertension, anxiety, depression, and asthma. Examination demonstrated a firm 30-mm breast lesion at 10 o’clock position in her left breast, 7 cm from the nipple. No axillary lymphadenopathy was appreciated. She was subsequently referred to a general surgical outpatient clinic and underwent further investigations.\nMammography revealed a poorly circumscribed mass, measuring 40 × 24 mm, in the lateral aspect of the left breast at the level of the nipple. There were irregular and stranded contours without suspicious calcifications (). The right breast appeared normal. Ultrasound (US) revealed a lobulated, heterogeneous, hypoechoic mass lesion at the region of palpable abnormality (). The mass measured 31 × 17 × 21 mm with accompanying distortion of the surrounding structures in combination with edema and skin thickening. Given the nature of these imaging findings, the lesion was considered suspicious for malignancy.\nFive days following mammogram and US the patient represented to her general practitioner with increasing left breast erythema and swelling. Pus had also begun to be discharged from the upper inner quadrant of the left breast. She was commenced on oral clindamycin for cellulitis and was referred for a US-guided biopsy. US revealed that the lesion had significantly increased in size with marked skin thickening and erythema. This was thought to represent an inflammatory lesion; however concerns remained that this may have occurred secondary to an underlying malignancy. Aspiration of the main lesion was attempted under US guidance with a 19-G needle; however, the highly viscous nature of the pus precluded aspiration. The patient was advised to continue taking oral antibiotics.\nThe patient presented to the emergency department a few days later with ongoing discharge from her left breast. Examination revealed an open wound in the left breast with a hard, non-mobile, tender lesion palpable underneath. The wound contained central necrosis with surrounding purulent discharge and accompanying erythema extending to the nipple. Peau d’orange changes were also present (). The patient was noted to be hemodynamically stable. Her white cell count was elevated at 13.0 × 109/L and her C-reactive protein was 123 mg/L. Her blood sugar level on presentation was elevated to 25.2 mmol/L.\nA repeat US was conducted with no drainable collection noted. The underlying mass at the 10 o’clock position with edematous changes in the surrounding subcutaneous tissue was again noted. The patient was admitted under the general surgical team and commenced on intravenous trimethoprim and sulphamethoxazole.\nA magnetic resonance imaging (MRI) was performed to aid in operative planning. The MRI revealed no evidence of malignancy or adenopathy in the right breast. The left breast contained a large collection, measuring100 × 40 × 60 mm. The MRI features were in keeping with a large abscess with accompanying feature of skin breakdown and necrosis. There was extensive inflammation and engorgement of feeding vessels with no suspicion of underlying malignancy ().\nThe patient underwent an emergency radical excision and debridement of the necrotic tissue. The necrosis extended down to the level of pectoralis fascia. Once adequately debrided, the wound was extensively irrigated with normal saline. A vacuum-assisted closure (VAC) device was placed over the wound to aid with healing. The patient was commenced on intravenous (IV) lincomycin with recurrent wound checks at VAC changes performed. There was no further necrotic tissue identified and the patient was discharged home on day 5 with planned follow-up through the general surgical outpatient clinic. shows wound healing 2 weeks post operation.\nA tissue sample was sent to microbiology and was positive for Staphylococcus aureus and Streptococcus agalactiae. Histological examination revealed the presence of an abscess with acute suppurative inflammation and ulceration of the overlying skin. Accompanying fat necrosis was also noted. There was, however, no evidence of dysplasia or malignancy.\nA follow-up mammogram was conducted 6 months post debridement and the appearance was in keeping with nearly complete resolution of the previously visualized opacity (). |
A 51-year-old man presented to our institute with an enlarging, painless, nodular mass in the right upper lid that began 4 months prior with rapid increase in size over the last 3 months. The mass became significantly prominent over the last month prior to presentation resulting in discomfort, ulceration, and bleeding on manipulation. Physical examination revealed a solitary mass in the middle third of the right upper eyelid, overhanging the lid margin that was 9 mm × 12 mm in size, pinkish, firm, fleshy with small-dilated blood vessels on the surface with central ulceration and crusting []. The mass was underlying the right upper lid skin extending beyond the lash line without invading the palpebral conjunctiva. It was firm to hard in consistency and tender to the touch and did not appear to extend to the deeper underlying tissues. There was no regional aurical, cervical, or submandibular lymphadenopathy. The remainder of the ocular and general physical examination including examinations of the liver and lungs was normal. Basal cell carcinoma or squamous cell carcinoma was suspected on the basis of the clinical examination. A biopsy was sent to the pathology service.\nA complete, wide excision of the nodular mass with a 3 mm clear margin of healthy surrounding tissue was performed along with primary closure []. The pathology service identified malignant nodular hidradenoma, a rare eccrine sweat gland tumor (described below). At the last visit, 6 months after excision, there was no recurrence of the lesion. The patient was subsequently lost to follow up.\nThe specimen submitted to the pathology department comprised of a nodular mass 1.5 cm in diameter. The cut surface was yellowish with few cavities.\nHistopathologic examination revealed a tumor in the dermis with surrounding fibrous capsule. Two types of tumor cells were noted with predominance of one cell-type which was polyhedral to round in configuration with round to oval nuclei and prominent nucleoli surrounded by faintly basophilic cytoplasm. The second cell-type was clear, round to oval with eccentric nucleus. The tumor cells were arranged in lobules and separated by delicate fibrous collagenous tissue []. The lobules were lined by cuboidal or columnar cells with few cystic spaces, brisk mitotic figures with surface ulceration, and infiltrating margins. No areas of necrosis were noticed. The tumor cells exhibited an intracytoplasmic substance that stained positively with periodic acid-Schiff stain and were diastase-sensitive. There was positive immunohistochemical reactivity to epithelial membrane antigen. A diagnosis of malignant nodular hidradenoma was performed on the basis of the histopathologic and immunohistochemical studies []. |
A 68-year-old female patient was hospitalized with the main complaint of spinal pain that had lasted for one month. The patient had undergone a rectal cancer operation two years earlier and, later on started undergoing anticancer treatment continuously. However, metastasis in the lungs was found one year earlier. Lumbar MRI (magnetic resonance imaging) taken at the time of hospitalization showed evidence of metastatic cancer at the T9-L1 vertebral body, but the patient was transported to our department for pain management as the cancer was judged to be inoperable. The patient complained of 'collapsing' spinal pain on a VAS (visual analogue scale) 9 during an examination. The pain was tenderness from T9 to L1 along the mid-line. The pain became more severe when she changed position, stood up, or sat down, whereas it lessened in its severity to VAS 4 when she assumed a supine position. In a neurologic examination, the result of the straight leg raise test was normal, the deep tendon reflex was also normal, and no weakened muscle strength or hypoesthesia was found. The patient was not able to take oral analgesics due to nausea and vomiting. Although 25 µg/hr through a fentanyl patch was administered, pain relief was incomplete. When the patient complained of breakthrough pain, an intravenous injection of 30 mg of ketorolac or 25 mg of pethidine was carried out four or more times per day. This reduced the pain to VAS 2 for only one hour, marking the effective duration of the analgesic.\nAn explanation of the diagnostic epidural block was given to the patient and a dorsal spine epidural block was performed after obtaining her consent to the operation. With the patient in the prone position, the T9/10 interspace was checked under C-arm guidance and the puncture point was marked at the center line. After the skin around the puncture point was disinfected with a betadine solution, we carried out local anesthesia with 1% mepivacaine 3 ml and used an 18-gauge Tuohy needle to make the initial puncture. Applying the loss of resistance technique via imaging and normal saline, the epidural space was verified. After checking that there was no regurgitation of cerebrospinal fluid or blood, 5 ml of contrast media was injected. Images were taken after verifying that the contrast media had not been injected into a blood vessel or the subarachnoid space through an anteroposterior view and an oblique view, and a mixture of 0.125% bupivacaine 6 ml and triamcinolone 20 mg was then injected. The patient's pain score did not change immediately after the drug injection, but after 30 minutes, the pain was reduced to VAS 2. The vital signs of the patient were continuously measured and no variation from the normal state was noted. Her consciousness was also normal. There was no abnormal finding, such as dizziness or respiratory distress. After one and half hour of hypoesthesia, the patient was recovered from sensory block and moved to the ward.\nAlthough the pain score was reduced for a while, we reviewed the developed X-ray film in an effort to determine why the nerve block effect was so late in working and whether the blocked neuromeres were irregular. We found that the contrast media had collected at the central part of the spinal canal in an irregular pattern, as shown in the anteroposterior view (), and that it had not spread into the nerve root. An oblique view () showed that the contrast media was collected in a bulging pattern at the rear side of the intrathecal space, which indicated that the injection was not a subarachnoid injection and that it differed from a common epidurogram result.\nSubsequent pain control in the ward was carried out using a substitutive fentanyl patch (50 µg/hr) every third day and oral administration of the short-acting analgesic IR-codon at 5 mg a day. The patient stopped complaining of severe pain (VAS 2-3), and a continuous epidural block was therefore not utilized. In a follow-up after about 4 months, the pain was reported to be well controlled without an increase in the use of analgesics or specific complications. |
A 58-year-old female with a past medical history of atrial fibrillation refractory to two previous ablations not on anticoagulation therapy due to upper gastrointestinal bleeding, severe aortic stenosis, breast cancer with bilateral mastectomy, obesity, cirrhosis, esophageal varices with history of bleeding and end stage renal disease on hemodialysis presented to the Emergency Department for progressive dyspnea and decreased exercise tolerance over the course of several months. Given her history of aortic stenosis, transthoracic echocardiography was performed to evaluate severity of aortic stenosis as contributor to her progressive symptoms. Transthoracic echocardiography revealed mild to moderate right ventricular systolic dysfunction with normal left ventricular systolic function and small left ventricular volume, as well as mild mitral stenosis, severe aortic stenosis. In light of the echocardiogram findings, patient underwent an elective right and left cardiac catheterization via the right femoral artery to further define coronary anatomy and measure right heart and pulmonary artery pressures. After completion of the procedure, Angio-Seal was deployed to close the femoral arterial access site and manual hand pressure was placed over the access site for several minutes. Within minutes thereafter, the patient reported 10/10 throbbing pain of the right leg distal to the knee, associated with paresthesia to the lower limb. Physical examination revealed edematous right leg and foot and absent right dorsalis pedis and right popliteal pulses that were neither palpable nor identifiable via doppler ultrasound. Interventional Radiology and vascular surgery were urgently consulted given concern for acute lower limb ischemia. Right lower extremity angiogram was performed immediately, with images as below in . Angiography demonstrated complete occlusion of the common femoral artery with the Angio-Seal device in the sub-intimal plane of common femoral artery (CFA) dissecting the calcific atheromatous plaque from the CFA and resulting in CFA thrombosis. Vascular surgery performed right groin exploration with right femoral artery cutdown, extraction of the Angio-Seal device, atherectomy, endarterectomy with patch angioplasty. Repeat right lower extremity angiography demonstrated restoration of blood flow to the right leg and foot. On physical exam however, dorsalis pedis pulses remained nonpalpable, but were detectable with doppler studies. Tissue plasminogen activator (tPA) and nitroglycerin were infused into the distal popliteal artery in efforts to maximize distal perfusion, and within 24 hours, pain had completely resolved, dorsalis pedis and popliteal pulses were palpable on physical exam, and no sensory or motor deficits were sustained. Patient was subsequently discharged without further event. |
A 63-year-old male patient presented to the clinic with the complaint of movement in a maxillary anterior prosthesis that had been placed five years ago. Clinical and radiographic examinations revealed that his maxillary right lateral incisor, used as the abutment tooth for a three-unit fixed dental prosthesis, had a secondary caries with inadequate structural support, causing bucco-lingual movement of the prosthesis. A noteworthy finding in this prosthesis was a maxillary right central incisor root remnant, which had been covered by soft tissue and remained for five years underneath the pontic site (). The radiographic and clinical evaluation showed no inflammation, dehiscence, external root resorption, or any known pathologies, and the arch form was maintained without any sign of ridge deformation. It was evident that a submerged root of the maxillary right central incisor had prevented bone resorption, especially in the interproximal area. Due to the severe secondary caries, the prognosis for the maxillary right lateral incisor was poor: it was thus submerged as a root remnant at the pontic site. The tooth was endodontically treated due to the periapical lesion, then decoronated at a crestal bone level similar to that of the maxillary right central incisor. No surgical intervention was performed, and an interim fixed dental prosthesis supported by the maxillary right canine and maxillary left central incisor was fabricated, relieving pressure on the soft tissue under the pontic sites. After a three-month healing period, the root was completely covered by soft tissue, and the periapical lesion was disappeared (). No noticeable changes were observed in the alveolar ridge of the pontic site either vertically or horizontally. Upon completion of the healing process, a metal ceramic fixed dental prosthesis was fabricated and cemented with a resin-modified glass-ionomer cement. Since the submerged roots preserved the bone and soft tissue, the gingival contour of the pontic site was in harmony with the gingival margins of the adjacent abutment teeth. At a two-year follow-up visit, the bone level at the submerged root site was stable, and the gingival contour under the pontic site was maintained (, ). The patient was satisfied with the outcome of the prosthetic rehabilitation. |
A 17 year old male student was referred to the Federal Medical Centre Yola by his school teacher and stepfather because of breast enlargement and periodic perineum bleeding associated with school absence. The Teacher confirmed the story and noticed that the student had been walking with a stoop in an effort to hide the enlarged breasts.\nThe patient first noticed the breasts enlargement at the age of 13 and a year later started to have a monthly vaginal bleeding for 4–6 days. The patient was given a female name at birth, however at the age of two years the family thought that the child had good sized “phallus”. The child was taken to a local hospital where the family was told that the gender cannot be assigned until the child is older and therefore he was given a male name and kept company with the same gender. With development of female secondary sexual characteristics around the time of puberty, the parents were convinced that the child had been assigned the wrong gender and therefore they sought medical advice. On examination the patient was depressed and dressed in male attire but had female fat distribution. The growth parameters were normal with height of 163 cm and weight of 58kg. Pubertal assessment showed breast development & pubic hair tanner stage IV. Genital examination revealed a phallus of 6cm with redundant labia majora. The labia minora was almost fused in the midline, partially occluding the vaginal opening. There was also a reducible right inguinal hernia. Rectal examination indicated the presence of a uterus. Further investigations revealed normal electrolytes and total testosterone. There were no facilities to do 17 hydroxyprogestrone (17 OH-P), cortisol, ACTH or chromosomal karyotype however buccal smear was positive for Barr body indicating the presence of two X chromosome. Abdominal ultrasound scan showed normal looking uterus. Both ovaries were visualized and appeared normal with no mass in the suprarenal area. A laparoscopy confirmed the presence of female internal genitalia with normal looking ovaries. A clinical diagnosis of simple virilizing congenital adrenal hyperplasia (CAH) was made and the patient and her family were counseled for gender reassignment. She had clitorovaginoplasty and right inguinal herniorrhaphy as single stage and histopathology confirmed normal corporal tissue. Admission to the gynaecology ward was associated with dramatic psychological outburst but as time went by she gradually acclimatized to the new environment. The patient had accepted the gender reassignment after a series of counseling sessions by the local Imam, parents, teachers, nurses and doctors who individually and collectively helped her through this difficult part of her life.\nThis case illustrated the medical and social consequences of delaying the gender assignment of a child with ambiguous genitalia. In retrospect, this stress would have been minimized if the child was referred at an early stage to a pediatric unit with experience in dealing with this emergency. During the management of this case we were faced with two main issues: firstly making the diagnosis with limited resources and secondly dealing with the psychosocial consequences of gender reassignment at this age. As in most developing countries, no adequate psychology service was available to help in the counseling process; however the combined efforts of the local religious leader (Imam), senior members of the community, nurses and doctors were successful. The fact that the parents were convinced before seeking medical advice that the child was actually a female made our task rather easier.\nThe other challenge of this case was working out the diagnosis. Although making a definite diagnosis in such cases can be difficult without proper diagnostic facilities such as chromosomal karyotyping, 17 OH-P, cortisol, ACTH and urine steroid profile which were not available even at the regional teaching hospital, we utilized our clinical skills and the available facilities to reach a logical conclusion. The history of female gender assignment at birth and the development of female secondary sexual characteristic at the expected time with menarche at 14 years old indicated that we are dealing with a virilized female. This also suggests that the hypothalamic pituitary ovarian axis is intact and that the outflow tract is patent. The combination of normal female internal genitalia, Clitoromegally in a person with 2 X chromosomes, as indicated by positive barr body on buccal smear, and normal electrolytes were in keeping with simple virilizing ( none salt wasting) type of CAH. The total testosterone level was within the normal female range, however neither free testosterone nor dihydrotestosterone which acts on the external genitalia were available. Although patients with Turner's mosaic 45XO/46XX or mixed gonadal dysgenesis may have presence of Barr bodies, the clinical phenotype, Clitoromegally, normal sized uterus and ovaries and regular period can not be explained by either [, ]. The development of menarche has ruled out the possibility of androgen insensitivity syndrome (46XY). The fact that the Clitoromegally was observed at 2 years of age and persisted until puberty suggested that maternal androgen ingestion during pregnancy was an unlikely possibility in this case.\nTo reassign a sex for a 17year old who had been raised with the “dominant” gender one has to be unequivocal regarding the potentials for fertility and capacity for normal sexual function []. Although the size of the phallus was 6cm, the capacity for fertility without a penile urethra is remote. For an adolescent, the surgical management was aimed at achieving near normal cosmetic and function. Historically, clitoral reconstruction has evolved from clitoridectomy, through clitoral recession and now clitoral reduction. The disadvantages of clitoridectomy and clitoral recession are the loss of sensation, anorgasmia and pain following clitoral engorgement at time of sexual arousal respectively [, ] Clitoroplasty with preservation of the neuromuscular bundle the Spence-Allen technique obviates both of these risks and was the procedure performed on this patient.\nIn conclusion we reported on our experience in dealing with a case of medical, social and ethical dilemma particularly in places with limited facilities. Although our task would have been easier if the patient was younger and resources were available we showed that clinical skills together with combined efforts of various parties can be useful in places like ours. We suspect that some of our colleagues, in developing countries, had similar experience and hope that health care policy makers’ pay more attention to this sensitive area. |
A 25-month-old boy was observed during a general pediatric visit, following parental concern over speech delay, feeding, and sleep disorders. He was a first child without special neonatal history, looked after by his mother at home with scarce outdoors activities (the pregnancy of a second child occurred when he was only 9 months old and the mother felt too tired to go outside). Parents reported typical “infantile anorexia” with a child who refused to eat adequate amount of food for more than 6 months and who lacked interest in food and showed strong interest in exploration instead. The sleep schedule was erratic with very late sleep onset and many wakes during the night. Neurological examination was normal, except for the items of language and more largely social behavior. He presented as sad and restless, and during all adult initiated interactions, it was difficult to meet his gaze and he had no joint attention. He neither sought after nor desired adult interactions, but there was a small observable improvement in his responsivity toward the end of the session, probably due to the close attention paid to him. Following discussion with his father, it was noted that he did not engage in structured play, but preferred to “tinker repeatedly with locks,” suggesting stereotypical repetitive activity. Formal language testing was not possible as he did not use any verbal language although his parents stated that he would say a few isolated words at home “water,” when he was thirsty, or “not that.” Parents commented that he always held a hard object and used to turn the wheels of little cars close to his eyes. Although there was no evident stereotyped behavior during examination, parents commented that he sometimes bit himself when he was overexcited. During the consultation, when asked to draw, he evidently found the close proximity of adults challenging and started to draw on the table and then on books but not on the paper presented to him. He did not respond to “don’ts” but did respond to regular “increase” in volume of voice to “no.” He stopped, suspended his movement, and appeared to be thinking, which suggested an ability to hear and to be considering those around him.\nHe received normal results in the audiogram performed a few days later. Parents were asked to complete the Ages and Stages Questionnaire, Third Edition (ASQ-3). The ASQ-3 is a widely used, parent-reported screening measure. The ASQ-3 identifies developmental progress in 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. The questionnaire includes 30 items scored as yes, sometimes, or not yet on questions asking about a child’s ability to perform a task. All ASQ-3 results of the child except gross motor measure were below the cutoff score expected for the age.\nBecause of the boy’s autism-like symptoms, a diagnostic assessment tool was asked to an experienced child psychiatrist. The Childhood Autism Rating Scale (CARS) is a 15-item behavioral rating scale and each item covers a particular characteristic and behavior, with a first edition validated in French. Scores of less than 29, between 30 and 36, and above 36 on the CARS are considered indicative of normal, mild to moderate autism, and severe autism, respectively. In this first examination, the CARS gave a score of 36, which placed this boy in the “mild to moderate autism” category. None of the 15 items were normal; poor results were obtained in all the social categories (social relations, imitation, emotional responses, language) and in “level of activity.” A family screen time questionnaire revealed that he had been exposed to background all the day long, as well as foreground television (he watched the TV News with his father after work) since his first 6 months and that he was habitually watching YouTube Kid alone on the parents’ smartphone for 3 hours a day, especially during mealtime (as he was suffered of feeding disorders). On the family’s screen questionnaire, his mother reported using her mobile phone herself for more than 3 hours a day while his father reported essentially watching the TV.\nSubsequently, his parents were asked to completely stop any and all screen and media exposure for all the family (the sister is 6 months old). Written pieces of advices were provided to the father by the pediatrician to increase outdoors activities, play with traditional toys (as balloons or truck), and foster social interaction with same-age peers. A regular schedule for meals and sleep times was also recommended. Two and a half months later, the parents reported to the pediatrician that, as asked, they have stopped giving their smartphone and that the television was now only switched on when their son was asleep. Sleep quantity and quality have improved. At the examination, the boy was more stable, less agitated, and was now able to remain focused on his activities for a longer period of time. His language was observed to be somewhat jargonized, but with intentional prosody, and in which it was now possible to recognize words and groups of words. His play activities had become more varied. During this interview, he spoke to the adult and pointed his finger at the waiting room searching for a joint attention, in an attempt to tell a story in which the words “balloon” and “truck” appeared. In explanation, his father stated that that they had left a balloon and a truck in the waiting room. The boy’s language seemed to fulfill its communicative function. Complex instructions given by his father were well understood and executed. When he was asked to build a tower of 6 cubes, the boy obeyed, displayed observable signs of pleasure, and made the activity last, indicating an increased interest in toys. He made seemingly easy and often sustained eye contact with those around him and was positively responsive to smiles. The CARS assessed by the same child psychiatrist gave him a new score of 21, which placed him in the “non-autistic” category. Some items were categorized as close to or completely normal (body use, nonverbal communication, and level of activity), and the overarching impression was one of a non-autistic child. On the other hand, his language remained abnormal. Pieces of advice were repeated to parents to support the progress, and 6 months later, the child was integrated thanks to the intervention of the pediatrician in a public day care center.\nA new ASQ score is assessed at the age of 3 years: the communication, problem solving, and personal-social scores are normal. Only the fine motor measure is still under the cutoff score expected for the age. Screen time is now limited to 20 minutes a day. |
A 43-year-old Asian man presented to the emergency department in our institution due to generalized weakness in April 2018. One month prior to admission, his family noted that he showed poor oral intake and consistently complained of epigastric discomfort. He was diagnosed as having impaired fasting glucose and hyperlipidemia at the age of 42 on routine medical checkup. Eight months ago, he underwent total thyroidectomy with both central and sentinel lymph node dissection due to papillary thyroid carcinoma and the pathologic stage was diagnosed as T3N1bM0 on the permanent pathologic report. After that, the first radioactive iodine (RAI) therapy was conducted and an iodine [–] whole body scan was planned to determine whether to perform the second RAI that was on the next day of visiting the emergency room, therefore, he had to stop the thyroid medication for 3 weeks to prepare for the examination.\nAt the time of admission to the emergency room, he was noted to be somnolent and had a decreased level of consciousness. He opened eyes to pain, showed inappropriate verbal response and flexion withdrawal from pain, which suggested that Glasgow Coma Scale (GCS) was 10 out of 15. On physical examination, there was no pretibial edema and his pupils were equal in size and normally reactive to light. His abdomen was slightly distended with decreased bowel sound and his extremities were cold. His blood pressure was 127/96 mmHg, heart rate was 101 beats per a minute, and respiratory rate was 25 breaths per a minute with oxygen saturation 97% on room air. He was in a hypothermic state and his tympanic temperature was approximately 34.0 °C. Chest radiography revealed the findings of gastroparesis and paralytic ileus as presented in Fig. . An electrocardiogram at presentation showed sinus tachycardia with QT prolongation by 537 ms of corrected QT interval (Fig. ).\nArterial blood gas analysis revealed a state of metabolic acidosis: a pH of 7.00, partial pressure of carbon dioxide in arterial blood (PaCO2) of less than 10 mmHg, bicarbonate (HCO3) of less than 10 mmol/L, and base excess of − 34.6. Laboratory findings suggested hyperglycemia with glycosuria and ketoacidosis, which are presented in Table . Considering the history of total thyroidectomy and planned schedule for RAI, a thyroid function test (TFT) was conducted and revealed severe hypothyroidism. He was found to have a thyroid-stimulating hormone (TSH) of 34.126 uIU/mL (0.55–4.78 uIU/mL) and free thyroxine (T4) of less than 0.01 ng/dL (0.82–1.76 ng/dL) and triiodothyronine (T3) of less than 0.01 ng/mL (0.6–1.81 ng/mL). Even though he did not have any history of diabetes mellitus, we checked his glycated hemoglobin (HbA1c) due to hyperglycemia. Finally, the value of HbA1c was 16.5% which met the criteria for a diagnosis of diabetes.\nHe was admitted to the intensive care unit (ICU) for the management of DKA and myxedema coma. He received intravenously administered fluid with electrolytes and an immediately applied insulin pump. For hormonal replacement, liothyronine 5 mcg two times per day and levothyroxine 175 mcg once daily were administered via a nasogastric tube. He instantly responded to the therapy with a favorable clinical improvement. His mental status started to improve several hours after treatment and at the third day of hospitalization he showed a GCS of 15/15; his body temperature increased from 34 °C to 36.5 °C approximately 10 hours after admission. The metabolic acidosis was corrected 6 hours after administration of intravenously administered fluid with insulin pump and hyperglycemia was also improved; the insulin pump was discontinued then and switched to subcutaneous insulin 1 day after hospitalization. Repeated TFT before discharge revealed TSH of 21.798 uIU/mL (0.55–4.78 uIU/mL), free T4 of 1.02 ng/dL (0.82–1.76 ng/dL), and T3 of 1.04 ng/dL (0.6–1.81 ng/mL). The clinical course of this patient was summarized in Table . During the hospitalization, a workup for diabetes mellitus was performed and there was no evidence of pancreas mass or pancreatitis on abdominal computed tomography (Fig. ). Results from investigations for diabetes mellitus showed a fasting c-peptide of 1.08 ng/mL (0.48–3.30 ng/mL), anti-islet cell antibodies (ab) negative, and glutamic acid decarboxylase (GAD) ab of 0.01 U/ml which suggested that a diagnosis of type 2 diabetes mellitus would be appropriate.\nHe was discharged from surgical ICU after 2 days, stayed for a further 8 days on the general ward and was discharged on the 11th hospital day with tolerable status. The dose of thyroid hormone medications was subsequently reduced at our out-patient clinic after he was discharged and an endocrinologist recommend insulin with orally administered hypoglycemic agents. |
A 28-year old male, presented with chest pain and mild dyspnea, of 20 days duration. He was a farmer and nonsmoker with no history of exposure to any occupational or inorganic dusts. The chest pain was retrosternal and pricking in character with no radiation and not related to the meals. Examination revealed averagely built person and no clubbing and lymphadenopathy. Respiratory system evaluation revealed signs of mass in the left hemithorax. Chest radiograph revealed a large mass near the left hilum []. Routine blood investigations were within normal limits. Computed tomography (CT) of the thorax revealed a large well defined, nonhomogeneous mediastinal mass, in the left hemithorax near the hilum. The mass was extending up to the pleural surface []. There was an involvement of the mediastinal lymph nodes. Fiberoptic bronchoscopy revealed extrinsic compression of left upper lobe bronchus with no intra bronchial extension. Bronchial washings, bronchial brush biopsy, and transbronchial needle aspiration biopsy of the mass ware inconclusive. Transthoracic fine needle aspiration biopsy of the mass revealed small round tumor cells with thin strands of fibrous connective tissue. As the diagnosis was inconclusive, the patient was taken up for thoracotomy with excision of the tumor. Intraoperatively it was observed that there was a large mass in the mediastinum with invasion of the great vessels and the mediastinal lymph nodes. Hence, tumor debulking was done to the extent possible. Complete excision of the tumor could not be done as it was infiltrating the great vessels and the pericardium. The tumor had extended up to the chest wall. Histologically, the specimen revealed round to oval tumor cells with scanty cytoplasm and hyper chromatic nuclei. These neoplastic cells also showed rosette formation []. Immunohistochemistry of the specimen proved the diagnosis of PNET with positivity of the synaptophysins and chromogramin. As the diagnosis of primitive neuroectodermal tumor was established, and wide surgical excision of the tumor was already been done, the patient was referred for radiotherapy and chemotherapy. The patient received radiotherapy with 4,000 Rads and chemotherapy with cisplatinum, bleomycin, and doxorubicin. The patient continued to be symptomatic, and his condition worsened over a period of next three months and he died subsequently four months after the diagnosis. |
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