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A 50-year-old caucasian woman was referred to our clinic with a 12 months history of severe, recurrent pain episodes in her right knee. She was a non-smoker, with no other notable family or medical history for any pathological condition. Systemic diseases such as gout, systemic sclerosis, dermatomyositis, and sarcoidosis or any metabolic or endocrine disorders such as hyperparathyroidism and renal failure were excluded. There were no past trauma incidents. Her orthopedic surgeon had diagnosed a calcifying lesion of the MCL 9 months prior to admission to our hospital and had treated her conservatively under the assumption of a calcifying tendinitis-like pathological condition. After some temporary pain relief she still suffered from pain at the medial side of the knee and limited range of motion. The conservative management included analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), electro-therapy and shock wave therapy.\nPhysical examination of the right knee revealed local pain and swelling over the medial femoral condyle with intact soft tissues and no joint effusion. The patient was able to fully extend her knee but flexion was limited to 120° with increasing pain at the MCL beginning with 90° flexion. Patellar mobility was not limited. There was no ligament laxity and clinical tests for detection of meniscus lesions were all negative. There was no sensorimotor deficit. Blood tests showed no evidence of haematological or metabolic abnormality. Knee x-rays revealed linear soft tissue opacity medial to the femoral condyle, suggesting a lobate calcifying lesion within the proximal and middle section of the MCL and surrounding tissue. Antero-posterior, lateral and merchant’s views verified the presence of the calcified lesion. MRI without contrast agent of the knee confirmed the presence of this lobate structure, which was characterized by an hypointense signal on the T2 weighted images, located in direct vicinity of the intact MCL in the coronal and sagittal plane, with direct contact to the ligament structure, which was seen in the sagittal and axial plane images of the knee. There were no signs for a mature bony lesion (Figs. and ).\nDue to failure of conservative treatment regimes, we recommended surgery and performed an arthroscopy followed by an open procedure with removal of the calcified lesion. Intraoperatively, we found areas of chondromalacia grade 2 of the patellofemoral compartment and the medial femur condyle. The calcification body was directly attached to the MCL, which was structurally intact. Its consistency was toothpaste-like analogous to the macroscopic appearance of a calcifying tendinitis of the shoulder. The directly adhering parts of the soft tissues were also removed.\nThere were no complications during the postoperative course. Weight bearing started with 20 kg and increased to full weight bearing over 2 weeks, which was well tolerated.\nAfter wound healing and recovery of the soft tissues, the patient was pain-free after 4 weeks. Clinical examination and radiographic evaluation in the next 12 months demonstrated no signs of recurrence without any clinical symptoms (Fig. ).\nDuring these follow up examinations, the patient described recurrent symptoms of pain and restricted movement of the right shoulder, which had persisted previously for over a year. She had suffered from calcifying tendinitis in both of her shoulder joints 17 years ago. Back then, the x-ray pictures had shown calcification bodies near to the greater tubercle at the insertion of the supraspinatus tendon. These lesions had been treated successfully using shockwaves at that time, and had not re-appeared since.\nA current MRI survey demonstrated a rupture of the supraspinatus tendon. The patient successfully underwent a shoulder arthroscopy with a rotator cuff repair in our department. Surgery revealed signs of degenerative changes of the tendon, which had led to the rupture, but no evidence for residual calcium deposits within the supraspinatus tendon were found (Table ). |
A 17-year-old Iraqi male presented to the emergency department with a 2 day history of right iliac fossa pain, vomiting and a few episodes of diarrhoea. A clinical diagnosis of appendicitis was made and he was treated with intravenous antibiotics and underwent an appendicectomy, the histology of which was normal. At the time of the operation, the surgeon noted the right colon appeared to be inflamed. The patient had no prior medical history and his family history was nil of note.\nA computed tomography (CT) scan was performed postoperatively which showed thickening of the ascending colon with some submucosal oedema in the caecum with associated local regional lymph nodes. However the patient’s condition improved enough to be sent home the day after his operation.\nTwo days later he returned to hospital with bloody diarrhoea up to ten times a day, with associated fever and a tender abdomen. Baseline admission investigations are shown in Table . Initial stool cultures were negative including for Escherichia coli 0157 (E. coli), and the patient was started on intravenous cefuroxime and metronidazole. An abdominal radiograph did not reveal colonic dilatation. A colonoscopy was performed which showed patchy pan-colitis, maximal in the ascending and descending colon.\nGiven the age of the patient and location of his symptoms, plus the initial findings on the CT scan, a diagnosis of inflammatory bowel disease was considered. The other main differential was an infective colitis caused by Campylobacter, Shigella, E. coli or Clostridium difficile. Tuberculosis (TB) was another possibility and although the patient was originally from Iraq there was no recent history of foreign travel or relevant contact history of TB exposure. The appearances at colonoscopy were most suggestive of Crohn’s disease so the patient was commenced on intravenous hydrocortisone. Colonic biopsies were taken with the histology results shown in Fig. .\nDespite 24 h of steroid therapy, the patient still had on-going bloody diarrhoea although his pain had now settled. His renal function had declined from a normal baseline to a serum urea of 11.3 mmol/L and a serum creatinine of 170 μmol/L, and despite being adequately hydrated with intravenous fluids he became anuric. He was also noted to be thrombocytopenic with a platelet count of 81. Additionally, the patient became anaemic and his blood film showed Red cell fragments: 10 fragments per × 40 objective field, indicating haemolysis. Clinically the patient became disorientated and agitated and he rapidly deteriorated developing partial-complex seizures. This rapid deterioration required intubation and he was promptly admitted to the intensive care unit (ITU). A diagnosis of typical Haemolytic Uraemic Syndrome (HUS) was made following the history of gastrointestinal illness coupled with an acute kidney injury and thrombocytopenia. His levels of ADAMTS13 were normal, making a diagnosis of Thrombotic Thrombocytopenic Purpura (TTP) less likely. The patient received haemofiltration and plasma exchange with fresh frozen plasma but showed little signs of improvement so after 10 days he was commenced on Eculizumab a monoclonal antibody. He remained on the ITU for a further 35 days and spent a further 28 days on renal high-dependency unit during which time he gradually improved. He remained seizure free with normalisation of his platelets and biochemical profile and was discharged well from hospital. |
A 38-year-old female patient was diagnosed with a multifocal hepatocellular carcinoma in July 2000. Hemihepatectomy of the right lobe, resection of segment I and cryosurgery of a satellite lesion in segment II were performed one month later. Because of recurrence of the tumor, a wedge resection of segment III/IV followed in February 2001. Concurrently, an Arrow pump system was implanted in a subcutaneous pocket on the lower right side of the abdomen. The catheter tip was placed at the origin of the gastroduodenal artery. From May 2001 to September 2001 she received HAC with 5 cycles of FUDR in a total dose of 600 mg to slow down tumor growth until orthotopic liver transplantation could be performed. In October 2001 the treatment had to be discontinued because of biliary toxicity with elevated liver enzymes and bilirubin. Five months later she had progressive disease and HAC was started again. Because of the previous toxicity, FUDR was administered in reduced dose. After completion of the fourth cycle, she presented to our emergency room with jaundice, fever and epigastric pain in June 2002. She was hospitalized and antibiotic treatment with ciprofloxacin was started. After isolation of Klebsiella pneumoniae from the blood culture, antibiotic treatment was changed to piperacillin and tazobactam. Percutaneous transhepatic cholangiography showed multiple liver abscesses. A few days later the patient developed severe hematemesis and melena necessitating blood transfusions. Gastroscopy showed blood remnants without any lesions of the gastrointestinal mucosa and hemobilia was seen in a repeated cholangiogram. Finally, computed tomography revealed a pseudoaneurysm of a segmental left hepatic artery, about 5 cm from the site of the catheter tip close to the hepato-enteric anastomosis (Figure ). The development of a hepatic artery-biliary fistula was assumed to be the cause of the gastrointestinal bleeding.\nAngiography was performed via a transfemoral access, and after placement of a 4 French catheter in the segmental artery the aneurysm was occluded by coil embolization (Figures , ). A few days later, the fever and jaundice resolved completely. The arrow pump was removed and no further chemotherapy was applied. The patient recovered uneventfully. |
A 37-year-old Syrian woman came to our clinic complaining of four large masses in the leg, thigh, neck, and abdomen. The complaint started 30 months ago as a small hard mass in the upper of the right thigh. The patient underwent a complete resection of the mass. Histological examination showed that it was a liposarcoma. Six months later, other four masses appeared in abdomen, neck, thigh, and leg. The masses showed rapid growth. During the last twenty-four months, the patient was neglected because of the crisis that affected every part of Syria. She was not followed up by regular imaging. Even after the masses were visible and large, she did not receive any therapy until she got presented to our clinic. Her family history was remarkable. Her brother and sister had lipomas. However, genetic studies were not performed because they are expensive and not available in our country. Furthermore, her drug and psychosocial history was passive.\nClinical examination revealed that the masses were hard, fixed and large (). Full blood count and biochemical investigations were within the normal range. Computed tomography (CT) showed masses in the abdomen, a large subcutaneous mass and a retroperitoneal mass, the pelvis, the neck and the thigh. The left cervical mass was invading the root of the neck, the cervical plexus, and the subclavicular artery. The upper outer right thigh mass was invading the femoral artery. All the masses had a low density, which was consistent with a lipomatous tumor ().\nA surgical biopsy from the thigh mass showed high-grade liposarcoma with prominent round cell component ().\nBecause of rapid recurrence and multifocal disease, the multidisciplinary team suggested chemotherapy with Doxorubicin and Ifosfamide. The patient was given five cycles of chemotherapy. Postchemotherapy follow-up showed a decreasing by 30 % in the masses size. Two months after chemotherapy, the patient underwent two major surgical operations. The first one was for resecting abdominal and cervical masses and the other one was for resecting femoral and popliteal masses (). Actually, the patient showed patience and she accepted all the offered treatments and procedures with satisfaction.\nThe first procedure was performed by a general surgery specialist with 15 years of experience in abdominal surgery. Abdominal incision showed seven tumor masses; a large retroperitoneal mass, an under left kidney mass, a peripheral retroperitoneal mass connected to the upper pole of the right kidney and compressing the inferior vena cava, two pelvic masses adherent to the right ovary and greater omentum, a small mass connected to the transverse colon, and a mass invading the sigmoid colon mesentery. They measured 30, 5, 10, 15, 5, 4 and 10 cm respectively. Therefore, the resectable masses were totally resected and the other masses were debulked. The cervical mass was only debulked to save neural and vascular elements and to avoid extremity amputation.\nSeventeen days later, the femoral and popliteal masses were resected after isolating the neurovascular bundles and nerves. This procedure was performed by an orthopedic surgery specialist with 10 years of experience in extremity cancer surgery.\nThe pathologic report was liposarcomatosis (myxoid type). Unfortunately, a day after surgery the vital signs of the patient deteriorated. She was transformed to the surgical intensive care unit (ICU) where she died. |
A 75-year-old man was diagnosed with gastric cancer in June 2012 at Showa University Fujigaoka Hospital. Fifty years previously, he had undergone a gastric bypass operation with a loop gastrojejunostomy to treat stenosis caused by a duodenal ulcer.\nHis medical history included chronic renal failure (managed with hemodialysis), right idiopathic pleural effusion, third degree AV block (managed by a pacemaker), and myelodysplastic syndrome. As of 2006, chronic gastric hemorrhage had been observed at the GE anastomotic site, and endoscopy was performed. In June 2012, an upper gastrointestinal endoscopy revealed a slightly irregular mucosa surrounded by a smooth elevated area at the stomal site. The irregular mucosa was biopsied, and a papillary and tubular adenocarcinoma were diagnosed. Endoscopic ultrasonography revealed that the tumor extended to the muscularis propria. CT showed an enlarged lymph node on the lesser curve of the stomach, which is suggestive of metastasis. However, the gastric wall did not appear thickened, which can occur secondary to neoplasia, and there was no indication of distant metastasis. The cancer was diagnosed as T2 N1 M0 stage IIB according to the TNM classification. Since the patient already had poor systemic function, surgery carried a very high risk of morbidity and mortality. Similarly, cancer chemotherapy could not be initiated. The surgeon repeatedly discussed the treatment options with the patient who ultimately elected surgical excision to avoid potential obstruction and hemorrhage at the stomal site. In October 2012, a distal gastrectomy, a small intestinal partial resection (afferent and efferent loops) and a Roux-Y reconstruction were performed.\nDuring the laparotomy, hepatic sclerosis and ascites were observed. The significant collateral vasculature and the strong adhesion between the stomach and the liver and between the jejunum and the transverse colon from the previous GE made surgery difficult. Numerous firm and small lymph nodes were identified in the lesser omentum and suspected to be metastatic. A small intestinal partial resection, including the BEE site, was performed followed by a distal gastrectomy. Metastasis was observed in the common hepatic arterial lymph nodes similar to the metastasis observed in the para-aortic nodes, and a curative resection was deemed impossible. The surgery lasted 6 h, and there was a 1,492-ml intraoperative hemorrhage. Immediately after transferring the patient to the intensive care unit, he suddenly stopped breathing, and resuscitation was initiated. It progressed into multiple organ failure and the patient died in December 2012.\nThe surgical specimen is illustrated in figure . A 5 × 4 cm type-5 lesion was identified in the posterior wall at the stomal site on gross pathologic examination. HE staining (fig. ) showed that the tumor histologically comprised two elements: a tubular adenocarcinoma on the gastric side and NEC-like cells in a typical mass lesion comprising infiltrating nests of small uniform tumor cells on the jejunal side, which made up 40% of the tumor. The gastric mucosa adjacent to the tumor did not show evidence of gastritis. Immunohistochemistry (fig. ) showed that the NEC-like cells were positive for neural cell adhesion molecules and partially positive for synaptophysin and somatostain receptor type 2, but negative for chromogranin A. The Ki-67 labeling index was >20%. The final pathological diagnosis was MANEC, according to the 2010 WHO classification system for digestive neuroendocrine tumors. |
A 31-year-old woman was referred to our center from another institution because of acute right lower limb ischemia. Earlier on that day she had undergone the procedure of radiofrequency ablation through a right percutaneous femoral approach due to supraventricular tachycardia. She had a history of an unsuccessful attempt of ablation in the past. The procedure itself was uneventful. The closure of the puncture site by the Starclose device was attempted by the cardiology resident. Despite deployment of the device, bleeding from the puncture site occurred and hemostasis was achieved with a kaolin-impregnated gauze (QuickClot, Z-medica) and compression. Six hours later the compression was relieved and the patient was allowed to ambulate. As soon as she started to walk she experienced a severe pain of her right lower limb. Acute limb ischemia was diagnosed and she was transferred to the Vascular Surgery Department. On admission, she reported severe pain of the right lower extremity. The foot was cold and pale with absence of capillary refilling. Both superficial and deep sensations were abolished. Her height, weight, body surface area and body mass index were 160 cm, 55 kg, 1.56 m2 and 21.5 kg/m2, respectively. Computed tomography (CT) angiography demonstrated occlusion of the proximal portion of the superficial femoral artery and occlusion of the popliteal artery and proximal segments of the tibial arteries. At the level of bifurcation of the common femoral artery two metallic objects were seen, one at the anterior wall and the other at the posterior wall of the femoral artery (). The diameters of the common femoral artery and superficial femoral artery were 5.5 and 4.5 mm, respectively. Because of the severity of acute limb ischemia, urgent surgery was performed. The femoral artery was exposed in the groin through a longitudinal skin incision. The presence of a well-incorporated clip was noted at the anterolateral aspect of the common femoral artery, and a recent, open puncture hole was seen on the anterior aspect of the superficial femoral artery. Longitudinal arteriotomy was performed. The thrombus at the origin of the superficial femoral artery was found and removed, and protrusion of a polyp-like structure at the posterior wall was demonstrated. This structure was formed by the posterior wall intima grasped by a Starclose clip (). The protruding intima together with the clip were excised and the arteriotomy was closed with a saphenous venous patch. Then through a medial approach the popliteal artery was exposed, and it was possible to remove the thrombotic material in one piece from the proximal and distal segment of the artery. Satisfactory inflow and outflow were achieved and arteriotomy was closed with a saphenous vein patch. The postoperative course was uneventful, and the patient was discharged on the second postoperative day with palpable distal pulses. |
A 33-year-old average built male reported with complaints of severe pain, gradually increasing swelling around the right knee and inability to bear weight on the right lower limb for last one month following history of trivial trauma. Pain was continuous, increased in night and was not relieved by rest. Patient had history of continuous and dull aching pain in the lower limb, used to get relieved by analgesics, for the last one and a half years. There was no history of fever, vomiting, weight loss, hemoptysis or loss of appetite. No other bony swelling was present elsewhere in the body.\nOn examination a swelling of 3 × 2 cm was present on the lateral aspect of the distal end of the right femur and a 3×3 cm swelling on the proximal part of the right tibia. The skin over the swelling was stretched but mobile. Local tenderness was present with rise of temperature. There were no subcutaneous dilated veins. Movements of the right lower limb were not possible due to pain. Hemogram and blood counts were within normal limits. Acid and alkaline phosphatase and serum calcium were within normal range.\nPlain X-ray of right knee showed subarticular eccentrically located expansile lytic lesion in the lateral tibia condyle, lateral condyle of femur and patella []. The MRI showed subarticular eccentrically located lesion in the lateral tibial condyle with serpiginous area of altered marrow signal intensity of the lower end of femur and patella to suggest the possibility of bone infarct and likely to resemble a multifocal giant cell tumor. The fine needle aspiration cytology done showed giant cell lesion of bone [].\nThrough a lateral para-patellar incision, lesions were explored. Femoral articular surface was found intact. Tibial articular surface was minimally damaged on its lateral corner. Patellar articular surfaces were not damaged. All the lesions from the femur, tibia and patella were thoroughly curetted and were chemically and electrically cauterized with phenol and electric cautery. A tricortical graft (6×4 cm) was harvested from the left iliac crest. A block of gel foam 5 × 4 × 1 cm was placed underneath the tibial articular surface in the subchondral area and the harvested bone graft was tailored to be placed below the gel foam and the remaining bony gap was filled with bone cement (Sandwich Technique). Bone cement was also filled in the right femoral condyle and patellar lesion after curettage. After saline lavage the wound was closed [Figures and ].\nPostoperative period was uneventful. Non-weight-bearing physiotherapy in the form of knee movements, quadriceps and hamstring strengthening exercises were started the next day. Partial weight-bearing was allowed after seven days with hinged long leg knee brace. On the 12th postoperative day sutures were removed, patient was ambulated with full weight-bearing after three weeks.\nOn first follow-up after one and a half month, patient showed excellent recovery in the form of quadriceps and hamstring strength with right knee range of movements from 5° to 110°. Follow up X-ray shows maintenance of joint space and no recurrence of lesions. Patient was able to bear full weight on the operated limb. On subsequent follow-up after six months onwards, patient had full range of painless movements of right knee with no clinical or radiological evidence of recurrence of lesion. Patient has resumed his job of driving vehicles and is doing all his daily activities without any difficulty.\nPatient was reviewed clinically and radiologically one year after surgery and there is no evidence of recurrence of the lesions in any of the bones. Patient has started his routine activities []. |
A 69-year-old Chinese man presented in 2005 with left nasal obstruction and occasional epistaxis after a cold to the Otolaryngology clinic at the Peking University People's Hospital of China, a tertiary care academic center in Beijing, China. He denied rhinorrhea, headaches, and ophthalmic or neurological symptoms. His medical history was remarkable for hypertension and coronary heart disease. Endoscopic examination revealed a large left sinonasal mass, and imaging confirmed the absence of bony erosion into the orbit or skull base. We performed endoscopic extirpation of the left nasal polyp under local anesthesia. Postoperative pathology revealed a benign nasal polyp.\nAt the age of 79 years (in 2015), the patient presented with similar symptoms at Beijing Tongren Hospital, Beijing. Physical examination revealed the presence of a polyploid mass partially filling the middle meatus with extension into the nasal cavity. Computed tomography (CT) and magnetic resonance imaging (MRI) examination of the paranasal sinus (Fig. ) revealed unilateral maxillary sinus disease, left orbital suborbital nerve canal hyperostosis, and findings consistent with inverted papilloma. Endoscopic sinus surgery was performed under general anesthesia. Intraoperative frozen pathology revealed carcinoma arising in inverted papilloma. The hyperostosis of the suborbital nerve canal of the maxillary sinus was removed and the margins of resection ended up positive. However, postoperative permanent pathology demonstrated carcinoma arising in OSP. The patient was recommended to have radiotherapy for the primary site of the tumor, but he declined.\nThe patient presented at age 81 years (in 2017) to Anzhen Hospital in Beijing with similar obstructive symptoms. CT and MRI (Fig. ) revealed inflammatory response of the left maxillary bone and a space occupying lesion of the left nasal cavity. A soft tissue density mass was found in the left nasal cavity and sinus, with absence of bony erosion into the orbit or skull base. Endoscopic sinus surgery with surgical navigation under general anesthesia was performed with complete removal of the tumor and negative margins by frozen section. Postoperative histopathology was high-grade nonintestinal adenocarcinoma. The patient still refused to undergo radiotherapy after surgery.\nAfter 5 months, the patient returned and physical examination showed a neoplasm in the left nasal cavity, with a rough surface, easy bleeding, and purulent secretions on the surface of the tumor. In addition, there were palpable enlarged, hard, immbolile submandibular lymph nodes on that side (2.2 × 2.0 × 1.8 cm). CT, MRI, enhanced MRI (Fig. ), and positron emission tomography-computed tomogramphy (Fig. ) were performed and revealed 2 masses in the nasal cavity. One was located at the bottom of the nose and extended along the lateral wall of the nasal cavity to cover the pharynx and the eustachian tube, violating the root of the inner part of the pterygoid muscle. The other was located in the top of the nasal cavity, occupying the ethmoid sinus and the anterior skull base, but not invading the orbit and skull base bone. Metastatic swollen lymph nodes were seen under the left mandible. Endoscopic surgery was performed again with surgical navigation, resecting the tumor completely with negative frozen margins. We also performed a selective left neck dissection. Postoperative pathology of the primary tumor was low-differentiated adenocarcinoma and we found metastatic adenocarcinoma with low-differentiation in the cervical lymph nodes. The patient disagreed to receive adjuvant radiotherapy and targeted drug therapy for KRAS gene.\nDuring 6 months’ follow-up after the last operation, the patient developed an in situ tumor recurrence 1 month after the fourth operation and refused to undergo surgery again. |
A 67-year-old male presented to our hospital with h/o of right hypochondrial swelling for the past 3 months. Patient underwent PCI to right coronary artery with two drug eluting stents (Everolimus eluting) for inferior wall myocardial infarction in 2016. He also had a PCI to left anterior descending artery with one drug eluting stent (Everolimus eluting) []. During the RCA stenting perforation occurred which was managed conservatively. Three years after the intervention patient observed swelling in the right hypochondrium associated with discomfort for which he was referred to gastroenterologist. In the process of evaluation for abdominal swelling, he was diagnosed to have right coronary artery stent extrusion with fluid collection around the stent []. At the time of presentation to our hospital patient was hemodynamically stable and had no complaints other than abdominal swelling.\nPatient was on antihypertensives & antiplatelet medication. His blood investigations & electrocardiogram were normal. Repeat angiogram was done at our hospital which showed occlusion of proximal right coronary artery with stent extrusion & patent left anterior descending artery stent with 60% stenosis of proximal left circumflex artery []. Computed tomographic imaging was done which showed heterogenous partially organised fluid collection around the right coronary artery within the epicardial fat. It is seen extending from the proximal right coronary artery to the right hemidiaphragm with mild thickening of the pericardium []. Thrombosed & occluded stent was seen in the collection. Patient was taken for coronary artery bypass grafting and retrieval of extruded stent. During surgery transoesophageal echocardiogram showed the extruded right coronary stent adjacent to right ventricle with some fluid collection around it. Intraoperative findings were severe right hemi pericarditis with some fibrous tissue adherent to RV extending in to the right hemidiaphragm. Right coronary stent was embedded in the fibrous tissue with some liquified fat within it []. Fibrous band was excised, and extruded stent was retrieved. Surgeon felt LAD has in stent restenosis of 50-60%, which was not reported by cardiologist during angiogram. Grafting to left anterior descending artery, posterior descending artery and obtuse marginal artery was done. Patient was started on noradrenaline intraoperatively and shifted to intensive care unit after surgery. Patient was extubated after 4 hours and shifted to ward on 2nd postoperative day. Sample taken for culture intraoperatively were found to be negative. Patient was discharged on fifth postoperative day with regular medications according to institution protocols. |
A 47-year-old female presented to an outside institution with chronic low back pain and right L5 radiculopathy, and an MRI of the lumbar spine was performed (not shown). It showed a mass-like lesion at the right L5–S1 foramen and a diagnosis of hernia or tumour was considered. Over a 1-month period, the patient was managed clinically with analgesics with partial resolution of symptoms.\nThe patient then presented to the emergency department of our hospital owing to her persistent symptoms and an MRI of the lumbar spine (T1 and T2 weighted sequences) was obtained (). At this point, no contrast injection was performed as it is not included in the low back pain/radiculopathy investigation protocol in the emergency department. It showed the previously described lesion at the right L5–S1 foramen, as well as other ipsilateral lesions in the posterior paraspinal muscles and the anterior epidural space. Most of the lesions had a mass-like appearance and low signal intensity in all MR sequences. Interestingly, one lesion in the posterior paravertebral muscle showed mixed signal intensity on T2 weighted sequence, defining a fluid–fluid level. All the lesions were unchanged compared with the outside scan. The radiology team suspected that the lesions were calcified and suggested a contrast-enhanced CT scan of the lumbar spine ( and ) to confirm their initial suspicion and rule out possible soft tissue components associated with the lesions. The CT scan confirmed the calcified nature of the lesions and also showed no contrast enhancement. It also contributed to an additional finding of interstitial lung disease, as seen in a few images at the base of the lungs in the thoracolumbar region. A CT scan of the chest was suggested () and showed signs of pulmonary fibrosis and oesophageal dilatation. At this time, the hypothesis of paraspinal tumoral calcinosis secondary to SSc was suggested.\nAdditional clinical investigation showed that the patient had a history of dyspnoea, generalized weakness, arthralgia and gastro-oesophageal reflux disease. On physical examination, Raynaud’s phenomenon with a distal phalanx skin ulcer of the left third digit, sclerodactyly and multiple facial telangiectasias were also observed. Laboratory analysis indicated that creatinine, calcium and phosphorus levels were normal. In fact, the patient had an established diagnosis of lcSSc over a period of 15 years. However, this information was not provided to the radiology department, making the diagnosis of lumbar paraspinal tumoral calcinosis secondary to lcSSc challenging.\nAfter a multidisciplinary team meeting, it was initially decided that the patient’s radiculopathy should be managed clinically with non-steroidal and steroidal anti-inflammatory drugs and follow-up MRI of the spine should be performed within 6 months. In case of non-resolution or worsening of the symptoms during the follow-up interval, it was decided that surgical decompression could be considered depending on the patient’s general clinical status. |
A 65 year old woman presented with a long standing goiter of 10 years duration and recent swellings over the back and the scalp since 3 months. The thyroid swelling was slow growing with no history of a rapid increase in the recent past. The patient's thyroid function tests (T3, T4 and TSH) were within normal limits and she had no pressure signs and symptoms. Her past history was non-contributory. A complete physical examination revealed a large, firm multinodular swelling involving the entire thyroid gland. There was no palpable cervical adenopathy and a review of all other systems was negative. Endoscopic and radiological (barium swallow) examination of the upper aerodigestive tract were normal. Her vocal cords were mobile. Examination also revealed fluctuant swellings of the left parietal and left thoracic paraspinal regions. An ultrasound of the neck revealed a 7.4 cm large heterogeneous tumor of the thyroid with bilateral lymphadenopathy of intermediate origin at levels II and III. Fine needle aspiration cytology of the thyroid gland and the scalp lesion confirmed a follicular variant of papillary carcinoma with metastatic deposits in the scalp. A biopsy of the scalp lesion was not performed in view of fine needle aspiration cytology diagnosis. A biopsy of the paraspinal mass too showed a follicular variant of papillary carcinoma. An elevated serum thyroglobulin level (> 800 ng/ml) supported the thyroid origin of the primary tumor. The chest x-ray was normal. The patient was staged as cT3 N0 M1 (Stage IVc, AJCC – TNM) []. The patient underwent a total thyroidectomy with central compartment clearance and bilateral selective neck dissections (levels II, III & IV). At surgery, the tumor was confirmed to arise from the gland. There were no separate lesions to suggest the presence of a thyroglossal cyst remnant or infiltration of the thyroid gland by a primary from an adjacent organ. Histopathology revealed a collision tumor with components of both a follicular variant of a papillary carcinoma and a squamous carcinoma. In view of the large tumor and dual histology, we planned for radio iodine therapy directed toward the follicular derived component of the thyroid tumor and external beam radiotherapy for the squamous component. The patient was referred for adjuvant treatment but unfortunately did not come for follow-up. At the last follow-up on the 4th August 2005 the patient was free of primary tumor; three months after completion of surgical therapy. Attempts to contact the patient via all possible resources were futile.\nThe total thyroidectomy specimen measured 8.5 cm × 5.5 cm × 3.0 cms, with a solid, encapsulated tumor involving the right lobe and the isthmus. On cut surface, a tan colored fleshy tumor measuring 6.0 × 5.0 × 2.5 cms was seen with a thin rim of thyroid parenchyma partially surrounding it. Juxtaposed to this tumor was another distinct gray-white tumor measuring 3.0 × 2.5 × 2.0 cms showing a central irregular cystic area. The left lobe was unremarkable. The largest node dissected was 0.8 cm in diameter and was grossly unremarkable.\nMultiple sections from the thyroid mass displayed an invasive follicular variant of papillary carcinoma with foci of capsular invasion. There was an obvious extrathyroidal extension of the tumor. Juxtaposed with the papillary carcinoma in close proximity was an independent primary tumour with histology of a moderately differentiated non keratinizing squamous carcinoma. The two tumours were separated by fibrous septae over a broad area. They intermingled minimally at the interface representing a true "collision tumor" (Figure , ). The follicular variant of papillary carcinoma showed a uniform follicular differentiation without papillary areas or squamous morules. Classical nuclear features of papillary carcinoma namely nuclear crowding, nuclear clearing, overlapping and grooving with irregularities of the nuclear membrane were evident (Figure ). These two tumors were distinct morphologically and were also independent without a zone of transition from papillary to squamous carcinoma. As the squamous carcinoma was non-keratinizing in nature, keratin pearls were not seen but clusters of cohesive cells with abundant eosinophilic cytoplasm and distinct cytoplasmic borders were noted (Figure , ). The squamous carcinoma revealed a large area of cystic degeneration in the center and also showed muscle infiltration at the periphery. A diligent search failed to reveal remnants of thyroglossal cyst or areas of anaplastic carcinoma. There was an absence of lymphoid tissue around the component of squamous carcinoma. The uninvolved lobe showed no evidence of Hashimoto's thyroiditis.\nOne of the fourteen dissected nodes showed a focus of metastatic papillary carcinoma (micrometastasis) without extranodal invasion. The disease was staged histopathologically as pT3 N1 M1 (Stage IVc, AJCC – TNM) [].\nThe components of papillary carcinoma were strongly positive for thyroglobulin and TTF1 (Thyroid transcription factor) while they were negative for calcitonin. The squamous carcinoma cells were positive for cytokeratin only but negative for thyroglobulin, TTF1 and calcitonin, confirming the independent origins of the tumors. |
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 17-year-old male patient visited our institution with a complaint of a painful movable mass on the lateral distal aspect of the right femur that was not caused by trauma. The mass had been slowly growing for 6 months and started to cause increasing pain from one month ago. The patient had no history of other systemic disease. In the physical examination, a firm and movable mass with a size of a quail egg was palpated in the lateral distal aspect of the right femur. The size of the mass did not change during joint motion. Neither muscle weakness and numbness nor abnormal sensation was observed in the lower leg. In the absence of abnormal findings on radiography, ultrasound was performed, in which a cystic tumor approximately 4.1×2.5 cm in size was identified in the quadriceps femoris (). A magnetic resonance imaging (MRI) was considered unnecessary because it had a relatively distinct border and was well-encapsulated. Exploration and excision of the mass were performed under the assumption of a vascular lesion or a lipoma within the vastus lateralis of the quadriceps femoris. Noninvasive methods such as aspiration and steroid injection could be an option, but surgical excision was our treatment of choice in order to reduce the possibility of recurrence. Intraoperatively, spindle-shaped swelling was observed and a firm mass was palpated in the vastus lateralis of the quadriceps femoris. The mass could be dissected with ease from the surrounding tissue and had a stalk as other ganglion cysts. When the muscle sheath was removed, the mass was found to originate from the muscle, not from the muscle sheath. In the naked eye, the intramuscular cystic mass was 3.4×2.2×1.4 cm in size, weighed 4.7 g, and had some muscle tissue on its smooth surface (). When dissected upon excision, clear jelly-like fluid was noted in the sac. The biopsy results showed that the cystic wall was composed of fibrous tissue, lacked a synovial lining, and had muscular tissue on the surface, which led us to the diagnosis of an intramuscular ganglion cyst (). Rehabilitation was started after two weeks of splint immobilization. There has been neither recurrence nor complications for the 1 year and 6 months of follow-up period. |
A 59-year-old Chinese man complained of sudden headache, nausea, and vomiting while watching TV and was diagnosed with brainstem hemorrhage by computed tomography scan (). After confirmation of normal clotting screen tests and platelet count, he was successfully treated with lateral ventricle puncture drainage without any hemorrhagic tendency (). Ceftazidime was intravenously administered at 2 g daily to prevent postoperative infection for 3 days. Two weeks after the operation, cerebrospinal fluid and peripheral blood analysis showed elevated white cell count, which could indicate infection, although this patient had no fever. Thereafter, ceftazidime at 2 g every 12 hours was administered to help treat the intracranial infection for 14 days. However, the results of microbiological tests were negative, and clotting screen test results remained normal. Three weeks after the operation, routine coagulation monitoring showed markedly prolonged PT (45.8 seconds [normal range 11–15.1 seconds]) and APTT (95 seconds [normal range 24–40 seconds]). With the specific etiology unknown, daily transfusion of 5 units of fresh frozen plasma and 800 units of prothrombin complex concentrate for 1 week was administered, but coagulopathy was not improved. He was referred to our hematology clinic for evaluation of markedly prolonged PT (68.3 seconds) and APTT (200 seconds). The patient did not show any clinical sign of ongoing bleeding during his hospitalization. We confirmed that bovine thrombin was not used during surgical procedures. He had a normal diet and had been diagnosed approximately 10 years earlier with essential hypertension, which was controlled by a combination therapy composed of an angiotensin-converting enzyme inhibitor and a long-acting calcium channel blocker. The patient had no personal or family history consistent with a spontaneous bleeding diathesis. The patient’s medical history and clinical examination did not indicate the presence of an autoimmune disease.\nClotting screen tests showed significantly prolonged PT and APTT and marked reduction of FV activity, whereas other coagulation indexes including thrombin time, fibrinogen, prothrombin, and factor X, as well as platelet count were normal. A mixing test with equal volume of normal plasma failed to correct prolonged PT, APTT, or reduced FV activity (). FV inhibitor titer was 10 Bethesda units.\nHowever, the abnormal coagulation was dramatically corrected in 8 days after withdrawal of ceftazidime and treatment with prednisone 30 mg/day. Importantly, clotting test results in this patient remained normal during the 1-year follow-up period. A consent form was obtained from the reported patient. |
A 40-year-old man with a known diagnosis of Immunoglobulin D (IgD) lambda multiple myeloma presented with relapsed multiple myeloma (MM). He first presented in September 2007 with the chief complaint of cough and left sided abdominal pain. Physical examination was significant for splenomegaly. His labs were significant for pancytopenia. A bone marrow biopsy in September 2007 was significant for 100% cellularity and sheets of atypical cells positive for CD138 and lambda light chains consistent with multiple myeloma. Protein electrophoresis showed a monoclonal spike (M spike) and an elevated IgD level of 190 mg/L. A diagnosis of IgD multiple myeloma was made and he was initially started on dexamethasone and later in October 2007 thalidomide was added to his regimen. Patient had intermittent lapses in his thalidomide treatment because of his insurance issues and his IgD level slowly kept rising. In July 2008 his IgD level was found to be 293 mg/L. A bone marrow biopsy performed in July 2008 was significant for 5% plasma cells by immunohistochemistry. He was continued on dexamethasone and thalidomide. A repeat bone marrow biopsy in July 2009 showed 40% plasma cells. At that point bortezomib was added to his regimen to reduce his tumor burden and he was referred for autologous peripheral blood stem cell transplantation (PBSCT). Patient only took 50 mg of thalidomide instead of usual 100 mg. His repeat bone marrow biopsy in February 2010 showed persistent multiple myeloma with 20% monoclonal plasma cells with overall cellularity of 60%. In March 2010 his IgD level increased up to 531 mg/L. At that point his thalidomide dose was increased to 200 mg daily. Patient was having issues with compliance. Eventually, he underwent autologous peripheral blood stem cell transplant (PBSCT) on January 2011 after 6 cycles of salvage CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) chemotherapy. He was transplanted with stable disease with his pretransplant IgD level of 112 mg/L. He did not receive maintenance therapy and only 10 months after transplant there was evidence of myeloma progression with IgD level increasing to over 500 mg/L in October 2011. Patient at that point chose to pursue alternative therapies and was lost to follow-up. He presented again in April 2012 with severe lower back pain and an IgD level of 4020 mg/L. He was immediately started on pulse dose dexamethasone and lenalidomide was added in May 2012 (25 mg daily for 21 of 28 days). His IgD level decreased to 60 mg/L in November 2012 consistent with a very good partial response (VGPR) and he underwent a second autologous PBSCT in January 2013. His posttransplant course was complicated by some chemotherapy associated nausea, diarrhea, and neutropenic fever. He recovered well and was discharged home in stable condition. His day 100 bone marrow biopsy in April 2013 showed 20–40% plasma cells and an IgD level of 107 mg/L consistent with disease progression. Patient was restarted on lenalidomide 25 mg daily and had an initial response with a decrease in his IgD, which nadired at about 23.9 mg/L in June 2013 but his IgD quickly began to rise again.\nDespite lenalidomide and dexamethasone, his IgD continued to rise to as high as 500 mg/L and at that point he was started on Pomalidomide in December 2013. He completed 2 cycles of Pomalidomide and dexamethasone but his disease continued to progress so he was switched to bortezomib, Pomalidomide, and dexamethasone in September 2014 for about 4-5 months and later carfilzomib, Pomalidomide, and dexamethasone for an additional 5 months from January 2015 to May 2015 without much improvement. He was started on bortezomib, Panobinostat, and dexamethasone in July 2015 but could not tolerate this regimen. He was deemed to be unsuitable for allogeneic stem cell transplant by his insurance. He was requiring PRBC transfusion twice a week to maintain his hemoglobin to >7. He was not a candidate for clinical trials because of his cytopenias. At that point we decided to treat him with daratumumab. His pretreatment IgD levels in December 2015 were 4000 mg/L and came down drastically to 5 mg/L in May 2016 after 5 cycles of daratumumab showing very good partial response (). During his first infusion, he developed a grade 3 infusion reaction. His other side effects to medication were transient neutropenia and E. coli and Giardia diarrhea for which he was treated with antibiotics. His transfusion requirements which had been very high throughout his disease course requiring multiple transfusions with packed red blood cells (PRBCs) also came down dramatically with stable hemoglobin levels after the start of daratumumab (). Patient continues on daratumumab, with his last IgD level at 12 mg/L in June 2016. |
A 90-year-old woman presented with pain and locking of the right knee. She was unable to walk after stumbling over a curb and falling. On initial examination, the right knee was locked at an angle of 40° and could not be moved voluntarily. Local findings comprised a depression on the anterior surface of the right knee and a bony protuberance immediately distal to this. The right knee was swollen. No signs of trauma were seen, such as skin abrasions or subcutaneous hemorrhage. In terms of imaging findings, plain frontal radiography of the right knee showed inferior displacement of the patella with a fracture line on the lateral condyle of the femur (). Lateral radiography showed that an osteophyte on the superior pole of the patella had become impacted in the femoral trochlea (). No rotational abnormality of the patella was evident. The inferiorly dislocated patella was easily reduced when the knee was gently extended and was accompanied by a grating sound. Patellar reduction was confirmed on plain frontal and lateral radiography. Lateral radiography also showed an osteophyte on the superior pole of the right patella with a floating bone fragment nearby (). Sagittal magnetic resonance imaging (MRI) showed that the insertion of the femoral quadriceps tendon was not detached and no rupture of the tendon was present. Surgery was later performed with the aim of achieving early ambulation. Intraoperative findings revealed a pointed osteophyte 1.5 cm × 1.5 cm in size on the superior pole of the patella and a floating bone fragment was believed to have resulted from the fracture of the osteophyte (). Insall-Salvati ratio for assessment of patella height was 1.07. There was no finding of patella baja. The osteophyte was resected as far as possible, and the bone fragment was removed. Fixation of the fracture of the lateral femoral condyle was carried out using a May anatomical bone plate (KiSCO Corp, Kobe, Japan). The right knee was immobilized in the extended position with a plaster slab for 1 week after surgery, and range of motion training of the right knee was started on postoperative day 7. Partial weight-bearing was initiated from week 5, and full weight-bearing was permitted from week 9. Range of motion at 15 months postoperatively was 0° extension and 120° flexion, and plain radiography showed that synostosis had been achieved. No recurrence of inferior dislocation of the patella has been identified, and the patient has followed an uneventful course and is ambulatory. |
An 11-year-old boy was brought to us 4 days after having undergone a LA for AA at a peripheral hospital. The surgery had been undertaken some 48 hours after the onset of symptoms and an inflammed appendix had been removed. His pain had resolved after surgery, only to return after 24 hours. He was unable to tolerate oral liquids and had developed loose motions from the second postoperative day onwards. In view of his unsatisfactory progress, he was brought to our tertiary care hospital.\nOn arrival, he was in severe pain with a pulse of 116/ min, blood pressure of 100/84 mm Hg and respiratory rate of 24/minute. His abdomen showed generalised distension and tenderness along with rigidity. The bowel sounds were diminished. His investigations revealed a haemoglobin of 11.6 gm% and white cell count of 16,200/mm3 with 80% neutrophils. The serum electrolytes and serum creatinine were normal. An erect chest X-ray showed free gas under the diaphragm and abdominal X-ray showed multiple air fluid levels with ground glass appearance in pelvis. Computed tomography (CT) revealed dilatation of small bowel loops with thickening of one of the loops. Free fluid along with air pockets was seen in the peritoneal cavity. An emergent laparotomy was undertaken through a right supra-umbilical transverse incision. This revealed presence of faeculent fluid in the peritoneal cavity and dilated bowel loops. The appendicular stump, caecum and colon were unremarkable. Thorough examination of the bowel failed to reveal any perforation. A tubular structure measuring 3-cm in length was found floating freely between distended small bowel loops; this was retrieved. A through lavage was given and a drain was placed in pelvis. Postoperatively the boy made a slow but satisfactory recovery and was discharged on day 7. A superficial wound infection he developed was treated by laying the wound partially open and dressing it. Histopathological examination of the retrieved tubular structure was confirmed to be a part of the appendix. At the follow-up visit at 8 weeks he had recovered completely. |
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 50-year-old male patient diagnosed four years prior with pulmonary hypertension related to schistosomiasis mansoni was admitted to the emergency room of the Federal University of Minas Gerais School of Medicine Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. He presented with new onset, progressively worsening retrosternal chest pain and shortness of breath (functional class III pulmonary hypertension according to the World Health Organization). He had been diagnosed with chronic myeloid leukemia seven months prior and had since been on chemotherapy. At admission, transthoracic echocardiography revealed a large non-obstructive central thrombus in the right main pulmonary artery. The right atrium was dilated, and there was mild tricuspid regurgitation, with an estimated pulmonary artery systolic pressure of 63 mmHg. He was diagnosed as having in situ thrombosis as a complication of the long-standing pulmonary hypertension. After the possibility of acute coronary syndrome had been excluded, he was discharged on warfarin. He was re-admitted two months later due to progressively worsening, refractory chest pain. At that time, he had an SpO2 of 96%, and a third heart sound was audible at the lower left parasternal space, accompanied by a murmur of tricuspid regurgitation. The lungs were clear, and the peripheral arterial pulses were symmetric. Laboratory test results were unremarkable, including serum levels of creatine kinase, creatine kinase MB isoenzyme, and troponin. A resting electrocardiogram showed evidence of acute myocardial ischemia in the anterior leads. Transthoracic Doppler echocardiogram revealed a pulmonary artery systolic pressure of 62 mmHg, a thrombus in the right pulmonary artery, as in the previous examination, and the presence of a flap at that level that was compatible with pulmonary artery dissection (). The diagnosis was confirmed by subsequent CT pulmonary angiography (CTPA; ). He was transferred to another cardiovascular treatment facility, where attempts were made to correct the defect with an endovascular procedure (via the femoral vein). During the perioperative period, the patient presented with refractory cardiogenic shock. Multiple efforts to resuscitate the patient were unsuccessful, and he died in the operating room. |
A 63-year-old female was referred to our clinic for evaluation of progressively-worsening dyspnea over the last 1 year by a pulmonology clinic. We learned that she had exercise-induced dyspnea for 20 years. She was also hypertensive and had been diagnosed with atrial fibrillation for the past 2 years. Her physical examination and laboratory findings were within the normal range. An elevated right hemidiaphragm with hypoplasia of the right lung and a shift of the heart to the right side was seen on a routine chest X-ray. Her electrocardiogram revealed atrial fibrillation with normal ventricular rate response. Echocardiography revealed normal left ventricular systolic function and a normal left atrial diameter. We detected an increase in the systolic PA pressure (PAP=60 mm Hg) with normal right ventricular function. Lung scintigraphy showed a heterogeneous and decreased perfusion in the right hemithorax compared to the left side. We decided to perform computed tomographic pulmonary angiography (CTPA), since the chest X-ray was abnormal, to exclude the chronic thromboembolic pulmonary hypertension (CTEPH). CTPA revealed an absence of the right PA and dilated left and main PAs. Through magnetic resonance angiography of the aorta and PA, we confirmed the absence of the right PA and its branches, together with any additional anomalies. We performed right heart catheterization and coronary angiography to exclude coronary artery disease. The PAP as measured was 55/25 mm Hg with a mean value of 36 mm Hg and the pulmonary capillary wedge pressure was 15 mm Hg. Pulmonary angiography also showed an absence of the right PA with a dilated left PA and the vasoreactivity test was negative. Coronary angiography revealed normal coronary arteries, although we detected advanced collaterals arising from the conus branch of the right coronary artery, supplying the right PA’s branches (Figs. , , Videos , ). The patient was discharged with sildenafil and oral anticoagulant therapy. At the three-month follow-up, there was a significant improvement in the clinical condition. We did not replace her therapy with an endothelin receptor antagonist or riociguat. |
The patient was a 69 year-old caucasian male with recently diagnosed diabetes and a history of non-disabling stroke several years before. There was no record of hypertension, hypercholesterolemia, tobacco use or previously known coronary artery disease. Importantly, he was not taking any cardiovascular medication, including ASA.\nThe patient first presented to the emergency department of a referral hospital complaining of lower chest pain and vomiting. The ECG showed no signs of acute ischemia and, as biomarkers of myocardial necrosis tested negative, the patient was discharged with no further evaluation. During the next days, chest pain persisted and, on day five after the initial symptoms, he went back to the emergency. At that time the ECG showed inferior pathological Q waves, slight (~1 mm) ST-segment elevation and biphasic T waves on the inferior leads and a test for cardiac troponin I was positive. The patient was admitted with the diagnosis of subacute inferior myocardial infarction with recurrent angina and anti-thrombotic and anti-ischemic medications (including low molecular weight heparin and GP IIb/IIIa inhibitors) were started. Due to the persistence of chest pain the patient was referred for urgent coronary catheterization, which was performed at our institution on day five after symptom onset. Angiography showed a critical stenosis of the right coronary artery with TIMI 2 grade flow, with no other significant coronary lesions. An angioplasty procedure with deployment of a drug-eluting stent was successfully undertaken and the patient transferred to the CCU for routine monitoring.\nOn day seven after the first chest pain episode, clinicians were surprised by a new and persistent 4 to 5 mm ST-segment elevation affecting leads V1 to V5, I and aVL (Figure ). The patient's clinical status remained remarkably stable as he experienced no recurrent chest pain, heart sounds could be eared clearly, there were no murmurs or bruits and blood pressure was in a somewhat expected range (~120/80 mmHg), considering that pressure lowering drugs had been newly introduced in incremental dosage. Serial evaluation of biomarkers of myocardial necrosis showed no increase relative to earlier post-PCI values, but white cell counts and CRP levels were both slightly elevated. At this point, a bedside transthoracic echocardiogram (TTE) was performed, showing a global small-to-moderate echodense pericardial effusion, somewhat larger in the posterior and inferior aspects of the heart, with no signs of tamponade (Figure and ). There were no regional wall motion abnormalities of the anterior wall and, in addition to basal inferior-wall akinesis, a canalicular tract from endo to pericardium was seen along the interface between the necrotic and the normal contracting myocardium (Figure , , , ). Power-Doppler evaluation additionally suggested an abnormal blood leak across the inferior LV wall (Figure , ) and, on the basis of these findings, a LVFWR was suspected. While the transoesophageal echocardiogram with intravenous echocontrast brought no further input, cardiac MRI images (Figure ) corroborated the TTE findings and reinforced the diagnostic suspicion of LVFWR, leading to urgent surgery. After pericardiotomy and cloth evacuation there was a significant increase in the systemic blood pressure, suggesting that tamponade might have been impending. The myocardial tear was identified and successfully repaired with a tephlon band supported suture technique. Recovery was uneventful allowing hospital discharge 5 days after the operation. Two years after the event the patient is still alive and leading a normal life.\nAs previously mentioned, mechanical complications of acute MI, including LVFWR, apparently tend to become less frequent in day-to-day practice, at least in part due to the our growing ability to deliver safe and effective reperfusion therapies (both pharmacological and mechanical) to a wide range of MI patients.\nThe time frame for the occurrence of LVFWR may vary widely. In the pre-thrombolytic era incidence peaked between days 5 and 7 after the MI, but rupture has been reported to occur as late as one month or even beyond [-].\nTraditionally, factors considered to increase the risk of LVFWR would include advanced age (6th decade or later), female gender, hypertension without left ventricular hypertrophy, delayed or no reperfusion, the anterior location of the AMI, no prior angina, a first myocardial infarction, poor collateral circulation to the infarct related area, use of NSAIDs or steroids during the acute phase, and high serum levels of C-reactive protein [,,].\nAlthough cardiac rupture following AMI cannot be explained by any single factor, in this particular case, variables predicting the anticipated risk of cardiac rupture were related mainly to treatment delay and patient's age. Gender differences regarding the outcome after AMI have been well established, and even in the direct PCI (d-PCI) era, female sex has still been reported to be an independent predictor of LV rupture [,].\nDespite being theoretically more probable in the inferior-lateral wall, it seems that the fact that anterior infarcts are more common, renders anterior wall ruptures more frequent []. However, a thorough literature review showed that, in the specific case of subacute LV wall rupture, inferior infarctions seem to be involved in the majority of the cases [-]. It has been stated that this might be due to the fact that patients with anterior wall ruptures may be less protected because blood tends to accumulate and to form adherent cloths in the posterior-inferior wall [].\nDespite age and general clinical status would have made this patient eligible for on site reperfusion therapy, absence or delay of timely reperfusion (owing to late diagnosis) was perhaps the major risk factor for LVFWR. The reported decrease in the incidence of MI-related cardiac rupture in the thrombolytic and subsequently in the d-PCI era is relatively consistent. Regarding the absolute risk of mechanical complications, there is general agreement in that any reperfusion is better than no reperfusion. However, perhaps particularly in elderly patients, the relation between the use and the timing of thrombolytic treatment (which is the most widely used reperfusion strategy) and the risk of LV rupture, has been matter of concern [,]. This is due to the fact that up to 30% of MI patients arrive to the hospital later than the optimal time-frame for thrombolysis to be potentially beneficial []. Although still controversial, there is evidence to suggest that, contrary to data provided by previous reports and post-hoc analysis of pivotal clinical trials [,], neither thrombolysis itself nor the time delay to thrombolytic treatment actually seem to increase the absolute risk of LVFWR. In the LATE trial [], Becker et al. found no significant differences in the incidence of LVFWR in patients treated with a rt-PA based regimen within the 6 to 12 hour period after symptom onset and those randomized to the active treatment arm between 12 and 24 hours. However, there was a significant interaction between the assignment to active treatment and the time of rupture occurrence, as thrombolysis appeared to accelerate rupture events, typically to within 24 h after treatment []. Several possible mechanisms underlying this paradoxical effect of fibrinolysis have been proposed, such as extension of myocardial hemorrhage, weakening and dissection of the necrotizing zone [], diminishing of the myocardial collagen content [], and digestion of collagen by collagenases and plasmin [-]. Whether or not d-PCI would have similar effects has been recently examined in a retrospective analysis of a single centre registry of 1250 patients treated with d-PCI. In the 12 patients who had LV rupture (including free wall rupture and VSD), this complication occurred somewhat later than with thrombolysis, but earlier than that reported for non-reperfused patients []. The relative advantages of PCI versus lytics in this high risk group of patients have been evaluated in the SENIOR-PAMI trial []. In this yet unpublished study, 483 patients aged ≥ 70 years old were randomized to primary PCI or thrombolysis; despite a small difference favoring PCI, it failed to significantly reduce the 30-day mortality rate (10% vs 13%), thus suggesting that the incidence of fatal mechanical complications could have been quite similar. However, as the overall reduction in the incidence of the composite endpoint of death, MI or stroke favored PCI over thrombolysis (11.6 vs 18%; p = 0.05), this study might have been underpowered to evaluated the benefits of PCI in isolated hard endpoints such as MI-related death.\nWhen the acute form of LVFWR occurs, it usually results in an abrupt haemodynamic collapse with cardiac tamponade and electromechanical dissociation. Death ensues in a matter of minutes to hours in the large majority of cases, as cardiopulmonary resuscitation maneuvers are uniformly unsuccessful.\nLess frequently, in up to one third of the cases, the rupture can be sealed by the epicardium or by a haematoma on the epicardial surface of the heart, forming a "LV diverticulum" or contained myocardial rupture. This situation represents a subacute pathologic condition standing somewhere between free rupture into the pericardial cavity and formation of a pseudoaneurysm [,-]. This much less spectacular scenario – gradual or "oozing type" rupture – may evolve over hours or even days, and presents mainly with pericardial effusion related signs and symptoms.\nMyocardial free wall rupture should be suspected in patients with recent MI who have recurrent or persistent chest pain, sometimes of the pericardial type, haemodynamic instability, syncope (resulting from transient electromechanical dissociation), and pericardial tamponade. New ST segment changes ("saddle shaped ST-segment elevation") may be the chief clinical manifestations [,]. In fact, electrocardiographic findings in LV rupture patients may be related to its type and severity. Electromechanical dissociation (with a diagnostic accuracy that reaches 97%) and bradycardia are features of the acute variety, while new ST-elevation in the affected leads or persistent non-inversion of T-waves may suggest the less noisy "stuttering" type of rupture [,]. In this setting, interventions that can dramatically change prognosis can be employed, as long as an accurate diagnosis can be timely established. Clinical course depends mainly on the rate of bleeding and the compliance of the pericardial sac. Signs of restricted ventricular filling may be absent if the effusion develops slowly enough and bleeding ultimately subsides [,,,].\nIn a scenario of relatively low threshold for clinical suspicion, the unexpected ECG changes were the key to the diagnosis. Otherwise, patient was only to be exposed to the natural history of the disease which, at this point, may be rather unpredictable [-]. In our institution, the risk stratification protocol after an acute MI includes an echocardiographic examination. However, unless a complicated clinical course ensues, it is performed only after the patient has stepped down to the ward. Thus, no additional investigations were to be made at that time.\nIn those who are haemodynamically unstable, which was not the case of our patient, right heart catheterization will usually provide useful information and may help in the differential diagnosis with other life threatening complications, such as VSD. In the typical patient, right atrial pressure will be comparable to pulmonary capillary wedge pressure [].\nEmergency pericardiocentesis has the potential for the identification of haemopericardium and relief of cardiac tamponade. Despite rarely seen in the acute MI setting, cardiac tamponade may be caused by serous or serohaemorrhagic pericardial effusions; also, the risk of chamber puncture and the theoretical possibility of "thrombus displacement" and "decompression" of the contained rupture, can, not only hamper the diagnostic accuracy of pericardiocentesis, but also make it potentially harmful. Given these considerations, we strongly feel that this procedure should not be "routinely" used as a diagnostic tool and should be kept for situations of absolute need for tamponade relief [].\nIf a mechanical complication is suspected, emergency bedside transthoracic and/or contrasted transesophageal echocardiograms are considered the gold standard diagnostic tools [].\nPericardial effusion is the most common finding, usually with echodense intrapericardial echoes. The absence of pericardial effusion in a patient with AMI excludes the diagnosis of myocardial rupture, but its presence as an isolated finding in this context does not definitively confirm the diagnosis. Right atrial and right ventricular wall compression as well as Doppler signs of a compromised ventricular filling, can also be identified by 2D echocardiography. Direct signs of rupture like a myocardial tear, as in this case, will be seen only occasionally [,]. In a prospective study involving 1247 MI patients (33 with subacute LV rupture), the presence of cardiac tamponade, pericardial effusion greater than 5 mm, high density intrapericardial echoes or right atrial or right ventricular wall compression had a high diagnostic sensitivity (≥ 70%) and specificity (≥ 90%). Despite data reporting on high positive predictive values of intrapericardial echoes and echocardiographic signs of tamponade alone, still the number of false-positive findings for every single variable may be relatively high (>20%) [,]. However, when combined with syncope, in the appropriate clinical setting, their diagnostic accuracy may reach 100% [].\nIn our case, Doppler examination suggested an abnormal intramyocardial tract, but could not definitely demonstrate active bleeding into the pericardium. The detection of blood flow at the site of rupture may not be feasible in many cases, as the myocardial tear is most often anfractuous and sometimes covered by thrombi and thus blood flow velocities may be low. Despite the potential ability of contrast echocardiography to decrease the number of false-positive diagnoses [-] – by showing leakage of contrast from the left ventricle into the pericardial effusion – it was of no help in our patient.\nThe role of new imaging techniques in this setting, such as cardiac MRI, although promising, remains observational and anecdotic [-]. Trials assessing the relative value of echocardiography and high resolution CT scans or cardiac MRI are limited not only by clinical, but also by obvious ethical and logistic issues. The wide availability of ultrasound makes this technique "difficult to beat" in the clinical ground, as the expensive technology and expertise needed for cardiac MDCT or MRI imaging are not promptly available in the majority of the hospitals, even in those where cardiac surgery is promptly available. Nevertheless, we should emphasize the high grade of concordance between echocardiographic and MRI images (Figure and Figure ). Although MRI had, in our case, a paramount importance in the establishment of the diagnosis and in the decision to proceed to surgical treatment, standard and/or contrast enhanced echocardiograms, in expert hands, will generally be trusted as the ultimate diagnostic tools.\nDespite cases of a fairly good long term survival following a conservative approach have been described [,], there is general agreement in that surgery provides the only potentially definitive treatment option and that the diagnosis of subacute LVFWR usually requires a surgical decision []. However, the finding that patients presenting with LV pseudoaneurisms might have survived to subacute forms of LV rupture (with only mild hypotension or asymptomatic pericardial effusions) may argue against the absolute need for surgery, suggesting that a conservative management can be an acceptable choice in carefully selected patients, namely those at high surgical risk.\nOne prospective study reported a 44% survival rate among MI patients with confirmed or strongly suspected LVFWR who survived resuscitation maneuvers after electromechanical dissociation (EMD) or presented only with hypotension without EMD [] and were treated conservatively. However, in this study there wasn't a surgically treated group suitable for comparison and the possibility of other causes of cardiac tamponade could not be definitely ruled out. Medical management included pericardiocentesis as needed, prolonged bed rest and strict control of LV pressure (preferably with beta blockers) and avoidance of obstipation. Blinc et al., in a retrospective analysis, reported much poorer results with a survival rate of only 10% []. Intra-aortic balloon pumping has also been employed effectively in unstable patients unresponsive to inotropic agents and fluid replacement [] but some have found its use to be debatable, unless persistent ischemia and/or LV pump failure also ensues [,].\nThe very high surgical risk, which can be unacceptable if the procedure is to end up as "blank" sternotomy, is the major drawback posed to surgeons. Thus, all efforts should be made to confirm the diagnosis in order to reduce the number of false positives. The goals of surgery are to stop bleeding, to relieve cardiac tamponade and to prevent a second rupture. When possible, off-pump sutureless techniques using biocompatible glues and patches to cover the necrotic/ruptured area are increasingly being preferred to infarctectomy and direct myocardial suture, and are thought to yield better results [,,,]. However, some reports have suggested that inferior-lateral ruptures – as in the case of our patient – may be adequately treated with direct suture. Coronary artery bypass grafting is also indicated as needed. Emergency coronary angiography in order to determine which coronary arteries to bypass is warranted in the subacute setting, although the possibility of proceeding directly to surgery and perform empirically based bypassing of all of the major epicardial coronary arteries as also been described [].\nDespite high perioperative mortality rates (33 to 55%), a rather well preserved post-procedure left ventricular function, as well as a fairly good functional long term prognosis are increasingly being reported [,-]. |
The patient is a 45-year-old man who was admitted for the first time in 1994 at the age of 31 for persistent headache. Work-up revealed a large left tentorial meningioma. He had no history of cranial radiation during childhood or clinical features of neurofibromatosis type I or II. He underwent gross total surgical resection. Pathologic evaluation, which was recently re-reviewed, showed an atypical meningioma with the following features: hypercellularity with sheets of monotonous meningothelial cells displaying a prominent mitotic activity with around 4 mitoses per 10 high power fields. In May of 1997, follow-up brain MRI revealed a recurrence in the vicinity of the original tumor bed. Surgery was performed with gross total tumor removal. Pathologic evaluation again showed meningioma with similar pathologic features. In September 1999, he developed multiple small tumor recurrences in the parietal, occipital and cerebellar lobes for which he underwent stereotactic radiosurgery (SRS) with excellent results on tumor control. In September 2001, the patient developed additional recurrent lesions in multiple sites in the infratentorial, retroclival, left optic nerve sheet, and foramen magnum regions.\nHe was again treated by stereotactic radiosurgery with good tumor control defined as a complete disappearance or progressive decrease in lesion size. In June 2003, he received further SRS treatment to new cerebellar, premedullary and craniocervical junction lesions. In February 2004, he developed numerous lesions outside previously treated sites and was given whole brain radiation therapy (WBRT) of 36 Gy as a palliative therapy because of the multiplicity and the progression of the brain lesions. Surprisingly many of the small lesions disappeared after WBRT and the patient remained asymptomatic until August 2005 when he developed left facial numbness. Brain MR imaging at that time showed a recurrent lesion in the left cerebellopontine (CP) angle, an area that was previously treated by SRS and WBRT. He was given 10 sessions of stereotactic radiotherapy (30 Gy in 10 fractions) and achieved a good partial response but this lesion grew back and caused progressive left facial numbness due to left Vth nerve compression. This was treated by another craniotomy and surgical resection. Histopathologic examination showed meningioma with the same pathologic features and additional elements like the presence of foci of geographic necrosis and a hemangiopericytomatous pattern of vasculature (Figure ). Mitotic count was now up to five per ten high power fields and Ki-67 labeling index was up to 15% (Figure ). The tumor was focally positive for epithelial membrane antigen (EMA) and negative for CD31 and CD34. The lack of CD34 immunostaining excluded the possibility of hemangiopericytoma or solitary fibrous tumor of the meninges. Occasional cells were weakly positive for S-100 protein. In July 2007, follow-up MRI showed tumor progression at the same CP angle site for which a redo SRS treatment was debated and finally delivered without significant acute toxicity. Of note, the question of chemotherapy was raised many times but the patient refused to receive any systemic therapy.\nIn November 2007 and because of persistent low back pain, the patient underwent MRI of the spine and pelvis. These showed two large masses in the left and right sacroiliac and gluteus muscle regions measuring 11 × 9 cm and 8 × 7 cm, respectively, causing bone destruction of the left sacral wing with extension in the left sacral neural foramina (Figure ). Surgical biopsy was performed and this revealed metastatic atypical meningioma, with similar characteristics to its intracranial counterparts. Further work-up included CT scan of the abdomen which revealed large bilateral renal metastases (Figure ). CT of the chest was negative. The patient was evaluated by medical oncology but declined systemic chemotherapy. Brain MRI showed no disease progression. He is now receiving palliative care for pain control. |
A 33-year-old man presented to the emergency department of our hospital with a twisting injury to his right knee and an open fracture of the left lower thigh that occurred while he was operating a rotary snow removal vehicle and his left lower thigh became trapped in the rotary blade. Physical examination revealed that the right knee joint was fixed at 30° flexion with a lateral shift of the patella. The contralateral open fracture was classified as grade 3A using the Gustilo–Anderson classifications ystem. No neurovascular injury to either leg was detected. Radiographic evaluation confirmed lateral dislocation of the patella and posterolateral subluxation of the knee ().\nOn the day of injury, the open fracture of the left lower thigh was stabilized with an external fixator after debridement and the dislocated patella of the right knee was reduced. However, closed reduction for knee joint dislocation could not be performed successfully. Plain radiographs after manipulation showed widening of the medial joint space and tibial posterolateral displacement (). The characteristic dimple sign was observed over the medial joint line (). On the medial aspect of the injured knee, the medial femoral condyle was palpable just beneath the skin.\nTwo days after the injury, closed reduction was attempted under general anesthesia. The knee was flexed to 120° and valgus stress and internal rotation of the lower thigh were applied. The dislocated knee was reduced and the dimple sign disappeared. The posterolateral dislocation could be reproduced by external rotation at 100–120° flexion. After reduction, ligament instability tests were positive for valgus stress, with signs of posterior sagging in the posterior drawer test, and negative for the Lachman test, pivot shift test, extension recurvatum test, and dial test. A subsequent arthroscopic examination also revealed a complete midsubstance tear of the posterior cruciate ligament (PCL) () and a partial tear of the posterolateral bundle of the anterior cruciate ligament (ACL), which were not reconstructed (). A peripheral longitudinal tear of the lateral meniscus was repaired using the Fast Fix 360 Meniscal Repair System (Smith & Nephew, Andover, MA, USA) ().\nThereafter, a 7-cm medial longitudinal incision was made to repair the medial collateral ligament (MCL). The medial retinaculum and capsule were torn along with the distal end of the vastusmedialis. The MCL was completely detached from the femoral footprint. Button holing of the medial femoral condyle through the medial retinaculum and the capsule could be reproduced by valgus stress and external rotation in the knee flexion position (). In addition, the dislocation could be reduced by internal rotation of the lower thigh. The MCL was fixed to the femoral footprint using Suture Anchors (Mitek Products, Johnson & Johnson Company, Westwood, MA, USA). The medial retinaculum and the capsule were also repaired. Postoperative radiographs showed normal alignment (). Range of motion (ROM) exercises was started after 3 weeks of immobilization with a cylinder cast. Full weight bearing with a knee brace was allowed 4 weeks after surgery. One year postoperatively, no knee symptoms were observed and the ROM was 0–145°. There was no ligament instability except for the PCL at grade II. |
The second case is a 75-year-old gentleman with a background of ulcerative colitis who underwent an elective open tube graft repair for an 8 cm inflammatory aneurysm. In retrospect, inflammatory features are seen to extend distally to the iliac bifurcation on initial imaging (). Thus, the patient may have benefited from the management of this at the initial surgery.\nFourteen months later, he presented to the emergency department with melaena and haemoglobin of 62 g/l. Following resuscitation an OGD was normal and CT angiography was unable to determine any definitive active bleed but suggested a possible AEF given the close proximity of the third part of duodenum to the aortic graft. Twenty-four hours later, the patient collapsed with a large amount of melaena and frank rectal bleeding in hemorrhagic shock. A new CT scan showed an AEF between distal right common iliac artery and ileum () not associated with the suture line of the previous open repair. Of note, this was found to be present on initial emergency imaging when reviewed by a specialist vascular radiologist.\nThe previous open aneurysm repair was relined with 84 × 24mm COOK® bifurcated endovascular aortic aneurysm repair (EVAR) and 13 mm COOK® limb extension into the right external iliac artery with embolisation of the internal iliac artery. Procedure completed with 24mm COOK® stent extension into contralateral common iliac artery. The patient recovered well from the initial procedure and returned to theatre the next day for laparotomy and resection of the distal ileum adhered to the inflammatory iliac aneurysm. Joint case with the emergency general surgery team at the local hospital performed with extensive washout and small bowel side to side stapled primary anastomosis.\nAside from a prolonged ileus, the patient made a good recovery with intravenous antibiotics and steroids. The patient was discharged on lifelong antibiotics according to local microbiology guidance. At 3 months and 12 months follow up, no evidence of recurrence of AEF, sepsis and no associated mortality. This patient will continue on lifelong surveillance with cross-sectional imaging. Informed consent was obtained from each patient and next of kin when appropriate for this case review. |
A 70-year-old white man developed right knee pain and swelling followed by left ankle pain and swelling over a week. Over the next 4 months, his symptoms progressed to include both knees, both feet, and both hands. Due to the severity of his symptoms he was unable to ambulate or carry out normal activities of daily living. He initially took ibuprofen 800 mg three times daily with some mild improvement, but at the time of presentation, it offered no relief.\nIn addition, he endorsed morning stiffness that persisted for most of the day. Due to the stiffness in his joints, he could no longer ambulate and presented to our clinic in a wheelchair. He previously was fully functional and independent in his activities of daily living. He was an avid fisherman and was unable to pursue his interests at all.\nHis past medical history was significant for metastatic melanoma initially diagnosed 2 years ago. His initial lesion was located over the left side of his neck and he had a Mohs procedure with negative margins. He was monitored closely for 1.5 years until he was found to have new right lower lobe lung nodules on positron emission tomography (PET)/computed tomography (CT) with increased fluorodeoxyglucose (FDG) uptake. Wedge resection of the right lower lobe revealed metastatic melanoma with wild type BRAF and no C-KIT mutations. Continued surveillance demonstrated an increasing number of right pulmonary nodules over the next 6 months. Dual therapy nivolumab (1 mg/kg every 3 weeks for four doses followed by 240 mg every 2 weeks) and ipilimumab (3 mg/kg every 3 weeks) immunotherapy was started. After the second cycle of his immunotherapy he developed severe non-infectious colitis requiring hospitalization. His immunotherapy was stopped and his colitis resolved with supportive care and glucocorticoids. Without further immunotherapy, he developed new left pulmonary nodules within 6 months that were increasing in size. Single agent immunotherapy with nivolumab (240 mg every 2 weeks) was started 4 months before his presentation to Rheumatology. With single agent immunotherapy, the pulmonary nodules receded fully and no further metastatic disease was seen on subsequent PET/CT imaging 3 months later.\nHis medical history was also notable for hypertension and benign prostatic hypertrophy.\nHe was treated with hydrochlorothiazide, aspirin, and nivolumab. He had no known drug allergies.\nThere was no family history of connective tissue disease or inflammatory arthritis. His mother died from colon cancer in her 80s and his father had coronary artery disease. He was married with three living children. He served in the Navy during the Vietnam War and worked as a mechanic after his military service until retirement. He denied any history of recreational drug or alcohol use. He reported a 20-pack year tobacco smoking history, but quit over 10 years ago.\nHe denied having any chest pain, shortness of breath, rashes, oral or nasal ulcers, alopecia, Raynaud’s disease, fevers, chills, night sweats, or unintended weight loss. He did endorse feeling weak because of his chronic condition.\nHe appeared his stated age and in no apparent distress. His temperature was 37 °C, blood pressure 116/78, heart rate 70 beats per minute, and oxygen saturation 100% on ambient air. His musculoskeletal examination was significant for tender boggy synovitis of his bilateral metacarpophalangeal joints (MCPs), proximal interphalangeal joints (PIPs), wrists, elbows, knees, ankles, and metatarsophalangeal joints (MTPs). There was no palpable effusion in any joint but he had significant soft tissue pitting edema present over his extremities. There was +3 pitting edema over the dorsum of both hands and feet extending up to his wrists and mid-shins respectively. There was mild erythema and warmth present over his joints, most notable over his MCPs (Fig. ). There was decreased range of motion in his hands, feet, ankles, elbows, and knees. There also were extensor tendon rubs noted on range of motion of his MCPs bilaterally by palpation and auscultation. The remainder of the musculoskeletal examination and general physical examination was unremarkable. There were no rheumatoid nodules noted on examination.\nResults of the laboratory evaluation are shown in Table . Our patient’s erythrocyte sedimentation rate and C-reactive protein (CRP) were quite elevated. The remainder of his laboratory tests was unremarkable. Ultrasound and X-ray imaging of his hands were obtained (Figs. and ) demonstrating soft tissue swelling and extensor tenosynovitis. There were no erosions present.\nHe was started on prednisone 40 mg (0.5 mg/kg per day) and tapered gradually over the course of 6 weeks to 10 mg daily. He had a very rapid response to the prednisone with almost complete resolution of his symptoms. Once his prednisone was decreased below 10 mg he began noticing a steady return of his symptoms. During this time period he continued treatment with nivolumab and on surveillance imaging he had complete resolution of metastatic disease. Due to the marked response of his melanoma to immunotherapy, it was felt that paraneoplastic RS3PE was unlikely. Although at the time there were no published reports of nivolumab or other checkpoint inhibitors causing a RS3PE picture, it was felt that because of the temporal relationship between the nivolumab and the acute onset of his symptoms that they were related. The numerous previously described autoimmune conditions associated with checkpoint inhibitors raised the possibility that this presentation of RS3PE was another rheumatological manifestation. The clinical dilemma we were left with was that our patient had previously demonstrated a very rapid relapse of his stage 4 melanoma when off treatment, yet was incapacitated with the side effect of the treatment. After a careful discussion with his oncologist, we elected to maintain a steady dose of prednisone of 7.5 mg daily to control rheumatological symptoms and continue nivolumab. At 9 months, he demonstrated minimal pitting edema, no inflammatory arthritis, and continued full response from nivolumab therapy. |
A 16-year-old boy, with no medical history, presented to the emergency department in March 2014 complaining of severe headache of 1-month duration. The headache was progressive in nature and associated with recent development of vomiting and blurred vision. There was no history of fever, weight loss, recent travel, or contact with sick patients.\nThe neurological examination showed massive papilledema with vertical nystagmus and diplopia.\nThe laboratory test results were normal including complete blood count, urea, electrolytes, and liver function tests. Provisional clinical diagnosis of intracranial space-occupying lesion was made, and MRI of the brain with intravenous gadolinium was performed for further evaluation. The MRI [] showed an enhancing midline mass at the pineal region causing obstructive supratentorial hydrocephalus.\nAdditional laboratory tests for AFP and BHCG showed normal results. Pineal gland germinoma was suspected. MRI of the whole spine was performed and returned to be normal. The patient was initially managed by third ventriculostomy and external ventricular drain placement. CT examination after removal of the ventricular drain is shown in .\nThe patient underwent excision biopsy with frozen section histopathology demonstrating granuloma consistent with TB with encephalitis without any malignant cells. The final pathology report confirmed the diagnosis and showed few small non-necrotizing granulomas, perivascular lymphocytic infiltrates, and reactive microglia without evidence of malignancy. ZN stain for acid bacilli was negative. However, considering the low sensitivity of the stain, TB was the leading diagnosis while sarcoidosis was the less likely second differential consideration. Sarcoidosis was excluded as CT chest was normal and angiotensin-converting enzyme level was negative. The decision was made to start the patient on anti-TB medications for 18 months and dexamethasone for 6 weeks. MRI was performed 2 months after the start of treatment [] and showed significant decrease in the size of the enhancing lesion.\nThe patient was followed up in the clinic for 2 years, and all the symptoms have resolved except for persistent binocular diplopia. MRI examination after 1 year of the treatment [] was performed and showed further decrease in the size of the granuloma.\nIn December 2016, the patient presented again with new onset of gradual left side hypoesthesia, weakness, and unsteady gait. He did not report fever or night sweats. Neurological examination revealed normal fundoscopy without papilledema. The 3rd cranial nerve palsy was present on the right side with diagonal diplopia in all direction including primary gaze. Motor examination showed mild left-sided drift with no hyperreflexia.\nSensory examination showed left-sided numbness with impaired left upper and lower limb proprioception. The right-sided dysdiadochokinesia was also noted.\nMRI examination [] was done and showed two new enhancing lesions at the right cerebral peduncle and right thalamus. CSF analysis was normal. PPD test was negative. The patient was diagnosed as paradoxical reaction and recommenced on anti-TB medications.\nThe treatment was effective with resolution of the patient’s symptoms. MRI examination performed in March 2017 [] and December 2019 [] showed resolution of the tuberculoma with residual gliosis. The patient is currently asymptomatic and following in the clinic. |
A 69-year-old woman was admitted to our hospital because of weight loss and progressively worsening dyspnoea. Her previous medical history was unremarkable. She was admitted to the internal medicine department. A cardiologist was consulted because of atrial fibrillation with rapid ventricular response and an enlarged cardiac silhouette on her chest X-ray. On physical examination her blood pressure was 120/70 mmHg with a heart rate of 120 beats/min. She had engorged jugular veins and an enlarged liver without peripheral oedema. Her ECG showed atrial fibrillation and low voltage. No Q waves were noted. An echocardiogram showed a large pericardial effusion of more than 30 mm and a swinging heart (Fig. ). The left ventricle was small and hyperdynamic without wall motion abnormalities. There was no collapse of the right ventricle. The inferior vena cava was dilated without inspirational collapse. Because of imminent cardiac tamponade a pericardiocentesis was performed with the immediate evacuation of 800 cc of haemorrhagic pericardial fluid. Six hours after this procedure control echocardiography was performed which showed only a small amount of pericardial fluid, but now a poor left ventricular function with general hypokinesia and anterior and septal akinesia. T-wave inversion and Q waves were seen on the ECG in the anterolateral leads (Fig. ) but the cardiac markers were not elevated. She was treated with ACE inhibitors, diuretics and low-dose beta blockade. Analysis of the pericardial fluid showed malignant cells and on a chest CT scan a mass was detected. Subsequently, she was diagnosed with small cell lung carcinoma (SCLC) stage IV with metastasis to the pelvis, pericardium and brain and treated with radiation therapy. She was discharged and returned several months later with complaints of fatigue and progressive dyspnoea. Echocardiography again showed a large pericardial effusion; the left ventricle now had a normal systolic function without wall motion abnormalities. The ECG now showed normal R progression in the anterior leads with disappearance of Q waves (Fig. ). She was again treated with pericardiocentesis and was discharged the following day. After this episode she died at home as a consequence of her progressive lung carcinoma. |
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 54-year-old male physician presented to the emergency department with a 4-day duration complaint of ataxia and bilateral lower extremities numbness (right greater than left) which had progressed. Additionally, he had experienced an episode of fecal incontinence without any bladder issues. The ataxia had been progressively worsening without significant focal weakness.\nHis medical history was significant for ENB of the anterior cranial fossa treated with resection and radiation therapy 13 years prior to this admission. He then underwent left cervical lymph node resection and local radiation of his ENB metastasis 6 years after the initial craniotomy due to the finding of an anterior neck mass. Two years later, during a posttrauma evaluation for neck pain, it was noted on his bone scan that he had multiple metastatic lesions to the cervical spine without any cord compression. At that time, he started on chemotherapy with Cytoxan, adriamycin infusion, and DTIC. After some response in his cervical lymph nodes, he was taken off chemotherapy for a period. Due to progressive adenopathy, the patient started on cisplatin and VP-16 for several months. Once again, his symptoms stabilized.\nThree years prior to this admission, due to a diagnosis of leptomeningeal spread, the patient underwent a repeat craniotomy for resection of his anterior fossa recurrence, followed by whole brain radiation. Following a complaint of mid-lower back pain, he was diagnosed with a T11 lesion and had local radiation. To treat progression of his leptomeningeal disease, he completed three cycles of temodar in the year prior to this admission. His medical history also included scoliosis surgery with Harrington rods 25 years prior to his last admission.\nOn physical examination, the patient had slight weakness of his left lower extremity, especially his left extensor hallucis longus. He had decreased light touch and pinprick sensation of his right T11 dermatome and diminished proprioception of his left lower extremity. He had decreased rectal tone and hyperreflexia of his left knee with trace right ankle reflexes. There was a positive Babinski sign on the left. Due to artifacts from Harrington rod scoliosis correction of his thoracic spine, we obtained a CT myelogram in addition to the MRI of his thoracic spine. The CT myelogram revealed a near-complete block of contrast at T8-9 (). His cervical spine MRI showed stable metastasis to his C5-6 level without any cord compression. Multiple bony lesions throughout the spinal vertebras were noted.\nGiven the patient's medical history and symptoms, surgical resection was recommended. He underwent a posterior laminectomy from T7–9. Epidural and intradural extension of the tumor to the ventral left side of the cord with significant cord compression was noted. With a finding of arachnoid plane between the tumor and spinal cord, microsurgical technique was used to remove 80–90% of the tumor and duraplasty was performed from T7–9 to create space in case of tumor recurrence.\nMicroscopic examination of T8 lesion revealed a small cell tumor lacking necrosis (). Immunohistochemical analysis showed diffuse immunoreactivity for neuron-specific enolase and synaptophysin (Figures and ), with scattered cell positive for chromogranin A (). S100 stain showed perilobular disposition of flattened cells, indicative of sustentacular differentiation (). The findings were of a metastatic neuroendocrine carcinoma, compatible with an esthesioneuroblastoma.\nPostoperatively, the patient did well with a stable neurological exam followed by completion of 2 cycles of chemotherapy with Cytoxan, adriamycin, and DTIC. At his follow-up visits every 3 months, his tumor remained stable on CT and MRI studies for a period of one year.\nShortly thereafter, the patient presented with worsening ataxia and bilateral lower extremity numbness and paresthesias. His motor exam was worse indicating bilateral 4/5 strength diffusely in his lower legs. The MRI and CT myelograms of his thoracic spine revealed recurrent tumor extending above the resection cavity from T7-8 with significant cord compression ().\nThe patient underwent a microsurgical resection of his intradural tumor with extension of his laminectomy. Ventral-lateral extension of his tumor to the neural foramens was noted. The canal was widened and once again, duraplasty from T6–9 was performed. The histology was of a persistent esthesioneuroblastoma. Postoperatively, his exam remained stable and he was discharged to a rehab facility. The patient subsequently had local radiation to his thoracic surgical cavity and his lower cervical spine (C5-6), which showed progression of his tumor without significant clinical symptoms.\nA year later, despite radiotherapy and aggressive treatment, the patient again presented with worsening lower extremities weakness. His MRI and myelograms illustrated recurrence of his tumor in his upper thoracic spine and contrast block at the T8 level (). Consequently, the patient underwent staged resection and exploration of his tumor from T4–T10 with decompression of his neoplasm. Onlay duraplasty with subarachnoid drain placement above the resection cavity was performed. He continued treatment with physical therapy and was followed by the pain service for his neurogenic pain and spasm.\nEight months after his last resection, the patient's MRI studies showed progression of his tumor with soft tissue masses throughout his thoracic spine and diffuse gliosis. No further significant canal stenosis was noted (). He was dependent on a wheelchair, but physical therapy felt that he might get some improvement in strength with intense rehabiltiation. Thus, he was transferred to inpatient rehabiltiation. Three years later, he passed away from pneumonia. |
Our patient, a six-year-old girl, was taken by her parents to the Upazila Health Complex's emergency setup, which is the rural primary health care center of Bangladesh with per vaginal bleeding for the last 2 hours. According to the child's mother, bleeding was mild at the beginning, but it increased with time. There was no other bleeding site, and she had no history of obvious trauma or sexual abuse. The patient did not have any significant past history. Her vaccination was complete according to the EPI (Expanded Program on Immunization) schedule of Bangladesh. She was a bit anxious and pale. Her blood pressure was 95/65 mm Hg with a pulse rate of 118 per minute, and respiratory rate was 30 per minute. She had an average body weight for her height.\nOn examination, she looked pale, and her abdomen was normal. Her perineal area was packed with several pieces of cloth that were soaked with blood. After removing the pieces of cloth, there was active bleeding from external genitalia. Her hymen was intact, and there were no signs of injury in the external genitalia. Through perineal examination of the patient was not possible at that time because she was agitated. An external pack was given by a sanitary napkin, and the patient was transferred immediately to OR after fluid resuscitation. Meanwhile, further questioning, the parents revealed that she had a history of swimming in a nearby pond just before the incident, which allows us to consider leech bite as a differential diagnosis.\nLater on, the patient's perineal area was examined thoroughly in the OR under deep sedation. We explored the perineal area, and it was negative for any injury or lacerations or signs of trauma. There was bright red blood and clots over the introitus. After removing the clots and blood, it was evident that bleeding was coming from the vagina. Vaginoscopy was not performed in the first attempt with a view to avoiding unnecessary injury to the hymen. The vagina was widened and exposed with finger, which revealed several pieces of clots. After removing the clots with mosquito forceps, a moving black object was seen along the right lateral wall of the vagina. About 200 ml normal saline was irrigated into the vagina, which facilitates dislodgement of 1.5 cm leech from the vagina to the introitus. Then, it was removed gently by forceps. After that, a mucosal injury was found along the right lateral wall just above the external vaginal opening and which seems to be the site of active bleeding. No photo was taken of the external genitalia because of the parent's religious belief.\nThe vagina was further flushed with 100 ml normal saline, and iodine-soaked gauze was used as an internal vaginal pack. The patient was transferred to the inpatient department with a diaper, and her diaper was checked every 30 minutes. There was no more bleeding, and the internal pack was removed after 12 hours. Further examination of external genitalia showed no active bleeding, and the patient was stable. She was discharged after 24 hours of her admission with an oral antibiotic. After seven days of follow-up, we did not find any signs of infection or complication. |
On January 10, 2014, a 43-year-old woman was admitted to our hospital with a persistent enlarged mass in her right breast. The mass was painless and without nipple discharge or hemorrhage. Her medical history was unremarkable, whereas her family history discovered that her mother was diagnosed with left breast cancer at the age of 60. On physical examination, the patient had a palpable, soft tumor, approximately 2 cm in diameter mass, located in the upper lateral quadrant of his right breast. It was a well-defined, mobile mass, not adherent to either the skin or chest wall. No axillary lymph nodes were found and all laboratory studies were within normal limits.\nCurrent mammography revealed a well-defined homogeneous lesion corresponding to the palpable mass of 28 mm × 34 mm in size located in upper lateral quadrant (). Targeted breast ultrasonography demonstrated a large heterogeneous and hypoechoic lesion, in the upper lateral quadrant with its largest dimension approximately 3 cm. Fine-needle aspiration was performed and the results were suggestive for mesenchymal tumor. The patient eventually underwent an excision biopsy and frozen section analysis confirmed the presence of an encapsulated mesenchymal tumor of unknown biological potential with positive surgical margins. Subsequently, the patient had a larger tumor excision without sentinel lymph node biopsy.\nGross pathology of the resected specimen demonstrated a 4 × 3 × 2 cm measuring, coloured tumor without skin infiltration and containing hemorrhagic fluid. The histological examination of the tumor showed a typical vascular pattern with vessels forming a continuous ramifying network filled with erythrocytes. The tumor cells appeared round to fusiform with a dense reticulin meshwork surrounding the individual tumor cells (). The calibre of the vascular spaces varied considerably. Areas of hemorrhage and cystic degeneration were found. The mitotic activity was not significantly increased without necrosis. Affiliated immunohistochemistry was performed. The tumor cells expressed CD34, bcl-2, CD99, and vimentin and were negative for LCA (leukocyte common antigen), desmin, SMA (smooth muscle antigen), CK7, CK34, BE12, CK19, and CK20, (). This immunohistochemical expression profile and the morphological aspect were consistent with the diagnosis of a malignant hemangiopericytoma with low grade of differentiation. Moreover, due to the R0-resection, adjuvant radiotherapy was not mandatory and simply meticulous follow-up was advised.\nApproximately one year after diagnosis the patient remains well, without tumor recurrence. |
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. |
Herein we report a case of a 55-year-old female patient who sought medical attention complaining of generalized “swelling,” mainly of the hands and feet. The edema had begun at the ankles 35 years previously when she was pregnant. According to the patient, the edema worsened at the end of the day. Over the years, the edema spread to the hands and wrists and currently affects the entire body causing abdominal discomfort at the end of the day. Over the years, the patient sought several medical specialists to reduce the symptoms of edema. However, no effective results were obtained in spite of the therapeutic approaches, mainly with diuretics. She was referred to the Clínica Godoy, Brazil, where the medical history was taken and a physical examination was performed. Generalized edema was identified, especially in the lower limbs, which was present in the early morning and worsened during the day especially on hot days. Another important fact reported by the patient was the weight gain of 1 to 2 kg by the end of the day. A bioimpedance test was performed using the In Body S10 apparatus, which detected a large amount of extracellular fluids in the entire body and intracellular fluids at the upper limit of normality. By bioimpedance, the volume of fluids in the lower extremities and trunk was above the upper limits, as was the ratio between extracellular fluids and total fluids which characterizes edema (). The upper limbs had a higher than normal volume of fluids, but without characterizing edema. After analysis, the diagnosis was idiopathic cyclic edema, clinical stage II lower limb lymphedema, lipedema stage I and excessive weight. Calcium dobesilate b.i.d. was prescribed and after four days another bioimpedance was performed that showed a significant reduction of the fluids of the upper limbs and trunk that was within the range of normality for the whole body. This study was approved by the Research Ethics Committee of the Medical School in São José do Rio Preto (#048856/2016, CAAE 56497016.6.0000.5415). |
A 73-year-old Hispanic woman presented to clinic with a rapidly growing pigmented left lower eyelid lesion with extension of pigment to the bulbar conjunctiva. Biopsy results revealed malignant melanoma of the left lower lid, skin, and bulbar conjunctiva. The patient refused orbital exenteration and decided to undergo tumor excision surgery with the hope of achieving negative margins. She subsequently underwent a left lower eyelid resection with the use of a TPF reconstruction.\nA full-thickness defect was created using a no.15 blade to excise the lower lid from the sidewall of the nose, down to the level of the inferior orbital rim and across the entire horizontal length of the infraorbital rim and to the lateral canthus area. The eyelid and portion of the upper cheek was removed in toto ().\nA 2 × 5 cm composite nasal cartilage-mucosa graft was harvested from the left septum of the patient and was placed into the defect as a tarsus with the mucosa facing the eyelid (Figures and ). The fornix was first reformed by suturing the remnants of the bulbar conjunctiva to the sutures. The medial canthus was reformed by placing two sutures through the remnants of the medial canthal tendon. These sutures were then placed through the medial edge of the cartilage mucosal graft in a mattress fashion and then tied. Sutures were placed through the periosteum of the lateral orbital rim slightly above the original insertion site of the lateral orbital tubercle and used to secure the lateral edge of the composite graft.\nTo begin the TPF, the superficial temporal artery was palpated approximately a centimeter anterior to the root of the helix. Local anesthesia with epinephrine was infiltrated along the course of the skin incision from the tragus of the ear along the course of a hemicoronal scalp incision. The incision was made to the level just deep to the hair follicles of the scalp. Dissection proceeded in the immediate subfollicular plan to expose the underlying superficial temporal artery and vein with their investing fascia. Bipolar cautery was used to prevent compromise of the flap vascularity. After exposing the artery and its fascia to approximately the midline of the head, the fascia was incised to generate an approximate 4-5 cm wide flap. In a lateral quadrant, dissection was carried down to the level of the periosteum. At this level, periosteum was reflected away from the bone exposing the underlying temporalis muscle and temporalis fascia. The fascial flap was then elevated off the underlying deep temporal fascia and pedicled entirely on the superficial temporal artery and vein (Figures and ).\nUsing endoscopic visualization and endoscopic instruments, a tunnel in a plane deep to the TPF, just above the true temporalis fascia was created approximately 2 cm above the zygomatic arch to the level of the lateral orbital rim. At the level of the orbital rim, the flap was retrieved and pulled across the lower lid defect and sutured into the medial canthus area over the composite nasal cartilage-mucosa graft (). The TPF was then secured to the rest of the lower lid defect. At the superior edge, the TPF was secured to the tarsus mucosal graft, ensuring draping of the mucosa over the edge of the TPF. The TPF was then secured at the lateral canthus area by placing a vicryl suture through the periosteum of the lateral orbital rim, and then through the edge of the TPF. The inferior edge of the TPF was anchored to the remnants of the suborbicularis oculi fat pad using multiple bites of vicryl suture.\nOnce the TPF had been anchored into position overlying the defect, attention was then turned to the skin graft. An elliptical skin graft approximately 5 × 8 cm was removed from the forearm and was placed over the TPF and secured at the cardinal points using buried sutures (). The remainder of the closure was completed using a combination of interrupted and running sutures. Great care was taken at the lid margin to ensure that mucosa from the composite graft was draped over the margin edge to prevent rubbing of keratinized skin against the globe. A pressure dressing was applied to the area to prevent hematoma formation. Postoperatively, the patient healed well, and her pain was well controlled. The flap was edematous in the immediate postoperative period, but the edema resolved, and the flap was successful. |
A 31-year-old pregnant Caucasian female, gravida 3, para 1, at 28 weeks of gestation was admitted to the hospital complaining of a sudden onset of moderate lower abdominal pain. She denied trauma. The patient’s past medical history was unremarkable. There was no history of intrauterine device. The patient reported one uncomplicated miscarriage, followed by uterine curettage, after which she became pregnant and delivered vaginally at term. Uterine perforation was not suspected during uterine curettage, on the other hand no laparoscopy procedure was done after curettage to exclude injury. The second pregnancy and delivery were uneventful. The course of the recent pregnancy had also been uneventful. A physical examination revealed vital signs that were within normal ranges. An abdominal examination revealed that her abdomen was soft and tender. The uterus was soft and not tender, and contractions were not present. The patient was feeling fetal movements well, and a fetal non-stress test showed that the fetus was reactive. The severity of pain increased gradually. Initial laboratory investigations showed no abnormalities. An ultrasound scan showed a live fetus in a longitudinal lie with cephalic presentation. The placenta was on the anterior wall of the uterus. Abnormal placental localization and hematoma were not found. The amniotic fluid index was in the normal range. The pain was increasing gradually, and the next day, the patient was transported to a tertiary referral hospital. Upon admission, the patient’s abdomen was tender, with guarding. Her vital signs were within normal range. The uterus was soft and not tender, with irregular uterine contractions. The patient was feeling fetal movements well, and the result of a fetal non-stress test was reactive. An ultrasound scan was performed again, and it revealed free fluid inside the peritoneal cavity. In the Pouch of Douglas, there was a 75 × 35 mm nonvascularized area, which suggested the presence of a blood clot. The other abdominal structures were without abnormalities. A blood analysis showed a 2 g/dL decrease in hemoglobin level. An exploratory laparotomy was performed, and 1000 mL of blood was evacuated from the abdominal cavity. The adnexa were without macroscopical changes. The left parametrium was enlarged and purplish. The fundal height was appropriate for the number of weeks of pregnancy, without any macroscopic changes in the anterior wall. The enlarged gravid uterus was moved gently forward to reveal the posterior wall. On the posterior wall, there was a defect (approximately 10 cm) in the muscular wall, with active bleeding (Fig. ). The amniotic sac was intact inside the uterus. No pelvic adhesions were found, and no endometriosis foci were found. Bleeding was excluded from the gastrointestinal tract, spleen, liver, kidneys and the mesentery. Due to the extent of the defect and the magnitude of the bleeding, a caesarean section was performed, followed by hysterectomy. A live female infant weighing 1000 g, with Apgar scores of three was delivered. The estimated blood loss during surgery was 2000 mL. Six units of packed red cells and three units of fresh frozen plasma were given to the patient. Histopathological examination of the uterus did not reveal muscle disease or endometriosis. The patient was discharged from the hospital in good general condition after 11 days. The baby was discharged from the hospital after 70 days, also in good general condition. |
This case involved a 71-year-old woman with a primary complaint of gait disturbance. The patient had a history of hypertension and cerebral infarction, and she had been taking oral antihypertensive and antiplatelet agents. The patient had no sequelae of cerebral infarction, after which she had a good course taking oral antihypertensive and antiplatelet agents. Diabetes mellitus is a common cause of Charcot arthropathy, but the patient did not have diabetes mellitus. The patient also had no family history of a cause of Charcot arthropathy or a neurological disease. She had a history of the present deformities of the left knee joint and ankle from around 65 years of age, but the patient left them untreated because she did not have severe pain. From around 69 years of age, varus deformity of the left ankle progressed. The patient developed difficulty walking and, therefore, visited our department for consultation. Physical examination showed that the left leg was shorter by 20 mm, with a functional leg length discrepancy. The patient was limping, but not using any assistive device. Marked varus instability of the left ankle was observed during the stance phase of walking (). Range of motion in the left knee joint was extension of -15° and flexion of 75°. There was marked swelling, but no instability (). The left ankle joint had marked swelling, and the foot was medially dislocated. A skin ulcer had formed at the lateral malleolus ().\nPlain X-ray of the left knee revealed marked narrowing at the joint space, depression and an osseous defect of the medial tibial articular surface, and marked proliferative changes of the femoral condyle (). Plain X-ray of the left ankle joint showed medial dislocation of the talus bone, accompanied by an old fracture of the medial malleolus, an osseous defect of the distal medial tibial articular surface, and an osseous defect of the proximal talus articular surface (). A lower extremity full-length standing X-ray showed a femorotibial angle (FTA) of 202° ().\nThe patient had an HbA1c level of 6.1% and a fasting glucose level of 103 mg/dL; the patient was not considered to have diabetes. Syringomyelia was not observed on whole-spine MRI. The Treponema pallidum hemagglutination test was positive. White blood cell and C-reactive protein levels were normal. There were no general bacteria on culture of synovial fluid from the knee and ankle joints. On electrophysiological testing with the nerve conduction velocity test, a bilateral delay in motor nerve conduction velocity was observed in the deep peroneal nerve, and similarly, a bilateral delay of sensory nerve conduction velocity was observed in the sural nerve.\nTotal knee replacement and ankle (tibiotalar arthrodesis) fusion were performed with the patient under general anesthesia in the supine position and a thigh tourniquet. The medial parapatellar approach was used for the knee joint. A marked intra-articular osteophyte and formation of giant loose bodies surrounding the femur were observed (). The large mass of local bone was saved for ankle arthrodesis ().\nA 5 mm defect was observed at the medial tibia. After drilling, cement was inserted as filling. The posterior-stabilized (PS) type was fixed with cement (), and the wound was closed. Next, surgery on the ankle joint was performed using an anterior approach. The distal tibial articular surface and proximal talus articular surface were rasped, drilling was performed, and the bone was repositioned to a neutral position without shortening (). Subsequently, an autologous bone graft from the knee was placed at the talocrural joint space, and the wound was closed. Ilizarov external fixation was used to fix the bone. First, two straight wires and two half pins were inserted into the proximal-to-mid tibia and attached to the proximal full ring, and then, six straight wires were inserted into the calcaneus and attached to the distal foot ring. In addition, six straight wires were inserted into the distal tibia for strong fixation ().\nThe total operative time for the combined procedure was 152 minutes. The hemoglobin concentration decreased from 13.9 mg/dL preoperative1y to 9.8 mg/dL on postoperative day 1, but the patient was not transfused. On postoperative day 3, knee drainage material was removed, oral antiplatelet administration was resumed, and walking with full weight-bearing was permitted. Hospitalization was prolonged for 14 days. The ankle fusion appeared to have healed by 9 weeks, as evidenced radiographically and on CT by the absence of a lucent line at the arthrodesis site. The external fixator of the ankle was removed on postoperative day 92. At follow-up 7 years after the simultaneous surgery, the patient was satisfied with the procedure. Her American Orthopaedic Foot & Ankle Society scale ankle/hindfoot scale scores improved, from 32 before surgery to 91 after surgery. SF36 scores improved, from 24.1 (physical component summary) before surgery to 51.1 (physical component summary) after surgery and from 16.5 (mental component summary) before surgery to 59.5 (mental component summary) after surgery. The Visual Analog Scale improved, from 75 before surgery to 0 after surgery. The Knee Society subjective and physical examination score improved, from 25 before surgery to 85 after surgery. The patient's clinical score was checked on the day before surgery and 3 months after Ilizarov external fixation removal. |
A 57-year-old female with a prior history of hypertension, was diagnosed with Stage IIIC high-grade serous ovarian carcinoma (HGSOC) nearly 5 years ago. The patient received neo-adjuvant chemotherapy with paclitaxel and carboplatin every 3 weeks for 3 cycles. A repeat scan done post 3 cycles showed partial response to treatment and patient underwent a cytoreductive surgery at an outside center. The surgical pathology was consistent with Stage IIIC disease noted earlier with lack of good response to carboplatin and paclitaxel given neoadjuvantly. Hence treatment was switched to gemcitabine, cisplatin and bevacizumab during adjuvant therapy for 3 cycles. A repeat scan done post completion of treatment showed complete resolution of disease.\nThe patient remained disease free but had a relapse with the PET scan showing FDG avid lesions in the liver and pouch of Douglas after 3 years. The patient was started on second-line chemotherapy with gemcitabine, cisplatin and bevacizumab. However, bevacizumab was discontinued after first dose as the patient developed internal bleeding in the operative bed. Next two cycles of chemotherapy were continued with gemcitabine and cisplatin alone without bevacizumab. A CT scan done post completion of 3 cycles of treatment showed response to therapy. The patient did not continue any further chemotherapy at this time due to toxicity issues. No PARP inhibitor was offered due to BRCA negative status on germline testing at the time. The patient developed progressive disease after 9 months and underwent a second surgery with excision of the vaginal vault and the pelvic mass and omentectomy. Histopathology was suggestive of metastatic HGSOC. For the ideal therapeutic options, the sample was sent for multi-analyte Exacta® analysis. The overview of the treatment given is summarised in ().\nThe integrative, multi-analyte Exacta® test includes molecular analysis of comprehensive gene expression, DNA mutation profiling, chemosensitivity assay, immunohistochemistry and immunocytochemistry. For targeted transcriptome analysis, RNA from tumor tissue and adjacent normal tissue were used. Significant differential expressed genes were called using the following threshold: absolute log fold-change ≥ 2 and p-value < 0.05 (). The gene expression analysis showed the expression of 6984 genes in which 1970 genes were differentially regulated when compared to adjacent normal tissue. Out of 1970 genes 957 genes were upregulated and 1013 genes were downregulated (Supplementary Table 1). Next generation sequencing analysis for mutations and amplifications of 409 oncogenes and tumor suppressor genes was carried out on the FFPE tumor tissue and cell free DNA. Tumor mutation analysis detected mutations in genes CTNNB1 (p. G34V), TP53 (p. N263fs), PKHD1 (p. R3107Q) and IGF2R (p. A1425A) mutations. Copy number alteration analysis showed a copy loss in chromosomal regions including 4p, 4q, 5p, 5q, 6p, 7p, 10q, 11p, 12q, 13q, 17p, 17q, 18q, 19p and a copy gain in 7q and 16p. Longitudinal mutation profiling of cell-free DNA (cfDNA) was performed for the serial monitoring of circulating tumor burden in patient. Mutation load varied in the range 0% to 0.13% until 2019. However marginal increase in the mutational load of 0.26% and 0.56% was observed in the next follow-up samples (). TP53 (p. A159V and p. W146fs) gene mutation was observed in cell free nucleic acid analysis and are reported to be associated with early relapse and adverse prognosis in HGSOC. She was negative for any germline mutations.\nThe immunohistochemistry of the tissue samples revealed strong nuclear staining for ER (90% of tumor cells) and PR (80% of tumor cells); and moderate staining for AR (30% of tumor cells) (). Chemosensitivity assay was performed on circulating epithelial cells (CECs) isolated from peripheral blood sample and showed high and modest response to vinorelbine and temsirolimus respectively.\nPatient was then proposed treatment with Exacta® based novel regimen with weekly injection of temsirolimus and oral therapy with tab bicalutamide 50 mg once daily. Temsirolimus was used due to the presence of PTEN loss (10q23.2) on genomic analysis and due to chemosensitivity analysis showing response in vivo. Bicalutamide was used due to the immunohistochemistry showing AR expression and also due to the fact that PTEN loss is known to confer resistance to aromatase inhibitor based therapy targeting the ER/PR. She was also started on supplementary treatment with quercetin and vitamin E capsules as per Exacta® based recommendation. The patient received 3 cycles of the combination therapy. However, temsirolimus was stopped since she started experiencing vasomotor side effects and patient was continued on tab bicalutamide 50 mg once daily, quercetin and vitamin E. She remains with no evidence of disease and no disease relapse over the last 30 months of Exacta® guided therapy. |
Twenty-four-year-old morbidly obese African American gravida 1, whose pregnancy was complicated by poorly controlled asthma, was subsequently admitted fourteen times over the duration of her pregnancy for medical stabilization, seven of those admissions being in the first trimester alone. At 30 weeks gestation the patient was admitted for asthma exacerbation, and a chest X-ray was performed. A well-circumscribed 0.64 × 0.59 × 0.64 radio-opaque lung nodule was identified on a posterior/anterior view (). When the patient was initially questioned about the foreign body in her left main stem bronchus, the patient stated that she had swallowed her tongue piercing. The patient went on to say that this was her third tongue piercing in a 15-month time span; all others were swallowed incidentally as well.\nGiven the patients' poor respiratory status now complicated by an aspirated foreign body, pulmonology was placed on consult to assist with management. The risks versus benefits of bronchoscopy in the antepartum period were discussed in detail with the patient as well as a physician team that was involved in the care of this patient. It was decided that the combination of poorly controlled asthma and anesthesia is needed for the proposed bronchoscopy; the risk of respiratory failure was too high for the mother who was only at 33 weeks gestation at that time. Surveillance of the fetus was done with serial ultrasounds on a biweekly basis and nonstress tests were done on a daily basis. Estimated fetal weight was consistently found to be at the 40th percentile adjusted for gestational age, with no signs of fetal distress on daily fetal testing. Eventually at 35 weeks the patient was induced for maternal indications due to a deteriorating respiratory status and went on to deliver vaginally a liveborn male infant without complications. The placenta that was delivered was noted to have very large calcifications (some as large as three to four centimeters in diameter), which confirmed the degree of hypoxia that occurred during this pregnancy.\nFollowing childbirth the patient was brought to the endoscopy suite for a diagnostic as well as a therapeutic bronchoscopy. Of note, the patient's asthma was still poorly controlled despite delivering her child one week earlier. The patients' asthma continued to show no improvement despite treatment with high-dose steroids as well as routine beta 2 agonist therapy. It was decided to go ahead with removal of the foreign body in the left lung with the hope that her respiratory status would improve with expulsion. A flexible video bronchoscope was performed because of the distal location of the tongue piercing; her bronchial tissue was noted to be very friable and bled easily when grazed by the bronchoscope. The bronchoscopy failed to retrieve the foreign body, and as a postprocedure the patient was intubated by the anesthesia team because of extremely low oxygen saturations postprocedure and subsequently spiraled down into respiratory failure as feared earlier by the pulmonology team. An upright chest X-ray post procedure was done and the left lower base of the lung was noted to be completely clouded over; a supine X-ray was done as well; clear bases were seen bilaterally suggesting a gravitational shift of blood pooling in the left lung. The patient went on to spend two weeks intubated in the intensive care unit (ICU) with the diagnosis of acute respiratory failure, complicated by a postobstructive pneumonia secondary to the foreign body. Two more bronchoscopies were attempted to retrieve the tongue piercing, once again using flexible bronchoscopy, but both ended in failure. Despite aggressive antibiotic treatment, her pneumonia was not improving. The patient was finally taken to the operating room, and a left lower lung lobectomy was performed ().\nPostoperatively the patient returned to the ICU extubated, only on 2 liters via nasal cannula. The patient was discharged from the ICU on postoperative day 2, and spent five days on a medical/surgical step-down unit before being discharged to a rehabilitation facility. When discharged from the hospital, the patient was off all antibiotics and was only on a steroid taper as well her asthma medication regimen she was on prior to getting pregnant. After a two-week stay in an inpatient rehabilitation facility as well as a five-day stay at an inpatient psychiatric facility for major depression, the patient went on to make a full recovery. |
A 62-year-old man with a background history of diabetes mellitus presented with a five-month history of progressively enlarging, painless mass on the anteromedial aspect his left arm (Figure ). It was associated with constitutional symptoms, whereby patient claims to have lost 9 kg in the period of three months. He also noticed several areas of pigmented lesion over the mass which were painless. Over time, the swelling started to ulcerate with surrounding rashes, which prompted the patient to seek medical attention. There was no history of malignancy in his family. His occupation as an engineer in the Middle East caused him to have prolonged exposure to ultraviolet light. On examination, there was a large mass located on the anteromedial aspect of his left arm. The overlying skin has a bluish discoloration with several areas of pigmentation and presence of dilated veins. Firm in consistency with an ill-defined margin, it was adherent to the overlying skin and to the underlying muscle. No palpable thrill was detected to suggest a vascular in origin. Tinel test was also negative excluding that lesion arises from a nerve. A small subcutaneous nodule was located proximally to the lesion. Despite the size of the lesion, there was no limitation of movement at the elbow or shoulder. Distally the neurovascular bundle was not compromised. Proximally, a smaller mass was detected in the axilla which was suspicious of an enlarged lymph node. The presence of an enlarged lymph nodes led us to surmise that lymphoma was a more likely diagnosis than a soft tissue sarcoma.\nWith the above differential diagnosis, staging was next step in the management of this patient. Magnetic resonance imaging (MRI) illustrated a large heterogenous multilobulated left arm mass (Figure ). The fascia is breached, involving the subcutaneous layer and skin with presence of satellite nodules surrounding the mass. The neurovascular bundles were displaced laterally, however, displayed normal flow signal. There are enlarged matted left axillary lymph nodes, with the presence of necrotic center. Tru-cut biopsy was performed, and histopathology revealed malignant melanoma (Figure ) as evidenced by infiltration by malignant cells arranged in sheets and the surrounding stroma shows dense melanin pigment deposition. Subsequently, PET scan was performed as part of staging for malignant melanoma which reported a hypermetabolic multilobulated soft tissue mass at medial aspect of left arm likely primary lesion with nodal and lung metastases.\nPatient underwent wide local excision, axillary dissection of the left arm malignant melanoma followed by left upper limb reconstruction with left functional latissimus dorsi flap with split skin graft harvested from the left thigh (Figure ). Intraoperatively, the left arm mass measured 9 x 10 x 15 cm (Figure ) and was adherent to the underlying biceps muscle. There were several subcutaneous nodules surrounding the mass that was only detected by palpation. The neurovascular bundles although closely related to the tumor was not encased in it. The axillary mass measured 8 x 5 x 6 cm (Figure ) was not connected to left arm mass. Postoperatively, patient recovered well with no neurological deficit.\nFinal histology showed a pT4bN3 malignant melanoma with a Clark’s level of V and Breslow tumor thickness of >10 mm with lymphovascular invasion. Further histological testing showed the tumor to be strongly positive for S100 and Melan-A BRAF mutation was also detected in this patient, which directed our oncologist towards commencement of dabrafenib and trametinib for this patient. Unfortunately, patient succumbed to brain metastasis prior to treatment. |
A 29-year-old gravid one woman with body mass index 22 (before pregnancy) referred to our outpatient clinic in 34 weeks of gestation with acute pain in her right hip joint since ten days ago. There was no any past medical and social history. The pain was associated with limping, which had progressively increased during the past ten days. It was alleviated by rest and exacerbated on ambulation. The physical examination of the right hip joint revealed a reduced range of motion of 0–90° for flexion and 20° for external rotation, limited by pain, whereas rotation of the left hip showed no limitation. She had an orthopedic visit administrating analgesics without any improvement. Therapy included unloading the joint with crutches and exercise. Hence, hip magnetic resonance imaging (MRI) was requested, which was refused by the patient. She was admitted to our center due to fetal distress and diagnosed with the abnormal non-stress test during the 38th week of gestation. She delivered through cesarean section and gave birth to a healthy female neonate with an APGAR score of 10 and birth weight of 3150g. After the delivery, patient hip joint pain increased significantly; hence, a pelvic MRI was performed revealing increased intensity in Short Tau Inversion Recovery (STIR) T2-weighted and matching decreased intensity in T1-weighted images of the right femoral head without a collapse in favor of bone bruising extending to the femoral neck (). The left femoral head and neck were found to be normal. She was diagnosed with transient osteoporosis of the hip; thus, Ca-D and analgesics were prescribed in therapeutic dosage. Her pain aggravated during the following week, and she was unable to walk with severe limping. Pelvic radiography was performed, revealing the collapse of the right femoral neck in favor of femoral neck fracture (). The spiral computed tomography (CT)-scan of the right hip joint was done to confirm the diagnosis that showed small stress fracture of the femoral neck was suspicious (), due to patient’s pain and the decision of orthopedic team open reduction and cannulated screw fixation of right femoral neck fracture was performed. Postoperatively, a rheumatologist was consulted, who requested dual-energy X-ray absorptiometry (DEXA) of the lumbar vertebras 2-4 showing a Z-score of –2.7 and a bone mineral density (BMD) of 0.877 g/cm2, representing osteoporosis. The DEXA of both femoral necks revealed osteoporosis (Z-score=-2.3). For finding the cause of osteoporosis in this patient, Ca, phosphorus, and parathormone (PTH) serum levels were checked that were in the normal range. Also, all the other laboratory data, including 24-hour urine for Ca secretion and liver and thyroid function tests showed no any abnormal finding (). Hence, hyperparathyroidism, hyperthyroidism, renal dysfunction, excess Ca excretion, and liver disease were excluded. Only 25-OH-vitamin D serum level was found to be insufficient. A total of 1000 units of daily Ca supplements and vitamin D along with 70mg weekly alendronate were prescribed for the patient. The patient advised to the cessation of breastfeeding. After a month, the pain was relieved and she was able to walk without limping. On a 2-year follow-up, the DEXA of lumbar vertebrae 2-4 (Z-score=-1.4) and hip revealed (Z-score=-2.2) a significant improvement in bone mineral density, in 4-year follow-up Z-score in lumbar vertebras and hip were -1.5. At present, she takes part in her daily routine activities without any concern, but she is still under observation. |
A 74-year-old Caucasian female with myasthenia gravis admitted with melena and a hemoglobin of 5.8 g/dl. Her history was significant for small bowel perforation requiring bowel resection and anastomosis two years before the current presentation followed by multiple admissions for anemia treated with blood transfusions and iron supplementations. She did not have any personal or family history of malignancies or bleeding disorders. She was diagnosed with myasthenia gravis a year before the current presentation and was started on pyridostigmine and high dose steroids initially. The steroids were tapered down to prednisone 5 mg daily, six months before the current presentation. She reported non-compliance with her medications for myasthenia gravis. One month before the current presentation, she had an episode of life-threatening acute gastrointestinal bleeding; however, endoscopy did not reveal a clear bleeding source, and the cause was attributed to erosive esophagitis. During the current admission for melena, both endoscopy and colonoscopy failed to show active bleeding. Tagged red blood cell scan, CT angiogram (CTA), capsule endoscopy showed oozing from the bowel anastomotic area. Surgical exploration was deferred given her multiple comorbidities. Later embolization of the bleeding vessel at the site of anastomosis was done by interventional radiology. One week after the procedure, she started to have melena and CTA demonstrated active extravasation again from the anastomotic area. Coagulation studies were performed in the setting of repeated bleeding and showed isolated activated partial thromboplastin time (APTT) prolongation which was not corrected by mixing study. Her FVIII activity was markedly reduced to <1% and factor IX activity was normal. Prothrombin time, fibrinogen, von Willebrand factor, lupus anticoagulant, malignancy workup, and hepatitis panel were normal. Bethesda titer showed elevated inhibitor levels at 91 Units. Steroids and rituximab were administered, and she was discharged with a plan of weekly rituximab for four weeks. She was readmitted two days after the discharge with spontaneous chest wall hematoma. CTA showed a large left pectoral hematoma measuring 14 x 13 x 5 cm with active extravasation (Figure ). Factor Eight Inhibitor Bypassing Agent (FEIBA), recombinant factor VIIa, and steroids were given to control active bleeding. Clinically patient had stability of bleeding. However, during her subsequent hospital course, she acutely became unresponsive and resuscitative efforts proved to be unsuccessful, and the patient passed away. Intracranial hemorrhage was considered as a possible cause for her sudden death; however, an autopsy was not performed according to her family’s wishes. |
A 61-year-old female sustained a right diaphyseal humeral shaft fracture that was initially treated with intramedullary nail fixation using a deltopectoral splitting approach. Eight months after her index surgery she complained of instability and pain at the fracture site. Radiographs revealed an atrophic-appearing nonunion (). She underwent intramedullary nail removal, debridement of the fracture site and compression plating of her fracture non-union using a combined deltopectoral and anterolateral approach. Intraoperative fracture biopsy specimens revealed no evidence of inflammation with <1 white blood cell per high-powered field. A small rhBMP-2 sponge was placed alongside the fracture site. She was seen in the outpatient clinic on post-operative day 7 and noted to have a large erythematous and edematous region centered over the incision. She was started on a short course of oral antibiotics. Radiographs at her initial follow-up did not show any loss of fixation or hardware failure. She was seen in the outpatient clinic on post-operative day 9 with continued complaints of significant swelling and pain in her arm. There was now gross motion noted at her fracture site and radiographs demonstrated loss of fixation with pullout of the distal screws (). The swelling and erythema appeared to be out of proportion to that which would be expected with loss of fixation (). The patient returned to the operating room for revision fixation and debridement for suspected deep postoperative surgical site infection. Intraoperative findings were not consistent with infection. Considerable woody edema was found within the biceps and brachioradialis muscle bellies, centered over the BMP sponge. She underwent revision internal fixation and removal of the rhBMP-2 sponge (). One week postoperatively, her swelling was significantly decreased, and radiographs demonstrated acceptable alignment of her fracture site without evidence of hardware failure or loosening. Three weeks post-operatively, her arm swelling had completely resolved and radiographs demonstrated stable fixation with progressive healing at her non-union site. Final follow-up at 1 year revealed complete union at the fracture site and a normal soft tissue envelope. |
A 31-year-old intoxicated, unrestrained male was brought in by EMS after crashing his car into a truck. On arrival he was hemodynamically appropriate. He complained of right arm and abdominal pain. Primary survey revealed no deficits. The secondary survey revealed tenderness over the anterior chest wall and the right upper quadrant of the abdomen. His right upper extremity had an obvious deformity with motion limited by pain but with no vascular compromise. A chest X-ray was obtained in the trauma bay which only demonstrated a single right side fourth rib fracture. His initial hemoglobin was 14.3 g/dL. The patient's physical exam was complicated by alcohol intoxication and therefore underwent CT imaging of his brain, chest, abdomen, pelvis, and spine column to rule out life threatening injuries. Imaging revealed a thoracic aorta pseudoaneurysm in the region of the ligamentum arteriosum () and a duodenal transection ().\nWe decided to first treat the duodenal trauma with an exploratory laparotomy. Prior to the start of the operation we discussed the aortic injury with anesthesia and emphasized the need for heart rate and blood pressure control. The patient was placed on an OR table compatible for fluoroscopy to also allow for endovascular intervention in the same setting. During the exploration, we noted a grade 3 duodenal injury involving 60% of the circumference of the second portion of the duodenum. The ampulla was visualized and was not involved. The decision was then made to close the injury by primary repair in two layers including inner 2-0 Vicryl sutures in a continuous manner and a second layer of Lembert stitches using 2-0 silk. Pyloric exclusion was considered, but given the feasibility of the primary repair we opted not to exclude. An omental patch was secured in overlay over the repair. A distal jejunostomy was placed for feeding and three large JP drains were placed posterior, anterior, and lateral to the repair. A nasogastric tube was kept in place. At the completion of the duodenal repair, the patient remained hemodynamically normal and demonstrated no signs of hypothermia or instability. The patient seemed physiologically appropriate to tolerate a second procedure. At this point, a joint team of vascular and cardiothoracic surgery proceeded to repair the thoracic aorta in the same setting.\nAn endovascular approach to his aorta was taken by right common femoral artery cut-down. An arch aortogram was initially performed showing evidence of a bovine arch. The site of aortic transection was identified distal to the left subclavian artery with an associated pseudoaneurysm. There was no active extravasation of contrast. An endovascular stent was used to cover the transection site and left subclavian artery and terminated at the bovine insertion of left common carotid artery proximally to obtain adequate seal. A 28 mm × 120 mm thoracic endovascular prosthesis was deployed for the repair. Repeat aortogram revealed complete coverage without evidence of leak and good flow through bovine arch. The left subclavian remained perfused through collaterals. The arteriotomy and the groin wound were closed and the patient remained intubated at the end of the case.\nThe patient was brought to the surgical ICU, where he was extubated and transferred to the floor the following day. J-tube feeds were started on postoperative day (POD) 2. The patient also had his right humerus fracture repaired on POD 4. He underwent an upper GI series with gastrografin on POD 6 that demonstrated no leak. His NGT tube and drains were subsequently removed, and he was started on oral diet. He was discharged home POD 8 with the j-tube in place. A CT scan obtained prior to discharge showed the endovascular stent to be in good position. |
A 39-year-old male presented with a one-year history of pain, swelling of the gingiva and an occasional pus-like discharge in the right mandible. Several teeth had slowly become loose and one tooth had fallen out. The patient was previously prescribed antibiotics by a local dentist who considered the problem to be a bacterial infection. The symptoms were alleviated, yet the problem was never completely resolved. Eight months prior to the current presentation, an initial panoramic radiography of the jaw was taken in a local hospital and the patient was diagnosed with osteomyelitis of the jaw. Although it was suggested that the patient should receive further treatment at a tertiary hospital, since the symptoms were tolerable, this advice was not followed in the eight months previous to the current presentation. At this time, the patient was immediately admitted to the Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) for further investigation.\nClinical palpation of the right mandible revealed that the lateral surface of the mandibular body bulged and that the inferior margin of the body was concave. The first molar was missing and mobility of the neighboring teeth was detected. The second and third molars sloped anteriorly, resulting in immature tooth contact. There was a conspicuous pit in the right mandible, between the first premolar and the second molar, yet no obvious pus-like discharge was found (). The midline of the mandible was shifted to the right by ~2 mm.\nThe initial panoramic radiograph showed an osteolytic lesion in the right mandible, ranging from the canine to the third molar, and with a moth-eaten margin. The lesion had already invaded the cortices and resulted in a pathological fracture of the mandible (). As the supporting bone was destroyed, the involved teeth appeared to be floating in the osteolytic lesion. The displacement of bone fragments led to immature contact of the lower third molar with the upper second molar (). A second panoramic radiograph taken at the Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) showed that eight months later, although the lesion had continued to expand slightly, there was apparent new bone regeneration in the previous osteolytic area, which had resulted in a malunion of the fractured bone segments (). The continuity of the right mandible was also confirmed by computed tomography (CT) scanning ().\nTo establish a diagnosis, an incisional biopsy was performed. This showed clusters of medium-sized cells with coffee bean-like nuclei that were folded or grooved; the characteristic feature of Langerhans cells. A few eosinophils were also found around these characteristic cells (). These clusters of cells were finally identified as Langerhans cells by their intense immunoreactivity for S-100 protein and cluster of differentiation (CD)1a (). The diagnosis of LCH was consequently confirmed.\nNuclear bone scanning with technetium-99m was then performed to investigate whether other bones were involved; besides the right mandible, the left ilium and the left fifth rib also showed increased uptake of the radionuclide (). CT scanning also confirmed the osteolytic focus in the left ilium (). No more organs were found to be involved by either chest radiography or magnetic resonance (MR) scanning of the abdomen. The patient was finally diagnosed with LCH with multifocal bone lesions.\nAs multiple bones were involved, surgical oblation or curettage was not the first treatment option. The patient was referred to the hematological department and received combination chemotherapy. The chemotherapy lasted for nine months and was divided into six courses. In each course the patient was administeres 750 mg etoposide, 160 mg vincaleukoblastine and 1.47 g prednisone. |
A 57-year old female presented at the Orthopaedics and Traumatology polyclinic with complaints of pain in the left hip. A prosthesis had been applied to the left hip six years previously in another hospital. Pain which had started very mildly 4-5 years previously had increased over time. Because the surgery was performed in another center, we were unable to ascertain if there was any problem during the surgery or inserting the ceramic liner, and there was no recollection of any trauma in the patient’s anamnesis. It was later ascertained that Smith and Nephew EP-FIT plus ceramic insert was used in the first surgery. The patient had no complaints of any abnormal sound arising from the hip. The findings of the physical and radiological examinations were consistent with aseptic loosening. On the hip radiograph, there was noted asymmetry in the centralisation of the femoral head within the acetabulum (). Revision surgery was planned for loosening of acetabular component. The patient was operated on using the previous incision site. There was no loosening of the femoral component. The femoral head was ceramic. The ceramic liner was totally fragmanted and detached from the acetabular component, which was observed to be in approximately 10 degrees retroversion. The pieces of the ceramic liner were as small as seen in the radiograph ().\nThere was widespread debris in the joint. A defect, approximately 28mm in diameter, was observed in the weight-bearing area in the centre of the acetabular component (). This defect was thought to have been formed by the ceramic femoral head settling in this area. The acetabular component and one screw were removed. The head of the second screw was observed to have been completely smoothed out and not causing any damage to the bone stock and was not removed. The acetabulum was then reamed and grafted and the acetabular cup was fixed with two screws in appropriate anteversion. It was observed that the ceramic liner pieces remaining around the joint did not lead to restriction of the hip movements after the trial components were placed, and it was decided not to excise these ceramic liner pieces (, indicated by arrow). The revision surgery was completed using a ceramic insert and ceramic head (). The patient did not have any complaint about her hip in the post-operative two years follow-up. |
A 73-year-old lady presented to the Accident & Emergency (A&E) department immediately after a fall from standing height with a painful deformed right elbow. Initial radiographs demonstrated a dislocation of the elbow with no associated fractures (). The joint was manipulated by the A&E staff and the arm was placed in an above elbow plaster back slab with 90° flexion. Postmanipulation radiographs confirmed the reduction albeit with some subluxation of the radio-capitellar joint (). The patient was discharged home. Four days later she was reviewed at the fracture clinic by a locum doctor who also did not appreciate the importance of subluxation on the post-reduction film and did not repeat the radiographs. The arm was placed in an above elbow complete cast and a review was scheduled in a further two weeks. At this review, three weeks following her injury she was in severe pain and the elbow was noted to be obviously clinically dislocated with extensive bruising and swelling. Fortunately the hand remained neurovascularly intact. Radiographs confirmed the now chronic dislocation (). At this point the soft tissues prevented further closed reduction.\nThe patient had significant medical comorbidities: ischaemic heart disease with previous coronary stents; left ventricular failure; complete heart block with a permanent pacemaker; type 2 diabetes; a BMI > 35 and emphysema treated with long-term steroids. She was discussed in the departmental trauma meeting and due to her high anaesthetic risk, poor soft tissues and general frailty she was assessed as not suitable for our standard operative treatment with collateral ligament repair and stabilisation with a hinged external fixator. The options suggested by the consultant body at the trauma meeting were to offer either non-operative treatment (pain control medications and a brace) or percutaneous trans-articular pinning. Both these options have significant drawbacks in terms of functional outcome. We have previously described a new operative technique that we proved to be technically feasible in a cadaveric study []. The technique utilises the harvest of a central strip of triceps tendon which is distally based and remains attached at its insertion. The central triceps strip is passed through a fenestration made in the olecranon fossa and fixed to the coronoid process to construct a complete osseo-tendonous ring (coronoid, olecranon and triceps tendon) that holds the ulna congruent with the trochlea of the distal humerus (). The hypothesis is that this will allow early range of motion rehabilitation and avoid the instability that would come with non-operative treatment or the stiffness associated with trans-articular pinning. After discussion of the possible benefits and risks of each option the patient elected to have the new technique.\nThe surgery was performed under regional anaesthetic. The elbow was reduced and stressed to assess the competence of the collateral ligaments. The radial collateral ligament and both the medial and lateral ulnar collateral ligaments were completely disrupted such that the joint did not remain congruent even in flexion beyond 90°. Dislocation occurred with both external and internal rotation of the fore arm. The triceps tendon reconstruction described above was performed with an operative time of 45 min. There were no technical difficulties or complications and a congruent stable reduction was achieved (). The patient was allowed to use the arm freely with no bracing and was discharged home on the second postoperative day. She made an excellent initial recovery. At two weeks the elbow was painfree and the wound had healed with no evidence of infection. Elbow flexion was 15–90° at two weeks and 0–110° at three weeks. Supination and pronation were normal at two weeks. She was allowed to use the arm freely including lifting and carrying as she was able. Unfortunately at four weeks following the reconstruction the patient was readmitted with a further dislocation of the elbow (). The reconstruction was explored in the operating theatre and was found to have failed by the grasping suture in the triceps graft cutting out of the tendon. Why this occurred could not be elucidated from assessing the elbow intraoperatively. It is possible that the triceps tendon was not strong enough to resist the forces applied to the reconstruction during our initial unrestricted rehabilitation protocol. The grasping suture in the graft was revised but this time with a modification to form a complete loop from the triceps insertion through the olecranon fossa and ulna shaft back to the triceps insertion thus reenforcing the reconstruction (). We prescribed a more conservative rehabilitation regimen following the revision. She was advised to perform active range of motion exercises with the support of a brace but no lifting or carrying of any weight. Again she made a prompt recovery. At two weeks following the revision the joint was congruent, there was no infection and elbow flexion was 10–110°. At four weeks after the revision the brace was discontinued and her range was 0–120°. Her recovery was again impressive, regaining a full painfree range of motion of elbow flexion and extension, and forearm pronation and supination. This is preserved at her most recent follow-up two years postoperatively and her radiographs confirm ongoing joint congruence (). |
A 58-year-old male presented to the emergency department with right lower extremity swelling and a large ulceration on his right lateral leg for nearly six years (). The patient had been treated in Guyana with topical agents and dressing changes, without improvement. In the ED, right lower extremity duplex demonstrated popliteal vein thrombosis as well as traumatic fistula between superficial femoral vein and superficial femoral artery. Duplex ultrasound also showed distal femoral vein to measure 4.36 cm AP, mid femoral vein 1.12 cm, and an enlarged lymph node noted in the groin measuring 4.56 × 1.60 cm. CT angiogram of the abdomen, pelvis, and lower extremities showed right superior femoral arteriovenous fistula and a tortuous right common iliac artery that may be causing a May Thurner's type compression of the R common iliac vein ().\nPatient subsequently underwent bilateral extremity angiogram and selective catheterization of the right common iliac artery via retrograde left femoral approach. Angiogram revealed a patent but enlarged right common femoral artery, a patent right profunda artery, and a patent and enlarged right superficial femoral artery (SFA) with a distal arteriovenous (AV) fistula connecting the superficial femoral artery to the femoral vein with venous flow upwards (). On pelvic imaging, there also appeared to be very late venous filling possibly of a venous malformation, which was not seen on previous imaging (). There was a large venous aneurysm just distal to the fistulous tract. The remainder of the arterial outflow was normal giving rise to a patent popliteal artery and patent tibial trifurcation.\nThe decision was made to pursue endovascular repair of the patient's fistula. Given concerns that the SFA was so enlarged and at risk for significant hemorrhage, a superficial femoral artery cutdown was performed (). The SFA was dissected free from its surrounding structures. The anterior wall of the SFA was punctured in an antegrade fashion and a 12-French sheath was then placed. There was some bleeding around the 12-French sheath which required clamping of the proximal superficial femoral artery with a vascular clamp. A Gore iliac branch endoprosthesis which measured 10 mm distally 16 mm proximally for a length of 7 cm was opened and deployed in standard fashion across the arteriovenous fistula. It was postdilated using an angioplasty balloon. After postdilation angioplasty there was good apposition against the wall and the fistula filled very slowly via collaterals and not via inline flow (). In addition, the patient maintained his outflow via the popliteal artery. Split thickness graft was placed over the ulcer and negative pressure therapy was utilized. The VAC was taken down and there was excellent take of the skin graft. Patient has subsequently undergone Unna booth therapy and the wound has healed completely after 3 months (). |
A 54-year-old Japanese female visited an oral surgery clinic with a complaint of swelling in the inner region of the left cheek for the past one month. On clinical examination, a mobile swelling (size, 1 cm x 0.75 cm) with a clear boundary was observed on the left buccal mucosa. No associated pain was reported and the overlying mucosa was normal in appearance. The swelling was clinically diagnosed as benign buccal mucosa tumor. The tumor was excised under local anesthesia and was diagnosed as acinic cell carcinoma (AcCC) after histopathological examination. The margins were still positive for the tumor and further resection was advised. The patient reported to the Health Sciences University of Hokkaido Hospital for resection of the residual tumor two months after the initial surgery. Clinically, the patient was asymptomatic. The level 1B lymph nodes on both sides were palpable, bean sized, mobile, elastic, and soft. Intraorally, a surgical scar of about 7 mm was present on left buccal mucosa. There was no pain on pressure in the region of the scar (). The patient had a history of noninvasive ductal carcinoma (ductal carcinoma in situ [DCIS]; Tis N0M0) in the right breast, which was treated by excision and 57 Gy of radiotherapy five months ago. On investigation for oral lesion, no obvious abnormalities were detected on the computed tomography- (CT-) scan, contrast MRI, and ultrasonogram. Positron emission tomography- (PET-) CT did not suggest transition to and from any of the distant organs. The margin was resected under general anesthesia and sent for histopathological examination (). No relation to the parotid gland was found at the time of surgery.\nHistopathologically, the excised margin appeared as a fragmented tissue with no encapsulation. The tumor tissue was composed of cells with dominant microcystic structure with eosinophilic cytoplasm and eosinophilic secretory material. Papillary and tubular pattern of cell arrangement were also found but were limited to small area. A few vacuolar cells and some areas with hemosiderin deposition were observed. Furthermore, normal muscle tissue and atrophied salivary gland tissues were also seen ().\nThe secretory material was positive for diastase digested Periodic acid-Schiff (d-PAS), Mucicarmine, and Alcian Blue staining. No zymogen granules were found in the tumor cells. Immunohistochemistry (IHC) revealed strong positive reactions to vimentin, cytokeratin-19, and S100 protein. Mammaglobin was strongly positive, whereas discovered on gastrointestinal stromal tumors 1 (DOG-1) showed a negative reaction (). The histological sections of breast carcinoma were examined in suspicion of metastases; however, features of ductal carcinoma in situ that appeared completely different from those of buccal mucosa tumor were noted. Based on these histomorphologic and IHC profiles, the case was diagnosed as SC of the minor salivary gland in the buccal mucosa. |
A 28-year-old female [para 2, living 2 (P2 L2)], had undergone an elective cesarean one month prior to her presentation in view of a previous cesarean section. The surgery had been uneventful, and she had been discharged on the sixth postoperative day. She came to the OPD after seven days with the complaint of bleeding per vaginum with a history of the passage of clots. On examination, bleeding was found to be more than average. The patient was medically managed, and the subsequent ultrasonography returned normal findings.\nAfter transfusing one unit of blood and giving antibiotic coverage, the patient was discharged with bleeding per vaginum within the normal limit. The patient presented to the OPD again after 10 days with the same complaints. On PV examination, bleeding was still present. Intrauterine packing was done and kept for 24 hours. Packing was removed after 24 hours, and she was kept under observation for the next 48 hours with no bleeding PV. Again, after 10 days, the patient returned with the same complaint with ultrasound suggestive of a focal hypogenic mass devoid of any vascularity extending from endometrium to subserosa on the left side. The patient was referred to our center and the decision was taken to manage the case laparoscopically.\nIntraoperative findings were as follows: bladder was found adhered to the anterior uterine wall, which was dissected down. A Hematoma was present at the right end of the cesarean scar, extending up to the broad ligament. Cesarean scar sutures had given away. Active bleeding was present from the right angle of the scar.\nRetroperitoneal dissection was performed, and bilateral internal iliac arteries were ligated. The cesarean scar site was exposed, and older suture material was removed. Complete scar site was restored with Vicryl No. 1 after taking both angles separately. Hemostasis was confirmed. The patient had an uneventful recovery and was discharged on the day after surgery. Ultrasound performed at eight weeks postpartum showed a normal uterus. |
A 44-year old woman presented with a two hour history of sudden onset palpitation while walking her dog but no syncope. She had no significant past medical history of note but a paternal uncle had died suddenly at the age of 50 years and her father had been diagnosed as having cardiomyopathy and had an implantable cardioverter defibrillator implanted several years previously. She was taking no regular medication. On arrival into hospital she had a blood pressure of 110/60 mmHg and pulse rate of 215 beats per minute; there were no signs of cardiac failure. A resting 12-lead electrocardiogram (ECG) revealed a regular broad complex tachycardia, which was diagnosed as ventricular tachycardia (); this diagnosis was based on previously reported criteria []. The patient reverted to sinus rhythm spontaneously and repeat 12-lead ECG revealed no abnormalities (). Transthoracic echocardiography and exercise tolerance test were normal. Coronary angiography and cardiac magnetic resonance imaging scan were also normal.\nThe patient was referred for electrophysiological assessment and treatment. Following counselling and informed consent, she was admitted for electrophysiology study which was carried out under local anaesthesia and intravenous sedation. Catheters were inserted via femoral venous access with a decapolar catheter (Irvine Biomedical Inc, California, USA) placed in the coronary sinus (CS) and quadripolar catheters (Bard Electrophysiology, MA, USA) placed at the right ventricular apex and His bundle position. Programmed stimulation demonstrated concentric, decremental retrograde and antegrade conduction. A spontaneous tachycardia was observed during the study with the same morphology as the clinical tachycardia (). The tachycardia cycle length was 447 ms and V:A time was 246 ms with earliest atrial activation at His bundle / proximal CS position (); there was no His bundle signal preceding ventricular signal during tachycardia. Earliest local ventricular activation during tachycardia was at the distal CS suggesting either a ventricular tachycardia with 1:1 retrograde atrial activation or an antidromic atrioventricular re-entry tachycardia involving a left free wall accessory pathway. A late atrial premature stimulus delivered from CS 7-8 reset ventricular activation without fusion during tachycardia () supporting the diagnosis of an antidromic AVRT. Intravenous adenosine (6 mg) terminated the tachycardia with last activation in the atrium () suggesting adenosine-sensitive property in the antegrade limb of the tachycardia (i.e. the accessory pathway). A trans-septal approach was taken to map the location of the accessory pathway during antidromic tachycardia with an irrigated tip deflectable ablation catheter (D curve Thermocool, Biosense-Webster, USA). The mitral annulus was mapped during tachycardia with earliest ventricular activation identified at the left free wall. Ablation caused termination of tachycardia which was still inducible after ablation cessation. A retrograde approach was then used with successful ablation achieved at a location with good unipolar signal ( and). There was no recurrence of tachycardia following ablation and tested with programmed stimulation with intravenous isoproterenol infusion. The accessory pathway demonstrated unusual characteristics: it had no retrograde conduction, was slowly conducting with conduction only apparent in the antegrade direction in tachycardia, and had an effective refractory period longer than the AV node. These features are consistent with 'Mahaim-like' properties and have rarely been reported for left sided pathways. |
A 10-year-old girl presented to our clinic with complaints of dyspnea on exertion and cyanosis of extremities after exertion. She had undergone surgical closure of IVC type of sinus venosus ASD 2 years ago. After surgery she had an episode of sudden onset stroke from which she recovered completely. The child was evaluated multiple times at the primary center and echocardiogram was done that apparently showed intact atrial septal patch with no other abnormality.\nOn clinical examination, she was noted to have a central cyanosis with systemic saturation of 85%. Her heart rate was 84/ min and her blood pressure was 110/70 mm Hg. Clinically there was no auscultatory abnormality. Her electrocardiogram was normal. Her operative notes mentioned that after rerouting the right lower pulmonary vein to the LA, the fenestrations in the atrial septum were divided and enlarged to make a large defect that was then closed with a pericardial patch. Echocardiogram revealed a small fenestration in the ASD patch with left to right shunt. The superior vena cava (SVC) was seen draining normally into the right atrium (RA) and the pulmonary veins were seen draining to the LA. But the IVC flow could not be definitely documented draining to the RA []. A contrast (agitated 5% glucose saline) echocardiogram was performed from the venous access in the lower limb. It showed appearance of the contrast first in the LA and subsequent filling of all four cardiac chambers suggestive of drainage of the IVC into the LA [Figures and ]. Her serum hemoglobin was 15 gm% and her packed cell volume (PCV) was 52%.\nShe was taken up for a diagnostic cardiac catheterization. An arterial blood gas sample taken though a radial artery showed a PaO2 of 105 mm Hg on FiO2 of 40%, suggestive of hypoxemia. A right femoral venous access was taken with a 6F sheath. A 6F Judkins right coronary (JR) 3.5 catheter was passed though the IVC and was seen directly entering the LA. The JR 3.5 was exchanged for a pigtail catheter that was placed in the IVC just below the diaphragm. A contrast angiogram done in anteroposterior (AP) and left anterior oblique with cranial angulation (LAO Cr) showed the contrast entering the LA directly through the IVC and a small fenestration in the ASD patch through which the contrast filled the RA []. The SVC was entered after crossing the fenestration and entering the RA. Angiogram in the SVC showed its normal drainage into the RA with no spill over into the LA. The child was referred for surgery with the plan to redo the atrial patch directing the IVC to the RA. |
A fourteen year old girl was hemodialysis dependent for four months due to reflux nephropathy and dysplasia of native kidneys. Fifth postoperative day after living related renal transplantation (organ donor was her father) the girl suddenly felt severe, diffuse headache, she had a crisis of consciousness, psycho motor agitation, and tonic-clonic seizures. She did not involuntarily urinate nor there was any foam in the mouth or tongue biting. The attacks lasted for about ten minutes after which the girl was asleep for about an hour. As she gained full consciousness and woke up she had a partial and short-term amnesia. At the moment of the attack physical examination of the heart and lungs was normal, and basic laboratory tests (blood count, markers of inflammation, acid-base status, blood sugar, electrolyte status) taken at the time of the attack were within normal values. Her blood pressure during the attack was 140/85 mmHg, pulse 110/min. Three days after the first attack she had high blood pressure 190/115 mmHg, without any new attacks, but with headaches which required modification of antihypertensive therapy. Clinical presentation after the first attack required a constant consultations of pediatrician and neurologist who indicated further neuroradiological diagnostics that eventually showed multiple acute ischaemic changes in the light of posterior reversible encephalopathy syndrome (PRES), with lesions of the parietal and occipital lobes and cerebellum that progress to frontal and temporal lobes bilaterally ( and ). Due to severe general condition, late developed hypertension, and delayed renal graft function with high values of renal function parameters, hemodialysis support was started. Even with all the measures being taken patients condition remains severe, and because of the potential neurotoxic effects of previous immunosuppressive therapy (corticosteroids, mycophenolate mofetil, tacrolimus) changes in calcineurin inhibitor therapy and drug dosage adjustment were made (tacrolimus–cyclosporin switch). The level of tacrolimus was adequate to post transplantation period and it was 13 ng / ml. We mainly suspected that it was a case of neurotoxic drug effects, tacrolimus in particular, based on clinical presentation and association of neurologic manifestations with delayed graft function which is also commonly caused by effects of calcineurin inhibitors. Prompt improvement in patients health after calcineurin inhibitors were replaced has further confirmed our assumptions. During in-hospital stay intensive monitoring and multidisciplinary approach were maintained, and patients condition was stabilized and improved, parameters of renal function were normalized so there was no realistic need for the hemodialysis support, whilst early repeated radiological examinations showed a discrete progression of ischaemic lesions. Control endocranial MRI findings after two months showed prevailing regression of previously visualized ischaemic brain lesion (), and clinical laboratory tests showed good and preserved kidney graft function with normal values of serum creatinine. In her following, monthly check-up examinations the girl was without any nurological symptoms. |
A 7-year-old boy who presented with dizziness, headache, and left-sided hemiparesis was transported by ambulance to the pediatric department of another hospital. He was admitted for further investigations. He had been born with developmental disorders. From 1 year before this admission, he had complained of dizziness and nausea once a week but had been diagnosed with orthostatic dysregulation at another hospital at that time. After admission, he underwent further investigations. Magnetic resonance imaging (MRI) revealed ischemic strokes in the right thalamus, right occipital lobe, and bilateral frontal lobes (Fig. ). Magnetic resonance angiography (MRA) demonstrated obstruction of the right posterior cerebral artery (Fig. ). Echocardiography detected a 4 × 3-cm giant mass that with unclear origin in the left atrium (Fig. ). This mass was prolapsing into the left ventricle during diastole (Fig. ). The left atrium was dilated, and moderate mitral valve regurgitation was noted. He was diagnosed with an ischemic stroke due to embolism caused by cardiac tumor. He was then transported to our hospital, where we performed emergent surgical resection of the tumor. Under a median sternotomy approach, cardiopulmonary bypass was instituted by aortic and bicaval cannulation. After inducing cardioplegic arrest, the right atrium was opened. The atrial septum was incised at the fossa ovalis, and a giant gelatinous tumor inside the left atrium appeared (Fig. ). The neck of the tumor was adherent to the left atrial side of the atrial septum. The tumor and its neck, including part of the atrial septum, were fully resected and the atrial septum was directly closed. The patient had no difficulty with weaning from cardiopulmonary bypass and was extubated 3 h after surgery. Histopathological diagnosis was myxoma. Postoperative echocardiography showed no residual tumor, and only mild mitral valve regurgitation was noted. Echocardiography results from his sister and parents which were collected at his admission were normal. He was discharged to his home on postoperative day 19, by which time he had almost recovered from left-sided hemiparesis and could walk unaided. |
A 27-year-old Sri Lankan male was admitted to a local hospital with severe epigastric pain and vomiting following a binge of alcohol, 2 months prior to admission to our unit. He was taking three units of alcohol daily during last 6 years. The abdomen was distended with free fluid. Examination of the other systems was normal. His serum amylase was significantly elevated on admission and CRP level after 48 h was elevated (Table ).\nChest X-ray revealed a small pleural effusion on the right side. Ultra sound scan of the abdomen showed a coarse echogenic liver with gross ascites.\nFollowing this episode he had persistent anorexia and weight loss with intermittent abdominal pain. He did not have fever or vomiting. Bowel opening was normal. He was subsequently transferred to our unit from the local hospital with worsening abdominal pain and distension. On clinical examination he was emaciated and was mildly pale. He was not icteric. He was hemodynamically stable and had a right sided small pleural effusion. Abdomen was distended and tense. Investigations revealed high amylase and low albumin (Table ).\nContrast enhanced CT scan of the chest and abdomen showed a large multilocular cystic lesion occupying almost the entire abdominal cavity. The largest locule in the right side measured 30 cm × 15 cm × 14 cm displacing the liver medially and the right dome of the diaphragm superiorly. Two smaller locules were seen in the lesser sac, compressing the central abdominal structures. Cysts contained clear fluid with no enhancement of the walls. No separations or evidence of haemorrhage was seen (Figs. , , ). There was a small right side pleural effusion with collapse consolidation of the medial segment of the right lower lobe. Pancreas appeared as a thin line likely to be due to partial atrophy and compression and there were no duct dilatations, calcifications or necrosis. A small locule of fluid was seen in relation to the tail of the pancreas. Heart was deviated to the left, due to the largest cyst which was extending into the right hemi thorax. No Para aortic or pelvic lymph node enlargement was seen. The liver, gallbladder and spleen appeared normal. Both kidneys were normal in size with normal contrast enhancement. There was a small amount of free fluid in the pelvis.\nEndoscopic ultrasound (EUS) guided drainage was planned as a therapeutic procedure and was performed using a large channel linear-array echoendoscope (Fujinon, Tokyo, Japan). On the EUS, the pseudocyst was visualized bulging into the posterior-lateral wall of the stomach. The cyst was entered into with an electro cautery-assisted cystotome (Wilson Cook, Winston Salem, NC, USA) and a 0.035 in. guide wire was introduced (Fig. ). A 15 mm × 30 mm lumen-opposing metal stent(LEMS) (Boston Scientific, Marlborough, MA, USA) was deployed under fluoroscopic vision. Dilatation was done with a 10 mm CRE balloon. A large amount of clear fluid was drained (Fig. ). Repeat EUS was done a week later due to persistence of the collection on conventional ultra sound scan. A loculated portion of the cyst was seen to be persisting and a second 15 mm × 20 mm LEMS was inserted by an identical procedure (Fig. ). Pus discharge was noted from the previous stent, which was cleaned and washed out. Then 10Fr × 10 cm double ended pigtails were inserted into both stents. The peri-procedure period was covered with broad-spectrum antibiotics. The cysts were not visualized on subsequent ultra sound scans. Stent removal was done after 3 weeks leaving the pigtails insitu. The patient made an uneventful recovery and was discharged to be reviewed in 6 weeks. |
A 55-year-old white man, presented with an 8 week history of pain and non-fluctuant swelling at right submandibular area []. He had his right molar tooth extracted and a partial denture was made 10 years ago. One month before our examination, he had a swelling on the affected site and he was prescribed 300 mg clindamycin phosphate IM antibiotics for 5 days by his general dentist. Previous to this, he had paresthesia in the right lower lip for 3 days. Otherwise, the patient had no important medical history. He did not take any systemic medications regularly.\nExtraoral physical examination revealed a right mandibular swelling involving the ramus and the body. Vital signs were normal with hydrated skin and no neck adenopathy present.\nThe intraoral physical examination revealed anesthesia over the peripheral distribution of the inferior alveolar nerve on the affected side with decayed lower and upper canines. The intraoral mucosa was intact and a smooth surfaced non-tender lesion measuring about 2 × 2 cm was noted in the right mandibular premolar-molar area. The orthopantomography showed an ill-defined radiolucent osteolytic lesion of the right molar region under the inferior alveolar canal [].\nThe lesion has an irregular radiolucent area mimicking a dentoalveolar infection located in the corpus of the mandible just below the mandibular canal in the radiographical evaluation.\nThe incisional biopsy under local anesthesia was performed and a histopathological diagnosis of low differentiated adenocarcinoma of the mandibule was given. It was stated in histopathological report that there was a malignant tumoral tissue consisting of solid islands composed of atypical epithelial cells in desmoplastic stroma []. Nuclear pleomorphism in the tumoral islands was marked and cytoplasmic small vacuoles were seen []. This tumoral configuration is compatible with poorly differentiated adenocarcinoma. However, this morphology is not common in oral cavity tumors, including salivary gland tumors. For this reason, it was thought that the tumor was primarily metastatic. This high-degree adenocarcinoma was thought to be originated from the lung, gastrointestinal system, or breast. However, breast was excluded because the patient was male. Classical colorectal carcinoma morphology[] was not seen in this tumor but glandular morphology of gastric adenocarcinoma was more evident. The focus of this tumor was thought to be primarily lung according to the solid island configuration and focal cytoplasmic vacuolization.\nAfter obtaining the report of the biopsy, the patient had consulted the medical oncology department whereour histopathological diagnosis of lung cancer was approved. There was a mass on the left upper lobe of the lung in posteroanterior chest radiogram []. Enlarged aorticopulmonary, subcarinal, left hilar lymph nodes and a mass on superior segment of the left upper lobe of lung on a thorax computed tomography was noted []. However, the patient refused treatment of lung cancer for 1 year. On September 8, 2006, the patient appealed to medical oncology department because his condition became worse. Etoposide 50 mg/day for 21 days, ondansetron 8 mg 3 × 1 IV/po, or granisetron 3 mg 2 × 1 IV/po, or tropisetron 5 mg 1 × 1 IV/po as chemotherapy was initiated but unfortunately, the patient died 5 months after the start of the chemotherapy. |
A 50-year-old woman was admitted to our hospital for vacuum-assisted removal of bilateral breast fibroadenomas due to progressive growth of the masses. The patient had no history of trauma, hypertension, coagulation disorders, or any other systemic disease. She previously underwent an ultrasound-guided biopsy of bilateral breast masses, and the histological diagnosis was fibroadenomas. Ultrasound-guided VAR was performed with an 8-gauge needle under local anesthesia until the masses were no longer sonographically visible. The patient was discharged on the same day without any immediate complications.\nThe patient was followed up after 3 months and reported to be a good condition without any discomfort. On physical examination, the lateral part of the right breast presented mild arterial pulsation without any palpable active mass or breast bruising. The two-dimensional ultrasound showed that there was a well-defined anechoic nodule in the right breast at 9 o’clock, 3 cm from the nipple (). Color Doppler ultrasonography demonstrated that it was a localized dilated intramammary artery with an intact wall, measuring 6 mm × 4 mm, and no evidence of fistula and surrounding thrombosis was found on repeated scans (). Spectral Doppler displayed a high-speed turbulent arterial flow component inside (). Power Doppler showed that blood flow was filling it in (). The patient denied a history of trauma to the right breast or anticoagulation therapy during the follow-up visit, and no cystic structure was found in previous breast ultrasound examinations. Based on these findings, the patient was diagnosed with an iatrogenic aneurysm of the breast.\nFinally, a multidisciplinary consultation was conducted regarding the patient, and a variety of management schemes were proposed for the treatment of the true aneurysm, including conservative treatment with regular imaging surveillance, surgical resection, or interventional procedures. After explaining to the patient the pros and cons of various treatment protocols, she preferred conservative treatment with regular breast ultrasound examination. The patient was also aware of the complications of the aneurysm and was told to present at a nearby hospital if there was breast pain or bruising. A recent ultrasound scan revealed no increase in aneurysm size, and she has remained asymptomatic for 18 months. |
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 69 year-old man was admitted to our hospital complaining of congestive heart failure. His medical history included long-standing hypertension. On admission the patient had a blood pressure of 180/70 mmHg with diminished femoral pulses. Electrocardiographic analysis showed left ventricular hypertrophy and left bundle branch block. Transthoracic echocardiography showed an 80 mm Hg peak gradient and 0,8 cm2 surface area in the aortic valve. The left ventricular ejection fraction was 35%. Coronary angiography revealed severe disease of the left anterior descending coronary artery, and the coarctation was confirmed by aortography. There was a severe coarctation just distal to the left subclavian artery. Computerized tomography angiography to determine the anatomy and severity of the coarctation, showed bilateral internal mammary artery dilatation (Figure ).\nStandard median sternotomy was performed using a vibrating saw. A large internal mammary artery was observed that was unsuitable for use as conduit for revascularization (Figure ). Cardiopulmonary bypass was performed using high arterial cannulation in the ascending aorta and single venous cannulation in the right atrial. We used systemic cooling to a temperature of 33° and antegrade cardioplegia was administered for myocardial protection. Before cardioplegic arrest, the heart was retracted and the posterior pericardium was exposed, the descending thoracic aorta and the esophagus were palpated and the pericardium was opened. Following cardioplegic arrest the coronary artery bypass grafting was performed with a saphenous vein to the left anterior descending coronary artery. After revascularization, the heart was retracted and a partial occlusion clamp was applied to the anterior wall of the descending thoracic aorta where an end-to-side anastomosis with a 22 mm vascular graft was constructed using 3-0 polypropylene running suture. The graft was routed anterior to the esophagus, posterior to the inferior vena cava, and anterior to the right inferior pulmonary vein. After performing the distal anastomosis of the vascular graft to the descending aorta, an aortic valve replacement was performed using a 23 mm Sorin Bicarbon prosthesis. The native bicuspid aortic valve was very calcified. The aortic clamp was removed, the vascular graft was cut obliquely and a proximal anastomosis was fashioned end-to-side to the external side of the ascending aorta using a partial occlusion clamp. The proximal anastomosis of the saphenous vein was performed over a different partial occluding clamp. The patient came off bypass with minimal vasoconstrictor support. Cardiopulmonary bypass and myocardial ischaemic time were 135 and 80 minutes respectively. The postoperative period was uneventful, and the patient was discharged on his tenth postoperative day on hydrochlorothiazide, enalapril and Dicumarine. Three years later, he is classified as having NYHA class I.\nA volume rendering reconstruction of the postoperative computerized tomography scan showed a vascular graft between the ascending aorta and descending thoracic aorta and the aortic coarctation (Figure ) and the bypass to the left anterior descending coronary artery (Figure ). |
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 50-year-old housewife presented in the emergency department of our level 1 trauma center with complaints of pain and immobility of the left hip joint and inability to bear weight forthe past 20 days. She gave a history of bilateral anterior groin pain (left > right) for thepast 4 months. She also had a history of limping, difficulty in sitting cross-legged, and squatting for the same period. The pain was insidious in onset and progressed over time to make her bedridden. On examination, there was tenderness over bilateral hip joints (left > right), external rotation deformity, and 1cm shortening of the left lower limb. Movement of the left hip joint was extremely painful and was not encouraged. There was pain at extremes of motion of the right hip joint. The patient was able to do straight leg raise on the right side but not on the left side. Neurovascular examination was bilaterally unremarkable. The patient had no comorbidities and was not on any long-term medication. There was no history of trauma (trivial or overt), excessive physical activity, or fragility fractures in the past. The patient was postmenopausal for2 years. The patient was actively mobile before the onset of symptoms. She consulted a local practitioner during initial stages of her discomfort who had prescribed her NSAIDs. However, there was no relief and pain progressed to such an extent that she was not able to bear weight. A 20 days earlier anteroposterior pelvis with bilateral hip radiograph () showed sclerosis over bilateral inferomedial femoral neck with cortical breach in the right side and an undisplaced complete fracture line over the left side. The neck shaft angle was 130° on the right side and 114° on the left side. Plain radiographs were orderedon presentation which showed a displaced fracture neck of femur on the left side collapsed in varus and sclerosis over inferomedial aspect of the right femoral neck with cortical breach. A computed tomography scan confirmed the X-ray diagnosis (). Blood investigations showed a normal calcium profile, Vitamin D, and serum parathyroid hormone levels. DEXA scan showed normal t- and z-scores in hip and spine. Whole spine radiographs revealed no abnormalities. Thus, a diagnosis of bilateral FNSFs was made and the patient was admitted for surgical stabilization. She underwent osteosynthesis with three cannulated screws on the right side and 2 days later underwent total hip arthroplasty for displaced fracture on the left side (). Postoperatively, she was allowed full weight-bearing mobilization on the left side and toe touch on the right side. There were no post-operative complications. Radiographs were repeated at 3 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively which showed union at the right side with no further varus collapse or implant failure (). The left side with hip prosthesis was also normal. At 1-year follow-up, the patient was pain free, able to walk full weight-bearing without support and carry out her daily activities comfortably. |
A 28-year-old married female educated up to Grade 12, belonging to the Hindu nuclear family of middle socioeconomic status, presented with a history of recurrent abdominal pain beginning at the age of 16 years. The abdominal pain was severe in nature originating in the epigastrium and left hypochondrium, further radiating to back and associated with vomiting. The pain used to get aggravated on the consumption of food for around 2 h, and relieved on bending forwards. The pain was episodic in nature, with each episode occurring once in 2–3 months and lasting for 3–4 days at a time. The patient was diagnosed to have chronic pancreatitis by a gastroenterology specialist and was prescribed pancreatic enzymes three times daily, along with tramadol 50 mg orally or injection as and when required for severe pain. The patient used to take Tramadol 50 mg orally or intravenously once in 2–3 months during episodes of severe pain. Around 2011, the patient underwent lateral pancreaticojejunostomy and was completely pain free following surgery for the next 2 years. Thereafter, in 2013, she again started to have similar pain as before and was given similar treatment (injection tramadol SOS for severe pain), which she would take once in 2–3 months. Two years later, the patient developed intermittent low mood, which gradually increased to persistent pervasive sadness of mood along with other depressive symptoms of moderate severity.\nIn 2017, when she had been again given injection tramadol intravenously for pain relief, the patient also experienced improvement in her mood and felt a sense of relaxation, which she liked. She continued getting herself injected with tramadol for pain relief daily for the next 1 week. However, after 1 week of continuous injection, the patient started to develop an intense desire to experience the relaxing effects of tramadol. Hence, she started to complain of pain (despite not having pain) to her family and got herself injected with tramadol daily. She started using one ampoule daily initially; however, she increased the dose gradually to 6–7 ampoules per day for 10 months, as she would not have the same effects with the previous dose. On days when she could not take the injection, she developed withdrawals in the form of severe anxiety, body ache, restlessness, lacrimation, and irritability, which used to get relieved only after taking the injection tramadol. She started to have repeated thoughts about when and where she can go and get herself injected again and started to neglect her household responsibilities, because of which her children had to shoulder the burden of household chores. She used to get herself injected always the help of trained persons such as doctors or chemists. She used to go to different medical shops in a single day itself to get injected and would spend even up to1 h waiting and convincing the local chemist or doctor to inject her under the plea of having severe abdominal pain. She developed scarring of veins, extravasation of injection leading to swelling, and seizures two to three times, despite which she continued to use the injections. She would be remorseful for her injection use behavior and think of stopping multiple times; however, she would not be able to control the use of injection tramadol.\nThe patient's depressive symptoms also persisted in the same intensity in this period. She also started to report of persistent abdominal pain daily, following which she was admitted to the gastroenterology department at the authors' institution. The patient continued to ask for tramadol injections in the gastroenterology ward and reported of depressive symptoms to the treating team, following which the patient was referred to the psychiatry department. In view of comorbid depressive symptoms and daily tramadol use, the patient was shifted to the psychiatry ward for further assessment and management. |
A 15-year-old Caucasian boy with no relevant medical history went to the emergency department after suffering trauma in his right hand caused by a fall forward while playing football. He presented a deformity at the base of the second finger, swelling, and painfully restricted motion. Rotational deformity of the second finger associated with radial deviation and hyperextension was found during physical examination, but neurovascular structures were intact.\nThe X-ray () showed fracture of the proximal phalanx diaphysis of the second finger of the right hand with deviation. Closed reduction under sedation was performed applying traction and ulnar deviation followed by syndactyly and immobilization with Zimmer splint. The control X-ray () revealed acceptable reduction, and the patient was referred to follow-up at the outpatient consultation. The conservative treatment was kept for 25 days, with apparent fracture healing on the X-ray (), but the patient presented limitation on active flexion of the finger which was interpreted as a sequel of the immobilization. Thus, he was referred for physical therapy rehabilitation. Six weeks after the initial trauma, the patient was observed at the emergency department for new right-hand trauma. On examination, no active flexion of the third phalanx of the second finger of the right hand was noticed. The X-ray didnot show any new fracture (). Then, the patient underwent an ultrasound that revealed deep flexor tendon entrapment at the previous fracture focus. A surgery was proposed and accepted by the legal guardians. The patient was prepared to surgery. After the Bruner incision in the palm face of the affected finger, the entrapment of the deep flexor tendon within the proximal phalanx was observed (). Then, tenolysis of the entrapped tendon was made () enabling the visualization of the bone space created by the fracture and where the tendon was trapped (). After that, a reconstruction of the pulleys was performed using a portion of long palmar tendon ( and ) with good immediate functional result (Video 1). The X-ray performed 2 weeks later (), documented a good result.\nFour weeks later, the patient had good clinical evolution with almost complete recovery of mobility. |
A six year old female child was brought by her parents with flexion deformity of both the thumbs. The deformity was noticed when the child was six months old, but the finger could be extended to the neutral position at that time. Since one year, extension has not been possible and the finger becomes painful if it is tried. The child did not have any other anamoly. There was no history of trigger thumb in maternal or paternal families.\nOn examination, IP joints were in 40o of fixed flexion. A 2*2 cm tender nodule was found at the crease of MCP joint. There was no triggering, but minimal extension at IP joint was possible when thumb was flexed at MCP joint. There was no associated MCP joint laxity. Both thumbs presented with similar findings. Figs , - The child was diagnosed of having bilateral trigger thumb. Surgical management was decided upon. Under General anaesthesia, with tourniquet applied to the arm, transverse skin incision was made opposite the MCP joint crease. Neurovascular bundles were retracted on either side. The thickened A1 pulley was split longitudinally. But full extension of IP joint could not be achieved. Another constricted annular pulley was found just proximal to A1. It too was released, and IP joint was completely extended. The nodular thickening of FHL was left undisturbed. - Complete active extension of IP joint was possible post-operatively, but the joint tended to be in flexed position. A removable extension splint was given and the patient was asked to do active finger movements atleast thrice a day after removing the splint. The deformity subsided after two weeks and the splint was removed. Neurovascular function was intact. Figs , - After two months of physiotherapy, the patient had following movements:\nPatient has minimal restriction of IP joint flexion of right thumb and minimal MCP joint hyperextension of left thumb. The child is followed for two years during which she did not develop any complication. There is no functional impairment. |
In February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pulmonary anomalies were identified either. Our patient responded well to antitubercular antibiotic therapy and his clinicians, together with his family, decided to keep him under control with clinical follow-up, avoiding surgery for the moment. |
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 25-year-old Chinese male was admitted because of respiratory symptoms and a large mass on the computed tomography (CT) scan suggestive of primary lung carcinoma. This patient presented with 45 days of an irritating dry cough and right chest pain without other abnormal findings such as fever, wheezing, hemoptysis, or superior vena cava syndrome. He had no smoking history and no family history of lung cancer. A review of systems was noncontributory. On admission, peripheral blood count, serum chemistry, and urinalysis were normal.\nAn enhanced chest CT scan revealed a huge pulmonary tumor over the right upper lung field with mediastinal and hilar lymphadenopathy surrounding the right upper lobe bronchus. Angiography showed encroachment on the superior vena cava (Figure ). Abdominal CT, MRI scan of the brain, and a bone scan were all normal. Bronchoscopy showed a subsegmental bronchus of the right upper lobe being pressured from outside without mucosal invasion, and bronchoscopic biopsy did not show any malignancy. Before hospitalization, the patient had undergone a CT-guided fine-needle aspiration biopsy in another medical center and a preoperative diagnosis of squamous cell carcinoma was made. This conclusion later proved to be a misdiagnosis.\nOn 21 December, 2009, after establishment of a venous bypass between the right internal jugular vein and the right femoral vein, a surgical exploration was performed through a standard posterolateral incision under general anesthesia. There was a huge tumor (18 × 16 × 15 cm3) located in the right upper lobe surrounding the roots of the right upper lobe bronchus and invading the surrounding tissues and organs, including part of the right middle lobe, the middle and lower portion of the superior vena cava, the right side of the pericardium, the right phrenic nerve, and the trunk of right pulmonary artery (Figure A). Several oval nodules found at the same time in the middle lobe were suspected to be metastatic lesions. Mediastinal and hilar lymph nodes were enlarged and had a tendency to integration. Intraoperative frozen section of lymph node sampling proved all of them to be metastatic poorly differentiated carcinoma.\nBased on these findings, sleeve lobectomy of the right upper and middle lobes was performed successfully to achieve complete tumor resection. Portions of the surgical procedure were sophisticated, including sleeve resection and reconstruction of the right bronchus and pulmonary artery, reconstruction of the superior vena cava, partial resection of the pericardium, and systematic mediastinal lymphadenectomy (Figure B). Postoperative histopathological assessment of the huge lobulated gray-yellow lung mass revealed that the tumor was situated in the lung parenchyma and involved visceral pleura. The tumor cells exhibited large vesicular nuclei and frequent mitoses without tumor necrosis. Immunohistochemically, the tumor cells expressed CD20, CD23, CD30, CD43, Kappa, and MUM1, but not CD117, TdT, CD10, or Bcl-6. The proliferation fraction as determined by staining with Ki-67 was 80%. Based on these findings, the diagnosis of diffuse large B cell lymphoma (Figure ) was made. The diagnosis of PPL was based on characteristic histological and immunophenotypical features according to the Kiel classification and the WHO classification []. Mediastinal [nos. #2, 3, 4, 7 and 9] and hilar [nos. #10] lymph nodes contained tumor. All of the negative surgical margins (bronchus, pulmonary artery, and superior vena cava) were confirmed. The tumor was determined to be stage IIE by the Ann Arbor classification system [].\nFive weeks after the operation, the patient received adjuvant therapy with CHOP (cyclophosphamide, Adriamycin, vincristine and prednisone) and Rituximab (a humanized monoclonal anti CD-20 antibody) for six cycles. For economic reasons, he did not receive maintenance therapy of Rituximab. After a 27-month follow-up period, as shown in Figure for16-month after operation, the patient is well and without evidence of locally recurrent or distal disease. |
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 33-year-old man presented to our clinic with complaints of watering, redness, and purulent discharge in the right eye. The patient reported seeing a physician a year earlier in Georgia due to fatigue, nausea, vomiting, and diarrhea. After his diarrhea and vomiting had resolved, he had swelling of the lymph nodes on the right side of the neck. After returning to Turkey for treatment, he had received cephalosporin and penicillin for suspected pharyngitis. When night sweating and weight loss were added to his complaints, he had presented to another hospital where his treatment was changed to amoxicillin-clavulanic acid 1 g 3 times a day and ciprofloxacin 750 mg twice a day, and incisional drainage was performed on the lymph nodes of his neck. When his symptoms failed to resolve completely, he had presented to the department of infectious diseases of a different university hospital. Serum agglutination test was positive for F. tularensis at a titer of 1/1280 and he was prescribed streptomycin 1 g per day for 9 days followed by 1 g twice a day for 5 days for a total of 14 days, followed by doxycycline 100 mg twice a day for 1 week. Ultrasound examination of the neck had revealed multiple abscesses in the right submandibular region and pathological lymph nodes including multiple calcifications in the right cervical chain, while magnetic resonance imaging of the neck showed retropharyngeal abscess narrowing right nasopharynx and oropharynx and submandibular lymphadenopathies (LAP) including cystic and necrotic areas (). He reported that the LAPs had resolved after a few months with no recurrence, but complaints of watering, swelling in the lacrimal sac area, hyperemia, and pain in the right eye developed a few weeks later. The patient presented to our clinic with recurrent swelling around the lacrimal sac, hyperemia, and purulent discharge.\nOn examination his best corrected visual acuity was 20/20 in both eyes. Intraocular pressure measured by automatic tono-pneumometry was 15 mmHg in each eye. On slit-lamp examination, epiphora was noted in the right eye and the left eye was normal. There was swelling in the area of the right lacrimal sac (). Fundus examination was normal in both eyes. In nasolacrimal lavage, the patient’s right nasolacrimal duct was occluded and the common canaliculus was patent. Discharge of purulent material from the right lower punctum was noted after lavage. A sample of the purulent discharge was collected and sent to the microbiology laboratory for culturing and the patient was started on oral amoxicillin-clavulanic acid 1 g twice a day and topical ciprofloxacin drops 4 times a day. Antibiotherapy was discontinued because the culture was negative. Consultation from the otorhinolaryngology (ENT) department was requested to rule out any intranasal pathology. The patient underwent ENT examination, followed by nasal endoscopic examination. In addition, to rule out intranasal pathologies that may present an obstacle to surgery, the paranasal sinuses were examined using computed tomography. No intranasal pathologies were detected in ENT evaluation. Dacryocystorhinostomy surgery was recommended to the patient, but he refused the procedure. |
A 39 year old man with no previous abdominal surgery was incidentally found to have a 2.5 cm mass in the neck of the pancreas on a computed tomography (CT) scan evaluation for acute diverticulitis. Past medical history was only significant for hypertension and gastroesophageal reflux disease. At the time of diagnosis, patient denied symptoms such as diarrhea, hypoglycemia, intractable peptic ulcer, weight loss, fever or migratory skin rash. CT guided fine needle aspiration biopsy confirmed a nonfunctional neuroendocrine tumor. Due to its malignant potential, decision was made to proceed with a surgical resection.\nPatient was taken to the operating room and positioned flat with 60 degree left side up supported by a bean bag. After adequate administration of general anesthesia, pneumoperitoneum was established using Hasson's technique through a 10 mm left paramedian port. Two additional 5 mm working ports were placed on either side to create adequate triangulation toward the pancreas (). A 30 degree telescope was then inserted to inspect the peritoneal cavity. No macroscopic pathology was observed throughout the peritoneal surface and on the liver region. A handport device was then placed in the midline under direct vision.\nDissection was initiated with splenic flexure mobilization using a laparoscopic electrocautery. The lesser sac was carefully entered by elevating the stomach and dividing the gastrocolic ligament. The pancreas was then inspected and solitary lesion within the neck of the pancreas was clearly visualized (). Intraoperative ultrasound showed a 2.5 cm tumor located in the neck of the pancreas over the superior mesenteric vein (SMV)-splenic vein confluence. The lesion was found to be full thickness involving the major pancreatic duct rendering enucleation not feasible. After complete peripancreatic tissue dissection with careful attention to the superior mesenteric and splenic veins, central pancreas was transected using LigaSure™ sparing a large healthy appearing pancreatic tail. The proximal cut edge of the pancreas was inspected to ensure adequate hemostasis. The resected portion of the pancreas was placed in an impervious bag and retrieved through the handport.\nThe remaining pancreatic tail was then elevated for a short distance to approximate the posterior wall of the stomach in preparation for the pancreaticogastrostomy anastomosis. Pancreatic duct was then cannulated using a 3 Fr Geenan™ stent () and a retrogastric pancreaticogastrostomy was performed using interrupted silk sutures in a single layer fashion (). Two Blake drains were placed in the lesser sac. Specimen weighted 20 grams showing neuroendocrine tumor features with negative margins on frozen section. Proton pump inhibitor and octreotide were administered postoperatively.\nLaparoscopic assisted central pancreatectomy was performed successfully with operative time of 180 minutes and blood loss of 200 ml. Postoperatively recovery was unremarkable and the patient was able to ambulate on postoperative day (POD) 1. Nasogastric tube was removed by the second POD. A slight increase in drain output up to 200 ml/24 hours was noticed following introduction of regular diet on POD 5. Drain fluid showed mildly elevated amylase and lipase. The patient clinical condition continued to improve without symptoms until hospital discharge on POD 9. Permanent pathology report showed a well differentiated pancreatic endocrine neoplasm of uncertain potential behavior with negative peripancreatic lymphnodes. Three days following discharge, patient presented to the emergency room due to drain malfunction which was simply managed by 2 cm drain retraction and reattachment. Repeat CT scan showed a minimal peripancreatic fluid collection around the surgical bed without oral contrast extravasation. Abdominal drains were removed in 2 weeks postoperatively and the patient continued to do well at 3 month follow-up without any signs of pancreatic insufficiency. |
A 39-year-old West African man who was a teacher was referred for weight loss and recent abdominal pain. He presented the following symptoms: generalized episodic abdominal pain of progressive onset that was relieved by diarrheal stools occasionally associated with rectal bleeding over the past 2 months. The patient had recurrent skin lesions of different ages on the lower limbs that had started to appear 6 months before the onset of abdominal pain. These lesions began with an inflammatory nodule that resolved within a few days with a pustule that ruptured quickly and spontaneously gave way to an ulceration whose diameter quickly reached several centimeters. The healing was spontaneous and left hypertrophic stigmata.\nThe patient was not a drinker or smoker and was of middle socioeconomic status. He had no personal or family medical history, especially cancer or blood or inflammatory disease. Upon admission, he had a body temperature of 37.4 °C, a pulse rate of 81 beats per minute, and a blood pressure of 110/85 mmHg. His physical examination revealed a moderate general condition, moderately colored conjunctiva, pain in the left iliac fossa, and hypogastrium without a palpated mass. The result of his rectal examination was normal. His dermatological examination demostrated objectified large, circumferential scarring lesions on both lower limbs and progressive ulceration on the posterior side of the left thigh (Fig. ). His Glasgow Coma Scale score was 15; he had no sensory or motor deficit, and the result of examination of his cranial nerves was normal. Biopsy of the progressive lesion showed a suppurative and inflammatory central zone with ulceration and neutrophil infiltration. The results of cytobacteriological (aerobic and anaerobic culture) and fungal studies were negative.\nWe concluded that these skin lesions were PG. Colonoscopy for the exploration of abdominal symptomatology revealed a necrotic and hemorrhagic budding lesion 20 cm from the anal margin, confirmed by contrast enema, which showed a narrowing of the lumen of the rectosigmoid junction. Biopsies taken during colonoscopy revealed an adenocarcinoma. An abdominopelvic computed tomographic scan revealed thickening of the rectosigmoid without associated metastases (Fig. ). The results of preoperative checkup (rhesus grouping; complete blood count; prothrombin time; activated cephalin time; tests for uremia, creatinemia, and glycemia; chest x-ray; and electrocardiogram) and liver checkup (serum glutamic-oxaloacetic transaminase (SGOT), serum glutamate-pyruvate transaminase (SGPT), alkaline phosphatase, gamma glutamyltransferase (GGT), total and direct bilirubin) were normal. A median subumbilical laparotomy confirmed a stenosing tumor of the rectosigmoid junction. A rectosigmoid carcinologic excision was performed with immediate colorectal anastomosis. Regular bandages were placed on the PG lesions. Postoperative treatment was initiated with ciprofloxacin 500 mg and metronidazole 500 mg twice daily for 10 days and tramadol 50 mg three times daily for 5 days. The anatomopathological examination of the surgical specimen (using hematoxylin and eosin-stained sections) confirmed the diagnosis of adenocarcinoma of the rectosigmoid junction (Fig. ). The tumor was classified as pT2N0M0 with negative excision margins. There were no postoperative complications, and the patient was discharged on postoperative day 7. No adjuvant treatment was performed. Thirteen months after the operation, all the skin lesions had healed without reemergence of new lesions, and the patient did not have metastases or tumor recurrence. |
Our patient was a 62-year-old Caucasian male with a history significant for obstructive sleep apnea and osteoarthritis. He visited his primary care provider with a swelling over his left temple that was present for a long time but had gradually increased in size for the past several months. The swelling was around 3.5 × 3 cm in size on presentation with newly developing tenderness in the left temple. There was an initial suspicion for giant cell arteritis and hence a temporal artery biopsy was done which was negative. The swelling continued to progress causing proptosis, tearing, discharge from the left eye, and redness over the left temple and orbit. Initial laboratory investigations including SPEP, liver function testing, prostate-specific antigen, ESR, and CRP were within normal limits. CT maxillofacial with contrast showed a 3.8 × 2.7 cm lytic lesion on the left orbital wall with associated heterogeneous soft tissue that was suspicious for malignancy. CT head with and without contrast did not show any significant findings.\nThe interventional radiology (IR) team performed a CT-guided biopsy of the left periorbital soft tissue mass which showed soft tissue diffusely infiltrated by a moderately differentiated adenocarcinoma with a prominent cribriform pattern. Tumor cells had moderate cytologic atypia, numerous mitotic figures, and evidence of individual cell necrosis. Immunohistochemistry was positive for GATA-3 and negative for PSA and TTF-1. The consideration then was a primary adenocarcinoma of either lacrimal or sinonasal origin or a metastatic adenocarcinoma likely from the breast. MRI of the brain with and without contrast showed a fairly well demarcated, lobulated mass with mixed cystic and solid components along with heterogenous enhancement involving the left lacrimal gland and the lateral wall of the left orbit. The mass extended into the left suprazygomatic space and orbit. The left lateral rectus muscle was displaced. The overlying muscle in the left supra zygomatic masticator space demonstrated edema and enhancement. Nasal endoscopy did not reveal any evidence of malignancy in the upper aerodigestive tract. PET CT imaging from the skull to the thigh showed increased metabolic activity of the left orbital soft tissue mass with adjacent lytic changes involving the left orbit. There was no evidence of metabolically active lymphadenopathy in the head and neck nor any evidence of distant metastatic disease. ENT, neurosurgery, ophthalmology, medical oncology, and radiation oncology teams were involved in the care of the patient.\nThe patient underwent an en bloc resection of his lacrimal gland tumor which required orbital exenteration. Biopsies were sent. Since his tumor extended to the skull base, a craniotomy was performed and a small dural leak repaired with a pericranial graft. shows the relationship of the tumor to the eyelid. Microscopic examination demonstrated the adenocarcinoma to be arising from a PA of the lacrimal gland (), with the PA component demonstrating p63 positivity (). The tumor showed an invasive cystic growth pattern with papillary and cribriform arch formations, invading the fibroadipose tissue and adjacent bone. The cystic structures were lined by neoplastic cells with apocrine features and nuclear pleomorphism ranging from low to high grade. Up to 8 mitotic figures/10 high-power fields were seen within the areas of high-grade features. Foci of invasive solid component were identified with cribriform architecture and high nuclear atypia (). There was no evidence of perineural or lymphovascular invasion. Foci of hemorrhage, granulation tissue, and dystrophic calcification were also identified within the cystic component of the tumor. Immunohistochemistry showed the carcinoma cells to be positive for androgen receptor (AR), GCDFP15, HMWK903, and CAM5.2, while staining negative for S100, cytokeratin 5/6, p53, HER2/neu, progesterone (PR), and estrogen receptor (ER) (Figures –). The Ki 67 index was focally elevated at 22% as shown in . The overall findings supported the diagnosis of invasive ductal adenoCa ex PA of the lacrimal gland with the carcinoma component showing features ranging from low-grade papillary cystadenocarcinoma to intermediate-/high-grade ductal carcinoma.\nPostoperatively, he received chemotherapy with 6 cycles of cisplatin with concurrent radiation therapy (RT). Six months after diagnosis and 2 months after completing chemoradiation, there was a suspicion for recurrence of the tumor and the patient had to undergo reexcision of the surgical site. Biopsies however did not show any definitive evidence of recurrence. Throughout his clinical course, he had multiple episodes of temporal abscesses and bacterial meningitis and had to undergo several craniotomies. Due to the complicated course and poor prognosis, the family decided to adopt comfort measures alone and the patient eventually succumbed to severe sepsis and cardiorespiratory arrest 1 year after his diagnosis. |
A 61 year-old lady presented to clinic with a lesion in her anterior abdominal wall. It was present for four weeks and initially thought to be a sebaceous cyst but had rapidly expanded in that time frame. She had no other symptoms of note. On clinical examination the patient had a lesion measuring 4 × 3 cm firm, fixed, hemispherical with a smooth edge. There was a punctum and some indurated fat around it.\nHer past history was of a right-sided breast cancer, she underwent a wide local excision and axillary dissection for a grade 1 lobular carcinoma with no nodal involvement. She underwent adjuvant treatment with radiotherapy and tamoxifen.\nShe was initially referred due to concern that this lesion was related to her previous breast cancer, however clinically it appeared benign and she underwent elective excision of the lesion under local anaesthesia.\nHistopathology revealed a tumour growing as solid sheets diffusely infiltrating the dermis and subcutaneous fat with significant areas of necrosis. The tumour was monomorphic with intermediate sized cells with scanty cytoplasm. There was a hint of rosette formation (Figure ) but no other differentiating features relating to pigment, gland formation or mucin. Special stains showed cytoplasmic glycogen (Figure ) and immunohistochemistry showed strong expression of CD99, focal expression of CD56 and focal dot-like expression of cytokeratins, expression of S100 but no expression of other melanoma markers. The combination of morphology and immunochemistry was consistent of the spectrum of primitive neuroectodermal tumours.\nShe was referred to Oncology for adjuvant therapy. Staging CT scan of the chest, abdomen and pelvis revealed ill defined haziness in the subcutaneous fat of the right upper abdomen but no solid or cystic lesions were apparent. No other significant abnormalities were seen. Whole body bone-scan showed no evidence of bony metastases. Bone marrow trephine biopsy showed normocellular marrow with no evidence of neoplasia.\nAlthough the lesion appeared to be completely excised the recommendation was for adjuvant chemotherapy. She was commenced on 6 cycles of Vincristine, Doxorubicin and Cyclophosphamide. |
A 51-year-old male received a penetrating stab wound to the abdomen and underwent an immediate emergency laparotomy. Findings at laparotomy were splenic hilar injury, a through-and-through enterotomy of the stomach and transection of the left renal vein. The stomach was repaired, a splenectomy was performed and ligation of the left renal vein was undertaken with temporary clamping of the aorta. The abdomen was packed, and a temporary topical negative pressure closure of the abdomen was undertaken. The patient required 24 units of packed red cells, 20 units of fresh frozen plasma and 4 units of platelets to achieve resuscitation. Twenty-four hours later, the patient was returned to the operating room for a relook laparotomy. The transverse colon had patchy ischaemia, so a damage control resection of the colon was undertaken. Minor bleeding points on the abdominal wall were controlled. The topical negative pressure closure was reapplied. On the fourth postoperative day, a second relook laparotomy was undertaken. The colon was anastomosed. The abdomen was unable to be closed, and the topical negative pressure dressing was reapplied. On the ninth postoperative day, a further attempt was made to close the abdomen but this was not successful. The topical negative pressure closure was reapplied.\nOn the 11th postoperative day, a component separation was performed. The topical negative pressure dressing was removed leaving the defect shown with the anterior sheath retracted away from the midline (see Fig. . The overlying skin was released bilaterally from the abdominal wall, and the anterior rectus sheath was released. To achieve this, the external oblique was incised at Point A, and the incision taken high to the costal margin and as low as possible to allow maximal release. The internal oblique is then exposed (Point B), and the released edge is visible at Point C (see Fig. ).\nA posterior sheath release was then performed to provide medial movement of the sheath, so that it could be closed in the midline (see Fig. . A 25 × 25-cm biologic mesh (Strattice™ Reconstructive Tissue Matrix,–LifeCell Corp.) was rotated to a diamond shape and secured in the pre-peritoneal space, to the lateral fascia (see Fig. . The rectus muscle was closed, and the component separation allowed for the anterior sheath to be closed in the midline (see Fig. . Primary skin closure was undertaken, and the patient returned to the ward.\nOn the 16th postoperative day, he suffered a witnessed ventricular fibrillation cardiac arrest. He was resuscitated and subsequently anticoagulated. The following day a computed tomography scan revealed a large abdominal wall haematoma anterior to the rectus sheath. He returned to theatre on the 17th postoperative day. The fascia was found to be intact, and the haematoma evacuated. Topical negative pressure was reapplied. On the 21st postoperative day, the skin was reclosed. He returned to the ward and was discharged on the 49th postoperative day, following implant of a cardiac defibrillator, with an intact wound (see Fig. ). |
A 12-year-old female patient reported to the Department of Periodontics, People's College of Dental Science and Research Centre, Bhopal, with a history of swelling in the upper lip and gums since last six years. Patient gave history of trauma during playing six years back, which resulted in laceration of upper lip, for which a local doctor was consulted. This was followed by appearance of swelling in the upper lip which increased gradually in size and was constant since the last two years. Patient also gave a history of swelling and spontaneous bleeding from the gums, because of which she refrained herself from oral hygiene maintenance.\nIntra oral examination showed generalized gingival hyperplasia with maxillary arch with a typical bluish purple gingiva at the interdental areas of 11 and 21; associated with grade I mobility Also, localized gingival enlargement was present in relation with mandibular incisors and canine [Figures –]. Generalized bleeding was observed at slightest provocation of gingiva. No abnormalities were detected on general systemic examination, and hematological investigations which included a coagulation profile. Orthopantomogram was also inconclusive [].\nPeriodontal treatment which was initiated with phase I therapy using hand instruments resulted in spontaneous brisk bleeding which was difficult to control. The bleeding site was suctioned and severe hemorrhage was controlled by digital pressure which took no less than 20 to 25 minutes. Because of the severe nature of hemorrhage encountered, some type of vascular abnormality was suspected and the patient was referred to physician for opinion.\nUltra sonography of the upper lip was performed which showed marked thickening of upper lip with multiple dilated vascular channels in the submucosal layer of upper lip. Dilated and enlarged arteries were seen with marked increase in systolic and diastolic flow predominantly on left side of midline. The findings were suggestive of post traumatic AVM [].\nAngiography is the corner stone of diagnosis of vascular lesions which helps in visualizing exact angioarchitecture of the lesion essential for treatment planning. A transfemoral angiography was performed which confirmed the diagnosis of a small high flow AV malformation measuring (approx. 16×9×12 mm) situated in the middle of upper lip []. The arterial feeders were from right internal maxillary artery and venous drainage via bilateral ophthalmic vein into bilateral cavernous sinuses and partly via bilateral facial vein into bilateral jugular vein.\nThe patient underwent a surgery in a private clinic where the mass associated with upper lip was excised using circumferential excision and the defect was closed. The patient did not turn up for further recall and reported back after two years for periodontal treatment. Intraoral examination revealed gingival enlargement was still present, and also a recurrence of the malformation of lip was noted as the central nidus of the lesion present in the midline of the upper lip was not removed. After consultation with the physician and oral surgery department, it was decided to undertake periodontal treatment after embolization of the lesion.\nLocal anesthesia was administered to the patient and the osseous topography of the bone was determined using bone sounding. Gingivectomy and gingivoplasty were performed at the same time, so as to achieve the normal topography of gingiva. Bleeding points were marked using pocket marker so as to outline the course of incision. The incision was started using no. 15 scalpel blade from the distal most tooth apical to the bleeding points marking the course of the pocket and directed coronally to a point between the base of the pocket and crest of bone. The incision was beveled at 45 degree to the tooth surface, so as to recreate normal festooned patter of gingiva. The incised tissue was removed and the area was degranulated using gracey curettes. Taking into consideration the bleeding encountered and the extent of gingival enlargement, the surgery was performed sextant wise, the bleeding during the surgery was relatively less as compared to initial phase due to embolization of the lesion. The intrasurgical bleeding was controlled using pressure pack and postoperative bleeding was controlled by cold compression.\nPost embolization of the vascular lesion present with the upper lip and following gingivectomy procedure, the patient was followed-up for a period of one year and no recurrence was noted [Figures –]. The final aesthetic result was acceptable by the patient. |
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 11-year-old female patient presented to the department of pedodontics and preventive dentistry with a chief complaint of extraoral swelling on the left side of the face at the lower border, near the angle of the mandible. The history of presenting illness revealed that the swelling had been present for the past 6 months and had mildly increased in size for the past 2 months. The swelling had been asymptomatic. Extraoral examination revealed mild facial asymmetry and a hard nodular mass which was nontender on palpation. The skin overlying it was normal with no signs of inflammation or ulceration []. Intraoral examination revealed the presence of permanent dentition with missing left permanent mandibular first molar (36). No obliteration of buccal vestibule was noted and mucosa overlying missing first molar tooth was normal []. Orthopantomograph revealed a large radiodense mass with a lucent rim on the left side of the posterior mandible overlying the unerupted molar tooth which was assumed to be tooth 36. The mass was lying just over the erupting path of the tooth 36 acting as a hard tissue barrier for its eruption. Radiographically, it was also observed that the left permanent mandibular second molar (37) was missing []. A provisional diagnosis of complex odontoma was made. A decision to surgically excise the mass under general anesthesia was made with doubtful preservation of the unerupted molar tooth, followed by histopathological examination to confirm the diagnosis.\nInformed consent was taken from the parents to carry out the procedure under general anesthesia. Following a complete pediatric and anesthetic evaluation, tooth 36 was removed via extraoral approach using submandibular incision [ and ]. Platelet-rich plasma (PRP) was inserted in the socket and skin sutures using 4–0 prolene were placed. Excision of the hard tissue mass was done through an intraoral approach [ and ], following which PRP and sutures were placed. The hard-tissue mass along with the first molar tooth was sent for histopathological examination. The extracted tooth was identified as 36 based on the morphology of the crown, and based on the histological findings, a definitive diagnosis suggestive of complex odontoma was made [].\nThe postoperative course was uneventful. In the 3rd month of follow-up, the patient reported no signs of discomfort or pain []. The patient continues to be under follow-up and prosthetic replacement of missing molars is planned for future. |
A 49-year-old African American female patient first noted pain in her distal right thigh in April 2008, which was managed with narcotic medication until December 2009. The patient underwent bone debridement at an outside institution. Pathology from this initial surgery was inconclusive. The patient underwent bone debridement once again in January 2010 at the same institution, as a result of her continued lower extremity pain and imaging abnormalities; pathology was again inconclusive but was thought to be consistent with osteomyelitis. The patient received several weeks of antibiotic therapy with vancomycin and daptomycin. She discontinued narcotics after this initial resection.\nThe patient was pain free until November 2010, at which time she sought an evaluation with an orthopedic surgeon and was again started on narcotic analgesics. She was ultimately referred to our clinic and underwent repeat magnetic resonance imaging (MRI) in March 2011, at which time was noted abnormal signal and enhancement about the bone/cement interface around the mid distal femoral bone cement with interval focal cortical erosion compatible with residual or recurrent lesion or infection. A CT-guided biopsy was performed and demonstrated lymphocytic infiltrate with increased B-cells. Molecular analysis by polymerase chain reaction (PCR) analysis did not show a clonal immunoglobulin gene rearrangement, arguing against a lymphoproliferative disorder.\nIn May of 2011, the patient underwent surgery at our institution. The cement was removed, the lesion was aggressively curettage, tissue was obtained for histology and culture, and antibiotic-impregnated cement beads were placed in the bone defect. Pathologic evaluation showed the lesion to be consistent with extranodal RDD. Pathognomonic features such as emperipolesis and replacement of the bone marrow by diffuse infiltrating of histiocytes and intervening bands of proliferating plasma cells were noted. The histiocytes stained positive for CD68 and S-100 by immunohistochemical study (). Tissue cultures were negative and the patient was taken back to surgery for removal of the antibiotic-impregnated beads and packing of the cavity with allograft bone.\nThe patient did well for approximately a year, at which time her pain recurred. Imaging indicated resorption of the bone graft consistent with recurrence of disease. The orthopedic oncologic surgeon consulted with colleagues at several institutions across the country; the consensus opinion was to repeat aggressive curettage. This procedure was performed followed by packing of the bone defect with allograft bone in July 2012. Pathology examination again confirmed extranodal RDD, with the same features as before.\nUnfortunately, the patient’s pain recurred once again in January 2013 and imaging was again consistent with recurrent disease. At that time she was referred to the radiation oncology clinic. She was complaining of severe right lower extremity pain that was exacerbated by movement. The pain would last for several days and only resolve with narcotic medication and bed rest. Repeat imaging in April 2013 (Figure 2A) noted a lobulated focus of signal abnormality and enhancement along the postero-lateral aspect of the femoral shaft at the posterior-superior margin of the bone graft window defect, which was worrisome for recurrence. On exam, she had weakness of the right lower extremity with pain on knee extension and tenderness to palpation of the surgical incision region in the lateral distal thigh. No significant edema, skin discoloration or warmth was noted. The patient was ambulating with the assistance of a walker and required a wheelchair to move around the clinic. The decision was made to proceed with palliative external beam radiotherapy, 30 Gy in 15 fractions (). The dose was selected after conducting a literature review to determine the dose response of this disease to radiotherapy. Though limited evidence is available, it appeared that there are a high rate of non-responders if a dose less than 30 Gy is utilized. After 5 fractions over the course of five days, the patient’s pain resolved entirely. She no longer required pain medication and was ambulating without assistance. She experienced no adverse events from the radiation. She began physical therapy and rehabilitation shortly after completion of radiotherapy. At her first follow-up in June 2013, the patient had no clinical symptoms. Initial follow-up MRI noted an area of signal abnormality and enhancement at both the proximal and distal aspects of the curettage bed that had increased in prominence; due to the patient’s lack of symptoms, this was felt to be inflammation related to radiotherapy, and the decision was made to continue observation. Subsequent imaging in October 2013 and January 2014 found this area to be stable, and the patient remained asymptomatic (Figure 2B). At the time of report, the patient had been disease free and asymptomatic for approximately 15 months. |
JP is currently a 58 year old man with multifocal urothelial tumors of the urinary bladder despite two courses of intravesical mitomycin C and one six week course of BCG.\nThe patient appears well but has a significant past medical history consisting of diabetes mellitus, coronary artery disease, mild congestive heart failure, chronic renal disease, and peripheral neuropathy. He stopped cigarette smoking at age 35 after 15 years of smoking 1.5 packs/day. He has had a coronary artery stent placed.\nThe patient has a BMI of 38 kg/m2. He weighs 106 kg and is 168 cm in height. He is thus markedly overweight with a large abdominal girth. His recent creatinine is 2.13, BUN 38. This has been stable for 3 years.\nHe presented with gross hematuria in 8/15. Imaging disclosed left hydronephrosis with a filling defect in the left renal pelvis. Ureteroscopy and biopsy revealed a low grade urothelial tumor in the renal pelvis. In April 2016 he underwent a robotic assisted left nephroureterectomy. The pathology indicated high grade pT3 urothelial cancer in the renal pelvis with small HG Ta and CIS in the ureter. There was Ta tumor at the distal margin. Adjuvant chemotherapy was discussed but was not given because of his renal failure. Subsequent serial imaging has been negative for any metastasis.\nBeginning in July 2016 he has developed multifocal low or high grade Ta urothelial cancer of the bladder. After the resection of over 10 HG Ta tumors in 7/16 he received intravesical mitomycin for six weeks. In 11/16 he had a TUR BT of multiple tumors from one to 5 cm, LG Ta. Although BCG is not likely to be effective for LG Ta he was given intravesical BCG for six weeks. The next TUR BT was 3/17 and once again there was mutifocal HG Ta tumors. This was followed with weekly mitomycin again.\nThe most recent TUR BT was in 7/17 and the pathology was LG Ta. The largest tumor was at the 1 o’clock position just inside the bladder neck and required a bugby electrode with the 70 degree lens to visualize and remove, as it was not visible with the 12 or 30 degree lens. His most recent cystoscopy was 10/17 and not surprisingly he has developed multiple small and large tumors which all appear Ta.\nThe patient’s quality of life has not changed as a result of the multiple resections. He has not had gross hematuria since the left nephrectomy. He has not developed an invasive tumor of the bladder.\nAlternative considerations for therapy are welcome such as a PDL inhibitor or other experimental treatment.\nPhotos will be of the tumor and the use of the blue bugby electrode for the tumor at the 1 pm location at the bladder neck. |
In February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pulmonary anomalies were identified either. Our patient responded well to antitubercular antibiotic therapy and his clinicians, together with his family, decided to keep him under control with clinical follow-up, avoiding surgery for the moment. |
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 19 years old male presented with a rapidly progressing painless neck swelling of 3 months duration. There were no complaints of fever or weight loss or symptoms suggestive of compression of adjacent structures. The patient was afebrile and had a cystic, non-tender, non-translucent and smooth swelling occupying the whole of the neck anteriorly, extending from the hyoid bone to the suprasternal notch. The lower limit of the swelling could not be reached. There were no neck nodes or dilated tortuous neck or chest wall veins.\nChest X-ray revealed widening of the mediastinum and a soft tissue neck swelling, continuous with the mediastinal shadow (Fig ). On neck ultrasonography, a predominantly cystic, multiseptate mass lying superficial to the thyroid lobes was evident. Fine needle aspirate cytology from the swelling showed largely necrotic material with few macrophages and mixed inflammatory cells on a background of proteinacious material, suggesting a diagnosis of a dermoid cyst. There were no acid-fast bacilli, bacterial and fungal elements on microscopy and culture. 99mTc-thyroid scan ruled out a thyroid lesion. Contrast enhanced CT of neck and mediastinum (Fig and ) showed a multi-septate, predominantly cystic neck mass, superficial to thyroid and strap muscles. The mass was continuous with a more solid intrathoracic mass with areas of calcification and cystic necrosis, extending up to the level of right atrium. The trachea was shifted to the right but there was no compression or infiltration of great vessels or mediastinal structures. There were no mediastinal lymph nodes and pulmonary lesions. A diagnosis of anterior mediastinal teratoma with cervical extension was made.\nThe patient was operated upon through a neck crease and median sternotomy incision under general anesthesia with endotracheal intubation. The posterior wall of the mass in the neck was adherent to the strap muscles. A solid mediastinal tumour with areas of necrosis, which seemed to be arising from the thymus gland, was found on sternotomy. The tumor derived its blood supply from the thoracic vascular channels as direct branches from aortic arch and the subclavian artery. There were no vessels feeding or draining the tumor in the neck. The mass was adherent to but did not infiltrate, the innominate vein. The neck and thoracic mass, along with a densely adherent 4 × 3 cm area of left mediastinal pleura, were removed in continuity, preserving nearby vital structures.\nThe resected surgical specimen was subjected to a detailed histopathological evaluation. On naked eye examination, the globular brownish mass measured 16 × 7 × 2 cms. The cut surface of the mass was cystic, filled with yellow pultaceous material and a mass of hair. There was a solid area projecting into the lumen of the cystic area, which had multiple cysts filled with gelatinous material. On microscopy, the cyst wall showed predominantly degenerate necrotic area, associated with inflammatory cells. Sections from the solid areas revealed cartilage, osseous tissue and nerve bundles with ganglionic cells, respiratory epithelium and sero-mucinous glands embedded in dense fibro-collagenous and fibro-muscular tissue. The lesion was thus labeled as a mature cystic teratoma on basis of the histopathological features.\nThe patient made an uneventful postoperative recovery. After five years in the follow-up, the patient has remained asymptomatic, and follow-up imaging studies in the form of chest x-ray examination undertaken 3, 14 and 36 months after operation, as well as a contrast enhanced CT scan of the neck and mediastinum performed 14 months after operation, have not shown any residual or recurrent mass. |
First and fifth minute Apgar scores were found to be 3 and 6 in a female baby who was born from the first pregnancy of a 32-year-old woman by cesarean section at the 32nd gestational week with a birth weight of 1220 g (10 p). An audible cry could not be heard despite crying effort in the baby who developed marked respiratory distress and cyanosis immediately after birth. It was learned that polyhydramniosis was found in the antenatal follow-up and preterm delivery occured because of unstoppable preterm labor.\nVentilation was applied via a balloon mask because of respiratory distress and cyanosis, but a sufficient response could not be obtained. Endotracheal intubation was attempted, but was unsuccessful. During intubation, the larynx was visualized and a membrane that caused severe laryngeal stenosis was observed at the level of the vocal cords. The department of otolaryngology was consulted to provide patency of the airway and continuance of patency and an urgent laryngoscopy was performed. Laryngoscopic examination revealed a fibrotic layer in the form of a band, which completely inhibited visualization of the vocal cords and a small patency compatible with pharyngo-tracheal duct at the level of the posterior commissure of the larynx, and an urgent tracheostomy was performed.\nThe patient was internalized in the neonatal intensive care unit (NICU) after tracheostomy and a orogastric catheter could not be advanced to the stomach on routine examination. Posteroanterior lung radiography revealed upper atresic tracheal enlargement due to esophageal atresia () and a few air bubbles showing that the patency at the level of the posterior commissure enabled partial ventilation of the baby (, ).\nDuring a TEF repair operation performed on the third day of life, it was observed that distal esophageal atresia also accompanied the picture. The patient, who was followed up in NICU, was separated from mechanical ventilation three days after the operation and continued her breathing by way of tracheostomy without any problem. Computed tomography (CT) and magnetic resonance imaging (MRI) performed after her general status was stabilized revealed that the size of the LA was 0.7 cm (, ).\nThe patient, who was followed up in our hospital with the diagnoses of prematurity, LA accompanied by PTD and TEF, was discharged with transient tracheostomy after family education was given. Currently, she is in her first year of life and her somatic and neurodevelopmental follow-up findings are near normal. She has been included in a permanent tracheostomy program. Written consent was obtained from the patient’s parents. |
A 23 year old female presented with a history of pain and swelling in her sacral region for four months. Initially it was mild in intensity but gradually progressed to severe, continuous pain necessitating regular use of injectable analgesics. It was radiating to both her lower limbs, more so on the left side. Plain radiograph of pelvis showed an ill-defined osteolytic lesion in the sacrum (). Magnetic resonance imaging (MRI) revealed an expansile heterogeneous lesion involving the sacral segments S1, S2 and S3. The lesion was hypo intense on T1 and hyper intense on T2 sequences. It measured 6 × 8 × 4 cm and was extending bilaterally up to the sacroiliac joint, affecting left side more than right ().\nThere was compression of sacral nerve roots due to the disease process. All other blood investigations including serum alkaline phosphatase were within normal limits. There was no distal neuro-vascular deficit and the patient had good bowel and bladder control.\nPatient underwent a Computer Tomography (CT) guided biopsy which confirmed the diagnosis of giant cell tumor of bone. Chest radiograph showed no metastasis. The case was discussed in a multidisciplinary clinic in view of the involvement of proximal sacrum, and a decision was made to treat the lesion with serial embolisation and parenteral bisphosphonates (monthly 4 mg of zolendronic acid), as intra lesional surgery would have a very high risk of loss of bowel and bladder functions. After two sessions of embolisation, symptoms were not relived and she developed retention of urine and started having difficulty in passing stools. Repeat MRI scan showed increase in the size of the lesion (7×9×7cm). Patient underwent intra-lesional curettage of the lesion. No chemical or thermal adjuvants were used in order to avoid injury to the neural structures. Patient was put on anticoagulation therapy and was kept under surveillance.\nSix months post-surgery, the patient again presented with pain at the primary lesion and bilateral limb swelling. The MRI revealed recurrence of the disease in the sacrum and expansion of the inferior vena cava (IVC) with a non-homogenous intramural mass which had heterogeneous signal intensity in both T1 and T2 images, suggestive of tumor thrombus (). This mass was extending superiorly up to sub hepatic region and distally into bilateral common and external iliac veins. A Positron Emission Tomography (PET) scan revealed a hyper metabolic intramural lesion involving right external iliac, bilateral common iliac and inferior vena cava extending up to sub hepatic region with standard uptake value (SUV) of 14.3 which was suggestive of tumor thrombosis. In addition, it also showed a hyper metabolic destructive lesion in sacrum with SUV max of 11.7 which was suggestive of recurrence of disease. An IVC filter was deployed to prevent pulmonary embolism. We placed a retrievable IVC filter through right internal jugular vein and performed thrombo-aspiration from the right femoral vein. Large amount of thrombus was aspirated using an 8 French guiding catheter (Vistabrite, Cordis Corporation). The aspirated thrombus showed characteristic histological features similar to the primary sacral lesion with no evidence of malignant transformation (). The sacral recurrence and the infrahepatic IVC tumor thrombus were treated with definitive radiotherapy using helical tomotherapy based Intensity Modulated Radiation Therapy (IMRT). The gross residual mass in the pelvis was treated with a dose of 50Gy/25 fractions at the rate of 2Gy/fraction while the infrahepatic IVC with tumor thrombus received 45Gy/25 fractions at the rate of 1.8Gy/fraction using simultaneous integrated boost technique. The patient was followed up with MRI at regular intervals. At the last follow up 3 years post radiation therapy, she had stable disease with reduction in vena caval obstruction symptoms and complete control of her bowel and bladder movements. |
In February 2014, an 11-year-old male presented with a history of recurrent respiratory tract infections and suspected tuberculosis following a case within his family. On physical examination, he appeared to be in good health. Chest auscultation did not reveal any specific pathological heart or lung sounds. Abdominal objectivity was negative. His parents did not refer any other relevant medical history about him. Tuberculin skin tests resulted positive and a chest X-ray showed a dishomogeneous parenchymal consolidation in the left lower lobe (). Suspecting active tuberculosis, a preliminary CT scan of the thorax was performed showing a heterogeneous consolidation with some cystic masses containing mixed fluid and air in the left lower lobe posterior segment, not in communication with the respiratory tract, and a probable expression of a dysplastic parenchymal area ( and ). These findings were suggestive of pulmonary sequestration, including a differential diagnosis of congenital pulmonary airway malformation, because of the presence of a cystic component within the consolidation. The injection of contrast medium showed an artery arising from the descending thoracic aorta that divided into two 1.2 cm after its exit, with both branches extending to the dysplastic area; therefore, a diagnosis of intralobar sequestration with associated aspects of bronchial atresia was made; superinfection and trapping of contiguous parenchyma coexisted. Just below the emergence of the previously anomalous vessel, another artery was detected that crossed the midline to achieve a healthy parenchyma in the right pulmonary base, configuring a pattern of aberrant systemic artery feeding a normal lung (–). Other congenital anomalies that appear to be related to pulmonary sequestration were absent; in particular, pulmonary venous drainage was regular through the pulmonary veins, there was no communication between the bronchus and the oesophagus, and no diaphragmatic defects or other gross pulmonary anomalies were identified either. Our patient responded well to antitubercular antibiotic therapy and his clinicians, together with his family, decided to keep him under control with clinical follow-up, avoiding surgery for the moment. |
A 67-year-old man was referred to our department with a diagnosis of IPDA aneurysm. The patient was asymptomatic and had a history of smoking and chronic obstructive pulmonary disease (COPD). He underwent thoracentesis for pneumothorax, followed by pleurodesis four months before the referral for the IPDA aneurysm. The aneurysm was unexpectedly detected during examination for the pneumothorax.\nA dynamic computed tomography (CT) scan showed a saccular IPDA aneurysm, with a diameter of 20 mm (). The aneurysm was located adjacent to the origin of IPDA from the superior mesenteric artery (SMA). Moderate calcification was observed on the aneurysm wall. CT also revealed chronic total occlusion at the origin of the celiac axis from the aorta. Due to the occlusion of the celiac axis, the IPDA and anterior inferior pancreaticoduodenal artery (AIPDA) had become well developed as major collateral sources from SMA to the common hepatic and splenic arteries (). The pancreaticoduodenal arcade arteries were very thick and entirely tortuous. We have predetermined local criteria to establish the therapeutic indications for visceral aneurysms. Treatment for visceral aneurysms, other than splenic artery aneurysms, is considered if the aneurysm size is >10 mm in diameter, regardless of the shape. The size of the aneurysm in this case met the criteria for treatment. Bilateral common iliac artery aneurysms were also occasionally detected; however, they were scheduled to be treated with stent grafting after treatment of the IPDA aneurysm.\nFor treating the IPDA aneurysm, coil embolization was initially considered. However, complete endovascular treatment seemed to be difficult because of the following issues: (1) The IPDA aneurysm was adjacent to the IPDA branching point from SMA, and the obturator placed for embolization of the IPDA aneurysm might drop off to the distal SMA, leading to acute intestinal ischemia. (2) Embolization of the IPDA aneurysm would block the dominant collateral blood flow to the celiac axis, which might cause severe acute global ischemia of the liver and spleen. To prevent severe ischemia in the celiac region, we also considered performing a balloon angioplasty at the origin of the celiac trunk prior to IPDA embolization. However, this procedure could injure the origin of the celiac axis due to the presence of severe atherosclerosis. Moreover, emergent conversion to thoracoabdominal aortic surgery was required to be avoided in this COPD patient.\nBypass surgery to the celiac region under abdominal exploration was considered necessary to secure the blood flow to the pancreaticoduodenal arcade before the removal of the IPDA aneurysm. Regarding possible inflow vessels for bypass grafting, the abdominal aorta and bilateral iliac arteries could not be used due to aneurysms or severe atherosclerosis. Both renal arteries exhibited mild atherosclerotic stenosis. SMA was the only available inflow vessel. Regarding target vessels, in addition to the common hepatic artery, AIPDA was available because it was well developed and emerged from the surface of the pancreatic head. In this case, SMA–AIPDA bypass grafting was thought to be better because it would require minimal manipulation and would avoid acute curvature of the graft.\nIn case ligation or resection of the aneurysm was impossible for some reason, coil embolization could be performed within several days of surgery by the time of bypass occlusion.\nDuring surgery, abdominal exploration and harvesting of a saphenous vein graft (SVG) were performed simultaneously. The dorsal side of the jejunal mesentery was entered between the origin of the jejunum and the inferior mesenteric vein; then, the aneurysm and IPDA were identified on the left dorsal side of SMA (). SMA was identified ventral to the jejunal mesentery and then encircled just proximal to the right colic artery. After lifting up the transverse colon, the well-developed AIPDA was identified on the surface of the pancreatic head (). The vessel was encircled very carefully to avoid injury to the pancreatic capsule. SMA–AIPDA bypass grafting was performed before ligation of the aneurysm (). The SVG–AIPDA and SMA–SVG anastomoses were created using 7-0 polypropylene sutures in an end-to-side manner. The bypass blood flow volume was 368 mL/min, as measured by a flow meter. The Doppler flow pattern seemed to be acceptable. The proximal neck of the aneurysm was carefully dissected and then doubly ligated, followed by ligation of the distal neck. A drainage tube was placed near the pancreatic head to monitor the concentration of amylase in the drainage fluid. The surgery duration was 5 h, and blood loss amounted to 130 mL. Preoperatively collected autologous blood (400 mL) was transfused during the perioperative period. The postoperative course was uneventful. The concentration of amylase in the drainage fluid peaked out on postoperative day (POD) 3. The first postoperative CT performed on POD 3 showed no evidence of acute pancreatitis, no enhancement of the IPDA aneurysm (), and good patency of the bypass graft (). The patient was discharged on POD 20. CT performed at 24 months after surgery showed a patent SVG graft. |
A 19-year-old Russian woman (height, 1.69 m; weight, 54 kg) with non-specific upper abdominal pain presented to a local hospital for evaluation. She complained of recurrent pain for weeks. Clinical examination revealed neither jaundice nor a palpable abdominal mass. The clinical laboratory data were normal.\nUltrasonography revealed a hypoechogenic, nearly spheric, homogenous formation with a smooth contour in direct contact with the underside of the liver and without any intermediate layer. The finding was most compatible with a large hepatic cyst. Computer tomography showed a clearly limited, hypodense, homogenous structure with a transverse diameter of 11 cm in the immediate vicinity of the liver, anterior to the right kidney, and posterior to the gall bladder (Fig. , upper panel). Cystic echinococcosis was excluded serologically. The documented adjacent lower computer tomography-slice depicted a similar hypodense structure, which was nearly circular and only 3 cm in diameter. The larger structure was interpreted as a congenital hepatic cyst due to the direct contact to segment 5 of the liver. The smaller structure was judged as an independent hepatic cyst because it resembled the large cyst, except for its smaller size (Fig. , lower panel). Further diagnostic procedures were not performed because the computer tomography was considered sufficient.\nBecause of the recurrent pain, a laparoscopic fenestration of the large cyst was recommended and this was performed at a primary care hospital. During the procedure, the cyst was approached via the inferior border. The cyst was in direct contact with the underside of segment 5, and the surgeon had no doubt about the liver as the origin of the cyst. A second cyst could not be identified.\nA puncture was performed, which resulted in the evacuation of more than 100 ml of bile. Then, the cyst was opened by a 4 × 3 cm incision. Laparoscopic evaluation of the inner cyst revealed two bile ducts and, under the assumption of eroded bile ducts, clips were attached to effect closure. After fenestration, a drain was placed into the abdomen.\nThe drainage was consistent with a biliary leakage on the second postoperative day. Bilirubin increased to 6.21 mg/dl and the patient developed jaundice. An endoscopic retrograde cholangiography showed a massive dilatation of the distal common bile duct. The injected radiopaque material leaked into the abdomen. The intrahepatic bile system could not be detected. A stent from the duodenum into the dilated bile duct was inserted.\nDue to these ambiguous findings, the patient was transferred to our university hospital on the third postoperative day. Computer tomography showed incipient pancreatitis. After re-evaluation of the original computer tomography, a large choledochal cyst involving the distal part of the common bile duct was recognized. The patient underwent repeat surgery on the fourth day after the original surgery, and a large choledochal cyst, Todani type 1A, with a diameter of 8–10 cm was found (Fig. ). The distal end of the stent was palpable in the duodenum, whereas the other end was visible in the fenestrated cyst (Fig. ). After further exploration of the choledochal cyst, the clips became visible in the cyst (Fig. ). However, these clips had not closed the suspected fistular ducts, but had occluded the right and left hepatic ducts (Fig. ). The clips were removed. The cyst was completely excised and the distal common bile duct was closed (Fig. ). A hepatojejunostomy was performed by a Roux-en-Y loop as the curative therapy. |
An 18-year-old female presented with a painful swelling in the left upper quadrant of her abdomen. She became aware of this problem 4 days before presentation. There was no history of previous illness, nor did she take any medication. Physical examination revealed a tender, painful spot and palpable mass in the left upper quadrant of the abdomen.\nBiochemistry indicated an elevated C-reactive protein value (14 mg/dl, normal <1). Tumor marker carbohydrate antigen (CA) 125 was within normal range and the lactate dehydrogenase value was not elevated.\nUltrasonographic evaluation revealed a structure in the left upper quadrant, inferior to the left kidney measuring 7 × 9.5 cm. There were calcifications visible and the study in Doppler mode revealed no apparent blood flow.\nSubsequent abdominal computed tomography (CT; fig. , fig. ) confirmed a nodular mass in the left upper quadrant measuring 6.5 × 7.5 × 10 cm. The mass was partially solid, partially cystic and had some calcifications. This mass was situated inferior to the left kidney. The spleen and pancreas were situated superior to this structure, the descending colon was posterior to this lesion and was closely related to it. The medial border of this mass was in close contact with the distal part of the transverse colon and the stomach. There was also contact with the jejunal part of the small intestine and a diffuse infiltration of the surrounding fatty tissue. There was no obvious lymphadenopathy and there were no intra-abdominal metastases.\nA CT scan of the thorax did not detect thoracic metastases. Colonoscopy was normal except for a small nodule at the cecum, which anatomopathological investigations confirmed to be a submucosal lymphoid nodule.\nExcisional surgery was planned and median laparotomy was performed. Exploration revealed that the tumor was located partially in the omentum majus and partially fixed in the retroperitoneum inferior to the spleen. There was no evidence of peritoneal or hepatic metastases during surgery, nor a connection with the small or large intestine. A wide excision of the lesion with a surrounding envelope of fatty tissue was performed. Perioperative frozen section after resection suggested the presence of a mesenchymal tumor.\nThe specimen weighted 260 g. It consisted of omental fat and peritoneum with a well-defined, encapsulated multinodular mass of 9 × 5.5 × 5.5 cm. Cross-section revealed a solid washed-out lesion with inlying yellow zones and a macroscopic aspect of necrosis.\nThe tumor was well defined with large inlying islands of necrosis. The tumor cells were monotonous and were closely packed together. The nuclei were of oval shape, irregular and had a notch. There was a moderate mitotic activity. The cytoplasm was vacuolated or lucid. Some cells were separated by connective tissue. Some tumor cells contained periodic acid-Schiff (PAS)-positive granules in the cytoplasm (fig. ).\nThe tumor that was resected during the laparotomy was positive for vimentin (fig. ) and CD99 (fig. ) (membranous) and negative for keratin, S-100, WT1, neuroendocrine marker (synaptophysin), inhibin, CD45, calretinin, CD117, CD34 and muscle markers (smooth cell actin and desmin). The morphologic and immunophenotype was consistent with ES. Molecular analysis by fluorescent in situ hybridization (FISH) confirmed an ES gene (EWS) rearrangement.\nThere were no postoperative complications. The patient was discharged from the hospital in good health on the 4th postoperative day. A whole-body positron emission tomography (PET)/CT scan was performed 4 weeks after surgery, which revealed no evidence for hypermetabolic activity.\nTwo months after treatment, the patient underwent laparoscopic resection of the left adnexa for cryopreservation. During this laparoscopy, 2 lesions of endometriosis were discovered and excised. The adjuvant chemotherapy regimen consisted of a 3-drug regimen including vincristine, ifosfamide and doxorubicin. There were 8 cycles planned every 3 weeks. After the first cycle, the patient had neutropenic fever which necessitated intravenous antibiotics. The subsequent second cycle was given in combination with neurokinine-1 receptor antagonist and granulocyte colony-stimulating factor (pegfilgrastim).\nA CT scan of the thorax and abdomen 3 months after surgery revealed no recurrence.\nAfter the third cycle, the patient had neutropenic fever and severe thrombopenia. The patient received intravenous antibiotics and a pool of thrombocytes. There were no other problems reported during the last 5 cycles of chemotherapy. The 6th cycle was one with a dose reduction of doxorubicin and ifosfamide (80%). During this regimen, she received intramuscular injections of luteinizing hormone releasing hormone to protect the right ovary.\nThe PET/CT scan performed 6 months after chemotherapy revealed no evidence for local, lymphatic or hematogenic recurrence. Ultrasound evaluation of the abdomen and X-ray of the chest revealed no recurrence 14 months after surgery. |
A 58-year-old African black woman with a medical history of diabetes presented to our institute with a rapidly growing skin lesion that was initially a small, round, painless nodule on the posterior face of the right elbow. In a physical examination at the time of admission, a 50 × 30-mm purple lesion with an irregular surface on the posterior face of the right elbow and extending to the forearm was found. No ipsilateral axillary lymph nodes were found. The patient had stage II disease. A biopsy excision was performed. The pathological examination showed a proliferation of round, small cells (Fig. , ). An immunohistochemical study using specific staining techniques confirmed the diagnosis of MCC and, more specifically, cytokeratin 20 (CK20) expression, which is often evident as a paranuclear globule (Fig. ); synaptophysin (Fig. ); CD99; neuron-specific enolase; and negativity of the melanocytic and muscular markers. The patient was lost to follow-up and consulted us 4 months later. The physical examination done at that time revealed a large inflammatory lesion of 100 × 50 mm on the third inferior side of the right arm with three ipsilateral axillary lymph nodes. A magnetic resonance imaging (MRI) scan of the right arm showed a process of the soft parts of 103 × 63 × 50 mm with three metastatic ipsilateral axillary lymph nodes (Fig. ).\nA biopsy of one of the axillary lymph nodes confirmed the diagnosis of MCC. Computed tomography (CT) of the chest, abdomen, and pelvis showed no distant metastasis. The treatment planning consisted of surgical amputation of the right arm with ipsilateral axillary lymph node dissection. A histopathologic examination revealed negative surgical margins. The margins were found to be microscopically uninvolved by carcinoma, with the closest margin at 4 mm (deep margin). Of 31 excised lymph nodes, 13 that were metastatic with capsular rupture were found.\nThe patient was referred to our radiation therapy department. At that admission, the examination revealed a clean amputation stump and no axillary lymphadenopathy, but the patient had a fixed mass in the right axilla. A CT scan showed a process in the right axillary region extending to the right subscapularis fossa (Fig. ). No surgical treatment was possible. A decision was made to perform radiation therapy of the right axillary and subscapularis regions. The total dose was 66 Gy with a conventional fractionation of 2 Gy per fraction in 33 sessions, 5 days per week, in the right axillary and subscapular areas in two oblique fields: anterior right and posterior left fields. The patient had grade 2 radiodermatitis as the only acute toxicity of radiotherapy.\nSix months later, the patient presented with dyspnea caused by lung metastasis, and she died 1 month afterward as a result of respiratory failure. |
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 26-year-old male Caucasian patient presents three times to our emergency room with recurrent vomiting and colicky abdominal pain during the years 2014 and 2015. Every time he reports at least 20 episodes of vomiting a day and a strong abdominal pain (8/10) predominantly in the epigastric region. During the crises, he is unable to intake liquids or food out of fear of triggering vomiting. Episodes last about 24 to 48 hours and are refractory to all standard treatments for nausea and vomiting. His personal medical history reveals Gilbert's syndrome and a myringoplasty at the age of 5. The patient consumes cannabis twice a day since at least 10 years alongside an alcohol consumption which is reported to be irregular with 3 portions a week in average. He has been presenting these episodes in an irregular pattern for about 5 years with a duration of 1-2 days. The patient does not present fever and reports to have rather liquid stools, without meeting criteria for diarrhea. Before his hospitalization, several blood tests, enhanced abdominal CT-scan, and abdomen ultrasound have been performed ambulatory to investigate his symptoms. Blood tests, including complete blood count, glucose, basic metabolic panel, and pancreatic and hepatic enzymes, were normal. Radiological workup describes sludge and small gall stones within the gall bladder without evidence of acute cholecystitis. Considering the history with the atypical pain pattern and vomiting, the diagnosis of symptomatic gall stone disease was retained and a laparoscopic cholecystectomy was performed in August 2015. After an initial clinical improvement, the patient relapses and presents the same symptoms few weeks later, without any change in intensity.\nAt our ER department, the patient had normal vital signs and no fever and physical examination was normal except for dehydration and light epigastric tenderness during abdominal examination. A neurological assessment was negative for any focal neurological deficit. Blood tests showed a slight leukocytosis (12 Giga/l) and slight hypokalemia (3.4 mmol/l). Hepatic profile showed typical signs of Gilbert's syndrome with an elevated total and unconjugated bilirubin without any other abnormalities. Stool cultures appeared to be negative. An esophagogastroduodenoscopy did not show any signs of ulceration or gastritis and the biopsies proved to be negative for a Helicobacter pylori infection. A cerebral MRI ruled out central causes of vomiting. A second abdominal CT-scan excluded any intra-abdominal pathology, especially no sign of superior mesenteric artery syndrome. Metabolic tests excluded diabetes mellitus, porphyria, and adrenal and thyroid diseases. The patient did not respond to standard treatments of nausea and vomiting as metoclopramide, ondansetron, or droperidol. The only effective measure to calm his abundant vomiting was hot showers or baths. The symptoms ceased right away after standing under hot water during his inpatient stay.\nThe patient was discharged from the hospital after two days with the recommendation to completely stop the consumption of cannabis. Follow-up nine months after discharge revealed that the patient had smoked cannabis again about two weeks after discharge in October 2015 with a relapse of symptoms and then never consumed cannabis again. He has been completely free of episodes of vomiting and abdominal pain since this time. |
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 previously healthy boy aged 7 years and 11 months was brought to the hospital emergency department suffering from persistent headache and vomiting. He had had a temperature of 38°C for a week and presented a motor deficit of the right arm associated with paresthesiae. A brain CT scan revealed a left fronto-parietal abscess (). Neither his medical history nor the clinical examination provided evidence of ENT (Ear, Nose, and Throat) infection. His mother reported that he had had dental treatment for decay in the left temporal molars three weeks earlier. A brain MRI scan showed a left fronto-parietal lesion of approximately 45 × 52 mm with a right lateral deviation of the median line (). He was immediately taken to the operating theatre for drainage and cleaning of the abscess. Intraoperative bacteriological specimens were taken, and broad spectrum antibiotherapy was set up using cefotaxime and metronidazole. Corticotherapy (Solumedrol®) was started the following day and continued for six days. Targeted antibiotherapy was set up when the bacteriological analysis results were available. Direct examination of the bacteriological culture found Gram + cocci in chains, and aerobic and anaerobic culture revealed the presence of Streptococcus intermedius. Two days after surgery, the child was apyretic, with normal heart rate and blood pressure but persistence of a motor deficit of the right arm. A dental examination revealed root abscesses on temporary molars 64 and 65, which were extracted under general anaesthetic thirteen days after the child's arrival at the emergency department (). Initial dental treatment was insufficient to manage a potential infection that later became acute.\nTwenty-three days after the initial drainage, a control MRI performed because of headaches and vomiting imaged an increase in the volume of the abscess, justifying a second drainage (). Bacteriological culture showed the specimen to be sterile. Two months after the first operation, the neurological situation had evolved favourably, the deficit affecting only fine motor skills of the right hand. The brain MRI scan showed a marked decrease in the abscess relative to the previous image (). Two months after his admission, the child was switched to oral antibiotherapy and could return home. Follow-up with control brain MRI was planned at the Children's Hospital at 3 weeks, with a view to stopping the antibiotic treatment. |
A 57 year-old man with hepatitis B was diagnosed with hepatocellular carcinoma post-liver transplant with subsequent liver, lung and bone metastases. He received palliative radiotherapy to the right shoulder and thoracic spine for bony metastatic pain. The patient was recruited to the study post-radiotherapy, and a summary of the patient’s baseline assessment is provided in Table . His most common reported physical activity over the past week was walking approximately 60 minutes per day, for three times per week.\nThe participant was prescribed a daily walking plan of 15 minutes per day at low to moderate intensity, to progress up to a total of 45 minutes per day at the end of the six weeks. All strength exercises were started at 1 set of 8 repetitions, slowly progressing up to 1 set of 12 repetitions for most exercises. After receiving palliative radiotherapy for progressive lymphadenopathy during Week Four, the participant reported worsening nausea and subsequent progression in his exercise prescription was delayed. During Week Four, the participant also exhibited increasing difficulties with balance due to intermittent syncope, and strength exercises were performed in the seated position where possible. The participant completed 14 out of the 18 prescribed strength exercise sessions.\nA summary of the participant’s post-intervention assessment is provided in Table . As monitored by the activPAL™ accelerometer, the average number of steps taken over the baseline week was 7232, with an average estimated total energy expenditure of 29.1 MET·hours; post intervention, the average number of steps taken during Week Six was 1159, with an average estimated total energy expenditure of 26.9 MET·hours. The majority of his steps were taken inside the home.\nOverall, the participant expressed high satisfaction with the physical activity program and identified the strength training component as among its top advantages. In terms of negative experiences, the participant indicated his inability to sustain the aerobic walking component on his own given his increased symptom burden post-radiotherapy. In follow-up, the participant passed away 42 days after completing the study. |
Case 1. Twelve days after the onset of unspecified symptoms, a Black male aged 16 years went to the emergency department and was admitted the following day with a febrile illness. The public health laboratory and CDC confirmed that the patient had a P. falciparum infection with 2% parasitemia. He was treated with atovaquone-proguanil PO and recovered. The patient was born in the United States, but his parents were from Nigeria and they spent substantial time there. In repeated interviews with health care providers and the local health department, the patient and his guardian reported that the last time he had traveled internationally was to Nigeria, more than 2 years earlier, in 2015, for approximately 15 days; he had never lived in Nigeria or another country where malaria is endemic. The patient stated that he had never had malaria, nor did he have a febrile illness after travel. However, the patient’s father was treated for malaria in Nigeria 1 or 2 years previously and had also received a malaria diagnosis in the United States in 2016, confirmed by the state public health laboratory. Blood specimens for the father (2016 illness) and son (2017 illness) were sent to CDC, and parasite sequencing and microsatellite analysis was conducted. Genotype profiles and microsatellite results showed that the parasites from the father’s 2016 illness and the son’s 2017 illness were not related. The patient traveled to a southern U.S. state 1 month before illness onset, although his infection could not be linked epidemiologically to any malaria case there. The local health department vector control staff conducted mosquito surveillance in the vicinity of the patient’s residence weekly during the month of his 2017 illness and did not find Anopheles species mosquitos, which are the type of mosquitos that transmit malaria. Although Anopheles quadrimaculatus is present in the region, mosquito surveillance in this county found only two specimens in 2017; both were located outside of city limits and far from the patient’s residence. The health department did not find evidence of local transmission. |
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 75-year-old male with a past medical history of osteoarthritis and obstructive sleep apnea presented to a tertiary care center with a gradual onset of shortness of breath. His symptoms began two weeks before presentation and was associated with mildly productive cough and fatigue. The patient worked as an engineer and denied occupational exposure. He had no significant medical problems, and was at his usual state of health, including hiking at high altitudes without any symptoms a few months before his initial hospitalization. Presenting vitals were notable for hypoxia with oxygen saturation in the range of 85% on room air as well as tachypnea. Physical examination identified bibasilar rales. Chest X-ray revealed patchy bibasilar opacities with air bronchograms (Figure ). The patient was admitted for acute hypoxic respiratory failure secondary to multilobar pneumonia and was started on broad-spectrum antibiotics. However, he failed to improve on antibiotics and his respiratory function gradually declined, requiring mechanical ventilation support on the fourth day of his hospitalization. A detailed medication review revealed that the patient was started on flavocoxid for his osteoarthritis of hips and knees two months prior to presentation. The medication was immediately discontinued. CT scan revealed diffuse bilateral lower lobe consolidation with areas of ground glass opacities, septal thickening and bronchiectasis, thought to be secondary to hypersensitivity pneumonitis (Figure ). He was unable to be weaned from the ventilator, until he was started on IV methylprednisolone and eventually was able to be extubated. His respiratory function never returned to baseline as he became oxygen-dependent after the hospitalization. He was discharged to a pulmonary rehabilitation program on a prolonged steroid tapering regimen.\nIn the following two years, he continued to have episodes of acute exacerbations of dyspnea and hypoxia with severe exercise intolerance. He was briefly started on mycophenolate mofetil and intermittently with prednisone for six months via the local advanced pulmonary clinic without improvement.\nOur initial encounter with the patient was approximately two years later when he presented to the same tertiary hospital with shortness of breath and hypoxia. His chest CT scan showed bilateral pulmonary embolism and diffuse "honeycombing" predominantly in the basilar region with subpleural reticular opacities. There was evidence of bronchiectasis and the findings were consistent with usual interstitial pneumonia pattern (Figure ). Extensive infectious work-up was obtained including viral respiratory panel, Bordetella, Legionella, and Mycoplasma testing among others. Rheumatological work up such as anti-nuclear antibody, rheumatoid factor, and antineutrophil cytoplasmic antibody was negative. He was diagnosed with drug-induced pulmonary fibrosis secondary to flavocoxid use. |
A 38 year old male patient with a single chamber pacemaker for symptomatic congenital complete heart block via the right subclavian vein approach a decade back, presented with pre-syncope that was determined to be because of intermittent failure to capture. Pacemaker interrogation revealed preserved battery voltage, high lead impedance and failure to capture at maximum output. Immediate temporary pacemaker was inserted through the right femoral vein. Baseline investigations were unremarkable and echocardiography done showed a normal left ventricular function. The patient was taken up for the lead replacement. Right axillary vein was successfully accessed but the guide wire could not be negotiated beyond a short distance. A venogram through the puncture needle revealed a blocked right innominate vein. We then proceeded to attempt from the left side. Axillary vein access was achieved successfully but the guidewire could not be negotiated beyond a short distance similar to what we had encountered in the right side. An angiogram of the left sided venous system through the partially inserted sheath was done which revealed an occluded left innominate venous system ( and ). With a multipurpose catheter introduced through the left femoral vein, a venogram at the level of superior vencava (SVC) was done. It confirmed the occlusion at the junction of SVC and bilateral brachiocephalic veins (). Lead extraction tools could have been utilized to remove the old lead and at the same time create a path to place a new lead. But financial constraints and limited experience made us to consider other options. We, after deliberation, proceeded to attempt transvenous angioplasty of SVC and left innominate vein. We used the multipurpose catheter that was positioned at the precise site of occlusion, from below in the same fashion as a coronary guiding catheter. The position of the guiding catheter was confirmed to be at the stenotic site with contrast and a 014" balanced middle weight (BMW)(Abbott Laboratories, IL,USA) guide wire was initially used to cross the "chronic total venous occlusion". Since we were not able to cross the lesion with it, a stiffer CROSS IT 100XT wire (Abbott Laboratories, IL,USA) was utilized to cross the lesion. The end of the wire now in the lumen of the left innominate vein, was snared through the left axillary vein and exteriorized (). A Voyager 3.5x20 mm balloon (Abbott Laboratories, IL,USA) was passed over the exteriorised end of the wire. Multiple dilatations were given at the site of block (). A 035" Glidewire (Terumo Corp, NJ, USA) was negotiated through the now dilated lesion from the axillary vein to the inferior venacava (IVC). Graded dilatations were given to the lesion with an 8F sheath and a 9 F sheath over the glide wire. Finally, customized coronary sinus sheath was passed into the RA via the left axillary vein through which the right ventricular pacing lead was placed. Post procedure, the patient had an uneventful course. He was shortly discharged with good pacing parameters. |
A 22 year old female patient, tailor by occupation came to emergency department with history of road traffic accident and injury sustained to her right elbow and forearm. On examination there was type 3B open fracture having wound over the lateral side of elbow with fractured lateral epicondyle, extensive lacerated wound over the dorsum of proximal 1/3rd forearm with open diaphyseal fracture of both ulna and radius in middle 3rd. On assessment of distal neurovascular deficits, patient found to have low radial nerve palsy with intact vascularity. Standard anteroposterior(AP) and lateral Radiographs were taken which showed lateral epicondylar fracture of humerus with posteromedial dislocation of elbow [] and diaphyseal fracture of both ulna and radius at middle 3rd level []. Tetanus toxoid, antibiotics after test dose along with analgesics were given. After primary wound toilet at emergency, case was posted to emergency operation (2hours since injury) with plan of wound debridement and open reduction and internal fiation/external fixation with minimal possible implants aiming biological fixation and radial nerve exploration. In the operation theatre the elbow was examined under general anaesthesia where no other findings were found except for lateral laxity tested by varus stress test after elbow was reduced. Primary wound debridement with excision of contaminated small lateral epicondylar fragment was done. The radius was fixed with rush pin and ulna was checked, where it was well reduced and in alignment. In view of post traumatic raw area, external fixator pins over the ulna spanning the elbow was planned on table and same was done []. Then radial nerve was explored utilising the wound and posterior approach where no obvious findings were found. Post operatively antibiotics and analgesics continued. Limb kept elevated for 2 days. Wound debridement was done every 2nd day and posted to operation theater after a week for wound coverage with split skin graft. Post op 5th day wound inspection showed well taken graft and no infection was found []. After 2 weeks, pins of humerus were taken out and elbow physiotherapy started and patient was discharged. After 2 months, pins of ulna taken out when she had 400 to 1200 of flexion and 600-600 of supination-pronation movements. After 4months, check X ray [ and ] was taken which showed union of forearm bones when pin was removed and all activities were encouraged except for lifting heavy weight. Range of motion by 6 months were 300-1400 flexion [ and ], 700-800 supination-pronation. Patient followed for 2 years. |
A 40-year-old Indian woman presented to our outpatient department with complaints of a lump in her left breast noted four months prior to presentation. The lump gradually increased in size and was non-tender. There was no history of nipple discharge. The patient denied any hormonal therapy or family history of breast disease. A physical examination found our patient to be obese and in no acute distress. A breast examination showed her left breast to be pendulous with a 6 cm × 5 cm × 6 cm irregular, firm mass fixed to the overlying skin in the midline above her left nipple. There was no nipple discharge or skin dimpling. There were no palpable axillary lymph nodes. Her right breast and axilla were found to be normal. The remainder of the physical examination was noncontributory. A mammogram of her breast showed a well-defined mass measuring 5 cm with lobulated margins and areas of calcification closely resembling bone. In addition, fine egg shell calcification around the tumor was also noted. A core needle biopsy was taken from the breast lump which was reported as osteosarcoma of the breast. Computed tomography of the chest and abdomen, serum alkaline phosphatase and a bone scan were all within normal limits. Our patient was prepared for surgery and a simple mastectomy was performed. The histopathological examination revealed a tumor consisting of highly pleomorphic oval- to spindle-shaped cells arranged in sheets and bundles separated by fibrocollagenous tissue (Figure ). The tumor cells had hyperchromatic nuclei and some showed mitotic figures. The stroma showed lymphocytic infiltration and areas of osteoid formation (Figure ). Areas of hyaline matrix were intermingled, with vacuolated cells showing cartilaginous differentiation. The picture was suggestive of osteosarcoma of the breast in a pre-existing phyllodes tumor showing areas of chondroid differentiation. The immediate post-operative period was uneventful and our patient was discharged on the fifth post-operative day after removal of the suction drain. Five years post-operatively our patient is doing well and is in regular follow-up. |
A seven year old right hand dominant boy allegedly fell down from a tree of six feet height and presented to the emergency room with an injury to his left forearm. He complained of pain, deformity of left forearm and inability to use left hand ever since the injury. On examination there was a tender swelling, deformity and abnormal mobility in the left forearm. Radiography of left forearm revealed fracture of both bones of forearm at upper and middle third junction (: Radiograph of left forearm showing fracture of both bones of forearm at upper and middle third junction). Manipulative reduction and above elbow plaster slab application was done under sedation (: Radiograph of left forearm after plaster slab application). Patient went home on the same day, against medical advice to stay back at hospital for observation.\nSubsequently he was treated by a traditional bone setter (quack) with multiple episodes of tight bandaging and massaging for a period of two months.\nPatient came back after three and half months with complaints of pain, wasting of left forearm, deformity of wrist and hand with inability to use his left hand. On examination there was decreased girth of left forearm, tenderness over the upper and middle third junction of left ulna with a palpable gap, positive Volkmann’s sign with flexion contracture of fingers. Flexion contracture of wrist flexors was noted and the grip strength was reduced. Intrinsic muscles of hand were spared. Sensory system of left forearm and hand was intact with no vascular deficit. Terminal limitation of movements at elbow with painful pronation and supination of forearm was noted. Radiograph of forearm with wrist and hand revealed atrophic non-union of upper and middle third junction of left ulna and malunion of left radius with positive Volkmann’s sign (flexion attitude of fingers with wrist in extension and the same getting corrected with the wrist in flexed position); (: Clinical photograph and radiograph of left forearm showing atrophic non-union of upper and middle third junction of left ulna with malunion of left radius with Volkmann’s sign).\nPatient was taken up for surgery under general anaesthesia. Atrophic non union site of ulna was exposed sub-periosteally and all the intervening fibrous tissue with necrotic bone ends was excised, edges were freshened till punctuate bleeding points were noted in the bone. Medullary cavity was opened on both the sides. This has resulted in a gap of five centimetres in ulna. Radius was exposed sub-periosteally in the middle third portion through dorsal approach and two and half centimetres of tubular radial graft was harvested. The cut ends of the radius were approximated and fixed with small (3.5mm) dynamic compression plate and screws leading to a two and a half centimetre radial shortening (: Intra operative photograph showing radial shortening osteotomy fixed with dynamic compression plate and screws). The two and half centimetre radial tubular graft was used as intercalary sturt graft at ulnar gap non-union site and was fixed with a rush nail from the olecrenon (: Intra operative photograph showing radial tubular intercalary autograft placed in the gap after the excision of non-union of ulna).\nThis has resulted in effective shortening of forearm by two and half centimetres to address the VIC component of the patient (: Post operative radiograph of left forearm showing in situ radial plate and ulnar rush nail holding the intercalary bone graft in place). The limb was supported with an above elbow slab converted to a cast after suture removal. Patient did not maintain the cast properly. The cast was found to be broken at the elbow with lagged out rush nail at 6 weeks follow up requiring implant removal. (: Six weeks follow up post-operative radiograph of left forearm taken after the implant removal from ulna). Forearm was supported with above elbow plaster cast for ten weeks. Finger stretching exercises/physiotherapy was started early in the post-operative period. Physiotherapy with range of motion elbow exercises and stretching exercises were stared after ten weeks. Patient was followed up regularly for three years and the fracture union was monitored by radiography. The radial osteotomy has united in six weeks and the ulnar intercalary graft site has united in ten weeks (: Ten weeks follow up post operative radiograph showing union of radius and ulna). Volkmann’s sign was negative after the surgery till date (: Post operative follow up clinical photograph of the patient showing absence of Volkmann’s sign). Functional evaluation of the limb revealed full flexion-extension at elbow, pronation-supination of forearm and normal grip strength of hand when compared with the contra lateral unaffected right upper limb. Three years following surgery, radial plate was removed owing to the patients request for implant removal (: Three years follow up radiograph of left forearm after the radial implant removal showing consolidation and incorporation of intercalary tubular radial graft in the ulna). |
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