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A 51-year-old immunocompetent male who had undergone DSAEK with IOL implantation in his left eye 7 weeks prior presented with complaints of redness and defective vision in his eye for 1 day. He was on routine postoperative medications with topical prednisolone acetate 1%, and gatifloxacin 0.3% eye drops, each to be administered three times daily. At his previous postoperative visit, 2 weeks earlier, his left eye had been quiet with a clear graft and normal intraocular pressure.\nIn his right eye, he had undergone DSAEK with IOL implantation in 2012 and was doing well. On examination at this visit, UCVA was 20/40 in the right eye and 20/200 in the left eye. Slit lamp examination of the left eye revealed moderate bulbar and tarsal conjunctival injection with papillae, a few randomly distributed coarse superficial punctate lesions, graft edema with overlying stromal edema, and no keratic precipitates. There was a mild anterior chamber reaction. A presumptive diagnosis of acute graft rejection was made in the left eye. He was admitted and aggressively managed with hourly topical prednisolone acetate 1%. He was also started on systemic steroids injection dexamethasone 2 cc intramuscularly once a day. Next day slit lamp examination of the left eye showed an increase in the corneal edema to the host stroma, involving the peripheral cornea as well. There was moderate anterior chamber reaction but no keratic precipitates. Visual acuity remained at status quo in both eyes. He was continued on the same treatment. On day two of admission, the patient complained of defective vision in his previously operated right eye and on examination, the visual acuity was found to be 20/80. The right eye showed a mild conjunctival injection, diffuse edema of the entire cornea and a few coarse superficial punctate lesions similar to the lesions seen at presentation in the left eye []. Left eye examination revealed a large epithelial defect approximately 6 mm × 4 mm in diameter with persistent graft and stromal edema []. The typical course superficial punctate lesions at presentation, deteriorating clinical picture, and poor response to topical steroids in the left eye with diffuse corneal edema later in both eyes raised suspicion of an infective pathology and hence in vivo confocal microscopy (IVCM) (heidelberg retinal tomography 3-rostock cornea module HRT3-RCM adopting standard techniques) was planned. IVCM in both eyes revealed bright, hyperreflective dots seen from the epithelium to the midstroma, highly suggestive of microsporidial spores [Fig. and ]. The topical and systemic steroids were discontinued, and the patient was prescribed topical fluconazole 0.3% 6 times a day and oral acetazolamide 250 mg twice a day. Ocular examination showed improvement, and he was discharged from hospital. He was advised to continue topical fluconazole while oral acetazolamide was stopped. The patient was called for a weekly review and on the third scheduled visit showed improvement in visual acuity with steadily resolving graft and overlying stromal edema. The UCVA had improved to 20/40 in the right eye and 20/60 in the left. A repeat confocal microscopy at 3 weeks revealed the complete disappearance of the hyperreflective dots in both eyes. The epithelial defect in the left eye had healed completely. Topical fluconazole was continued at a lower frequency, thrice a day for another week. |
In this case report, we describe a variant mesenteric artery originating directly from the abdominal aorta between the origin of the SMA and IMA in a 85-year-old Caucasian female body donor during routine dissection of the supracolic and infracolic regions. The cause of death in the donor was indicated as myocardial infarction. No past medical records were available for review.\nDuring the exposure of the celiac artery, superior and inferior mesenteric arteries, the intestinal loops were moved to the right and the peritoneum covering the posterior abdominal wall removed. The celiac artery and the superior mesenteric artery originated independently from the ventral surface of the abdominal aorta about 1 cm apart (Fig. ). The CA had a normal branching pattern (Fig. ). Branches from the SMA included the inferior pancreaticoduodenal, right colic, ileocolic, jejunal and ileal arteries. A middle colic artery that usually arises from the SMA was missing. The IMA was found to originate from the ventrolateral surface of the distal abdominal aorta about 6 cm from the origin of the SMA, and it gave rise to the sigmoid arteries and superior rectal artery. The left colic artery that usually takes its origin from the IMA was also missing.\nBetween the SMA and IMA, an additional mesenteric artery was found to originate from the ventrolateral surface of the distal aorta, about 2 cm proximal to the origin of the IMA (Fig. ). From its origin on the abdominal aorta, the variant artery ran obliquely superiorly toward the left colic flexure. It then gave rise to two branches, which had free anastomosis within the mesocolon of the transverse and descending colon. The first branch ran transversally to the left to supply the proximal part of the descending colon. The second branch ascended upward between the layers of the transverse mesocolon and gave rise to two branches that supplied the distal part of the ascending colon and the transverse colon. The distribution of the second branch is similar to the distribution of the middle colic artery, normally a branch of the superior mesenteric artery. In this case, the marginal artery of Drummond, an anastomotic vessel running in the mesentery along the inner margin of the colon, was contributed by branches from the SMA, IMA and the variant mesenteric artery. |
A 47-year-old man was referred to the Department of Oral Medicine & Radiology with a history of soft tissue growth in the palate for the past two months. The growth was sudden in onset, growing rapidly in size over the next two months and localized to the palate. The patient reported no pain during the onset of growth. However, for the past one week, the patient reported mild pain. On clinical examination, there was a diffuse, proliferative soft tissue growth of the maxilla extending from the marginal gingiva in the palatal aspect of the anterior tooth and involving the entire surface of the hard palate up to the level of the hard and soft palate junction along with erythema of attached gingiva in relation to posterior teeth palatally and buccally as well as Grade III mobility of all the anterior and posterior maxillary teeth (Figures and ). The cervical group of lymph nodes were nonpalpable clinically.\nThe referring private practitioner had advised a panoramic radiograph earlier which revealed severe bone loss in relation to maxillary teeth suggestive of generalized periodontitis and was inconclusive for any other relevant findings except for a root stump in the lower right quadrant ().\nThe patient was advised for a CBCT scan which revealed a moth-eaten appearance of the palate noticed bilaterally with involvement of nasopalatine canal anteriorly and external resorption of roots in relation to all the maxillary teeth present, with evidence of involvement of anterior and middle ethmoidal sinus, eustachian tube, and nasopharynx on the right side. Based on CBCT and clinical findings, a preliminary diagnosis of intraosseous malignancy involving the palate was suspected (Figures –). The patient was then scheduled for surgery with excision biopsy and total maxillectomy up to the floor of orbit.\nThe surgical procedure consisted of visualization of hard and soft palate and incision extending laterally around the maxillary tuberosity exposing the posterior border. Following exposure of the maxillary tuberosity, attachment to the soft palate and hard palate was divided. After soft tissue dissection up to the extension of the tumor, the extent of the bone which was tailored to the primary tumor including the lateral wall of the orbit and zygoma to be resected was marked. Following bone guttering, the bony resection was carried out using a chisel and mallet through the frontal process of the maxilla and lacrimal bone. Bleeding encountered during this procedure from the greater palatine artery and the branches of internal maxillary artery was controlled using pressure packing followed by ligation to achieve haemostasis. After mobilizing the segment, final osteotomy was done to separate the maxillary tuberosity from the pterygoid plates. Before removal, thorough clinical examination of the specimen was done to determine the adequacy of the tumor (Figures and and and ).\nThe tissue sample was sent for histopathological examination which revealed an unencapsulated tumor within the underlying connective tissue approximating the surface epithelium, with a varied pattern of arrangement of tumor cells that included solid nests, strands, ducts, and tubular and papillary patterns and was lined by 1-2 layers of oval/cuboidal cells along with a peripheral layer of flat cells suggestive of polymorphous low-grade adenocarcinoma of the palate (Figures , , and ). The patient is currently under follow-up for the past six months and is asymptomatic. |
The patient is a 25-year-old female with a history of intravenous drug abuse. Due to this, the patient developed tricuspid vegetations and subsequently underwent a median sternotomy and tricuspid valvuloplasty one year prior to our encounter.\nThe patient was involved in a motor vehicle accident 8 months prior to presenting to our service. She was an unrestrained driver and was thrown from the vehicle. She was subsequently intubated in the field. The patient underwent three separate intubations for neurosurgical procedures and was ultimately unable to be weaned from the ventilator at the completion of the last procedure.\nA tracheostomy was subsequently performed without complication per medical records. The patient was downsized from a size 6 cuffed tracheostomy to a size 6 cuffless tracheostomy on post-operative day 5 but had the immediate development of massive hemorrhage from her tracheostomy site. The patient was taken to interventional radiology where active extravasation from the right common carotid artery was visualized and a stent was placed.\nRoughly 5 months later, the patient presented to our otolaryngology service with a history of two moderate volume bleeding events from her tracheostomy and a desire to be decannulated. A stroboscopy was performed, and the patient was felt to have normal vocal fold mobility with concerns for subglottic stenosis. Due to her complex medical history and known carotid stent, a CT angiogram of the head, neck, and chest was ordered (Figures , , and ).\nNo extravasation was observed on CT angiogram. The right common carotid stent was noted to be 1 cm from the take-off of the common carotid artery from the innominate and was roughly 4 cm in length. The following morning, the patient presents to an outside emergency department with massive hemorrhage from her tracheostomy. The patient was subsequently transferred emergently to our University Hospital. At the time of presentation, the patient had no active bleeding. A size 8 cuffed tracheostomy tube was placed to her stoma, and the patient was taken to the operating room for a right neck exploration with concerns for a recurrent right sided tracheocarotid fistula.\nIn coordination with the thoracic and vascular surgery service, the patient underwent a right neck exploration, ligation and transection of the right common carotid artery, removal of a right common carotid stent, a right carotid to subclavian end-to-side anastomosis, and a right sternocleidomastoid muscle flap to repair the right sided tracheal fistula site. The findings included an exposed stent in the common carotid artery within the tracheocarotid fistula () which had necrotic and purulent debris in the wound.\nPostoperatively, patient was weaned from the ventilator in a matter of hours. Chest tube was removed on postoperative day three. Patient was transferred to a floor bed and passed a modified barium swallow study. She was given a regular diet on postoperative day 5 and discharged home with close follow-up. On follow-up, patient developed a mild tracheitis, successfully treated with Levofloxacin. Subsequent bronchoscopy has shown that the patient has a roughly 80% subglottic stenosis, and after the patient has healed we plan to begin attempts at dilation of her stenotic segment. |
The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. The implantation was surgically revised in 2002 and 2006. In 2014 she noticed hardening and swelling of her right breast. Because of the death of her husband, she did not seek immediate medical attention. She continued to have swelling and increased pain in the right breast. Magnetic resonance imaging (MRI) performed in January 2016 showed a large fluid collection surrounding the intact right silicone implant as shown in Figure . The case was managed by surgical drainage of fluid collection and capsulectomy. In February 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm moderately differentiated invasive SCC. It extended into the muscle, and in situ tumor was noted to extend to the peripheral margin. There was no perineural or lymphovascular invasion. Pathology of the left breast capsule showed chronic inflammation. Computed tomography (CT) of chest, abdomen and pelvis on February 2016 revealed absence of metastatic disease. The patient underwent re-excision of the remaining chest wall mass in March 2016. Pathology showed well differentiated SCC with negative margins. Chest wall fluid was negative for malignant cells. On slide review, it was noted that there was squamous epithelialization of the implant capsule with benign squamous epithelium on both sides. This indicated that the tumor is likely SCC of the implant capsule rather than primary SCC of the breast. Estrogen and progesterone receptor markers were negative as well. Afterwards, she received external beam radiation. She was treated with radiation while supine with free breathing. Four tangent beams were used to target the right breast with 50 Gray in 25 fractions, followed by a 10 Gray boost to the tumor bed delivered in five fractions. Radiation was delivered using opposed tangents completed in May 2016. No adjuvant chemotherapy was offered due to the rare histology and paucity of data. She followed up in clinic in June 2016 without complications or clinical recurrence.\nFollow-up CT scan performed in August 2016 displayed a right upper lobe lung nodule and findings were suspicious for local recurrence (Figure ). She underwent right video thoracoscopy and right upper lobe wedge resection. The pathology was consistent with metastatic moderately differentiated SCC. The patient declined chemotherapy at this time. CT chest and abdomen at another hospital showed new cavitary lung nodules and right renal and psoas abscess. In February 2017, retroperitoneal fine needle aspiration of the right renal collection was positive for SCC. In June 2017, she was admitted to the hospital for abdominal pain and was found to have progressive disease. CT abdomen and pelvis with intravenous and oral contrast on 6/16/17 demonstrated a 6.1 cm x 5.7 cm heterogeneous lesion in the right kidney lower pole with invasion into the adjacent right psoas muscle (Figure ). Progressive metastases to the liver, lungs and retroperitoneum were noted as well. Ultrasound-guided fine-needle aspiration and core biopsy of the liver was positive for metastatic SCC with keratinization and necrosis.\nHer hospital course was complicated by non-ST elevation myocardial infarction, recurrent anemia requiring transfusions, atrial fibrillation with rapid ventricular rate and hypotension. She was noted to have leptomeningeal spread. She was ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017, one year after her initial diagnosis of cancer. |
A 53-year-old man with major complaints of a sudden onset of headache and mental deterioration came to the emergency center of the hospital. On admission, he was drowsy and his Glasgow Coma Scale (GCS) score was 14, and no focal neurologic signs were detected. He had no medical history of diabetes mellitus, hypertension, tuberculosis, and hepatitis, and as for family history, his mother had suffered from cerebral hemorrhage.\nBrain computed tomography (CT) and CT angiography carried out on admission showed a subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH) with hydrocephalus, and a tortuous vascular structure that was observed around the brain stem and upper cervical spinal cord (). Cerebral angiography was performed when vital signs had been stabilized and headache had been controlled through conservative treatments. The cerebral angiogram on the left vertebral artery revealed multiple vascular structures around the V4 segment of the left vertebral artery, which were drained to both sides of the sigmoid sinus and vertebral venous plexus. A cerebral angiogram on the external carotid artery showed multiple vascular structures around the occipital artery, which were connected to the drained vein observed via the left vertebral artery angiogram. Embolization was attempted on the left occipital artery and the distal V2 segment of the left vertebral artery, but the treatment was halted due to reflux. Another embolization was performed from the V4 and V3 segment to some of the distal V2 segment of the left vertebral artery. The treatment was terminated after partial occlusion was identified (). As mental deterioration and left hemiplegia were observed after the embolization, cerebral angiography and brain CT were conducted. However, new lesions such as cerebral hemorrhages or vascular occlusions were not found. One week after the embolization, follow-up brain CT displayed subacute cerebral infarction on the left cerebellum and thalamus, and a mild mass effect on the fourth ventricle and brain stem. The patient still felt drowsy and scored 14 on the GCS after being transferred to the department of rehabilitation medicine. Manual muscle tests of the left upper and lower limbs were measured as medical research council (MRC) grade 2 and hypoesthesia of the left face and hemibody was found. The patient also complained of dysarthria and diplopia. Spasticity, bladder dysfunction, bowel dysfunction, or dyspnea was not noticed. The patient scored 6 on the Korean-modified Barthel index (K-MBI), and the functional independence measure (FIM) score was 40. He was able to move in a wheel chair, fully dependent on a caregiver. Brain magnetic resonance image (MRI) and MR angiography performed one month after the onset showed infarctions on the left cerebellum, medial thalami, and the left posterolateral side of the upper cervical spinal cord. The occlusion of the left vertebral artery, as well as reduction in vascular structures that had been located on the brain stem and upper cervical spinal cord, were detected (). At that time, somatosensory evoked potential (SSEP) obtained by stimulating the right median nerve and motor evoked potential (MEP) recorded from the right abductor pollicis brevis and abductor hallucis were normal. However, SSEP of the left median nerve and MEP from the left abductor pollicis brevis were not evoked, while the latency of MEP recorded from the left abductor hallucis was delayed. The patient was put on anti-thrombotic drugs and medications for improving cognitive function, while continuing to take active assisted range of motion exercise, Bobath neurodevelopmental treatment, mat exercise, and occupational therapy. Six months after the onset, he recovered enough to bring his Korean Mini-Mental Status Examination (K-MMSE) score to 21 points, while manual muscle tests of the left upper limb were grade 3, and those of left lower limb corresponded to grade 3-4. The patient showed a significant recovery by scoring 73 on the K-MBI and 86 on the FIM. He was able to take gait training with minimum dependence on a caregiver. |
The patient is a 75-year-old female with a history of irritable bowel syndrome as well as a history of a previously normal colonoscopy who presented with spontaneous hematochezia. She was noted during colonoscopy to have a fungating rectal polyp. The polyp had multiple fingerlike projections and did not saline lift. Multiple biopsies were taken and pathology was consistent with fragments of tubulovillous adenoma and granulation tissue. A follow-up colonoscopy was then performed 2 months later which noted a single frond-like, villous, broad-based rectal polyp that appeared to be located within a diverticulum (fig. ), and which had an area of distorted mucosal pattern consistent with malignancy (fig. ). A solution of saline and SPOT was injected into the submucosa but, similar to the previous procedure, the polyp did not lift. Endoscopic mucosal resection was attempted but was unsuccessful. At that point the patient was referred to Colorectal Surgery for a surgical evaluation. Based on the location of the polyp, the recommendation was for a low anterior resection.\nA preoperative CT scan demonstrated a dilated appendix with its tip near the rectum which was of unclear significance at that time (fig. ). During surgery, the appendix was found to be densely adherent to the right anterior rectal wall at the area that had been inked during colonoscopy. En bloc resection of the distal sigmoid colon and proximal rectum together with the appendix was performed (fig. ). At that time, frozen sections of both the distal rectal resection margin as well as of the appendix were performed. The distal margin was negative for carcinoma. There was a mass at the tip of the appendix with mucin in the lumen which extended proximally but did not extend beyond the distal one half of the appendix. The proximal appendix was normal in appearance (fig. ). The decision was made not to proceed with additional resection at that time but to await final pathology in order to guide further treatment. The patient's postoperative course was uncomplicated.\nPathology showed adenocarcinoma arising focally within an appendiceal tubulovillous adenoma with direct invasion into the rectum (fig. ). The tumor size was 2.5 cm at its greatest dimension and occupied the distal one half of the appendix. Histologically it was grade 1. Microscopically, the tumor penetrated through the surface of the serosa with direct invasion into the rectal lumen. The proximal margin and the mesenteric margin were uninvolved by invasive carcinoma. There was no lympho-vascular invasion identified and no lymph node involvement after examination of 12 lymph nodes. Final pathological stage was pT4bN0. |
A 49-year-old African American male presents with a large mass on the left shoulder that has been rapidly enlarging for the past 2 months. The mass grew over a presumed keloid scar, which developed approximately 1 month following a motor vehicle accident 12 years prior. During the accident, he suffered a contusion to the left shoulder that first bruised and subsequently formed a golf ball-sized mass. There was no breakage of skin on the left shoulder. He sought medical attention for the skin lesion at that time and was diagnosed with keloid, which was readily accepted as he had past medical history and similar family history. No treatment for the lesion was performed at that time. Since then, the lesion had been stable without any change in shape, color, or size until 1.5 years prior to evaluation, when he suffered a minor trauma to the lesion during a work-related injury that did not break the skin barrier. Following this event, he noticed that the lesion slowly increased in size under the skin without apparent cutaneous changes in appearance. Two months before the clinical encounter, he noticed a new rapidly growing nodule on the surface of the initial mass. He noticed no changes in symptomatology other than left shoulder pain and limited range of motion of the neck that became more prominent as the mass increased in size.\nOn examination, there were three discrete protuberant tumor nodules, gray-white, involving the skin and subcutis. The largest nodule measured 16 × 15 × 7 cm and the smallest nodule measured 7 × 6 × 3 cm ().\nThe tumor was ulcerated and necrotic without apparent attachment to underlying structures. Anterior cervical, posterior cervical, supraclavicular, and axillary lymph nodes were not palpable bilaterally, and there were no other masses observed. CT of thorax suggested the masses were superficial with no attachment to underlying bone or great vessels, and there was no evidence of metastatic disease or adenopathy. A wide excisional biopsy of the lesion was performed. The histological examination revealed a fascicular architectural pattern composed of plump spindle cells with high nuclear grade atypia and numerous mitoses leading to the diagnosis of high-grade fibrosarcoma arising from DFSP (). The spindle cells diffusely express CD34 ().\nThere were areas showing a transition from scar to DFSP (), and focal areas were consistent with keloid.\nThere was also invasion of the lesion into the underlying skeletal muscle as well as focal areas at the deep surgical margin. The post-op course was uneventful. Due to the location and extent of the invasion, further excision was not feasible. A multidisciplinary approach including radiation oncology will be pursued for further treatment. The current plan involves the placement of a skin graft over the incision site followed by radiation treatment to target the remaining lesion. The patient will continue to be observed for recurrence of the tumor to allow for early resection. |
This is the case of a 50-year-old Caucasian man from Italy, nonsmoker, with no alcohol or illicit drug intake. His oncology history began in July 2007 in another cancer center, after the surgical removal of an expansive lesion on his left hand achieving a complete negative margin (R0) resection. Histological findings of the lesion highlighted a monophasic synovial sarcoma. He was administered adjuvant local radiotherapy and was then followed up. In June 2008, a computed tomography (CT) scan detected local recurrence of the disease and appearance of new nodules in the middle and apical right pulmonary lobe; therefore, the patient underwent another surgery of the hand and local excision of the lung tumor, which was confirmed by the previous histological diagnosis. Taking into account the dissemination of the disease, in August 2008, he was treated with systemic chemotherapy including 4 cycles of epirubicin in combination with ifosfamide. After about 1 year, in May 2009, progression of the disease into the right lung was recorded; therefore, the patient underwent another 3 wedge resections (anterior segment of the lower and upper right lobe), which is a diagnostic for metastasis of synovial sarcoma. He was followed up with only clinical and instrumental controls (CT scan and laboratory tests). After several years, in June 2012, a contralateral progression of the pulmonary disease was detected (1 lesion in the lower left lobe) and CT scan showed pathological mediastinal lymph nodes. A wedge resection of the dorsal segment of the lower lobe was performed, histologically compatible with metastases, and 2 hilar and lobar lymph nodes, which had become inflammatory, were removed. According to the patient, he continued to be followed up until December 2015 when he was submitted once again to a wedge resection of the middle lobe for sarcoma metastases. After 10 months, the patient reported intermittent episodes of hemoptysis in the absence of other symptoms; the CT scan showed significant thoracic disease progression associated with pulmonary artery compression. Therefore, in October 2016, he started chemotherapy with trabectedin at a dose of 1.5 mg/m2, administered as a 24-h continuous intravenous infusion repeated every 21 days. The treatment was well tolerated for the first 3 cycles in the absence of toxicity. He continued with 4 cycles of trabectedin in December of last year. After 2 weeks, the patient began to complain of sudden weakness, difficulty walking and diffuse muscle pain until it became unbearable. The patient was referred to the emergency department of our hospital and then admitted to start symptomatic therapy and supportive care. The ECOG performance status was grade 3. The laboratory test was found to mark an increase in serum levels of myoglobin, creatine phosphokinase (CPK), and liver function (Table ). No kidney function injury was present. Fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography was performed and showed an intense widespread tracer uptake in the skeletal muscles, particularly in the upper extremities, sternocleidomastoid muscle, the long muscles of the neck, the muscle groups of the scapular tracks bilaterally, certain muscles of the chest wall, the rectus abdominis muscles, the iliopsoas muscles, and almost all the muscle groups of the upper and lower limbs (Fig. ), according to the clinical history and laboratory data. When asking the patient about his medical history, he did not report any muscle trauma but he had been taking a herbal drug for hemorrhoids (diosmin) during the last course of trabectedin. After hospitalization and stopping the intake of diosmin with parenteral hydration, a complete normalization of the laboratory findings was obtained (Table ) associated with a progressive recovery of muscle strength and mobilization of the patient starting from day 10 with a walking aid until complete full functional recovery and a recovery of ECOG performance status grade 0 by day 15. |
A 44-year-old Asian male patient gradually developed a ventral mass on the penis 7 years before presentation. Initially, the lesion was ~1 cm in diameter and occasionally accompanied by paresthesias and bleeding after friction. He had normal urination and did not visit the hospital at first. When an ulcer developed, he applied erythromycin ointment. Sometimes, the focal ulceration\nhealed, but the condition often recurred. The scope of the lesion gradually increased over the period of 7 years. Finally, he came to the dermatology department of our hospital and underwent penile lesion tissue biopsy. The pathological report showed that he had penile intraepithelial neoplasia. Considering the large range of lesions, he came to the urological ward for hospitalization and surgical treatment. The patient had no clear history of exposure to chemical properties such as arsenic. His HIV antibody test was negative. He did not have a history of smoking or alcoholism. The lesion was located on the ventral side of the penis and the total area was ~2.2 cm ×2.0 cm (). The surface of the penile lesion was pale red with a gray edge. It had an irregular shape and clear boundaries, and the lesion slightly protruded out of the surface of the skin. There was no obvious exudate on the ulceration, and there was no obvious redness or swelling of the surrounding skin.\nAfter continuous epidural anesthesia, a skin incision line was marked at a 1.0 cm margin from the edge of the lesion of the penis of the patient. The scrotal flap range that needed to be isolated was also set before resectioning of the lesion. We cut the skin of the lesion vertically along the designed incision margin line, deep to the deep fascia layer, and completely resected the lesion tissue on the surface of the deep fascia (). After careful hemostasis by bipolar coagulation, we designed a 5.0 cm ×3.0 cm scrotal flap based on the resected wound area and dissociated it on the surface of the deep fascia. With a formed pedicled scrotal flap, we stretched it to the ventral side of the penis and covered the surgical area of the penile skin (). Intermittent suturing of the subcutaneous tissue reduced cavity formation and local exudate accumulation (). The wound area was dressed in gauze under pressure, and the penis was wrapped with a self-adhesive bandage under appropriate tension to promote wound healing. No drainage tube was placed in the operational area. The bandage and gauze were removed to expose the wound and keep it dry 3 days after surgery.\nAfter penile lesion excision, the wound was covered by scrotal flaps with blood supply. There was postoperative edema in the penile wound without infection. At follow-up observation half a month after the operation, the wound edge did not heal completely because of tension (). Through care with wound dressing changes, the wound area finally achieved healing (). Pathological images () showed that the lesion tissue was covered with squamous epithelium and showed finger-like protrusion. The basal part of the lesion showed bulbous advancing growth. The epithelium in the lesion area had severe dysplasia, disordered arrangement of polarity, large nucleus, deep staining, and complete basement membrane. No definite infiltration of basal layer tissue was found. The lesion area showed infiltration of polymorphonuclear giant cells and lymphocytes. The pathological diagnosis was penile intraepithelial neoplasia with granulomatous inflammation. No diseased tissue was found at the incision margin. After 6 months of follow-up, the patient had no recurrence of penile intraepithelial neoplasia and had no obvious discomfort with penile erection. |
A 74-year-old man developed a ureteral cancer and underwent left nephroureterectomy with lymph node dissection at the Department of Urology of The Jikei University School of Medicine Daisan Hospital in September 2013. After radical surgery, he repeatedly received chemoradiotherapy to treat for para-aortic lymph nodes recurrence. Although enlarged abdominal lymph nodes did not disappear completely, further extensive therapy was not performed, and active surveillance was followed for these lymph nodes in consideration of his age and renal function since September 2015. He had no history of malignancy other than ureteral cancer, no breast disease, and no family history of carcinoma. A mass just below the nipple of his right breast was acknowledged in February 2016, and he visited our department in March. On primary clinical examination, a hard 3-cm mass with good mobility was palpated just below the right nipple. Breast ultrasonography (US) revealed an irregular, rough, internally inhomogeneous hypoechoic mass measuring 32 × 35 mm in the center of the right breast right beneath the nipple (Fig. ). A tissue needle biopsy was performed, and histological diagnosis was invasive carcinoma, which showed negative results for estrogen receptor and progesterone receptor. The mass was 1 cm larger in 1 month. Although the intraductal lesion around the carcinoma was not clear and the tissue similarity to that of the previous ureteral cancer was considered, few findings actively suggested breast metastasis of ureteral cancer, and it was initially diagnosed as a primary breast cancer. The abdominal US showed no liver metastases. Chest and abdominal computed tomography (CT) showed no axillary lymph node enlargement and no distant metastasis, other than the already defined para-aortic lymph nodes enlargement observed in previous CT (Fig. ). Preoperative chemotherapy was taken into consideration, but the patient preferred surgery alone. He underwent a mastectomy and a sentinel lymph node biopsy in April 2016. Gross pathology showed a 45 × 30 × 55 mm nodular lesion. The tumor cells had high nuclear atypia, and the mitotic figures were extremely prominent. There was no intraductal lesion and the border of the tumor was clear. It was very similar to that of the previous ureteral cancer (Fig. ). Additional immunohistochemical examination was performed, which showed negative results for mammaglobin, GCDFP-15, estrogen receptor, and progesterone receptor (Fig ). The histocytological and immunohistochemical findings led to the final diagnosis of breast metastasis of ureteral cancer rather than primary breast cancer. The postoperative course was good, but multiple lung metastases appeared 2 months after surgery. He eventually died of cancerous lymphangiopathy in July 2016. |
A 29-year-old nulligravida lady was referred to gynaecology clinic complaining of significant vaginal discharge for 8 months sufficiently heavy to warrant frequent changing of her panty liner. During the same period, the patient had several episodes of intermenstrual light vaginal bleedings. She was on oral contraceptive pills for 3 years, and the bleeding and the vaginal discharge did not change with cessation of the pills. She was screened for sexually transmitted diseases by her general practitioner, and the results were normal. Two large loop excisions of the transformation zone for intraepithelial neoplasia had previously taken place. On clinical examination, she was found to have a 50 mm sessile cervical fibroid arising from the posterior wall of the left cervical lip of the cervix. This was confirmed by vaginal ultrasound scanning. The patient was put off uterine artery embolization due to the small risk of ovarian failure and risk of bleeding and infection which could lead to a hysterectomy. Hence, she was advised to consider starting to try and conceive sooner rather than later. Eight weeks later she got pregnant. She had a scan at 7 weeks which confirmed viable intrauterine pregnancy. She had regular antenatal care but experienced recurrent vaginal bleeding throughout the pregnancy due to her cervical fibroids and hence, she had several admissions to the antenatal ward. Her haemoglobin was regularly monitored, and she was placed on prophylactic iron therapy. On one occasion, at 20 weeks gestation, haemoglobin levels had reached 8.4 gm/dL, and 2 units of blood were transfused. The patient was treated conservatively, and a plan of elective caesarean section was agreed on at 39 weeks gestation, but she was aware that this might be brought earlier if she developed heavy bleeding before the agreed on date. At 20 weeks the size of the fibroid increased to 81 × 78 × 88 mm (). Furthermore, at 36 weeks the size of the fibroid increased to 129 × 95 × 112 mm (), which is larger than the size of the baby's head, distending and filling the entire vagina. The fetal growth was normal.\nAt 37 weeks gestation she went into spontaneous labour and had an emergency caesarean section. A live male infant weighing 6.5 lbs was delivered in good condition. The immediate postoperative period was uneventful, and the patient began breast feeding whilst in hospital. The patient was then sent home with an appointment for an ultrasound scan in 8 weeks with the hope that the fibroid will decrease in size. She was informed that the fibroid may degenerate due to spontaneous thrombosis of the feeding blood vessels. However, the patient attended the gynaecology emergency admissions at 6 weeks following delivery with offence vaginal discharge, passing small pieces of tissues. On examination, there was excessive offensive vaginal discharge and the size of the fibroid mass reduced to 50 mm, appearing necrotic in some areas. She was given clindamycin vaginal cream and an appointment to come for an outpatient clinic a week later for a biopsy of the tumour. Histology confirmed cervical myoma and areas of degenerations. She was admitted 4 days later and had a cervical myomectomy via vaginal route. The entire myoma was enucleated.\nShe was reviewed in the gynaecology clinic 6 weeks later.\nThe cervix had healed well but appeared short. This might be due to the previous two cervical loop excisions for intraepithelial neoplasia of the cervix, in addition to cervical myomectomy. It was decided that cervical length monitoring will be needed during any further pregnancies from 14 weeks onward.\nAt the time of writing this case report, we were made aware by the patient that she is currently in her second pregnancy at 20 weeks gestation. She had a cervical suture at a different hospital in another town as she moved her place of residence. The scan revealed that the cervix is shortening. She was also placed on progestogen vaginal tablets. |
A 49-year-old Japanese female with a history of poliomyelitis in her right lower limb was referred to our hospital for evaluation of bilateral hip pain. She also had pain in her right knee and ankle. She could only walk with two crutches.\nShe had undergone one surgery on her right ankle when she was four years old and another on her right hip when she was nine years old, however, she had no medical records regarding the procedures. However, the ankle surgery was not arthrodesis.\nDuring physical examination, the patient experienced severe pain with bilateral hip motion. The range of motion of her hip joints were 80 and 80 degrees of flexion, 30 and 30 degrees of abduction 40 and 20 degrees of external rotation, and 0 and 10 degrees of internal rotation for the right and left hip, respectively. Her muscle strength of the paralyzed right hip joint was grade 2 of 5 in hip flexor, 3 of 5 in hip abductor, 3 of 5 in hip adductor, and 2 of 5 in hip extensor. Additionally, her muscle strength of the non-paralyzed left hip joint was grade 4 of 5 in hip flexor, 4 of 5 in hip abductor, 5 of 5 in hip adductor, and 4 of 5 in hip extensor. The circumference of the thigh at 10 cm above the proximal edge of the patella was 34 cm on the right side and 44 cm on the left side, and the maximum circumference of the lower legs were 26 cm on the right and 33 cm on the left. Her right lower limb presented a shortening of 5cm. She did not have any history of therapy for the developing dysplasia of the hip joint.\nRadiographs demonstrated that the right hemipelvis and femur were severely hypoplastic, and the right femur had a high neck-shaft angle. However, the right femoral head was not dislocated. We were able to see the osteoarthritis in the right hip joint due to residual poliomyelitis. In the left hip joint, the radiographs also demonstrated osteoarthritis; however, this osteoarthritis was thought to be due to developmental dysplasia of the hip (DDH) (Fig. ). Her whole right lower limb was severely hypoplastic with an obvious equinus foot (Fig. ).\nThe THA was planned for her symptomatic hip joints. She first underwent left THA, then underwent right THA four months later. For both THA, a posterolateral approach was used. The operations were performed using hydroxyapatite (HA)-coated cementless femoral components, HA-coated cementless acetabular shells, polyethylene liners and zirconia balls (Kyocera, Kyoto, Japan). Multihole acetabular cups were used on both sides. Five screws were used on the paralyzed right side and 2 screws were used on the non-paralyzed left side. The length of the operation time was 39 minutes for left THA and 54 minutes for right THA, and the total blood loss was 670g during left THA and 455 g during right THA. She started to move with a wheelchair two days after both operations. She had no neurological abnormalities, infections, or dislocations after THA.\nThe Japanese Orthopedic Association hip rating score (JOA hip score) increased from 41 to 71 in the left hip and from 61 to 71 in the right hip. The JOA hip score includes four categories, and 100 points as full marks: pain (40 points), range of motion (20 points), walking (20 points) and activity of daily life (20 points) []. The pain score improved significantly in each hip joint. The leg length discrepancy improved from 5 cm to 3 cm. Her muscle strength of the paralyzed right hip joint improved from grade 2 to 3 of 5 in hip flexor, 3 to 4 of 5 in hip abductor, 3 to 4 of 5 in hip adductor, and 2 to 3 of 5 in hip extensor. However, the muscle strength on the non-paralyzed left side did not significantly improve. The patient’s condition was satisfactory in both of her hip joints six years after bilateral THA. However, she is only able to walk with two crutches and an ankle brace because of severe right ankle pain. The radiographs taken at the last follow-up showed apparently solid fixation of the components with no osteolysis and no migration of the cup (Fig. ). |
The patient is a 73-year-old white female with a history of atrial fibrillation on warfarin therapy presented with complaints of fever, burning micturition, and abdominal pain. She was admitted at a community hospital for the treatment of complicated urinary tract infection. She was started on levofloxacin, intravenous fluids and continued on warfarin. After 3 days, she started having difficulty in breathing. Chest X-ray showed prominent pulmonary vasculature, and she was treated for congestive heart failure. The next day, she developed some difficulty in swallowing and underwent bedside swallow study, which showed oropharyngeal dysphagia. By the evening, she developed severe neck pain and noticed sudden swelling on the right side of her neck. In view of worsening respiratory distress, urgent computed tomographic of the neck was done, which showed hemorrhage in the thyroid gland with retrosternal extension along with significant deviation and compression of the trachea []. Emergent intubation with Fr 6 endotracheal tube was done and was transferred to our institute for further management.\nOn the presentation, her INR had increased to three, immediately corrected with four units of fresh frozen plasma and was continued on mechanical ventilation with sedation protocol. She was seen by ENT services and underwent biopsy of the thyroid gland to rule out any underlying malignancy. Even with anticoagulant therapy, spontaneous hemorrhage is considered rare, and the presence of underlying malignancy would definitely change her management. Her biopsy specimen showed nodular goiter with bleeding and no evidence of malignancy. Later, she underwent median sternotomy and excision of retrosternal goiter with combined collaboration of ENT and thoracic surgeons. During surgery, the thyroid gland was observed as extending up to the level of the innominate vein.\nShe continued to be febrile, tachycardic, and diaphoretic with elevated T4 levels, which was indicative of hyperthyroidism []. Because she was scheduled for elective major surgery, antithyroid medications were initiated for control of increase sympathetic activity. As expected, following surgery she developed hypothyroidism and was started on thyroid supplements. She was discharged in a stable condition to the sub-acute rehabilitation facility and is presently doing well at the time of this writing. |
A 23-year-old African American female with a history of recurrent submandibular abscesses and a submental abscess currently being treated with levofloxacin and metronidazole presented to the hospital emergency department with anxiety, paranoia, visual hallucinations, and psychosis. She had first been diagnosed with a dental abscess approximately one month prior and was prescribed clindamycin due to allergies to antibiotics including amoxicillin, ampicillin, and penicillin. Due to issues with medication non-adherence the patient subsequently developed bilateral submandibular abscesses and a submental abscess requiring repeat incision and drainage and transition to alternative antibiotics. She had been recently discharged from the hospital four days prior following repeat incision and drainage with the prescriptions for levofloxacin and metronidazole, which she had been taking as instructed. At outpatient follow-up two days after discharge, she reported feeling well and appeared to be clinically improving; she had no symptoms at that time. One day later she developed progressive paranoia and insomnia, and the following day she developed visual hallucinations described as dark shapes. She was then brought to the emergency department by family. Examination was unremarkable with the exception of the psychiatric examination; she showed a flat affect, poor eye contact, and had fluent speech. She appeared internally preoccupied with her hallucinations, and her responses to questions were somewhat limited. According to her family, she had no personal or family history of psychiatric illness and had never had these symptoms previously. Labs on admission included a drug and toxin screen which was negative and a head CT which showed no signs of intracranial pathologies. Other labs showed no evidence of metabolic causes for altered mental status such as hyponatremia, hypernatremia, other electrolyte abnormalities, hypoglycemia, or encephalopathies. Given her lack of psychiatric history and that her symptoms were not consistent with any primary psychiatric disorder or other organic cause, a concern was raised that the condition may have been caused by the antibiotics. The levofloxacin and metronidazole were promptly discontinued, and she was then transitioned to ceftriaxone. Over the following days, additional testing including an electroencephalogram was negative and no other causes of psychosis could be identified. She gradually improved and reported decreased paranoia, insomnia, and the absence of persistent hallucinations. Three days after discontinuing the antibiotics, she had returned to baseline mental status per the patient and her family. She was then transitioned to oral cefdinir and discharged to home with instructions to follow up with her surgeon and with psychiatry. |
The patient is a 46-year-old female with SCC of the breast. She initially had silicone gel breast implantation for breast augmentation in 1995. The implantation was surgically revised in 2002 and 2006. In 2014 she noticed hardening and swelling of her right breast. Because of the death of her husband, she did not seek immediate medical attention. She continued to have swelling and increased pain in the right breast. Magnetic resonance imaging (MRI) performed in January 2016 showed a large fluid collection surrounding the intact right silicone implant as shown in Figure . The case was managed by surgical drainage of fluid collection and capsulectomy. In February 2016, she underwent bilateral prosthesis explantation and bilateral capsulectomy. The pathology demonstrated a 4-cm moderately differentiated invasive SCC. It extended into the muscle, and in situ tumor was noted to extend to the peripheral margin. There was no perineural or lymphovascular invasion. Pathology of the left breast capsule showed chronic inflammation. Computed tomography (CT) of chest, abdomen and pelvis on February 2016 revealed absence of metastatic disease. The patient underwent re-excision of the remaining chest wall mass in March 2016. Pathology showed well differentiated SCC with negative margins. Chest wall fluid was negative for malignant cells. On slide review, it was noted that there was squamous epithelialization of the implant capsule with benign squamous epithelium on both sides. This indicated that the tumor is likely SCC of the implant capsule rather than primary SCC of the breast. Estrogen and progesterone receptor markers were negative as well. Afterwards, she received external beam radiation. She was treated with radiation while supine with free breathing. Four tangent beams were used to target the right breast with 50 Gray in 25 fractions, followed by a 10 Gray boost to the tumor bed delivered in five fractions. Radiation was delivered using opposed tangents completed in May 2016. No adjuvant chemotherapy was offered due to the rare histology and paucity of data. She followed up in clinic in June 2016 without complications or clinical recurrence.\nFollow-up CT scan performed in August 2016 displayed a right upper lobe lung nodule and findings were suspicious for local recurrence (Figure ). She underwent right video thoracoscopy and right upper lobe wedge resection. The pathology was consistent with metastatic moderately differentiated SCC. The patient declined chemotherapy at this time. CT chest and abdomen at another hospital showed new cavitary lung nodules and right renal and psoas abscess. In February 2017, retroperitoneal fine needle aspiration of the right renal collection was positive for SCC. In June 2017, she was admitted to the hospital for abdominal pain and was found to have progressive disease. CT abdomen and pelvis with intravenous and oral contrast on 6/16/17 demonstrated a 6.1 cm x 5.7 cm heterogeneous lesion in the right kidney lower pole with invasion into the adjacent right psoas muscle (Figure ). Progressive metastases to the liver, lungs and retroperitoneum were noted as well. Ultrasound-guided fine-needle aspiration and core biopsy of the liver was positive for metastatic SCC with keratinization and necrosis.\nHer hospital course was complicated by non-ST elevation myocardial infarction, recurrent anemia requiring transfusions, atrial fibrillation with rapid ventricular rate and hypotension. She was noted to have leptomeningeal spread. She was ultimately transferred from the medical intensive care unit to the palliative care unit for comfort care. She expired of her disease in July 2017, one year after her initial diagnosis of cancer. |
The complaints of the patient (a 99 year old male) was that he had patchy edema erythema on the left side of his head since May 2019. Subsequently, the erythema area gradually expanded without exudation and was occasionally itchy. At the same time, mild edema developed in both eyes and the erythema further spread to the head. During this period (> 2 months), the patient went to several local hospitals and received treatment such as external medication, but without any improvement in his symptoms. The erythema further spread to the left side of his face.\nA medical examination was conducted and revealed no abnormalities. Dermatological examination showed clear dark red or purplish red infiltrating patches on the head. They did not completely fade after pressing, with visible exudation and scabs on the surface. The surface of the infiltrating erythema of the left face showed densely distributed vesicles with a little exudation. Mild edema was observed around both eyes, as shown in .\nA head CT scan was performed on May 28th 2019 at the People’s Hospital of Yunyang County. The scan revealed atrophy and a widened bilateral frontal subdural space. Liver, kidney and blood coagulation functions were all normal (). A chest CT performed on June 5th 2019 showed that a few fiber proliferation foci were scattered in the right lung and the patient had a gallstone and also aortic sclerosis. The bilateral pleura were thickened and adhered. Cysts may have been present in the left lobe of the liver and in the right kidney (). Therefore, we made further examinations in the dermatology department of Chongqing Southwest Hospital on July 8, 2019. Samples from the left temporal lobe were obtained and clinically diagnosed. A pathological assay revealed that the epidermis was slightly hypertrophic. A number of fissured blood vessel formations were observed as well as vascular endothelial cell proliferation that was considered to be mild atypia. We also found a large degree of extravasation of red blood cells, and dermal inflammatory cell infiltration to varying degrees. The laboratory measurements revealed CD31 (+), CD34 (+), ERG (+), Ki67:50% (+), S100 (-), and CK (-) (), which were pathologically confirmed as AS (). The other indicators of routine blood tests are presented in . Combining all the data together, this patient was diagnosed with senile AS of the head and face and was referred to our oncology department for appropriate treatment. |
Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even a gentle breeze would cause intense pain. Exposure to hot water would feel cold, and cold water would feel hot. She was unable to walk more than one block and remained in bed for over ten hours per day. She suffered extensive personal and professional quality of life losses at this time.\nLooking for relief, she tried medical yoga and received temporary relief. She also practiced traditional Tai Chi which provided minimal to no relief. She continued to have intense pain which had a significant impact on her quality of life and ability to perform daily tasks, including walking. In 2014, she tried a Qigong class and reported feeling that there was something very different about this class. Almost immediately, she felt a strong sense of relaxation that she had reportedly not found in many years. She was unable to attend many classes, so she purchased a video of the movements. Over the next year, she began to practice the exercises consistently until she could attend formal classes.\nSusan credits the practice of qigong with saving her life. She says it gave her a reason to get out of bed and socialize in the very early days of her practice. She is now able to walk with no limitations and her pain has improved by approximately 90%. Within three months of beginning qigong, she was able to stop all medications and injections she was receiving for pain relief. She continues to have some weakness in her arms and her hands, but it does not interfere with her ability to complete her daily activities. Despite her extensive cervical spine surgery, she reports full mobility in her shoulders and has nearly recovered full mobility in her neck. Her energy has also greatly improved and she routinely teaches three Qigong classes per week. In addition to this, she teaches at special events, including a Qigong class at a large yoga festival with over 1000 people in attendance. Recently, she started her first full time job in over six years.\nJames is a 70-year-old male. Over ten years ago, he was diagnosed with multi-level degenerative disc disease (DDD) in his lumbar spine, as well as severe central stenosis or narrowing of his spinal column around his spinal cord at L3-4, L4-5, and L5-S1. In 2011, he had a CT scan and was told by his physician that it would not be long until he must rely on a wheelchair for all mobility. Surgery was presented as an option, but he was informed that the success rate was less than 10%.\nHe decided to forgo surgery and take his chances. Gradually, his legs became weaker and he would fall spontaneously. He worked as a salesman and as he was talking to clients, his legs would give out without warning and he would fall to the ground. To help his situation, he would park as close as he could to the entrance of stores or other destinations and would walk with carts or holding onto shelves or furniture. This would only help for so long before he would fall again.\nHe began looking for other options to help manage his condition. In 2012, he tried yoga. While it helped to temporarily control his pain, it had no effect on the weakness in his legs and he would continue to fall. One year later, at the suggestion of his wife, he tried a Qigong class. Due to his family’s personal schedules, he was unable to attend another class for two months. He decided to purchase a video of the movements he had learned and practiced them each day for 4–5 months until he was able to return to normal classes.\nSince participating in Qigong classes, he has not fallen even once, and has no reports of pain. He stated that “Qigong gave me my life back.” He has no other medical problems to mention and takes no medications. He revealed that the improvements he has experienced have gone far beyond what he expected. Where he used to fall often and without notice, he has not fallen since he began qigong and reports that he now even has a “spring to his step, and a spring in his heart.” Not too long ago, he sustained a left rotator cuff tear. After continuing to practice qigong, he had a full return of strength and movement with no pain or difficulty with his routine daily activities, all within six months.\nIn his professional life, he felt like he was burning out as an IT programmer but practicing qigong has reinvigorated him. He was able to complete many projects (some complex) that he never would have thought possible. He has since become certified to teach Qigong and tells anyone who will listen about his story. He has also witnessed many others gain significant benefit from the practice of Qigong and is thrilled that he gets to share this with others. |
A 69-year-old man presented with severe chest pain and was subsequently diagnosed with extensive anterior wall myocardial infarction. Echocardiography showed akinesia of the anterior septum and anterior wall, and left ventricular ejection fraction was 35%. During admission to the coronary care unit, his blood pressure and urine output were noted to be decreased. Despite inotropic administration, the patient's condition did not improve. Bedside portable echocardiography showed low mitral E velocity and reversed E/A ratio, suggesting volume depletion or dehydration (). Based on Doppler echocardiographic findings, fluid was administered rather than diuretics or volume restriction. After hydration, the patient's condition improved and blood pressure and urine output increased.\nVolume expansion is the first therapeutic measure when a patient presents with hemodynamic instability. However, when the preload of the heart is already high, volume expansion can be hazardous, especially in elderly patients with decreased left ventricular compliance. Because of this concern, despite the need for adequate fluid balance, dehydration in elderly critically ill patients who are admitted to the ICU is not uncommon but usually unrecognized. It is important to avoid hypovolemia in these patients because it can lead to subsequent unexpected complications, such as hypotension and renal failure. Close monitoring is needed in patients being treated with volume expansion because of the delicate balance between excessive pulmonary congestion and reduced preload. Although diuretics are appropriate for the relief of congestion and edema, they are most effective in patients with evidence of fluid retention. In addition, caution should be taken to avoid overdiuresis, which may result in intravascular volume depletion and resultant hypotension or prerenal azotemia. Unlike in patients with grade 2 or 3 diastolic dysfunction (with elevated filling pressures) in whom the addition of diuretics should be considered due to elevated filling pressures, patients with grade 1 diastolic dysfunction (abnormal relaxation) will not benefit from diuretic therapy because their filling pressure is usually not elevated at rest (). Echocardiographic evaluation can identify those patients who would benefit from diuresis. If there is no overt evidence of volume overload, then diuretics should not be used. |
A 20-year-old female patient was referred to our thoracic surgery unit due to deformity and bulging in the anterior part of chest wall in sternal area with mild pain. A tumor was suspected based on the chest X-ray and therefore a chest CT scan was done that revealed a large mass with differential diagnosis of primary sternal tumor in origin or anterior mediastinal tumor with invasion to sternum (Figures and ).\nA core needle biopsy was performed with pathologic diagnosis compatible with giant cell tumor. An incisional biopsy was done based on pathologist's recommendation which revealed a highly vascular mass with final pathologic diagnosis of aneurysmal bone cyst.\nThe best treatment option was deemed to be resection of lesion and due to the size of tumor, total sternectomy was planned.\nAt the time of surgery a longitudinally elliptical midline incision was performed which included previous biopsy site. There was no infiltration or adhesion of mass to skin and subcutaneous tissue and a well-defined, capsulated but highly vascular mass was dissected from surrounding tissues. Due to large dimension of tumor, pectoralis major muscles were pushed laterally to nearly mid clavicular lines (Figures and ). Thoracic cavity was entered with some difficulty in hemostasis on the left side and all attachments of sternum and ribs were cut 2 centimeters away from tumor. The same steps were repeated on the right side. There was minimal adhesion of tumor to right upper lobe that was lysed easily but dense adhesion to anterior part of pericardium was managed by partial resection of pericardium and repairing the pericardium with PTFE mesh. Due to involvement of manubrium, total sternectomy was achieved by disarticulation of bilateral sternoclavicular joints. Large 20 × 20 cm mass was completely resected and an extensive defect remained in the chest wall (Figures and ). According to previous planning a cryopreserved sternal allograft was considered to repair the defect. Sternal graft was harvested from suitable cadaver in our center and cryopreserved in another tissue bank about one month prior to operation and was finally transferred for transplantation. Graft was tailored gradually and fixed to patient's ribs by titanium mesh plates and screws and exactly fixed to bilateral clavicles (Figures and ). Subsequently covering of the graft by pectoralis muscles was not possible and therefore breast tissue was approximated in midline for covering the graft and skin repairing was performed without any breast disfiguration. Bilateral chest tubes were inserted and wide spectrum antibiotics were administered. After surgery, chest wall was completely stable and there was no need for ventilator support. Chest tubes were removed 3 days after operation and there was no sign and symptom of wound infection. Antibiotics were continued till fifth postoperative day and patient was discharged one week after surgery.\nIn serial visits 1, 2, 3, and 12 months after surgery the defect was completely stable with no complicating events. Final pathologic report was compatible with aneurysmal bone cyst (). Serial chest X rays of patient have been shown in . More than eighteen months after surgery, patient had some keloid tissue in primary incision with no evidence of tumor regrowth (). |
The index patient was a 34-year old female referred to the bariatric clinic by the general practitioner on her own request to treat her morbid obesity. She was born with a normal birth weight but large head circumference for which she never had a diagnostic analysis. At the age of five, her body weight was already significantly higher compared to her peers. No specific life events could explain her obesity. Cognitive development was normal and she followed normal education. She underwent treatment for recurrent nasal polyps. Her mother also had a large head size and suffered from morbid obesity as well. She was diagnosed with thyroid cancer and died from a pulmonary embolism after placement of an Adjustable Gastric Band. A maternal aunt was diagnosed with breast cancer before the age of 50 and the maternal grandmother died from breast cancer at young age. The younger sister of the index patient was overweight and was reported to also have a large head size (Figure ).\nSince childhood, the index patient followed several different coaching programs to change her eating behavior and exercise pattern to induce weight loss. She lost weight several times but was never able to maintain her weight loss. At the time of the intake procedure at the bariatric clinic, her height was 1.69 m (SD −0.2) and weight 164 kg (SD +6.8), resulting in a Body Mass Index (BMI) of 57.6 kg/m2 and a predominant abdominal obesity. Head size was not measured at that time since this is not part of bariatric screening procedures. Biochemical analysis of the blood revealed no abnormalities, and excluded endocrine hormonal disorders such as hypothyroidism. The fasting glucose level was 5.9 mM.\nThe combination of early onset morbid obesity resulted in suspicion of a genetic cause of her obesity. She was offered diagnostic genetic analysis of 52 obesity–associated genes to identify a possible underlying genetic obesity cause.\nThe patient was eligible for bariatric surgery and underwent a sleeve gastrectomy without complications (performed in 2014 using a standardized fashion). At 1, 2 and 3 years after surgery, she achieved a percentage Total Body Weight Loss of 39.4, 48.8 and 44.9, respectively. This resulted in a current BMI of 30.1 kg/m2. This was within the range of the results which were observed in a control group of 18 female patients, with a negative obesity genetic test result. These female patients were matched for age and BMI and achieved a percentage Total Body Weight Loss (TBWL) of 30.3 after 1 year, 31 after 2 years and 30 after 3 years of follow-up.\nA few months after surgery, the result of the obesity gene panel analysis was returned and showed heterozygosity for a known pathogenic mutation in the PTEN gene (): c.202T>C p.(Tyr68His). This mutation has been described previously in patients with PTEN Hamartoma Tumor Syndrome (PTEN HTS) (Marsh et al., ). No other pathogenic mutations were shown in the remaining 50 obesity–associated genes (Table ). At the genetic clinic, a head circumference of 63 cm (+5SD) and pedigree analysis (family history of multiple tumors) further supported the molecular diagnosis of PTEN HTS.\nAccording to the PTEN HTS guidelines, patients with pathogenic PTEN mutations are advised to visit the outpatient clinic for familial tumors, for lifelong surveillance of tumors that are associated with the PTEN mutations (Dutch Guidelines, ; Eng, ). Our patient underwent additional biochemical laboratory- and ultrasound screening to exclude thyroid gland carcinoma. Besides a few benign nodules on the ultrasound, no abnormalities could be determined. A yearly follow-up ultrasound of her thyroid gland and yearly serum thyroid stimulating hormone analysis was advised. Screening for breast, endometrium and colorectal cancer, also revealed no anomalies. |
Susan is a 51-year-old woman. As an adolescent, she developed scoliosis. Working as a hairstylist when she was 18 or 19, she began to have severe pain in her hands, making her work very difficult. She had carpal tunnel surgery on her right hand which provided temporary relief. Her symptoms slowly returned and she continued to have intense pain and difficulty with her daily activities. Seeking relief from her symptoms, she received treatment from chiropractors and Chinese medicine practitioners with no significant benefit. She also tried yoga and swimming but depending on the yoga movements or swimming strokes, she began to have more pain.\nWhen she was in her early forties, she began to have weakness in the lower half of her body. Her legs would frequently give out on the stairs, causing her to fall. Control of her bladder and bowel function also began to deteriorate. She had an MRI, and based on the results, she was scheduled for emergency surgery to stabilize her cervical spine and relieve spinal cord compression. She was informed that it would be an outpatient surgery and she would be home the same day.\nIn May 2011, Susan had a 6-level cervical spine fusion to stabilize her spine and relieve pressure on her spinal cord. When she woke up, she realized something was wrong. The entire right side of her body was paralyzed. What was supposed to be an outpatient surgery with a return home the same day ended up being an 8-week hospital and rehabilitation stay to learn how to walk again.\nIn August 2012, a second surgery was performed with the goal of pain relief. However, she reported her pain was significantly worse afterwards. She would receive weekly injections for pain relief that she reports would only marginally decrease her pain for about one week. She was also taking high doses of medication for nerve pain relief which she also reports provided marginal benefit. She had areas of heightened sensitivity on her legs where a bed sheet or even a gentle breeze would cause intense pain. Exposure to hot water would feel cold, and cold water would feel hot. She was unable to walk more than one block and remained in bed for over ten hours per day. She suffered extensive personal and professional quality of life losses at this time.\nLooking for relief, she tried medical yoga and received temporary relief. She also practiced traditional Tai Chi which provided minimal to no relief. She continued to have intense pain which had a significant impact on her quality of life and ability to perform daily tasks, including walking. In 2014, she tried a Qigong class and reported feeling that there was something very different about this class. Almost immediately, she felt a strong sense of relaxation that she had reportedly not found in many years. She was unable to attend many classes, so she purchased a video of the movements. Over the next year, she began to practice the exercises consistently until she could attend formal classes.\nSusan credits the practice of qigong with saving her life. She says it gave her a reason to get out of bed and socialize in the very early days of her practice. She is now able to walk with no limitations and her pain has improved by approximately 90%. Within three months of beginning qigong, she was able to stop all medications and injections she was receiving for pain relief. She continues to have some weakness in her arms and her hands, but it does not interfere with her ability to complete her daily activities. Despite her extensive cervical spine surgery, she reports full mobility in her shoulders and has nearly recovered full mobility in her neck. Her energy has also greatly improved and she routinely teaches three Qigong classes per week. In addition to this, she teaches at special events, including a Qigong class at a large yoga festival with over 1000 people in attendance. Recently, she started her first full time job in over six years.\nJames is a 70-year-old male. Over ten years ago, he was diagnosed with multi-level degenerative disc disease (DDD) in his lumbar spine, as well as severe central stenosis or narrowing of his spinal column around his spinal cord at L3-4, L4-5, and L5-S1. In 2011, he had a CT scan and was told by his physician that it would not be long until he must rely on a wheelchair for all mobility. Surgery was presented as an option, but he was informed that the success rate was less than 10%.\nHe decided to forgo surgery and take his chances. Gradually, his legs became weaker and he would fall spontaneously. He worked as a salesman and as he was talking to clients, his legs would give out without warning and he would fall to the ground. To help his situation, he would park as close as he could to the entrance of stores or other destinations and would walk with carts or holding onto shelves or furniture. This would only help for so long before he would fall again.\nHe began looking for other options to help manage his condition. In 2012, he tried yoga. While it helped to temporarily control his pain, it had no effect on the weakness in his legs and he would continue to fall. One year later, at the suggestion of his wife, he tried a Qigong class. Due to his family’s personal schedules, he was unable to attend another class for two months. He decided to purchase a video of the movements he had learned and practiced them each day for 4–5 months until he was able to return to normal classes.\nSince participating in Qigong classes, he has not fallen even once, and has no reports of pain. He stated that “Qigong gave me my life back.” He has no other medical problems to mention and takes no medications. He revealed that the improvements he has experienced have gone far beyond what he expected. Where he used to fall often and without notice, he has not fallen since he began qigong and reports that he now even has a “spring to his step, and a spring in his heart.” Not too long ago, he sustained a left rotator cuff tear. After continuing to practice qigong, he had a full return of strength and movement with no pain or difficulty with his routine daily activities, all within six months.\nIn his professional life, he felt like he was burning out as an IT programmer but practicing qigong has reinvigorated him. He was able to complete many projects (some complex) that he never would have thought possible. He has since become certified to teach Qigong and tells anyone who will listen about his story. He has also witnessed many others gain significant benefit from the practice of Qigong and is thrilled that he gets to share this with others. |
The article describes a case of bacterial meningitis and subdural empiema upon surgical tooth extraction, in a 46 years old man. The patient arrived at the emergency service of the Hospital with temporomandibular pain, swelling of left temporomandibular zone and fever. We would like to emphasize that the only important information that the patient referred in the anamnesis was a tooth extraction two weeks ago (tooth 38). Taking in account these historical precedents, intravenous antibiotic treatment was administered and a CT of neck and facial area was carried out too. The analysis of the CT showed the presence of an abscess in the corner of the jawbone (left size). The patient was admitted in maxillofacial unit where the surgical drainage of the infectious collection was carried out. From this moment we decided to treat the patient with washed of the infected area every 8 hours and intravenous antibiotic treatment. Consequently, after 7 days the patient was discharged from the hospital with disappearance of the symptomatology and normalizing of analytical parameters. Convinced of our well performance, we were surprised to see the patient consulting again to the emergency service two weeks later. He came to the Hospital presenting identical symptoms of the previous time. In addition, his family referred the appearance of fluctuations in the level of consciousness. The exploration of the patient evidenced welling of the temporomandibular space and fever. Moreover, we noted the presence of a fistula with pus output in the preauricular zone (left size). A new CT reported signs of meninges inflammation. To examine it, we consulted to the neurological service of the Hospital. In this regard, Neurology unit decided to perform a lumbar puncture and bacterial meningitis of dental origin was diagnosed. Cocos gram + were found in the cerebrospinal liquor. In addition, a brain MRI revealed the presence of a temporal subdural empyema (left size). We notified the CT and MRI results to Neurology and Neurosurgery units that decided to prescribe a triple intravenous antibiotics treatment and surgical washed of temporomandibular space. However, despite these treatments the patient persisted with symptoms and had no improvement. Furthermore, he started to show behavioral disturbances alternating with fluctuations in the level of consciousness. Importantly, as complication of meningitis the patient developed a cerebral vasculitis and a thalamic ischemic infarction was evidenced by new MRI. Due to the the poor clinical evolution we consulted to the Infectious diseases unit. They reviewed the treatment and administered antifungal coverage. Noteworthy, the patient started to improve with the new treatment some days later. In fact, a serial cranial CT and brain MRI mirrored size reduction of empyema and cerebral vasculitis. After two weeks, the pus output through the skin of the temporomandibular area ceased and serials of Cranial CT and Brain MRI certified the resolution of the neurological complications. Lastly, the patient was discharged from hospital with a check-up appointment in 3 weeks to monitor the clinical evolution. It is important to highlight that during this check-up, we observed that the patient remained asymptomatic. Finally, we also would like to put the emphasis on the importance of the collaboration between several specialists in order to resolve these cases, (Figs. -). |
A 14-year-old male patient presented with a 1 week history of pain in his anterior right thigh and anterior pelvic region, which was exacerbated by walking. This was preceded by an injury sustained whilst playing football. He was kicking a football when a severe pain in his right thigh developed, which rendered him unable to walk, and he had to crawl off the football pitch. On examination his gait was affected by pain in the right thigh, there was tenderness to the anterior superior iliac spine on palpation, and all hip movements were limited by pain.\nPlain film radiographs were reported by a local district general hospital radiologist as showing a faint ossification within the soft tissues immediately inferior and adjacent to the right anterior inferior iliac spine, suggestive of a rectus femoris avulsion fracture. However, when reviewed in clinic the consultant orthopaedic surgeon noted that there was some calcification around the anterior superior iliac spine which did not collaborate with the time since injury, and a magnetic resonance imaging (MRI) scan was performed.\nThe imaging reported an abnormality in the anterior right iliac crest with an avulsion fracture and a surrounding soft tissue mass (Fig. ). This solid mass was centred on the anterior superior iliac spine and measured 3 × 4 × 5 cm in size. The signal intensity of this mass was mildly hyperintense on T1-weighted images (Figs. a, ). At the referring hospital, these findings were thought not to correspond to a simple trauma, and suggested a possible underlying bone tumour.\nThe patient was referred to our sarcoma unit for an opinion, where the images were reviewed at a multi-disciplinary meeting. On the review of radiology performed by our specialist musculoskeletal radiologist, it was felt that there was an avulsion fracture of the anterior superior iliac spine with anterolateral displacement of the apophysis and a large surrounding haematoma (Figs. , , ). There was mild enhancing marrow oedema present in the anterior third of the iliac blade, but the signal intensity in the bone was otherwise normal. There was nothing to suggest that an infiltrative osseous tumour was present.\nRadiological features which were supportive of the diagnosis of a fracture rather than a tumour were:Presence of a clear fracture with avulsed tendon of sartorius. Bone marrow signal in the anterior superior Iliac spine was relatively normal with only a subtle oedema seen. The haematoma showed a slightly hyperintense T1 signal intensity and bright T2 fat-saturated (FS) signal. Tumour masses generally show low T1 and bright T2 FS signals (see Fig. ).\nBased upon the clinical history, examination and radiological findings, the MDT decision was that this was an avulsion fracture of the anterior superior iliac spine apophyses. The decision was made to treat conservatively: with rest, analgesia and physiotherapy. A biopsy was not felt necessary at this stage, but a careful, regular clinical follow-up was ensured. An interval MRI scan, performed after 3 months (Fig. ; see also Fig. ), showed that the avulsion fracture was demonstrating signs of healing. The initial haematoma was smaller, the degree of marrow oedema was significantly less, and there were no features of bone marrow oedema.\nAt 1 year follow-up, the patient had normal gait, there was no tenderness of the anterior superior iliac spine on palpation, and he had pain-free full range of movement of the hip. The patient had returned to active sports without any restriction. |
A 43-year-old male with a past medical history of heart murmur since the age of 11, obesity (BMI = 39.6 kg/m2), hypertension, and aortic valve disease was admitted for elective cardiothoracic surgery. The patient had previously been diagnosed with heart failure and severe aortic insufficiency via transesophageal echocardiography. The patient subsequently planned to undergo reconstruction of the ascending aorta and replacement of the aortic valve.\nOn the day of surgery, the patient was in his usual state of health with no signs of infection. The patient had no musculoskeletal symptoms and had never had shoulder complaints or undergone shoulder surgery. In the operating room, the patient was placed under general anesthesia using propofol as an induction agent and remained supine in a Skytron surgical table for the entirety of the surgery lasting three hours and 36 minutes. The surgery included reconstruction of the ascending aorta and the proximal arch with graft and prosthetic aortic valve replacement, followed by sternal closure with wires and a plate. There were no intraoperative complications and the patient’s mean arterial pressure was maintained at 70 mmHg throughout the surgery. The patient did not suffer any spikes in temperature or have any episodes of increased muscle rigidity.\nTwo days following surgery, the patient complained of bilateral shoulder pain and was unable to raise his arms above his head due to weakness and pain. He denied ever having experienced similar symptoms before. The patient had been restricted to bed rest and was continuously monitored via telemetry on the cardiac floor postoperatively. Upon orthopedic consultation, the patient was afebrile, normotensive, and in no acute distress. The patient’s chest, back, shoulders, and upper extremities displayed no bruising or break in the skin and were soft to palpation. The patient had a full passive range of motion (ROM) but displayed weakness abducting against resistance in the bilateral upper extremities. The patient denied focal tenderness to bilateral upper extremities and sensation was intact to light touch in the distribution of bilateral median, ulnar and radial nerves. The patient did not display tenderness upon palpation of the cervical spine and did not have radicular symptoms.\nThe patient’s creatine phosphokinase (CPK) level was checked two days postoperatively and noted to be 14,990 U/L (normal range male: 60-400 U/L; normal range female: 40-150 U/L) with a blood urea nitrogen (BUN) of 31 mg/dL (normal range: 6-23 mg/dL), creatinine of 0.9 mg/dL (normal range: 0.5-1.2 mg/dL), and potassium of 4.7 (normal range: 3.5-5.0 mmol/L). The patient subsequently received additional intravenous (IV) hydration. Magnetic resonance imaging (MRI) of the bilateral shoulders showed intramuscular hemorrhage involving the bilateral supraspinatus muscles (Figures -). There was also prominent intramuscular edema of the infraspinatus and teres minor muscles bilaterally, with mild intramuscular edema in the posterior deltoid and trapezius muscles bilaterally. These findings in addition to a markedly elevated CPK level were consistent with a diagnosis of RML. Of note, our patient was on Lovenox (Enoxaparin), 40 mg SQ daily which is standard of care for a patient after this type of cardiac surgery.\nThe patient was treated with a continuous IV infusion of normal saline for six days. His CPK levels consistently trended downward from 14,990 U/L on postoperative day 2 to 127 U/L by postoperative day 12; creatinine levels remained within normal limits and BUN levels were slightly elevated throughout the postoperative course (Table ). Physical therapy was ordered and the patient performed ROM exercises which aided in alleviating his functional restriction. Additionally, analgesics were given for pain. By postoperative day 12, the patient’s pain and weakness had completely resolved and there was no clinical or laboratory evidence of persistent RML. |
The 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, the long-term success of the stenting procedure could not be guaranteed due to the large sizes and high mobility of the aneurysms, so the patient was referred for surgery. |
A diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () with the absence of the right hepatic duct and an intrahepatic variation with insertion of the right inferior sectorial duct into the left common duct () as type A3 of Huang Classification []. |
A 48-year-old male weighing 60 kg presented to surgery outdoor with chief complaint of progressive swelling in the right side of the neck since last 3 months following trauma. The swelling was initially of small size which gradually progressed to the current size. On the basis of clinical finding and radiological report, it was diagnosed as subclavian artery aneurysm and surgical intervention was advised. The patient also had a history of angina 4 months back for which he was hospitalized and treated. He was advised tablet aspirin 75 mg and tablet clopidogrel 75 mg once daily on a regular basis. On local examination, the mass was around 3 cm × 3 cm × 4 cm, diffuse, pulsatile, soft in consistency, and mobile []. Magnetic resonance imaging angiography of the neck showed the aneurysm of subclavian artery, 1 cm lateral to the origin of internal carotid artery []. On two-dimensional echocardiography an ejection fraction of around 30% with mild left ventricular hypokinesia and grade 2 diastolic dysfunction was found. In view of poor cardiac functional status of the patient, RA with CEA was planned as the anesthetic technique. The patient was advised to stop tablet clopidogrel 7 days before the day of surgery. Coagulation profile was done, and it was found to be within the normal limit. Informed and written consent were obtained and the patient was explained about nil per oral. Tablet alprazolam 0.5 mg and tablet ranitidine 150 mg were advised to be taken on the night before and morning on the day of surgery. After taking the patient to the operation theater, all standard ASA monitors were attached and vitals were continuously recorded. Heart Rate was 100/min and electrocardiogram showed sinus rhythm, blood pressure was 140/80 mmHg, and SpO2 of 99% on room air. An 18-gauge intravenous cannula was inserted and ringer lactate drip was started. The patient was placed in the sitting position with the head flexed and resting on the thorax, to open the lowest cervical interspaces. After achieving cutaneous local anesthesia by injecting 3 ml of 2% lignocaine with adrenaline (1:200,000), an 18-gauge Tuohy needle was inserted through the midline approach into the C7-T1 interspace. The needle was advanced slowly, and epidural space was identified by the loss of resistance technique with a glass syringe []. Careful aspiration ensured that the needle had neither entered the subarachnoid space nor penetrated any epidural vein. Then, 8 ml of injection ropivacaine 0.5% with injection fentanyl 50 µg/kg was given in graded doses over 10 min and was left for 15 min after which the effect was checked. The upper limit and lower limit of the block were achieved from C3 to T4, respectively. The surgery was proceeded during which vitals remained stable throughout and the patient was comfortable. |
In May 2008, an 81-year-old man was transferred to the Department of Rehabilitation Medicine at our institute, after hematoma evacuation and a ventriculoperitoneal shunt operation for left thalamic hemorrhage, intraventricular hemorrhage, and hydrocephalus. He was previously diagnosed with dysphagia and had undergone PEG. When he was transferred to our hospital, he was still receiving nutritional support through the PEG, without any complications.\nThe first PEG site infection occurred in September 2009. The PEG tube was removed, and a new PEG tube was inserted at another site. He then received enteral feeding through the PEG for 4 years. His body weight was maintained at an appropriate level of 70 kg.\nIn June 2013, the patient stopped responding to verbal commands, but his cognition was intact, and he responded to pain. He could not roll over in bed, or sit up. In addition, new signs of infection were observed around the PEG insertion site. A round swelling and erythematous skin changes with pus-like discharge were seen (). On enhanced abdominal CT, inflammation around the PEG tube was observed (). When leukocytosis and increased levels of serum C-reactive protein (CRP) were confirmed, he was started on intravenous antibiotic therapy. The PEG tube had to be removed; hence, the patient was kept fasting, with peripheral nutritional support. One month after the PEG removal, the complications at the PEG site seemed to have resolved (). The leukocytosis resolved and serum CRP levels normalized, but the patient lost about 3 kg of body weight. A new PEG tube was inserted 2 cm above the previous PEG site (). When he was started on enteral feeding through the new PEG, leakage of gastric contents was observed. The leakage was from the second PEG site. On enhanced abdominal CT, there was a gastrocutaneous fistula around the second PEG insertion site (). As spontaneous fistula closure did not occur in spite of medical management for one month, the patient received simple suturing of the fistula and was kept fasting. After 2 weeks, the fistula was not closed. Surgical treatment under general anesthesia was too risky. Endoscopic intervention using hemoclips and fibrin glues was under consideration. However, the patient had already endured a very long duration of fasting, while waiting for the fistula to heal. He needed to be started on enteral feeding as soon as possible, and fistula closure was second to that. Also, additional endoscopic intervention could burden the patient considering his exhausted state. Instead, he could be started on enteral feeding if the tip of the feeding tube is placed more distally than the stomach, regardless of the fistula closure.\nA gastrojejunostomy tube was inserted via the newly inserted PEG tube under fluoroscopic guidance. This procedure was performed on August 27, 2013, 3 months after the PEG site infection. A guide wire and a gastrojejunostomy catheter were inserted into the third PEG tube. Through fluoroscopy, the radiologist confirmed that the tip of the catheter had reached the jejunum (). The patient was started on enteral feeding through the gastrojejunostomy without any significant complications (). |
A girl aged seven years and eight months was referred to our observation because of left peripheral facial palsy, causing the inability to close the left eye and dropping of the corner of the mouth. A first peripheral facial nerve palsy occurred when she was three years and one month old, with complete regression after corticosteroid treatment. At the age of three years and nine months, she was diagnosed with pure red cell hypoplasia, manifested as severe anaemia (haemoglobin: 3.00 g/dL; red blood cells: 1,000,000/mm3) with an extreme lack of erythroid precursors in the bone marrow, but high growth of them in culture, probably caused by anti-EPO antibodies. The detection of anti-EPO antibodies, however, is not routinely performed in a clinical setting. The autoimmune hypothesis was postulated on empirical bases, since haemoglobin levels did not increase after recombinant human EPO administration, but normalized after corticosteroid therapy, and the addition of autologous serum to the erythroid precursor culture inhibited EPO growth. When she was 4 years and 4 months old, the patient presented with a second episode of left facial palsy, combined with the acute onset of a strength deficit on the left side of the body. Mingazzini I and II were positive for the left limbs. The imaging assessment showed a haemorrhagic stroke corresponding to the anterior portion of the right putamen and of the external capsule with perilesional oedema, involving the anterior limb of the internal capsule. Blood pressure measurements performed during the hospitalisation revealed high diastolic blood pressure values. These findings suggest a central rather than peripheral involvement of the facial nerve. Three weeks after their beginning, the symptoms had completely regressed. At the age of five years and six months, a third episode of left peripheral facial palsy occurred. Brain magnetic resonance imaging (MRI) was repeated, showing gliotic evolution of the previous haemorrhagic insult without new lesions. The patient was treated with corticosteroids, with a good regression of symptoms. On the last episode, the patient had initially visited a first level emergency room, where laboratory tests, as well as ophthalmologic, neurologic, and otoscopic examinations and a head computed tomography (CT) scan performed were normal. When admitted to our department, the neurologic examination showed complete peripheral left facial palsy (House–Brackmann grade V). Physical examination showed the presence of a furrowed tongue as a synchronous anomaly. No active herpetic mucosal and skin lesions were found. The patient was started on a tapering dose of prednisone for 30 days and vitamin B group supplementation was added. The clinical course was favourable. Three months after, at last follow up, neurological impairment had clearly improved. Facial palsy gradually resolved after the third week of treatment. |
A 65-year old gentleman, a known case of coronary artery disease and severe left ventricular dysfunction underwent radiofrequency catheter ablation for recurrent shocks from implantable defibrillator due to frequent ventricular tachycardia (VT). The consent for the procedure and for the publication was taken from the patient. The procedure was done using CARTO XP mapping system through retrograde aortic approach. A monomorphic ventricular tachycardia with cycle length 410 ms, right bundle branch block morphology, superior axis of QRS in the frontal plane and positive concordance of QRS in the precordial leads was easily and repeatedly inducible. An activation map of the VT was created in the left ventricle and entrainment was attempted from an area on the anterolateral wall near the mitral annulus. Pacing was performed from the ablation catheter at 380 ms during VT (). There was entrainment with concealed fusion with an identical QRS morphology during pacing with an apparent post pacing interval (PPI) of 290 ms and stimulus to QRS of 330 ms. How can one explain a PPI shorter than the tachycardia cycle length during entrainment with concealed fusion? Radiofrequency ablation at this site resulted in termination of the tachycardia.\nA careful look at the figure reveals that the cycle length of the tachycardia shortens to 380 ms during attempted entrainment with an identical QRS morphology. However, the electrogram in the ablation catheter that is used to measure PPI is present earlier than the pacing stimulus and is not altered during pacing implying that it is a far field signal and not true near field electrogram.[] The large amplitude of this electrogram, possibly due to neighboring anterolateral papillary muscle, in no way excludes the possibility of it being a far field signal. The near field electrogram cannot be made out in the ablation catheter due to artifacts (due to enabling of RF energy) after pacing was stopped. It was not discernible at this site both in the distal and proximal bipole even when the pacing was disabled (not shown) probably because of very small amplitude of the true local electrogram. Though, there is entrainment with concealed fusion, absence of a discernible local electrogram in the ablation channel precludes measurement of true PPI. Thus, this site could be in the reentry circuit. Though, a long stimulus to QRS interval of 330 ms (80% of the tachycardia cycle length) points to an inner loop site, [] it can also be in the critical isthmus or the exit site with very slow conduction. Though, the chances of termination of VT at a site with stimulus to QRS interval greater than 70% of VT cycle length are small, ablation at this site successfully terminated the VT in this case. Scar related VT usually needs a linear ablation for termination, however, a single lesion delivered in the narrow critical isthmus may terminate the tachycardia as in the present case. The ablation line was created joining the successful site of ablation to the mitral annulus. The present case suggests that it is important to identify far field signals during ablation of ischemic VT and entrainment can help in their recognition. |
The patient is a 99-year-old woman, with a vision loss of 70% in the left eye and 40% in the right eye, who underwent basal cell carcinoma resection of the lower right eyelid 3 months before. The resection had an extension of 0.7 × 0.3 cm2, affecting the central margin of the lower eyelid and was treated with direct closure. The hystopathology report of the resection informed solid (nodular) type of basal cell carcinoma characterized by islands of cells with peripheral palisading and disorganized central cells. The margins of resection and the deepest layers were affected.\nAfter the hystopathology report, we decided to plan a more aggressive treatment around the scar of the previous resection. The scar was not well defined (Fig A), so we thought the best approach would be a total resection of the lower eyelid with a full-thickness resection around the scar that would imply a measurement greater than 75% of the full lower eyelid extension.\nWe had a case with 3 limitations for applying the advancement tarsoconjunctival flap: the old age of the patient, the elevated vision loss in the contralateral eye, and the high size of the resection. The patient was advanced in years with a severe vision loss in the contralateral eye, so the occlusion of the right eye and the risk of a second step operation would not be the best options. The defect would be too big for applying this technique. Reviewing the bibliography, we thought this patient could be a good candidate for the total lower eyelid reconstruction with the nasal chondromucosal flap, because it does not need eye occlusion and the reconstruction is achieved with one-step operation.\nBecause of the age of the patient, the operative procedure was performed under local anaesthesia with sedation instead of general anaesthesia. Although this is a large surgical field to perform under local anaesthesia, in our hospital, the final decision about the most suitable anaesthesia depends on the anaesthetist, who considered the local anaesthesia with sedation as the most appropriated method for this patient.\nPreoperative markings were done for harvest of the upper lateral cartilage in the nasal chondromucosal flap, which is based on the lateral terminal branch of the dorsal nasal artery, and for transposition flap of von Langenbeck, and then the resection was done (Fig B). The piece of resection was 2.8 × 1.9 cm2. The flap was designed along the lateral nasal wall and was based on the terminal branch of the dorsal nasal artery, to include the subcutaneous tissues down to the periosteum and the cranial portion of the upper lateral cartilage. The skin was incised for 2.5 cm along the border between the lateral nasal wall and the cheek from the inner canthus to the ala nasi. Then, the subcutaneous tissue was dissected, from lateral to medial, onto a line beyond the midline of the nose. The subcutaneous dissection was extended superiorly to the glabellar area and inferiorly to or beyond the lower margin of the upper lateral cartilages. A portion of the lateral cartilage with 1.2 × 2.1 cm2 of size was dissected. The flap was harvested from the pedicle including the portion of the lateral cartilage dissected (Fig C).\nThe flap was then transposed to reconstruct the posterior lamella of the lower eyelid (Fig A).\nWith the help of the loupe magnification, flap mucosa was sutured to the conjunctival margin. Transposition flap of von Langenbeck was used for repairing the anterior lamella and correcting ectropion (Fig B), lateral and medial periosteal fixation was performed to minimize the risk of lid malposition. The transposition flap of von Langenbeck consisted in a superiorly based lateral transposition cutaneous flap. Its base was immediately adjacent to the defect, with a length and a width approximately equal to the length and width of the defect. The flap was harvested and transposed into the defect.\nThe narrow skin bridge created by the extensive lateral nasal incision and the medial extent of the lid resection was reinforced with the stitches from the medial extent of the transposition flap. Wound closure was accomplished by a simple discontinuous subcutaneous pattern (4-0 polyglactin), continuous cutaneous pattern for the transposition flap of von Langenbeck (5-0 nylon), and discontinuous cutaneous pattern for the rest (4-0 nylon). The results, just after (Fig 4A), 3 months after (Fig 4B), and 6 months (Fig 4C) after the surgery, were aesthetically and functionally excellent, and as we can see, with the absence of any malposition, entropion or ectropion. This patient had a good result probably due in part to her aged skin, so maybe the procedure described would be a good alternative just in old people but not in young people. |
A 65-year-old Caucasian woman presented for evaluation of a rapidly enlarging nodule on the left preauricular cheek. The patient had diabetes mellitus type II and hypertension and was on immunosuppressive therapy for renal transplantation 8 years prior. Two years prior she had a cutaneous squamous cell carcinoma in situ (SCCis) on her left third finger that was excised using MMS. The patient was otherwise healthy on presentation. Physical examination revealed a 1.5 cm eroded erythematous nodule on the left preauricular cheek (). Initial shave biopsy showed an ulcerated neoplasm within the whole dermis extending to all margins of the specimen consisting of multiple irregular islands of atypical cells that stained uniformly with antibodies to pan keratin and uniformly negative with antibodies to S100 protein. A diagnosis of a poorly differentiated carcinoma was made.\nThe tumor was removed with MMS with negative microscopic margins determined by frozen section in one stage resulting in a 3.5 × 2.3 cm defect. Debulked specimen was sent for permanent section revealing a deeply infiltrating primarily undifferentiated carcinoma extending to the subcutaneous fat without evidence of keratinization but with a few foci of duct formation. The neoplasm was connected to and was continuous with the epidermis suggesting that it represents an undifferentiated squamous cell carcinoma (). However, due to the presence of ducts, eccrine carcinoma was considered as a potential diagnosis. Three months after resection, the patient presented with a 3 cm ulcerated nodule at the site of the prior excision (). The lesion had rapidly recurred within the incision line one month after surgery, causing pain in her jaw and neck. MMS was performed again with negative microscopic margins after four stages resulting in a 4.0 × 4.0 cm defect. The patient was then evaluated with a contrast neck CT for metastatic disease by otolaryngology, which revealed metastases to several lymph nodes and to the parotid gland. The patient underwent a left total parotidectomy, left radical neck dissection, and left anterolateral free flap reconstruction of the parotid defect. Examination of the tissue biopsy from the metastatic lesion revealed tumor cells with clear cytoplasm with morphology and immunophenotype consistent with sebaceous carcinoma (). The tumors cells were positive for p63 and focal CD10, negative for renal cell carcinoma markers RCC and PAX-8, and negative for myoepithelial marker calponin, melanoma markers S100 and HMB-45, and D2-40. The patient underwent radiotherapy but passed away from complications of the metastatic disease three months later. |
This is a case of a 25 years old Malay girl with learning disability and no significant past medical history, who started noticing a sacral mass since August 2015. The mass was painless and gradually increasing in size. The family members of this patient brought her to a traditional healer. They did not seek any medical treatment until late 2017. By this time, the mass over the sacrum was extremely large. Family members claimed the mass was preventing the patient from lying down flat supine. The patient was also unable to ambulate for the past 2 years. Hence, she was bedbound most of the time. It was difficult for her to sit on the wheelchair. She also felt tired to move because the mass was quite heavy. The family members claimed when the patient was lying down flat, she had to flex her hips and knees to achieve a more comfortable position. In addition, she often slept either in prone position or in supine with multiple pillows below her body. The mother also claimed over the last 2 months, the patient’s body had been getting thinner despite her physical weight was increasing due to the increase in size of the sacral mass. The patient had been passing stool and urine in pampers. There was no past medical history and no family history of cancer. Socially, the patient lived with her mother and siblings. The mother was the main care taker. Her father passed away 10 years ago because of heart attack. The patient previously attended a special needs school, but she stopped going to school since 2015 after developing the sacral mass.\nThis patient was managed in the Southern Region referral centre for Orthopaedic Oncology in Malaysia. On clinical examination in the Orthopaedic Oncology ward, the patient appeared cachexic, she had slightly pale conjunctiva, but she was not dysmorphic. Vital signs were Blood Pressure 142/90, Pulse Rate 98 beats per minute and Temperature 37 degrees Celsius. There was a large mass 40 cm × 30 cm × 20 cm over the sacrum. The mass was firm to hard in consistency and involved both buttocks and the gluteal fold (Fig. ). Dilated veins were noted under the skin overlying the sacral mass. Neurological exam of bilateral lower limb was normal. However, there was generalized wasting of all muscles over the bilateral lower limb. Anal tone was intact.\nLaboratory investigations taken were unremarkable. Computed Tomography of the Pelvis showed a large destructive sacrococcygeal mass measuring 43 cm × 38 cm × 27 cm with extension into the presacral space resulting in anterior displacement of the rectum, urinary bladder and uterus and posterior extension into the dorsal soft tissue with involvement of the gluteus, piriformis, and left erector spinae muscles (Figs. and ). Superior margin of the sacral bone involvement was up to S2. The mass was predominantly of fluid density with internal enhancing septation and calcifications which suggested primary chordoma more likely (Figs. and ). Magnetic Resonance Imaging done showed similar findings. Skeletal Survey Radiograph did not show any distant metastasis. A Trucut biopsy of the mass was done. Histopathological analysis showed tumour cells with “physaliphorous cells” positive for pancytokeratin, EMA, Vimentin and S-100 immunohistochemistry stainings with minimal mitotic figures and mild nuclear pleomorphism (Fig. ). Brachyury immunohistochemistry staining was not available in our centre. However, the clinical history, morphology of tumour on microscopy and immunohistochemistry staining available were consistent sacral chordoma.\nThe diagnosis of Sacral Chordoma was confirmed. Multidisciplinary team discussion done among Orthopaedic Oncology, General Surgery, Obstetrics and Gynaecology, Blood Bank, Anaesthetic and Plastic Surgery teams. A family conference was done. The family’s aim was for removal of the sacral mass to allow the patient lie supine on bed and sit on the wheelchair.\nSubsequently, the patient undergone Wide Resection and En Bloc Sacrectomy. The Posterior-Only Approach was used with a “Mercedes Star” 3 limbed incision. Duration of surgery was 8 h. The patient was supported with blood products transfusion during surgery. Intraoperatively, the sacral tumour had eroded the sacral bone from S2 to S5 (Figs. , and ). Sacrectomy was done at the level of S2. Sacral nerve roots S2-S5 were all infiltrated by the mass and therefore were unable to be preserved. The mass and surrounding gluteal muscles invaded by the tumour were also all resected. All resection margins were less than 1 mm from the tumour. Primary closure was done without any distant or local flap as per consultation with Plastic Surgery team. The tumour weight was 25 kg (Figs. , and ). Post operatively, the patient was monitored in Intensive Care Unit for 3 days. The patient developed neurogenic bowel and bladder post sacrectomy requiring enema and long-term urinary catheter. In addition, the post-operative course was complicated by wound breakdown and surgical site infection requiring wound debridement. Dressing was done as per local protocol until wound bed granulating well. Split Skin Graft was done about 3 months post wide resection once the tissue culture results were free of significant infection.\nThe patient also required extensive rehabilitation for transfer, ambulation and bowel and bladder care. Rehabilitation was difficult because the patient had learning disability and she had been habitually keeping her hips and knees flexed because of the sacral tumour for the past 2 years. During the last review 5 months post operatively, patient was able to sit on the wheelchair comfortably. The surgical wound was healing well with good uptake of the Split Skin Graft (Fig. ). |
A 40-year-old female patient was referred to the department of conservative dentistry and endodontics of Dr. Z. A Dental college, A.M.U Aligarh, India, with a chief complaint of severe pain associated with the left mandibular first molar and numbness in the left lower lip and chin. The patient reported that approximately 1 week earlier she had endodontic treatment initiated by a general dentist in her left mandibular first molar which had a carious exposure. On the next day after the initiation of endodontic treatment she developed severe pain in the left mandibular first molar and numbness in the left lower lip and chin. On reporting this to her dentist she was prescribed a combination of ofloxacin 200 mg and ornidazole 500 mg every 12 hours and aceclofenac potassium 100 mg and paracetamol 500 mg every 12 hours. The prescribed medication gave her relief from pain but no improvement in the feeling of numbness occurred and therefore her dentist made the referral.\nOn examination with a dental probe, the area of numbness was found, extending from the mandibular midline to the left second premolar both intraorally and extraorally (). There was no deviation in sensory response of gingiva and tongue on probing. The left mandibular first molar showed unremoved proximal carious lesion (DO) and a temporary restoration placed in the access cavity with the tooth in occlusion. Intra-oral periapical radiograph revealed apical periodontal ligament widening in relation to both mesial and distal roots and slight apical root resorption in distal root (). After complete evaluation, diagnosis of acute apical periodontitis with mental nerve paresthesia was established and with the written informed consent of the patient it was decided to carry on the endodontic treatment along with the conservative management of paresthesia.\nLocal anesthesia was administered in the form of inferior alveolar nerve block and the involved tooth was isolated with a rubber dam. The temporary restoration was removed and the access cavity was prepared in a normal fashion. There was no active discharge from the canals. The canals were irrigated with 3% sodium hypochlorite (NaOCl) solution, and the instrumentation was done with stainless steel k-files (Dentsply-Maillefer, Ballaigues, Switzerland) and hand ProTaper files (Dentsply-Maillefer). The working lengths were established with an apex locator (Raypex-5, VDW, Munich, Germany) and confirmed radiographically (). The mesiobuccal and mesiolingual canals were prepared to an apical preparation size of F1 ProTaper whereas the distal canal was prepared to an apical preparation size of F2 ProTaper. The canals were then dried with sterile absorbent points, calcium hydroxide was placed as an intracanal medicament and the tooth was restored temporarily with a zinc oxide eugenol based intermediate restoration. The patient was prescribed with dexamethasone 0.5 mg every 12 hours for three days and was also prescribed with an oral methylcobalamin supplement (1,500 mcg once daily) owing to its role in enhancing proper neuronal functioning.\nThe patient was recalled after one week. Although the tooth had become asymptomatic, the feeling of numbness was still there. No intervention was done at this appointment and the patient was asked to continue methylcobalamin supplement and report after three weeks. The patient reported after three weeks with remarkable improvement in the feeling of paresthesia. The area of numbness was now reduced and was confined to the left lower lip region (). The tooth was not tender on percussion or palpation but the obturation was still deferred to wait for the paresthesia to reduce further or to disappear completely. Two weeks later (i.e. 6 weeks after the initial visit) the paresthesia had mostly disappeared except for a small patch inside the left lower lip (). The tooth was completely asymptomatic and therefore obturation was performed at this visit with laterally condensed gutta-percha and a zinc oxide eugenol based sealer (). The patient was seen again at 10 weeks from the initial visit as the symptoms of paresthesia had then subsided completely, and the patient was scheduled for restoration of the tooth. The tooth was restored with porcelain fused to metal full crown (). The tooth stays in function 1 year post-operatively with the area of paresthesia returned to normal sensation (). |
A 44-year old male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.\nA multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.\nAfter induction of anaesthesia, arterial lines were placed in the left radial and left femoral artery. A right infraclavicular incision and a right groin incision was made this was to establish peripheral arterial cannulation access to the right axillary and right femoral artery. An 8 mm dacron graft was anastomosed to each vessel for indirect cannulation. Median sternotomy was performed to access the mediastinum and expose the heart and aorta. Following heparinisation cardiopulmonary bypass (CPB) was established with venous return from bi-caval cannulation. The body temperature was cooled to 25 degrees Celsius. The right superior pulmonary vein was used for venting. Once the cross clamp was applied, complete cardiac arrest was achieved using Custodiol 25 ml/kg crystalloid cardioplegia via a retrograde cannula through the coronary sinus. A further top up of cardioplegia was given once the aorta was opened through direct cannulation of the coronary ostia.\nThe aortic root, valve and ascending aorta were excised. The coronary ostia were fashioned as buttons from the native aortic root. The coronary ostia were noted to be significantly displaced, with distorted anatomy due to the patient’s disease process. Therefore, 8 mm dacron grafts were attached end-to-end to each ostia, with view to performing the modified Cabrol technique later following replacement of the root. The heart was then retracted in a cephalad position to access the posterior pericardium. A vertical incision was made to expose the descending thoracic aorta (DTA). An end to side anastomosis was formed with a 20 mm dacron graft to the DTA (Fig. ). This graft was then routed posterior to the inferior vena cava (IVC) and anterior to the right inferior pulmonary vein (RIPV), adjacent to the right atrium (RA). Root replacement was then performed with a 25 mm biological valved-conduit, as this was favoured by the patient over a mechanical prosthesis, despite the risk of a difficult redo procedure in the future. The 8 mm dacron grafts attached to the coronary ostia were anastmosed to the root conduit as neo coronary ostia. The distal part of the valved-conduit was anastomosed to the proximal arch under selective antegrade cerebral perfusion (SACP). Finally, an end to side anastomosis was fashioned between the 20 mm extra-cardiac graft (attached to the descending thoracic aorta) and the ascending portion of the valved-conduit. Valve-sparing root replacement was not considered in this patient due to the grossly abnormal aortic anatomy.\nFollowing rewarming and deairing the patient was successfully weaned off CPB. The bypass time was 160 min, the cross-clamp time was 120 min, and the SACP time was 40 min. Haemostasis was achieved and thereafter a routine closure of all incision sites. The patient remained in ICU for less than 48 h, and made excellent progress on the ward. Minimal anti-hypertensives were required and the patient was discharged on 8th day post operatively neurologically intact and independent. At 3 months follow up the patient underwent a repeat CTA scan which showed complete patency in the extra-anatomical graft and resolution of the collateral arterial network (Fig. ). |
A 12-year-old Hindu boy studying in the sixth standard was brought by his mother to the child guidance clinic of our hospital with chief complaints of getting angry easily, irritability, conduct issues in school like getting into fights and back answering the teachers, decreased academic performance over the last 2 years and aggressive behavior at home toward the younger sister who was 8 years old. The boy was apparently alright until 2 years ago when he developed a friendship with a group of boys in school who exhibited mischief, truancy, and bad behavior. Gradually, he developed these behavior resulting in getting punished and having multiple negative remarks in his school calendar. He had physical fights with other students in school and had even injured other students such that they had bleeding after the injury. The school decided that his aggression was excessive and advised him to visit a psychiatrist for an evaluation. He was reluctant to come and was brought forcibly by his mother for a consultation.\nOn detailed assessment, the boy had a normal birth and developmental history. He had a history suggestive of attention deficit hyperactivity disorder in childhood (up to the age of 8 years) which subsided as they had enrolled him into sports like football and he also underwent regular occupational therapy sessions. There was no history suggestive of any other psychiatric disorders in the child or that of epilepsy or head injury. The parents were well adjusted, and the family too did not have any interpersonal problems. The child admitted that he got aggressive and that though he would regret it later, it was difficult for him to control his aggression whenever it happened. The mother was psychoeducated about the problem and was suggested certain behavior therapy techniques like positive and negative reinforcement that would work overtime. She was educated about medical intervention for anger and conduct problems and agreed to the same. She was told to ensure regular follow-up when on the medication. The child was started on Risperidone 0.5 mg half a tablet t.i.d. (total dose 0.75 mg per day). The dose would later be increased week by week after evaluation. Within a week of starting the medication at 0.75 mg per day, the mother complained that her child starting passing urine in bed at night during his sleep. The mother ensured that the child went to the toilet before sleeping and was alarmed he never had enuresis in the past, and this was the first time ever that such symptoms appeared. She claimed that the enuresis had started within 2 days of starting Risperidone. We stopped Risperidone and decided to withhold medications for a week. Within 2 days of stopping Risperidone, the enuresis stopped. We started Risperidone in the same dose after a week of no enuresis and the very same night; the child had enuresis. Risperidone was then replaced with aripiprazole 5 mg per day, and the child is doing fine till date. |
A 29-year-old gentleman complained of swelling and progressive pain in his left big toe after falling foot first into a drain. From his description of the fall, it seemed like the big toe suffered from an axial loading and hyperdorsiflexion injury. He visited the emergency department of another institution where he was given symptomatic treatment and had dorsoposterior (DP) and oblique radiographs of the left great toe performed (). He was told that the radiographs did not reveal any acute fracture and was advised to rest and to attend at the Orthopaedic Surgery Specialist Outpatient Clinic 2 weeks later. The patient felt symptomatically better after a few days and had returned to running and playing field hockey. Three weeks from the initial injury, there was recurrence of pain and swelling in the left great toe and this was limiting the function of the patient. This prompted him to seek attention at our Specialist Outpatient Clinic.\nOn examination, the affected big toe was shortened and dorsally dislocated as compared with the contralateral side. There was tenderness and swelling at the IP joint. While walking, the plantar side of the great toe did not touch the floor. There was lack of active movement of the affected IP joint. The IP joint could not be maneuvered passively too. Normal motion was maintained over the left metatarsophalangeal joint. Plain radiography was repeated and showed obliquity of the IP joint line with an interposed sesamoid bone (). Dislocation of the IP joint of the left big toe was suspected based on the clinical presentation as well as subtle features appreciable on the radiographs as discussed with our radiologists. Manual reduction was attempted but was unsuccessful. In spite of advice for surgical reduction, patient was not keen initially as the prescribed analgesics were efficacious in treating the pain and patient was still able to walk and jog without severe symptoms. However, the patient returned 1 week later (4 weeks from initial injury), this time keen for surgical intervention due to persistent swelling and stiffness.\nThe risks and benefits of surgical intervention were discussed with the patient and informed consent was taken. The patient underwent open exploration, resection of interposed sesamoid, and Kirschner-wire fixation of the left great toe IP joint under general anaesthesia uneventfully as an ambulatory patient.\nThe left great toe IP joint was approached with a midline dorsal incision and split of the extensor expansion. Intraoperative radiographs confirmed the diagnosis of a dorsal dislocation of the IP joint with an interposed sesamoid (). The interposed sesamoid was found in the IP joint space and resected (). The IP joint was then ranged to be free from any mechanical block. However, spontaneous reduction of the IP joint was not possible likely due to soft tissue contractures owing to the subacute presentation. Decision was made for temporary fixation of the IP joint by Kirschner-wires. A 2.5 mm Kirschner-wire was driven percutaneously to hold the IP joint in its native reduction. An image-intensifier was used to confirm that the IP joint was in good alignment and reduction. The extensor expansion was repaired and layered closure performed.\nThe patient was followed up at the Specialist Outpatient Clinic at 2 weeks, 4 weeks, and 6 weeks postoperatively with serial radiographs to ensure enlocation of the left great toe IP joint and to monitor surgical complications. The patient remained well and radiographs showed an enlocated IP joint (). The Kirschner-wire was removed in the clinic at 6 weeks postoperatively. The patient was then prescribed with occupational therapy to improve the expected residual stiffness. Subsequently, the patient was seen at 3 months and 6 months postoperatively. He had returned to sports and was symptom-free at the last consult. |
A 93-year-old woman presented to the emergency room with complaints of inability to pass urine over the course of one day. The patient was a weak debilitated woman, residing in an assisted living facility with a Karnofsky Performance Index of 40 (disabled, requires special care and help). Her past medical history was significant for chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and atrial fibrillation needing oral Coumadin. On examination in the emergency room, the patient's vital signs were within normal limits, and the only history provided was the patient had not passed urine for a day by the patient's care provider. Clinical examination was positive for a mass palpable in the abdomen which was globular and firm in consistency. A routine set of blood work at the time was remarkable for anemia with a hemoglobin of 6 g/dL and an elevated INR to 4.5. A computed tomography scan of the abdomen and the pelvis at the time of admission with intravenous contrast revealed a large grade 3 RSH extending into the pelvis and causing compressive symptoms over the bladder outlet (Figures , ). There was no evidence of contrast extravasation in the hematoma. The patient was immediately transfused packed red blood cells to maintain a hemoglobin of more than 8 g/dL. Coumadin was held and INR reversed with the help of fresh frozen plasma and vitamin K. The patient had a Foley catheter placed to relieve bladder outlet obstruction. Over the subsequent day, the patient continued to have stable hemoglobin and make urine. In view of the patient’s poor performance index and high risk for surgery, a 14 French catheter was placed in the hematoma. Over the subsequent days, clinical examination revealed a reduction in the size of the abdominal hematoma and the Foley catheter was removed on four days post procedure. The patient was able to void independently. The catheter was removed and the woman was discharged from the hospital. At the two-week period, she continued to have a swelling which was smaller in size, however, she remained asymptomatic from it. |
A 32-year old male patient visited our institution with the chief complaint of pain in the right hip and the lower back which started after he had experienced a minor traffic accident ten months prior to his visit. The pain became severe when he bent his waist, and an paresthesia was found with a numbness going to the tip of the right middle toe. The physical examination showed a positive finding in the straight leg raising test (20 degree/60 degree). The lumbosacral plain film showed that the disc space between L4 and L5 was narrow. The patient had no particular history. The patient's pain was not relieved but continued even after a caudal epidural steroid injection as well as after interlaminar epidural steroid injections given at one week intervals. Because the magnetic resonance imaging (MRI) showed a central herniated lumbar disc between L4 and L5 and compression of the right L5 nerve root, we decided to perform ELND.\nThe patient was hospitalized one day before the operation, and provided written informed consent. He started fasting eight hours before the operation and showed nothing unusual in the preoperative blood test. On the day of the operation, cefazolin 1 g was intravenously injected one hour before the beginning of the operation for the purpose of preventing an operation related infection. The patient was put into the prone position on the surgical table after arriving at the operating room. The position was adjusted with a Wilson frame and a pillow at the abdomen so that lumbar flexion could be unfolded and the upper body could be a little bit higher than the lower body. Afterwards, a wide area around the sacral hiatus was disinfected with aseptic technique. Local anesthesia was performed in the region to be operated on with 1% mepivacaine. Under direct fluoroscopy guidance, an 18 G Tuohy epidural needle was inserted into the sacral hiatus through the epidural space, and a 0.8 mm guide wire was inserted through the Tuohy needle. Keeping the guide wire in position, the Tuohy needle was carefully removed. In the process of making a small incision on the skin with a No. 11 blade and inserting a dilator through the guide wire, an unexpected resistance was found with the access. Despite repeated attempts carried out several times, the insertion to the sacral canal failed. We stopped the operation temporarily and reviewed the lumbosacral MRI sagittal plane image. It was found in the image that the conjugate diameter of the top 1/3 of the S4 spinal canal was 3.40 mm, which was smaller than the 3.96 mm outer diameter of the dilator for the epiduroscopy introducer set used in the operation (4007 Epiduroscopy introducer set, Myelotec, USA), and smaller than the 3.89 mm outer diameter of the introducer sheath (). Therefore, we decided to perform a S4 laminotomy at the entrance of the narrowed sacral canal with a hiatus rasp () designed to widen the canal opening. After making an incision of about 2 cm on the skin and on the sacrococcygeal ligament, the rasp was inserted into the narrowed region expanding the narrow sacral canal space by applying repeated rotational force (). Then, the dilator was normally inserted, and the channel and the space leading to the epidural space were widened, and the procedure could be stably completed. The patient's symptoms improved, and he was discharged two days after the operation. |
A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and placement of compression sutures at the site of detachment helped ensure hemostasis. Her recovery and postpartum course were otherwise unremarkable, and she was discharged on postoperative day #3. The patient was examined at a six-week postpartum visit. No cervix was seen on speculum exam and on digital exam the cervix was flush with the vaginal vault. The pathology report for the detached cervix showed diffuse hemorrhage and vascular congestion; there was no pathologic evidence of placental abruption. |
A 52-year-old woman visited the department of orthopedic surgery due to the pain in her left hip for 3 months. She was a housewife who had never smoked, and she had been taking a medicine for hypertension. She had no recent trauma. A fracture of left femoral head and the enlarged right inguinal and the left iliac lymph nodes were found on the hip magnetic resonance imaging. She was referred to pulmonology department because her chest X-ray showed multiple bilateral lung masses (). The only respiratory symptom was mild dry cough. We found a lung mass that surrounds the left lower lobar bronchus, multiple peripheral lung masses, and the lymph node enlargements of the mediastinal areas from the chest computed tomography (). On both sides of her lower neck, multiple lymph nodes were palpable. The routine laboratory findings were not remarkable.\nShe had a history of total hysterectomy for uterine MMMT () one and a half years ago. Multiple pelvic lymph node enlargements were found 6 months later and a recurrence of MMMT was confirmed by surgical biopsy. At that time, there was no small cell carcinoma component in uterine cancer pathologically. No further treatment for MMMT was given to her. Based on her past history, we initially suspected lung and femur metastases of MMMT. The protruding mass lesion on the orifice of the left lower lobe basal segment was found and biopsied by the bronchoscopy. However, the pathologic features of this mass was the typical small cell lung carcinoma () rather than metastatic MMMT from uterus. We assumed that all of these findings are attributable to small cell lung cancer, and we started the treatment accordingly. She was treated with etoposide plus cisplatin. Radiation was delivered to her femur for palliation of pain. After 2 cycles of chemotherapy, most lesions that were located relatively central (mediastinal lymph nodes and the mass around the left lower lobar bronchus) slightly decreased, but the most of peripheral masses increased (). In the meantime, she had to undergo hemiarthroplasty of the left hip due to persistent pain. The pathologic finding of femur head was consistent with metastatic adenocarcinoma (). It was possible that the metastases of carcinomatous component of MMMT probably appeared in the femur. After these observations, we had the percutaneous needle biopsy for the peripheral lung mass on the left lower lobe which showed rapid growing even after chemotherapy because we suspected the possible presences of both primary and metastatic lung cancers. The pathology revealed the metastasis of sarcomatous component of MMMT (). This finding was coincident with the pathology of uterine cancer.\nAs the metastases to lung from MMMT progressed\nrapidly, her performance status was getting worse. She\nsuffered from anorexia, asthenia, and dyspnea. Eventually,\nmassive left pleural effusion developed. Cancer\nantigen 125 (CA-125) level of pleural effusion was 149.9\nU/mL (~35 U/mL). Tumor thrombi occluded the inferior\nvena cava and the external iliac vein. Salvage chemotherapy\nfor MMMT with ifosfamide and cisplatin was\ndone, but it was not efficacious. Unfortunately, she deceased\nbecause of acute renal and respiratory failure. |
An 8-year-old male child reported to the Pedodontics Out-patient Department at Center for Dental Education and Research, All India Institute of Medical Sciences with the history of trauma on the prior evening and complaint of fractured front tooth and sensitivity on eating and drinking. There was no history of pain or swelling. On clinical examination, it was found that the patient had a traumatic injury in relation to the right maxillary lateral incisor (tooth # 12) with an extensive fracture involving the entire crown (Ellis Class III fracture). The pulp was exposed and there was extensive loss of tooth structure with only about 3 mm of crown remaining []. There was no other evidence of injury to the periodontal ligament or alveolar bone. The tooth exhibited normal physiologic mobility. The pulpal exposure was more than 2 mm in diameter. The intraoral periapical radiograph revealed an immature root with blunderbuss apex []. The parents were explained the consequences of tooth extraction. The parents were very apprehensive about tooth extraction at an early age so it was decided to avoid tooth extraction and maintain pulp vitality by performing laser pulpotomy followed by prosthetic rehabilitation after completion of root formation. After an informed consent, it was decided to use a diode laser (940 nm, Ezlase, Biolase Technology Inc. USA) for the pulpal amputation. After administering local anesthesia, access cavity was prepared on tooth #12 using outward brush strokes of the bur to avoid further pulpal damage by laceration. A 400 nm focused tip was used after activation in pulsed mode at 2.0 W. Pulse length and pulse interval were set for 0.50 μs. The procedure was performed under standard aseptic conditions and recommended laser protection methods. The tip was moved in a contact mode just around the periphery of the exposed pulp so as to remove the coronal pulp without any damage to the underlying radicular pulp. Multiple applications of the laser energy were administered to ablate the pulp and achieve hemostasis. A sterile hemostatic pulp cap [] was created using the diode laser, which was then covered by nano-ionomer cement (N-100, 3M) []. Patient was recalled again after 24 h, 72 h and 1 week. Patient remained asymptomatic during this period. There were no adverse clinical signs or symptoms of sensitivity, pain or swelling. Thereafter, the patient was recalled after 1 month, 3 months, 6 months and 10 months and radiographs were taken at each follow-up visit []. There were no radiographic signs of internal or external resorption, abnormal canal calcification or periapical radiolucency post-operatively. The radiographs showed continued root development with complete apical closure at 10 months. The tooth showed a normal response to electric pulp testing. After root completion, conventional root canal treatment was performed under local anesthetic and obturation with Gutta-percha followed by fiber post placement and ceramic crown. |
A diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () with the absence of the right hepatic duct and an intrahepatic variation with insertion of the right inferior sectorial duct into the left common duct () as type A3 of Huang Classification []. |
A 72-year-old man was referred to our hospital due to unstable angina and dyspnea. The symptoms initiated a few hours before, and his medical background consisted of hypertension. The clinical examination revealed significant edema of both lower extremities, and there were no specific abnormalities at the electrocardiogram. The heart echo showed normal systole of the left ventricle with ejection fraction 65%, no pathological findings as regards the function of the heart valves, and increased pulmonary artery systolic pressure (PASP) which was estimated 55 mmHg while the volume of the right ventricle was 105 ml. As the angina persisted, the patient was submitted to a coronary angiography. The examination revealed a fistula between the left anterior descending artery (LAD) and pulmonary artery (PA) and in proximity to this a distal severe stenosis of the LAD (approximately 80%) (). Moreover, a significant stenosis (70%) at the ostium of obtuse marginal artery (OM) was detected.\nA coronary CT angiography was performed in order to verify this finding and to obtain more specific information (). At this point, it should be mentioned that the options examined were two, the surgical approach and the percutaneous transcatheter intervention. The percutaneous intervention could be performed with the deployment of a large stent on the LAD in order to treat the stenotic lesion and at the same time cover the fistula's ostium, as reported in the literature [], or the placement of vascular plug. After assessment of this information and shared decision-making of the heart team of our hospital, a surgical intervention was decided in the thought that multiple vessels had to be revascularized, acute events during the percutaneous intervention were possible, and a permanent solution would be the best option as the patient's physical status permitted an open surgery.\nThe patient was submitted to a typical median sternotomy with aortic and atrial cannulation. After harvesting the grafts (left internal mammary (LIMA) and saphenous vein (SVG)), we proceeded with pump procedure. The fistula between the LAD and PA approximately 5 cm was identified, and we meticulously investigated the operative field in order to exclude the case of existence of more fistulas (). This fistula was the only one and was ligated from both sides. After the completion of the ligation of the fistula, the coronary artery bypass grafting (CABG) was performed (LIMA to LAD and SVG to OM1).\nThe patient was hospitalized for 6 days with an uneventful postoperative rehabilitation and was discharged on the 7th day. Before discharge, a heart echo showed satisfying function of the left ventricle (ejection fraction 65%), PASP was estimated 35 mmHg, and the volume of the right ventricle was 85 ml. In the follow-up examination after 3 months, the PASP estimation was 30 mmHg while the other parameters remained unchanged. |
This paper reports a case of a 16-year-old Caucasian boy with a unilateral cleft lip and palate seen in the Maxillofacial Department at Great Ormond Street Hospital (London) for closure of his wide alveolar cleft. He had undergone repair of his cleft lip and of his cleft palate at the age of 6 and 14 months respectively and his medical history was unremarkable and he was born following full term pregnancy and a normal delivery.\nAt the age of 8 year deciduous teeth were extracted under a short general anesthetic. Both right and left maxillary canines were present in the arch as he had extensive orthodontic treatment in the past to allow eruption. Radiographs showed absence of the maxillary right central and lateral incisors, which had been extracted due to increased mobility (grade III) following infection.\nThe maxilla was composed of a lesser (right) and a larger (left) segment with a wide maxillary cleft [Figure and ]. As the right canine was not fully erupted, a total space of 15 mm was measured from mesial surface of the upper right first premolar to mesial of upper left central incisor. The former segment had undergone orthodontic expansion in 2005 in order to move to a more buccal position. An oro-nasal fistula was present.\nA secondary alveolar bone grafting procedure was initially declined due to the cleft size and a decision was taken for pre-grafting orthodontics and a segmental distraction approach in order to mobilize the lesser maxillary segment anteriorly to minimize the gap. One year of orthodontic treatment did achieve alignment of the maxillary teeth [Figure and ] and most importantly a 3 mm initial space between the 1st molar and the 2nd premolar in order to minimize risk of dental root injury during the surgery.\nUnder general anesthesia the right maxillary alveolar bony segment was exposed by a high maxillary sulcus incision, while the attached gingiva covering the crest of the ridge from the maxillary right 1st molar up to the right canine were not reflected. The palatal attached mucoperiosteum was minimally reflected in the area of the papilla between the 2nd premolar and 1st molar, enough to provide access for an osteotome. The aim of this study is to maintain the adequate blood supply to the osteotomized segment.\nIn order to mobilize the lesser segment a segmental osteotomy and a vertical extension were done with a saw under copious irrigation. The horizontal osteotomy was extending from the cleft site up to the 1st molar area aiming to avoid the roots of the teeth. This cut was done with an inclination of the saw of approximately 45° with the bevel facing the maxillary sinus in order to facilitate the sliding of the alveolar segment during the horizontal/rotational move at the distraction phase. The corticotomy through the buccal and palatal cortical plates was done with a fine fissure bur under copious irrigation between the 1st molar and 2nd premolar teeth aiming to avoid direct injury to the roots of the teeth and also any injury to the palatal mucosa. The segment was completely mobilised by using osteotomes in order to finish the cuts in the vertical segment both buccaly and palatally. Following completion of the osteotomies the distractor was cemented on the teeth and freedom of movement was tested. Patient went home on the next day on oral antibiotics and the overall healing phase was uneventful. No soft or hard tissue complications were noticed.\nFollowing a latency period of 4 days the distraction process was initiated at a rate of 1 mm a day (0.5 mm twice a day) for 7 days, followed by a consolidation period of 12 weeks. The outcome of the distraction was monitored closely with follow-ups every 2 weeks and no complications were noted. Oral photographs taken at the 3rd and 7th day of the distraction stage clearly demonstrate the expansion of the alveolar segment between the 1st molar and 2nd premolar []. The distance from mesial surface of upper right canine to the left central incisor was now reduced to 4 mm.\nHealing was uneventful during the immediate postoperative, distraction and consolidation stages. Clinical assessment revealed new bone and soft-tissue formation 8 weeks after completion of the distraction phase []. This was confirmed by ultrasonography []. After 2 months, the distractor was finally removed.\nOverall there was new bone and attached gingival formation in the right maxillary segment of 7 mm (overall distance between mesial root first molar up to root of premolar is 10 mm, but 3 mm distance was created with pre-distraction orthodontics). The width of the cleft was now minimized (4 mm) and was closed with a secondary alveolar bone graft with iliac crest cancellous bone. Healing was uneventful with no fistula present.\nFinally, orthodontic tooth movement (right canine) in the grafted cleft and restorative adjustment of the canine to make a lateral incisor, were scheduled for eliminating the dental space. Dental implants into the newly formed alveolar bone (right maxilla) can replace the posterior missing teeth in the future. |
The first patient was a man aged 25 years who has a history of RRP since he was 6 months old. Patients' first visit was complaints of shortness of breath. The complaint was preceded by a hoarse voice since 5 months ago. Endoscopic examination of the larynx showed a mass of laryngeal papillomas that filled the larynx so that the airway became narrow. Patients diagnosed with pediatric laryngeal papilloma type and upper airway obstruction. Patients undergo tracheotomy and proceed with microscopic laryngeal surgery to clear the papilloma mass.\nPatients undergo papilloma cleansing surgery every 2 to 4 months. The patients who live outside the city and far from the health center that capable of performing laryngeal surgery cause patients to repeatedly experience upper airway obstruction so that they undergo a repeated tracheotomy. It was obtained a history by one of the patient that has undergone tracheotomy 4 times due to repeated upper airway obstruction. Until the age of 25 years, patients have undergone surgery 88 times already. The frequency of surgery does not decrease even though the patient has reached adulthood. Papilloma of the trachea began to spread to the bronchi since the age of 12 years so that the tracheocele was maintained from 1992 until now.\nRepeated surgery causes stenosis in the larynx () so that the tracheocele is maintained. Another benefit of maintaining tracheoculosis is that it facilitates bronchoscopy when cleaning papillomas in the trachea-bronchi. A final endoscopic examination shows papilloma implantation in the trachea to the proximal right main bronchi (). HPV virus examination by the PCR method showed that the presence of HPV type 11 infection in patients with papilloma preparations ().\nHistopathological examination of papilloma tissue was revealed the squamous epithelium coated with papilloma with moderate dysplasia and epithelium that appeared to be koilocytosis (). CT-scan of the cervical-thoracic thoracic () shows laryngeal narrowing due to papilloma mass and in the thorax papilloma growths are found in the trachea to the carina and nodules are found in the right lung parenchyma. |
A 33-year-old pregnant woman had been transferred to our outpatient clinic with the concern for preterm labor at 23 weeks gestation but was ultimately sent home. After a triplet pregnancy achieved through an in vitro fertilization embryo transfer in a private clinic, the patient underwent a McDonald operation at 16 weeks gestation due to the risk of preterm birth in multiple gestations. The patient then presented to the emergency department of our hospital at 30 weeks and 2 days gestation due to premature rupture of membranes. She was prepared for an urgent Caesarean section at 31 weeks and 3 days gestation due to sudden contractions. In a seated position, the patient underwent a midline approach to the L3-4 interspinous space using an 18 G Tuohy needle. Cerebrospinal fluid leaked while identifying the epidural space using the loss of resistance (LOR) technique with 2.5 mL of air. Dural puncture was suspected, and the needle was removed. As a result, the initially scheduled epidural anesthesia was changed to spinal anesthesia. Subsequently, we successfully initiated spinal anesthesia using a 26 G Quincke needle in the same location. The patient was move to a supine position after administering 10 mg of bupivacaine. The Caesarean section was initiated after confirmation of adequate anesthesia up to the fourth thoracic segment. All three babies and the placenta were delivered. All vital signs were stable before and after the anesthetic injection, and no abnormal findings were observed at the time of the procedure. The patient was advised postoperative bed rest and began early ambulation on the first postoperative day. Since the patient complained of mild tinnitus during ambulation without any other associated symptoms, closer follow-up was initiated.\nOn the second postoperative day, she complained of headache, nausea, and other symptoms, and she began complaining of a stiff neck and vomiting on the third postoperative day. These symptoms were alleviated in the supine position but recurred when the patient assumed standing or sitting positions. No other focal neurologic symptoms were identified at that time, and vital signs were stable. Despite conservative management including bed rest, the administration of fluid, analgesics and anti-nauseants, her symptoms persisted. The patient was sent to the Department of Neurology on the fourth postoperative day for suspected PDPH. She was encouraged to undergo epidural blood patch. We were initially planning to perform EBP after the confirmation of PDPH based on computed tomography (CT) scans; however, the scanning was delayed after the procedure due to limited availability. Subsequently, the patient was placed in the left lateral position, and the epidural space was identified using about 2.5 mL of air with the LOR technique at the L4-5 spinal level. No leakage of cerebrospinal fluid was detected at that time. Fifteen milliliters of the patient's own blood were injected using an aseptic technique. No specific physical findings were identified at the time of the procedure. The patient stayed on bed rest in the supine position and slept in the same posture. The CT scan taken immediately after the EBP procedure demonstrated pneumocephalus in the prepontine and premedullar cisterns (). After waking on the fifth postoperative day, the first postprocedure day following the EBP, she started to complain of an abrupt vision abnormality. Her vital signs were stable and no neurological symptoms were detected other than her visual disturbance, apart from her persistent mild headache. Visual field and fundal examinations were conducted in the Department of Ophthalmology. A right homonymous hemianopia was detected in the Humphrey visual field test (), but no abnormal findings were identified on fundal examination. Magnetic resonance imaging (MRI) was performed due to the clinical suspicion of homonymous hemianopsia, and demonstrated air bubble movement toward the left retrochiasmal visual pathways ().\nAfter pneumocephalus was identified as the cause of her visual disturbance and headache, we administered prophylactic antibiotics and highly concentrated oxygen. The patient was then placed on bed rest. Her symptoms of visual disturbance improved considerably over the course of the day, and a follow-up CT scan was performed. No further air density was observed. Although her mild headache remained, the visual disturbance completely disappeared by the end of the fifth postoperative day. The patient was discharged on the sixth postoperative day and was asymptomatic at her outpatient follow-up visit one week later. |
An otherwise healthy 32-year-old female presented to the emergency room complaining of severe left knee pain and inability to move her knee through a range of motion after twisting awkwardly on a planted left foot during a dance aerobics class. Upon arrival she was nonambulatory with physical exam findings suggestive of lateral patella dislocation. The patella was palpated laterally and the knee locked at 20 degrees of flexion, with pain at any attempt at motion of the knee. Further exam revealed no other signs of global joint or soft tissue laxity. She did not endorse any signs or symptoms of previous patellar subluxation, instability, or hypermobility. Plain radiographs were obtained in the emergency department confirming the diagnosis of a lateral patellar dislocation with a 9 mm avulsion fracture of anterior medial border of the patella (Figures and ).\nUtilizing intraarticular local anesthetic injection as well as intravenous analgesia and conscious sedation, multiple attempts at closed reduction were made in the emergency room. Maneuvers with flexion, extension, and manual manipulation of the patella were unsuccessful in reducing the patella. This was followed by the use of bone reduction forceps in a percutaneous manner under sterile conditions to attempt to more directly manipulate the patella; however this too was unsuccessful. The patient was subsequently taken to the operative room that day where a closed reduction was attempted, now with complete muscle relaxation under the control of general anesthesia, and again no successful reduction could be obtained in a closed manner. A 2 cm incision along the lateral border of the patella was made where manual exploration revealed that the patella was incarcerated in the lateral patellar retinaculum and locked against the lateral femoral condyle. Reduction of the patella was completed with minimal effort after release of the incarcerated lateral tissues. Next, the incision was closed and a diagnostic arthroscopy was performed demonstrating trauma to the lateral femoral condyle and an 11 mm free floating chondral fragment identified in the medial gutter. Inspection of the articular surface of the patella revealed a corresponding chondral defect within the medial facet, which was debrided back to stable articular cartilage. Aside from this defect, no other articular step off was identified. The patient was placed into a hinged knee brace postoperatively and allowed to be weight bearing as tolerated. At postoperative follow-up, MRI was obtained demonstrating a vertically oriented osteochondral fracture measuring 10 mm in greatest dimension with less than 2 mm chondral step off and partial tearing of the medial patellar retinaculum (). Given the vertical orientation and nondisplaced nature of the fracture observed at the time of arthroscopy, the decision was made not to apply any internal fixation to the fracture. Analysis of the patient's relevant osseous anatomy revealed a TT-TG of 12 mm. Postoperatively she progressed through rehabilitation in a stepwise manner and, at 1-year follow-up, did not have any further episodes of pain, instability, or recurrent dislocation. |
A 28-year-old homosexual male was brought to the emergency department after he was found destroying property at his home. On presentation, he was very disorganized and stated that he had blood coming from his rectum. On physical exam, no rectal bleeding was found. He appeared euphoric and stated that his mood was happy and scared. He denied any past psychiatric history and any prior use of psychiatric medications. His urine toxicology screen was positive for amphetamines. He was admitted to the acute adult inpatient psychiatric unit for observation.\nCollateral information from his mother confirmed that he had a normal development and childhood and graduated from high school. She stated that he had always identified as a homosexual male, and had never expressed feelings of being a different gender or the desire to be a woman. He did not show any signs of mental illness until 3 years prior to his hospitalization when his mother states that he fell into a depression, which was characterized by talking to himself, lack of self-care, and loss of sleep and appetite. She corroborated that the patient had never taken psychiatric medications. At this same time his mother stated that she believes he started to use alcohol and drugs heavily, although she did not know what type or how often he used them. She denied any other mental illness or substance abuse in their family. During his first day in the hospital, the patient reported that his mood was good and denied any hallucinations, paranoia, or suicidal ideation. He remained disorganized, and spent his first night in the hospital pacing the unit without sleep. He was started on risperidone 0.5 mg twice a day for psychosis and risperidone 0.5 mg as needed every 8 hours for anxiety and agitation. He was placed on precautions for possible alcohol withdrawal due to possible recent alcohol use, which was reported by his mother. On hospital day two, the patient was seen coming out of the bathroom with another male patient. At this time, he was placed on hypersexual precautions and was instructed to maintain a 10-foot distance from all other patients. That same day, the patient suggestively groped a male staff member’s hand while receiving food. He was placed on one to one supervision due to his inappropriate behaviors. During his second night in the hospital he was recorded to have slept 4.5 hours. For the rest of his stay, he slept 7-10 hours each night. Risperidone was increased gradually to 4 mg nightly for psychotic mania and valproic acid extended release 1500 mg at nighttime was started with a goal of improving impulsivity and hypersexuality. Three days following initiation, serum values of valproic acid were 75 mcg/mL, with normal complete blood count and liver function.\nModest improvement in intrusive and hypersexual behaviors allowed for the discontinuation of the one to one sitter, but continued suboptimal response led to transition from risperidone to quetiapine on hospital day eight. On the 13th day of his hospitalization, the patient voiced that he felt like he was a woman. He stated that he heard voices telling him that he was a beautiful woman, and he asked to speak with a doctor as soon as possible about getting gender reassignment surgery. He continued to voice feeling like a woman for two more days. He also began to wear bright pink lipstick and dance and sing loudly.\nOn the 15th day of his hospitalization, his symptoms of mania remained uncontrolled, valproic acid extended release was increased to 2000 mg nightly, and quetiapine was cross-titrated to perphenazine. By the 23rd day of his hospitalization, with valproic acid levels of 88 mcg/mL, he no longer had any hallucinations or paranoid ideation, was no longer hypersexual, did not have feelings of gender dysphoria, and was much improved in his ability to converse rationally. He was discharged home on valproic acid extended release 2000 mg nightly, perphenazine 6 mg twice daily, and zolpidem 5 mg for insomnia. |
A case of left parietal calvarial osteomyelitis due to actinomycosis in a 32 years old previously healthy woman is described []. She presented in the puerperal period. There was no extracranial focus. She responded well to a combination of surgery and antibiotics.\nOur case is unique for both the site of occurrence and the relapse after 11 years. In the first episode in 2010 he had osteomyelitis involvement of only the outer table of calvarium. Adequate surgical excision was done, however, he did not comply with antimicrobial therapy and lost from follow up. The second episode was in the same site which suggests that it was a relapse rather than reinfection. This time lesion penetrated the inner table with extension to epidural space. Fortunately, there was no brain parenchymal involvement. No other focus of involvement with actinomycosis infection was identified in our patient.\nIn the case series reported by Smego et al., out of 70 patient with CNS actinomycosis only one patient had relapse []. This patient had temporal lobe abscess treated with needle aspiration followed by antibiotics, duration was not specified. He had relapse of actinomycosis as multiple brain abscess after 29 months. Relapse of actinomycosis have been described in many scenarios, all due to inadequate duration of antimicrobial therapy [, , , ]. Review of the cases reported before and our case indicate that Actinomycosis of the skull is a disease of young, immunocompetent patients. The presentation is usually insidious. Intracranial extension is common with some patients presenting with neurologic deficits. Imaging especially CT scan or MRI are very valuable to identify the lesion, however culture and histopathology are necessary to confirm the diagnosis. The mainstay of management for actinomycosis is medical therapy [], with surgical drainage indicated if the collection is large or to establish a diagnosis. Penicillin is the drug of choice. Patients with actinomycosis require prolonged (6- to 12-month) antimicrobial treatment with high doses of penicillin G or amoxicillin. The duration of antimicrobial therapy could be reduced for patients in whom optimal surgical resection has been performed []. The outcome is in general favorable; however, relapse is not uncommon reflecting the need to educate patients for the need of prolonged antibiotics therapy and the importance of adherence to treatment. |
Our patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. ().\nRadiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement (). Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.\nThe patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding soft tissue. The mass was encircling the ulnar neurovascular bundle with mass abutment over the radial bundle as seen in pre-op assessment. The mass was dissected freely from its attachment to those bundles preserving both radial and ulnar structures. The mass was then excised en-bloc having a dimension of 3.5 × 4x2.5 cm (). Histological assessment showed a lesion with fasciitis like features, myofibroblastic proliferation and scattered foci of osteoid formation that was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining and no evidence of malignancy (). The resected margins were however, positive for residual lesion with difficulty in obtaining negative margins due to the extensive nature of the mass. Post-operatively, the patient had an un-eventual course. She was informed about the need for close follow-ups for both clinical and/or radiological signs of lesion recurrence, pending early surgical intervention (see ). |
The patient was a 76-year-old man who came to the office in 2014 looking for possible treatments of his fractured central incisors. Nothing was found relevant about his medical condition. The patient shows a high risk for caries and also eccentric bruxism. He has partial edentulism in the superior left quadrant and multiple decay and fractured teeth. The initial approach was conservative aiming to keep the upper front by means of composite fillings (Figures and ). Then, the posterior superior quadrants needed to be restored with implants.\nThree years after, in 2017, the patient came back to the office referring pain of endodontic origin in the upper left canine. New and secondary subgingival caries were found in the six front teeth. The conservative prognosis was considered poor due to the subgingival depth and extent of decay presented by the lesions from canine to canine. After having discussed the treatment options, especially the surgical lengthening of the front teeth or the orthodontic extrusion, the patient decides to replace the residual teeth with a new implant-supported bridge similar to the recently performed prostheses of the posterior areas that were judged by him as a highly satisfactory treatment. The patient preferred not to involve these restorations in the present anterior treatment and limited it to place only two implants in the lateral incisors' positions ().\nThe treatment was carried out in a staged approach. Briefly, first, we extracted the lateral incisors, using the SST, and placed two immediate implants. The four residual teeth were then prepared to be used as abutments of a temporary bridge for the purpose of maintaining the aesthetics and function of the patient during the early osseointegration period. In a further step, the four remaining teeth were also extracted using the SST, and the initial provisional bridge was replaced by the second provisional screwed on the uncovered implants. Only one out of the four abutment teeth used for the temporization of root canal treatment was needed due to a periapical infection.\nWhen placing the two immediate implants into the alveolus of the lateral incisors, a section of the buccal part of the root (about the two middle thirds) was left in place and no biomaterial was used at all. An impression of the implants was taken to have the second temporary bridge available in the second surgery. Healing abutments were then attached with the proper height for the soft tissue to cover them but at the same time facilitating the uncovering. Finally, a temporary acrylic bridge was cemented onto the four abutment teeth 13-11 and 21-23 ().\nThree months later, the implants were uncovered, the four abutment teeth were extracted, again with the SST—partial extraction of the roots—but this time no more implants were placed in these sockets. The first provisional cemented onto the teeth was then replaced by a second acrylic bridge screwed onto the implants though temporary abutments ().\nThe partial extraction of the canines, aiming to leave a buccal slice of the root, was so hard to perform, and further instrumentation would lead to the socket destruction that a decision was intraoperatively made and a greater portion of the root, including the apex, was finally left. As the locations of the canines did not involve the implant sites, any potential complication could be addressed efficiently.\nOne month later, the prosthodontic phase was undertaken. Little if any differences in the buccal tissue volume and no noticeable aesthetic impact could be found after the multiple extractions (). The desired position of the incisal border was determined by various try-ins, and five months after implant surgery, the definitive prosthesis was placed. The final clinical aspect can be appreciated in the pictures (Figures and ). |
A diabetic 90 years old woman with cough and diffuse abdominal pain was admitted into our hospital with an initial diagnosis of sepsis. Blood sample investigation revealed mild leucocytosis with PRC augmentation and normal AST, ALT and bilirubin levels. Preoperative ultrasound revealed thickened gallbladder wall suggestive of acute cholecystitis. She has had previous sigmoid resection for diverticulitis and ERCP for choledocholithiasis without any mention of biliary abnormality. She was scheduled for a laparoscopic cholecystectomy during which the incidental intraoperative finding of a left sided gallbladder was made. Standard trocar positions were used (A) without any variation of technique, simply following the Strasberg criteria for safe cholecystectomy []. Having seen the anatomical variation (B), a careful dissection of Calot’s triangle was carried out, the cystic duct and artery were identified and isolated, and subsequent complete dissection of the gallbladder from the liver was done (C). This manoeuvre allowed us to demonstrate a right sided positioning of the cystic duct. Furthermore, a safe clipping and transection of the cystic duct and artery was achieved (D), and the gallbladder was extracted in an endobag. The postoperative course was complicated by an aggravation of diabetes and basal pneumonia which were controlled postoperatively in the intensive unit. The patient was discharged on postoperative day 16, in good condition. Retrospective analysis of the clinical case was done and a previous CT scan was reevaluated. Even with the knowledge of a left sided gallbladder, the CT scan was unable to demonstrate its attachment to the left side of the liver. This was probably due to the presence of a hypertrophic left lobe mimicking only a contiguity with the gallbladder, which itself appeared to be in a physiological position (). A vascular and biliary reconstruction was then evaluated with evidence of agenesis of the right anterior sector of the liver () with the absence of the right hepatic duct and an intrahepatic variation with insertion of the right inferior sectorial duct into the left common duct () as type A3 of Huang Classification []. |
The case we present here is about an 18-year-old female patient who reported to the Department of Periodontology with the chief complaint of loose and extruded right upper front tooth.\nOn examination, it was noticed that the right lateral incisor had extruded and moved labially giving an unesthetic appearance. There was a deep periodontal pocket distally and the tooth showed Grade II mobility []. Intraoral periapical radiograph showed bone loss distally reaching the apical third of the root along with periapical radiolucency [].\nPeriodontal treatment for this patient consisted of thorough scaling and root planning followed by education on plaque control measures. This was followed by root canal treatment of the affected tooth to eliminate the periapical source of infection. The tooth was assessed after 6 weeks, the mobility had reduced to Grade I and the plaque control of the patient was found to be satisfactory [].\nTwo weeks after reassessment, periodontal flap surgery was performed in the maxillary right lateral incisor area to completely eliminate the deep periodontal infection. After thorough root planning and debridement, a deep defect distal to the lateral incisor was observed []. It was decided to place platelet-rich fibrin (PRF) in the defect to aid in the regeneration of bone in the area and fasten the healing process []. After placement of PRF, 3.0 silk sutures were placed and Coe pack dressing was given [Figures and ].\nAfter 8 weeks the tooth was reassessed, the probing pocket depth had reduced to 3 mm in the distal site, but there was no spontaneous closure of the anterior space. A modified crown preparation was done on the affected tooth such that the resulting crown would close the anterior space in addition to provide long-term support to root canal treated tooth.\nSix months following the treatment, the patient presented with a clinically healthy gingiva and a probing pocket depth of 3 mm []. On posttreatment evaluation of radiograph of the area, it was found that a significant bone fill had occurred in the defect distal to lateral incisor [].\nA total volume of 10 ml blood was drawn from each patient by venipuncture of the right antecubital vein. Blood was collected in sterile glass test tubes without any anticoagulants and immediately centrifuged on a table top centrifuge (Almicro™ Instruments) at 3000 rpm for 10 min. This resulted in the separation of three basic fractions because of differential densities: The bottom red blood cells (RBCs), middle PRF, and the top layer of platelet-poor plasma (PPP). PPP was aspirated and discarded and the PRF was separated from underlying RBCs by the use of sterile stainless steel scissors.\nA triple wheel depth cutter bur (834-016, SS White, Lakewood, New Jersy) was used to prepare the depth cutting gauge at the incisal aspect of the tooth. Since the tooth was tilted mesially and labially, care was taken to reduce more tooth structure at the mesial and labial aspect. A radial shoulder finishing line configuration was prepared first by flat-end tapered diamond bur and then by end–cutting parallel side carbide finishing bur. An all ceramic coronal restoration was fabricated and fixed with light curing acrylic luting cement (Rely X luting cement, 3M ESPE, Ontario, Canada). Care was taken to keep the restoration out of occlusion with the opposite tooth. |
A 62-year-old, nonsmoker woman with no significant pathological antecedents presented to our hospital for almost complete dysphagia. At the time of presentation, the patient was underweight, reporting an approximate weight loss of 15 kg during the last month. During this period, she also observed the apparition of dysphagia first for solids and later also for liquids, which worsened progressively. Biochemical tests demonstrated slow increase of cancer antigen CA 125 levels (74.2 U/mL—units per millilitre), whereas all the other tests (including tumoral markers, urinary and liver tests) were normal. The upper digestive endoscopy raised suspicion of an extrinsic compression of the medial third of the esophagus (at 26 cm from the dental arcade), which did not allow performing the maneuver with a 10 mm endoscope. The stenosis was hardly crossed by using a pediatric 5 mm endoscope, which showed the extension of the affected area on 5 cm. A gastrostomy feeding tube was placed during endoscopy. However, the esophageal lining was normal on the entire surface, again raising suspicion of extrinsic compression ().\nIn this context, an endoscopic ultrasound was attempted to retrieve a biopsy, but the maneuver was unsuccessful due to the extreme compression of the esophagus. The patient later underwent thoracic, abdominal, and pelvic computed tomography that demonstrated the presence of suspect pulmonary nodules in association with a mass compressing the esophagus and invading the pleura, the pericardium, the esophageal wall, and the aortic wall ( and ), as well as a tumoral nodule in close proximity to the uterine cervix invading the right ureter and creating an ureteral stenosis. The cardiologic evaluation demonstrated the presence of a mild pericardial effusion, with no other significant modifications of the cardiac function.\nThe imagistic studies were further completed by pelvic magnetic resonance, which raised the suspicion of peritoneal nodules at the pelvic level and confirmed the presence of the tumoral nodule in close proximity to the uterine cervix invading the right ureter and with no apparent connection to the uterine cervix ( and ). In the meantime, other few-millimeter nodules of peritoneal carcinomatosis were found in the pelvic area with no other suspect aspects. The gynecological examination confirmed the presence of a tumoral mass of 3/1.5 cm invading the right ureter, developed in close proximity to the uterine cervix but with no apparent appurtenance to the gynecological tract. No other pathological images were encountered, and the Papanicolaou test failed to demonstrate any modification.\nDue to an important ureteral stenosis being found, the patient also underwent Cook catheter placement on the right side. At the time of the catheter placement, a cisto-ureteroscopy was performed, which demonstrated an extrinsic compression of the right ureter, with the ureteral and urinary bladder mucosa being normal (, and ).\nA diagnostic laparoscopy was performed on the patient, which demonstrated the presence of a few peritoneal nodules at the level of the pelvic area, retrieved in association with the nodule invading the right ureter. However, the right ovary was also found to have a pathological aspect, so it was retrieved by performing a right adnexectomy (, and ).\nThe final histopathological studies of the specimens demonstrated the presence of a well-differentiated adenocarcinoma, with the ovarian parenchyma presenting tumoral invasion on up to 90% of the volume (a–d). The immunohistochemical studies established the final diagnostic of pulmonary adenocarcinoma (diffuse and intense positivity for cytokeratin 7 (CK7) and thyroid transcription factor-1 (TTF-1); positivity for carcinoembryonic antigen (CEA); poor positivity for estrogen receptors (ERs); negativity for GATA3 transcription factor, paired-box gene 8 (PAX8), Wilms’ tumor 1 (WT1) factor, homeobox protein (CDX2), p16-cyclin-dependent kinase inhibitor 2A, and S-100 proteins; a–f). In this context, the genital, breast, gastric, colonic, esophageal, and pancreatic malignancies were excluded, with the final aspect pulmonary adenocarcinoma. Epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed cell death ligand 1 (PD-L1) tests were performed demonstrating the presence of mutations, so the patient was later confined to the medical oncology clinic for biological treatment. |
The 72 year old male patient was referred to our clinic with the complaint of bilateral axillary masses and numbness in the right hand. In his medical history, he had hypertension for 4 years but no history of trauma. A physical examination showed the presence of palpable pulsatile masses in his both axillae (12 cm in size in the right axilla and 8 cm in size in the left axilla) (Fig. ). His neurological and systemic examinations were within normal limits. An upper-extremity ultrasound examination revealed an aneurysm in a 12-cm segment of the right axillary artery, reaching 67 × 45 mm in dimension. There was a 27-mm thick thrombus at the edge of the aneurysm lumen. Adjacent to the aneurysm, there was a 48 × 40 mm hyperechogenic mass not related to the aneurysm. There was also an aneurysm reaching 40 × 43 mm in dimension in a 9-cm segment of the left axillary artery, with a 17-mm thick thrombus. A Doppler ultrasonic examination revealed a thrombus surrounding the lumen and a turbulent, pulsatile flow in the center. The aneurysmal segment was continuous with the brachial artery. There was no blood flow in the region adjacent to the right axillary artery (Figs. and ). On CT angiography, giant fusiform aneurysms were detected, measuring 140 × 77 mm in the right axillary artery and 93 × 45 mm in the left axillary artery. There were thrombi in both aneurysms, allowing the flow in the lumen. There was also an extension to the brachial artery and contour irregularities at the distal end of the right-side aneurysm. These latter findings were proposed to be due to a spontaneously healed rupture. A physical examination of the eyes, bones, skin and joints revealed no signs of collagen tissue disease, nor was it detected through laboratory examinations. Because the patient was symptomatic and had a high risk of aneurysm rupture, endovascular closure was initially planned. However, appropriate size stents could not be found for aneurysms so large and tortuous. Besides, the long-term success of the stenting procedure could not be guaranteed due to the large sizes and high mobility of the aneurysms, so the patient was referred for surgery. |
A 29-year-old male with shunted congenital hydrocephalus of unknown etiology with previous revisions in infancy and as a young child initially presented to the neurosurgery clinic with worsening headaches and complaints of blurred vision for more than 18 months. Computerized tomography (CT) of the head demonstrated a slight increase in his ventricular size; physical evaluation noted mild chronic papilledema and reduced visual acuity in his left eye, which was baseline following a car accident a few years earlier. He had a right parietal VPS in place; shunt series X-rays showed no shunt disconnections. In addition, abdominal X-rays demonstrated a retained peritoneal distal catheter from his previous shunt revision operations. Given the concerns for shunt failure, he underwent shunt exploration and revision for management. During the shunt revision surgery, the valve was found to be nonfunctional and was replaced; the retained peritoneal distal catheter was also removed laparoscopically by the general surgery team. His initial postoperative course was uncomplicated, and he was discharged on postoperative day 1 with decrease in his headaches and improvement in his subjective complaint of blurry vision.\nHe again presented 17 months later with continual headaches, decrease in vision, and increased ventricular size. This time he was noted to have acute papilledema and worsened visual acuity in his right eye. Given the concern regarding the age of the ventricular and distal catheter in his right parietal system, which had been placed at 4 months of age, it was determined that the placement of a new shunt system would be the best clinical option. He underwent another VPS revision with placement of a new right frontal VPS shunt and a new distal peritoneal catheter placed laparoscopically by the general surgery team []. His initial postoperative course was uncomplicated, and the patient's headaches decreased, however, he did experience a lasting deficit in his visual acuity. Two months postoperatively, he presented to the emergency room with complaints of an object intermittently protruding from his rectum. At this initial emergency room evaluation, his rectal exam was unremarkable; on shunt series X-rays, the distal catheter was within the peritoneal cavity []. The patient was subsequently discharged without neurosurgical consultation.\nOne month later, he presented with continued complaints of an object intermittently protruding from his rectum. During the emergency room evaluation, a neurosurgical consultation was obtained and the rectal exam revealed that the distal peritoneal catheter was protruding through his anus. X-rays corroborated the physical exam []; CT imaging clearly revealed the distal peritoneal catheter within the large colon and rectum []. On examination, the patient had no signs of peritonitis or meningitis, and he described no abdominal pain, feeding concerns, fevers, worsening headaches, or blurry vision. |
A 56-year-old lady presented with a 6 month history of rectal bleeding, passage of mucus and a change in bowel habit to more frequent stools. She had no abdominal pains and her weight was maintained. The patient had been born with bladder exstrophy and had multiple surgeries culminating in a cystectomy with ileal conduit formation at 5 years of age. She had suffered with recurrent urinary tract infections for most of her childhood and adult life but was otherwise well with no other major co-morbidities or risk factors for colorectal malignancy and had no family history of colorectal disease.\nColonoscopy revealed two large sessile polyps in the sigmoid colon in close proximity to each other and adjacent to a diverticulum-like structure (Fig. ). Each polyp was approximately 3 cm in size and both exhibited a type IV pit pattern with areas of irregularity suggestive of focally advanced disease. Histological examination confirmed both polyps were adenomas comprising both low and high grade dysplasia, without submucosal invasion (Fig. ). On closer inspection the mucosa around the diverticulum was also atypical but not adenomatous. The remainder of the colonoscopy was unremarkable with no other evidence of diverticular disease or polyps elsewhere.\nEndoscopic resection was considered as a therapeutic option however in view of the above characteristics as well as difficult endoscopic access surgery was preferred. Furthermore, radiological imaging had initially raised the possibility of invasive disease in view of sigmoid thickening. The patient underwent high anterior resection and an open approach was chosen because of suspected intra-abdominal adhesions following extensive pelvic surgery. An end colostomy was formed at the patient’s pre-operative request. At laparotomy the right fallopian tube was adherent to the sigmoid colon and adjacent to this a blind ending tube was noted to emerge from the anti-mesenteric border of the colon. This was marked for pathological identification.\nOur patient went on to have an uneventful recovery and her quality of life following surgery was good. Her wish to have a permanent colostomy stemmed from the fact that she had always suffered from an erratic bowel habit and that she was already knowledgeable with regards to stoma care in view of her pre-existing ileal conduit. |
A 44-year old male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.\nA multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.\nAfter induction of anaesthesia, arterial lines were placed in the left radial and left femoral artery. A right infraclavicular incision and a right groin incision was made this was to establish peripheral arterial cannulation access to the right axillary and right femoral artery. An 8 mm dacron graft was anastomosed to each vessel for indirect cannulation. Median sternotomy was performed to access the mediastinum and expose the heart and aorta. Following heparinisation cardiopulmonary bypass (CPB) was established with venous return from bi-caval cannulation. The body temperature was cooled to 25 degrees Celsius. The right superior pulmonary vein was used for venting. Once the cross clamp was applied, complete cardiac arrest was achieved using Custodiol 25 ml/kg crystalloid cardioplegia via a retrograde cannula through the coronary sinus. A further top up of cardioplegia was given once the aorta was opened through direct cannulation of the coronary ostia.\nThe aortic root, valve and ascending aorta were excised. The coronary ostia were fashioned as buttons from the native aortic root. The coronary ostia were noted to be significantly displaced, with distorted anatomy due to the patient’s disease process. Therefore, 8 mm dacron grafts were attached end-to-end to each ostia, with view to performing the modified Cabrol technique later following replacement of the root. The heart was then retracted in a cephalad position to access the posterior pericardium. A vertical incision was made to expose the descending thoracic aorta (DTA). An end to side anastomosis was formed with a 20 mm dacron graft to the DTA (Fig. ). This graft was then routed posterior to the inferior vena cava (IVC) and anterior to the right inferior pulmonary vein (RIPV), adjacent to the right atrium (RA). Root replacement was then performed with a 25 mm biological valved-conduit, as this was favoured by the patient over a mechanical prosthesis, despite the risk of a difficult redo procedure in the future. The 8 mm dacron grafts attached to the coronary ostia were anastmosed to the root conduit as neo coronary ostia. The distal part of the valved-conduit was anastomosed to the proximal arch under selective antegrade cerebral perfusion (SACP). Finally, an end to side anastomosis was fashioned between the 20 mm extra-cardiac graft (attached to the descending thoracic aorta) and the ascending portion of the valved-conduit. Valve-sparing root replacement was not considered in this patient due to the grossly abnormal aortic anatomy.\nFollowing rewarming and deairing the patient was successfully weaned off CPB. The bypass time was 160 min, the cross-clamp time was 120 min, and the SACP time was 40 min. Haemostasis was achieved and thereafter a routine closure of all incision sites. The patient remained in ICU for less than 48 h, and made excellent progress on the ward. Minimal anti-hypertensives were required and the patient was discharged on 8th day post operatively neurologically intact and independent. At 3 months follow up the patient underwent a repeat CTA scan which showed complete patency in the extra-anatomical graft and resolution of the collateral arterial network (Fig. ). |
A 75-year-old man underwent tension band wiring with cerclage wiring for treatment of a transverse patellar fracture of the right knee (). At 10 weeks postoperatively, radiographs demonstrated breakage of the superior portion of the cerclage wire (). Although he was advised to have all fixation devices removed after fracture healing and continuous follow-up, the patient was lost to follow-up after a clinical examination and plain radiography at 16 weeks postoperatively because he had no symptoms such as irritation due to the wire or limitation of range of motion. At 16 weeks, the wire was still radiographically at the superior part of the right patella.\nThe patient returned to our outpatient clinic 2 years after the surgery because the wire had perforated the skin anteriorly. He did not recall any trauma to the knee since the last follow-up. Radiographs of the right knee demonstrated that the cerclage wire was broken into pieces, and a fragment had migrated into the posterior compartment (). We could not decide from plain radiographs or three-dimensional computed tomography (3D CT) whether the wire fragment was in the posterior compartment of the knee joint or the popliteal fossa (). Because there was a risk of chondral damage if it was inside the joint or neurovascular damage if it was in the popliteal fossa, the patient agreed to surgery to remove the hardware.\nA skin incision was made anteriorly over the previous incision and all the wires were removed. An arthroscopic examination was then performed; before scoping the posterior compartment, we performed the routine arthroscopic assessment through the standard anteromedial portal. Any structural damage including chondral lesion due to the wire migration was not found. Then, we examined the posterior compartment through the posteromedial or posterolateral portal. However, we could not find the wire fragment by palpating with a probe. However, we could not find the wire fragment by palpating the posterior structures with a probe introduced through the posteromedial or posterolateral portal. Before finishing the arthroscopic examination and approaching the popliteal fossa from the posterior aspect of the knee, we used intraoperative fluoroscopy, which demonstrated that the wire fragment had moved when we palpated the upper part of the posterior septum with the arthroscopic probe. This suggested that the wire was embedded in the posterior septum. We therefore made a posterior transseptal portal according to the procedure of Ahn and Ha and enlarged the portal upwards with a radiofrequency probe []. We eventually found the fragment embedded in the septum and were able to remove it safely through the posteromedial portal (Figures and ).\nAfter surgery, the patient could walk without pain and showed full range of motion at final follow-up. |
The patient was a 76-year-old man who came to the office in 2014 looking for possible treatments of his fractured central incisors. Nothing was found relevant about his medical condition. The patient shows a high risk for caries and also eccentric bruxism. He has partial edentulism in the superior left quadrant and multiple decay and fractured teeth. The initial approach was conservative aiming to keep the upper front by means of composite fillings (Figures and ). Then, the posterior superior quadrants needed to be restored with implants.\nThree years after, in 2017, the patient came back to the office referring pain of endodontic origin in the upper left canine. New and secondary subgingival caries were found in the six front teeth. The conservative prognosis was considered poor due to the subgingival depth and extent of decay presented by the lesions from canine to canine. After having discussed the treatment options, especially the surgical lengthening of the front teeth or the orthodontic extrusion, the patient decides to replace the residual teeth with a new implant-supported bridge similar to the recently performed prostheses of the posterior areas that were judged by him as a highly satisfactory treatment. The patient preferred not to involve these restorations in the present anterior treatment and limited it to place only two implants in the lateral incisors' positions ().\nThe treatment was carried out in a staged approach. Briefly, first, we extracted the lateral incisors, using the SST, and placed two immediate implants. The four residual teeth were then prepared to be used as abutments of a temporary bridge for the purpose of maintaining the aesthetics and function of the patient during the early osseointegration period. In a further step, the four remaining teeth were also extracted using the SST, and the initial provisional bridge was replaced by the second provisional screwed on the uncovered implants. Only one out of the four abutment teeth used for the temporization of root canal treatment was needed due to a periapical infection.\nWhen placing the two immediate implants into the alveolus of the lateral incisors, a section of the buccal part of the root (about the two middle thirds) was left in place and no biomaterial was used at all. An impression of the implants was taken to have the second temporary bridge available in the second surgery. Healing abutments were then attached with the proper height for the soft tissue to cover them but at the same time facilitating the uncovering. Finally, a temporary acrylic bridge was cemented onto the four abutment teeth 13-11 and 21-23 ().\nThree months later, the implants were uncovered, the four abutment teeth were extracted, again with the SST—partial extraction of the roots—but this time no more implants were placed in these sockets. The first provisional cemented onto the teeth was then replaced by a second acrylic bridge screwed onto the implants though temporary abutments ().\nThe partial extraction of the canines, aiming to leave a buccal slice of the root, was so hard to perform, and further instrumentation would lead to the socket destruction that a decision was intraoperatively made and a greater portion of the root, including the apex, was finally left. As the locations of the canines did not involve the implant sites, any potential complication could be addressed efficiently.\nOne month later, the prosthodontic phase was undertaken. Little if any differences in the buccal tissue volume and no noticeable aesthetic impact could be found after the multiple extractions (). The desired position of the incisal border was determined by various try-ins, and five months after implant surgery, the definitive prosthesis was placed. The final clinical aspect can be appreciated in the pictures (Figures and ). |
We were offered a left cadaveric kidney from a 69-year-old female, retrieved by a different unit in the country. The cause of brain death was a large intracerebral haemorrhage. The donor was known to have hypertension that was well controlled with co-amiloride, a normal kidney function and no other significant medical history. On retrieval, the left kidney was found to have one artery and two veins.\nWhile preparing the kidney prior to transplantation, we found a 1.5 cm, saccular, thin walled aneurysm close to the hilum of the kidney that had not been noticed during retrieval (). The aneurysm was located at the branch point of the renal artery into multiple small branches; these were all aneurysmal as well. It was deemed surgically impossible to reconstruct all of these aneurysmal vessels and hence the kidney was not used for the purpose of transplantation. As there was consent for the purpose of research, the aneurysmal segment was excised and sent for histopathology and the kidney was sent for research purposes.\nThe histology of the aneurysmal segment revealed marked thinning of the arterial wall with widespread fragmentation and loss of elastic fibres in the tunica media, with increased amounts of mucopolysaccharide matrix material (so-called cystic medial degeneration). The right kidney from the same donor had normal anatomy and was successfully transplanted in another unit.\nThe aetiology of these aneurysms is unclear, although they appear to be related to arterial fibrodysplasia that is exaggerated at the branch points in the renal vasculature due to discontinuities in the internal elastic lamina at these points []; in our case ‘cystic medial degeneration’ was found on histological examination. The risk of rupture is low, but it carries a mortality rate of up to 80% [,]. There are case reports of laparoscopic nephrectomy and ex vivo repair of simple renal artery aneurysms in live related transplants [].\nOur aim is to raise awareness of this uncommon condition, among retrieval and transplant teams, especially in cadaveric and non-heartbeating kidneys, where it can be often missed as the arterial system is collapsed and because of lack of any previous imaging. If correctly diagnosed during retrieval, this can prevent unnecessary transportation cost and the kidney, if deemed suitable for repair, can be sent to an appropriate centre with adequate surgical expertise.\nConflict of interest statement. None declared. |
A 34-year-old woman, gravida 1, para 2, noticed a swelling and indolent mass at the back of the right lower leg and popliteal fossa during the 5th month of pregnancy. She had undergone five attempts of intracytoplasmic sperm injection (ICSI) and hormonal therapy previous to this pregnancy. The gestation had been without pathological findings to this point and the family history of the woman did not show any malignant tumors. The first medical consultation due to the swelling was in the 6th month at her general practitioner, who performed a sonography and advised an MRI scan. This was finally done at the 11th july 2012 which showed a hyperintense mass of 6,7 cm × 4,7 cm × 3,8 cm surrounding the lateral head of the gastrocnemius muscle. The X-ray of the knee was without any pathological findings.\nThe first presentation in our clinic for musculoskeletal tumors was 7 weeks before the calculated delivery date. The clinical examination showed a firm mass at the lateral back of the right lower leg, 10 cm in length from the popliteal fossa to distal (see Figures and ) adherent to the underlying muscles. The flexion of the knee was limited to 100°. The peripheral blood circulation and sensibility were intact at the day of presentation, but the patient described electric paresthesias occurring from time to time radiating from the knee along the lateral leg to the foot.\nThe results of anamneses and clinical examination and MRI diagnostic and the differential diagnosis were discussed with the patient and further treatment was planned. We recommended an open biopsy due to the close anatomic relation to the tibial and common peroneal nerve which could cause complications within a fine needle biopsy. We decided to observe the tumor and perform the open biopsy one week after the delivery (which was a secondary caesarean section) at the 09th August 2012. The biopsy was done in a face-down position using a posterior approach to the knee. We found the communal peroneal nerve surrounded by the superficial portion of the desmoid tumor and it was mobilized to get a representative biopsy of 1 cm³. The nerve was marked with a vessel loop in preparation of the total excision that was scheduled for one week later. The histopathological findings proved the tumor to be a desmoid one and we performed the complete resection on the 16th of August 2012. The tumor was situated on the surface of the lateral head of the gastrocnemius muscle, infiltrating the top of the head of the fibula and the lateral parts of the dorsal capsule of the knee. The communal peroneal nerve was surrounded by tumor 6 cm in length and had to be dissected, even though the tibial nerve was displaced by the desmoid tumor (see Figures –). The microscopy of the desmoid tumor showed R0 resection with a tumor-free margin of minimal one millimeter and proved the initial diagnosis of an extra-abdominal desmoids fibromatosis. The case was then presented in our multidisciplinary tumor board and a postoperative radiation was recommended to reduce the risk of recurrence especially in the area of the epineural neurolized common peroneal nerve. This was done from the 23rd of October until the 29th of November 2012 with a total radiation level of 56 Gy.\nThe routine follow-ups did not show any pathological abnormalities. The last clinical examination on the 7th of July 2014 showed an indolent scar after posterior approach to the right lower leg and popliteal fossa without palpable mass or skin defects. The movement of the knee had no limitations (extension/flexion 0/0/130°) and the patient described no restrictions of walking. The MRI scan during the follow-ups did not show any signs of recurrence. The patient achieved a Knee Society Score of 95 points indicating an excellent postoperative function. |
A 12-month old girl was referred to our pediatric oncology department for further investigation of an abdominal mass. On initial physical examination her weight was in 90th percentile, length in the 75th percentile. Her right cheek was slightly fuller than left cheek. The right arm and forearm were thicker than counterparts on the left. The right leg was thicker and measured approximately 2 cm longer than left leg. We noticed a right sided complex hemihyperplasia (, ) as well as a right-sided abdominal mass of 10 cm dia-meter. Her blood pressure and other vital signs were normal. A detailed medical history showed that the mother first noticed the asymmetry of her legs when she was three months old and took her to a pediatrician. The physician's presumptive diagnosis was congenital hip dislocation. Therefore a hip ultrasonography (US) was performed which showed no evidence of hip dislocation. An orthopedic surgeon was consulted, who ruled out a hip problem. Then the family was told it was something constitutional and no other recommendation was made. The infant was otherwise healthy during the following months, however the family noticed that the cheeks were also growing asymmetric but they took no other action since they were told it was constitutional and would do no harm to the child. The family history was unremarkable and she was the first and only child of the parents who was born weighing 3.5 kg after an uneventful pregnancy.\nAt the age of 12 months, when she developed macroscopic hematuria, an abdominal US showed a right sided renal mass. The patient was then referred to our hospital for further investigation and management. A renal mass and hematuria in an infant with isolated hemihyperplasia strongly suggested a Wilms’ tumor. An abdominal US and a computed tomography (CT) scan confirmed a cystic/solid mass of 10 cm in diameter at the right kidney consistent with Wilms tumor (). Left renal vein and inferior vena cava were free of tumor infiltration. Right kidney was normal and there was no evidence of intraabdominal extention of tumor beyond the kidney. Metastatic work-up including chest X-ray and chest CT showed no distant metastatic disease.\nA pre-operative diagnosis of Wilms tumor was made by clinical and radiological findings without biopsy. She was put on preoperative chemotherapy with two drugs (vincristine 1.4 mg/m2 weekly, 4 weeks; actinomycin-D 0.015 mg/kg/day, 1-5 days) since she had a large tumor to avoid capsule perforation during surgery. After significant regression with preoperative chemotherapy, a radical right nephrectomy was performed through a transabdominal approach. A final diagnosis of Wilms tumor, stage I favorable histology, was made. The patient received postoperative chemotherapy according to stage-I Wilms’ tumor (vincristine 1.4 mg/m2 weekly, 24 weeks; actinomycin-D 0.015 mg/kg/day, 1-5 days, 6 weeks interval). The treatment was well tolerated. We have been following her with regular (every three months) abdominal US and urine analysis to detect any recurrence of Wilms tumor or for the development of any other embryonal tumor. She has been in complete remission for four years. This screening process will be continued until she becomes 7 years old. |
A 72-year-old man was followed up in our clinic for two years for early cervical myelopathy secondary to C3 to C5 stenosis. His medical history was significant for dialysis-dependent end-stage renal disease due to chronic allograft nephropathy despite cyclosporine therapy for a living-related donor kidney transplant. He suffered a previous myocardial infarction treated with percutaneous coronary intervention and sick sinus syndrome, which required a pacemaker that was removed due to a postoperative abscess. He survived squamous cell carcinoma of the parotid gland with lymphatic involvement that necessitated radical resection and radiation of the head, neck, and axilla. He was also diabetic. At the time of his initial presentation to our clinic, his symptoms included very slight loss of coordination in his left hand and a mild sense of imbalance. He could still ambulate and live independently and therefore did not wish to proceed with cervical decompression and fusion.\nHe was lost to follow-up but returned to our clinic two years later. At this time, he presented with loss of coordination in both hands and could no longer ambulate. As a result, he was no longer able to care for himself. He remained dialysis dependent and was oliguric, but not completely anuric. Repeat cervical MRI revealed worsening stenosis at C3-5 compared to the MRI scan performed two years earlier. At this point, he wished to proceed with surgery. As per standard protocol, he was given 1 gram of intravenous cefazolin immediately prior to incision. He underwent posterior C3-5 laminectomies and instrumented fusion with lateral mass fixation. In an attempt to preserve his remaining kidney function and reduce his risk of SSI, we applied 1 gram of vancomycin powder over the instrumentation and soft tissues of the surgical exposure. Although there were not any previous reports of intrawound application of vancomycin powder in patients on dialysis, we felt it was a justified treatment to minimize his chance of SSI given his multiple risk factors for a postoperative infection.\nA serum vancomycin level six hours after surgery was 0.5 μg/mL. The level remained at 0.5 μg/mL in the morning following surgery. By postoperative day two, the vancomycin level was less than 0.2 μg/mL. There were no postoperative complications or changes in the patient's dialysis regimen. The surgical wound was well healed at six weeks' follow-up. It remained well healed without signs of infection 10 months later. |
A previously healthy 19-year-old male was transferred to hospital with extensive deep burns covering approximately 85 % total body surface area (TBSA). After initial assessment and debridement in the operating room, he was brought to the general systems intensive care unit (ICU) for acute renal failure likely due to myoglobulinuria. He remained in the ICU for 34 days until he was transferred to the burn unit. Several operations including multiple debridements and allograft applications were performed throughout his time in the ICU and burn unit. During his extended stay, he was treated for many complications, including multiple infections, pancreatitis, deep vein thrombosis, pleural effusion, cardiomyopathy, chronic diarrhea, depression, as well as upper airway and upper gastrointestinal tract bleeding secondary to ulcers. As well, he developed another acute kidney injury thought to be secondary to acute tubular necrosis and had multiple instances of elevated liver enzymes and abnormal liver function tests. Both of these organ insults were thought to be secondary to medications administered, as these values corrected with discontinuation of these insulting agents. In total, his acute care admission lasted approximately 15 months with 33 operations/procedures needed before he could be transferred to a rehabilitation unit.\nThroughout his prolonged stay, he was worked up for anemia as he required massive amounts of RBC transfusions to maintain an average hemoglobin value over his admission of 95 g/L. This value fluctuated regularly falling into the low 70s on many occasions necessitating the use of blood products. Multiple gastrointestinal bleeds presenting with melena were thought to be large contributors to this laboratory abnormality. The question of hemolysis was raised as early on in his treatment course; he occasionally had elevated lactate dehydrogenase and bilirubin values, as well as positive direct antiglobulin tests. However, his haptoglobin never fell below the normal range and multiple peripheral blood smears had minimal morphological evidence of hemolysis. His chronic anemia was managed with multiple RBC transfusions throughout his hospital admission.\nWhile in hospital, he had multiple zinc, selenium, and copper serum values in the low and normal ranges. However, he was noted to have elevated serum iron levels and an increased iron saturation index reaching 94 % (normal <60 %). His iron indices were followed throughout his stay as all values progressed to outside the normal limits (Table ). Subsequent magnetic resonance imaging (MRI) of the abdomen verified the diagnosis of hemochromatosis by showing iron deposition in the liver and spleen (Fig. ). A search for etiology revealed that in just less than 15 months, he had received 292 units of packed RBCs. He did not receive any exogenous administration of iron during his treatment course. With this information, it was thought that the increased iron saturation was due to a transfusional iron overload. Given his ethnicity and age in the presence of a clear alternative diagnosis, the clinical decision to forego genetic testing was made by the Internal Medicine and Hematology services. He had not manifested any typical signs or symptoms of secondary hemochromatosis. The Hematology service was consulted, and as per protocol, he was started on twice weekly phlebotomies []. Due to pre-syncopal episodes, he was unable to tolerate this, and thus, phlebotomy was performed weekly.\nThere is a wide differential of potential causes to consider in patients presenting with iron overload. In this case, the MRI suggested a pattern of iron overload consistent with a secondary (i.e., non-hereditary) process. A review of secondary causes reveals that he did not receive parenteral iron during his stay, did not have a history of chronic anemia or liver disease prior, is not of African descent, and did not have any neurological dysfunction to suggest aceruloplasminemia. Based upon the quantity of RBC transfusions administered during his course, it appears this is the most likely diagnosis.\nThis is the first reported case of transfusional iron overload resulting in secondary hemochromatosis in a burn patient. Previously, this phenomenon has been shown to occur in patients receiving chronic transfusions over an extended period of time for treatment of blood disorders [, ]. This evidence is in keeping with the notion that secondary hemochromatosis due to transfusions is mainly a concern in chronically transfused patients. It has been suggested that signs of iron overload could be present with as few as 10–20 transfusions []. This case substantiates that multiple acute transfusions may also lead to secondary hemochromatosis.\nBased upon this report, a screening protocol for secondary hemochromatosis may be useful in burn patients receiving acute transfusions, as has been suggested in the population receiving chronic transfusions; however, the details of such a protocol require further study []. Screening for secondary hemochromatosis requires straightforward measurement of serum iron indices, and treatment includes iron chelation and/or serial phlebotomy. There is a technique for phlebotomy described in the hereditary hemochromatosis population that could possibly be applied to transfusionally overloaded patients. The suggested regiment includes removing one unit of blood once to twice a week as serum ferritin analysis is performed periodically to ensure its decline []. Given the simplicity of screening and availability of treatment options, which reduce long-term morbidity, further research in this area is essential to document the prevalence of secondary hemochromatosis in the burn population and the potential need for such a screening protocol. |
A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and placement of compression sutures at the site of detachment helped ensure hemostasis. Her recovery and postpartum course were otherwise unremarkable, and she was discharged on postoperative day #3. The patient was examined at a six-week postpartum visit. No cervix was seen on speculum exam and on digital exam the cervix was flush with the vaginal vault. The pathology report for the detached cervix showed diffuse hemorrhage and vascular congestion; there was no pathologic evidence of placental abruption. |
An 80-year-old man presented with a 4-day history of swelling and pain behind the left knee with reduced mobility with very short distance intermittent claudication affecting the left calf and reduced range of knee movement. This patient in the preceding week was admitted under the care of medical specialty where a diagnosis of a spontaneous haematoma behind the thigh was made. Haematoma was thought to be a result of the patient being on oral anticoagulation (warfarin) for atrial fibrillation. The patient did not report history of trauma. He looked frail on the current admission on the vascular ward requiring support for some activities at home and had been on treatment for prostate cancer. He had previously also had coccygectomy for metastasis as well as a recent history of permanent pacemaker insertion for syncopal episodes and bradycardia. He also suffered from hypertension and was on a number of medications including warfarin. He was a lifelong nonsmoker and lived in a retirement home. There was no family history of aneurysms.\nExamination revealed extensive bruising at the back of the left thigh and knee with palpable femoral and pedal pulses. The popliteal pulse was difficult to feel due to a large haematoma. The left foot was viable with fully intact sensory and motor function. There was no clinical evidence of calf compartment syndrome on the left leg. The right foot was warm with all palpable pulses in the leg.\nAn initial ultrasound scan revealed PAA with no evidence of popliteal or femoral vein DVT. A CT angiogram performed on the same day showed generalized arteriomegaly and the ruptured 9.4 cm PAA involving only the above-knee popliteal artery () and relatively disease-free 3-vessel runoff to the ankle and foot. Options to treat this patient were either a surgical exclusion bypass with evacuation of haematoma or an endovascular treatment. For a number of reasons including patient frailty, associated comorbidities, and potential feasibility of successfully treating the PAA with a stent graft due to intact 3-vessel crural runoff, decision was made to treat the aneurysm by an endovascular approach.\nUnder general anaesthesia, the left common femoral artery was explored with a small open incision. An initial angiogram through a 5F sheath confirmed the CT findings of ruptured PAA with 3-vessel runoff (). The aneurysm sac was traversed using a curved catheter and a soft hydrophilic wire which was then exchanged to a stiff wire. A 5F sheath was exchanged to an 11F sheath to allow for insertion of 2 Viabahn (Gore®) covered stent grafts of 8-250 mm and 10-100 mm dimensions with a 4 cm overlap which were postdilated with 8 and 10 mm balloons. Postcompletion angiography revealed complete exclusion of the aneurysm sac with improved filling of the runoff vessels (). The procedure lasted for approximately 55 minutes.\nThe patient made a good recovery following the repair with a predischarge duplex scan demonstrating a successful exclusion of the aneurysm with good 3-vessel runoff. The patient was discharged on dual antiplatelet therapy which was continued for 6 weeks after which the patient continued on one antiplatelet and an anticoagulant treatment for AF. Subsequent 3-month surveillance duplex scans for up to a year showed a patent stent with intact distal circulation (). Duplex surveillance was discontinued after 1 year as per local protocol; a clinical follow-up after 18 and 24 months confirmed a patent stent graft with palpable pedal pulses. |
A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and placement of compression sutures at the site of detachment helped ensure hemostasis. Her recovery and postpartum course were otherwise unremarkable, and she was discharged on postoperative day #3. The patient was examined at a six-week postpartum visit. No cervix was seen on speculum exam and on digital exam the cervix was flush with the vaginal vault. The pathology report for the detached cervix showed diffuse hemorrhage and vascular congestion; there was no pathologic evidence of placental abruption. |
An 8-year-old girl presented with a 6-month history of slowly growing mass on the volar aspect of the right middle finger []. An incisional biopsy was done at a local hospital, but it was not conclusive and the specimen was not available for reexamination. Clinically, the mass was fixed to the dermis and the flexor sheath. However, there was no numbness and there was full range of motion of the finger joints. A magnetic resonance imaging showed an enhancing lesion that is adherent to the flexor sheath []. Excisional biopsy was done through a zigzag volar incision. Intraoperatively the tumor was found to have ill defined borders. It was adherent to the dermis, flexor sheath and both digital nerves. Part of the flexor sheath was resected and the tumor was shaved off from the dermis by sharp dissection. No skin excision was done and both digital nerves were preserved. The tumor size was 2 × 1.5 cm []. Postoperatively, a small area of the skin flap became necrotic and this was treated conservatively []. Histological examination showed all the classic features of EHE. The tumor consisted of numerous epithelioid cells which are arranged in clusters, trabeculae and cords in a myxoid background []. Another characteristic histological feature of this tumor is the presence of intracytoplasmic vacuoles []. The mitotic rate was 3/10 high power fields (HPF) with evidence of focal pleomorphism. The tumor cells were extended to all resection margins. A panel of immune histochemical stains was done and showed positive staining of tumor cells with CD34, CD31, and factor VIII []. Tumor cells were negative for other markers confirming the endothelial origin of the tumor. We considered the malignant potential of the tumor and the positive resection margins and we offered the patient further management in the form of wide resection of volar soft tissues and flap reconstruction. The family refused and elected for followup. The followup protocol was local examination and radiological workup for metastasis every 6 months. The patient is now 3 years after surgery with no evidence of local recurrence or distant metastasis [Figure and ]. |
A 28-year-old woman was admitted to the neurology department after two transitory episodes lasting several hours of language impairment resembling motor aphasia and mild confusion. On admission, the neurologic examination, brain computed tomography scan, and electroencephalographic findings were unremarkable. A transient ischemic attack was suspected by the clinical symptoms and medical history. Thus, the patient underwent a carotid duplex ultrasound examination, which showed a parallel arterial flow at the origin of the internal carotid artery, potentially resembling a double lumen (). To exclude the dissection of the internal carotid artery, considering the very close proximity of the double lumen to the internal carotid artery for an extensive length, magnetic resonance angiography of the neck vessels was performed. Magnetic resonance imaging excluded a carotid artery dissection but identified an arterial branch arising from the post–bulbar internal carotid artery and flowing in close proximity to it (). The patient provided written informed consent for the report of her case details and imaging studies.\nFrom a neurologic viewpoint, carotid duplex ultrasound is widely used in everyday practice, especially when a cerebrovascular etiology is suspected and for challenging conditions such as carotid dissection. Considering that normal ultrasound examination findings will not rule out a priori the possibility of a carotid dissection, the presence of supportive ultrasound findings (eg, a potential double lumen) should deserve great attention and further diagnostic examinations (eg, angiography with magnetic resonance imaging and/or computed tomography). In contrast, the evaluation of potential anatomic variants of the external carotid artery is a very rare eventuality in neurologic ultrasound examination of supra-aortic trunks.\nTherefore, considering the anatomy of the neck vessels, two anatomic variants with an aberrant origin should be considered: (1) an ascending pharyngeal artery, or (2) an occipital artery., In both cases, these arteries will usually arise from the external carotid artery but can rarely present as anatomic variants with an aberrant origin from the internal carotid artery, , , (). The temporal tap maneuver (with several limitations) is routinely applied to differentiate the external and internal carotid arteries (with tapping over the ipsilateral superficial temporal artery aiming to produce a reflected flow in the external carotid artery) during Doppler ultrasound examination of the carotid bifurcation).,\nTaking inspiration from these factors, we performed an occipital tap maneuver over the right occipital pole in the perfusion territory of occipital artery (where it passes under the sternocleidomastoid muscle and then perforates the fascia to connect the cranial attachment of the trapezius with the sternocleidomastoid muscle; ). During Doppler ultrasound, a reflected flow in the double lumen was observed, potentially differentiating these two anatomic variants and confirming the aberrant origin of the occipital artery from the internal carotid artery (; ). To the best of our knowledge, the present report is the first description of an anatomic variant (aberrant occipital artery) of the supra-aortic trunks potentially resembling a double-lumen appearance of the internal carotid artery. |
A 37-year-old woman was referred to our institution for further management of a mass lesion located in the thoracic cavity, which was revealed on a chest computed tomography (CT) scan taken at another hospital. She complained of left-sided flank pain that was aggravated with deep inspiration for twelve months and began to experience dyspnea for one month. She had a history of pulmonary tuberculosis with a six-month course of anti-tuberculosis medication 20 years earlier. She did not have a history of smoking or environmental or occupational exposures to toxins. The laboratory tests including tumor markers on admission were normal. The result of acid fast staining of her sputum was also normal. Findings of physical examinations were unremarkable. The initial chest radiograph taken at the other hospital 8 months previously demonstrated an ambiguous consolidation in the left lower lung without a definite mass lesion (). The patient did not receive treatment for the lesion but has been followed-up for eight months. A chest radiograph taken eight months after the initial visit revealed an irregularly shaped large mass occupying the left lower lung field and compressing the left lower lobe and diaphragm (). Compared with the initial chest radiograph, the mass had grown markedly. Consequently, chest CT was carried out immediately. Chest CT showed two irregularly shaped soft tissue masses adjacent to the parietal pleura in the left hemithorax, which contained dense calcifications without the invasion of the ribs ().\nFor correct diagnosis and proper treatment, surgical excision of the masses was performed through left thoracotomy via the 7th intercostal space. The intraoperative findings showed two hard and irregularly shaped masses with a hard osteoid surface. These masses were clearly separated. One was 8 cm in size and was located at the costophrenic angle, and the other was 4 cm in size, located adjacent to the inner surface of the shaft of the 6th rib. They had invaded the adjacent structures including the left lower lobe, chest wall, and the diaphragm, but had not invaded the adjacent ribs. These masses were radically excised involving the invaded organs to obtain adequate resection margins (), and the defect of the diaphragm was reconstructed with a 2-mm-thick polytetrafluoroethylene (Gore-Tex WL Gore and Associates Inc., Flagstaff, AZ, USA) patch. Histologically, the tumors consisted of osteosarcoma, pleomorphic sarcoma, and leiomyosarcoma. The microscopic findings (H&E stain) showed the histologic appearance of the mass (), which consisted of smooth muscle differentiation and osteoid production cells. Differences in nuclei size and shape were also observed in the H&E stain. In the immunohistochemistry stain, smooth muscle actin was detected. The microscopic findings of the two masses were the same, and therefore, these were considered seeding. The patient underwent four cycles of adjuvant chemotherapy with the regimen of high-dose methotrexate, cisplatin, and doxorubicin. Currently, she is doing well without any evidence of recurrence for 14 months after surgery. |
A 56-year-old male kidney transplant recipient affected by Lowe's syndrome was admitted to our hospital for a hematoma on his left forearm.\nThe patient had a history of end-stage renal disease (ESRD) and had undergone hemodialysis for 11 years through a distal AVF on his left forearm. In 2013, the patient received a deceased-donor kidney transplant and has been treated with immunosuppressive therapy with tacrolimus 1 mg + 0.5 mg daily ever since. He also had a recent history of ischemic stroke and accidental fall at home which caused a trauma of his left wrist.\nA week before the admission, the patient was evaluated by the surgical team of our department because of a painful and swelling mass on his left forearm where the AVF for hemodialysis was originally created.\nThe enlarging mass first appeared two months before and was treated in another hospital as a complicated AVF, and thus the vascular access was closed.\nDuring the hospitalization in our Nephrology Department, the patient underwent surgical revision of the hematoma and ligation of the distal radial artery. A left wrist radiogram was also performed which showed an area of diaphyseal osteolysis of the radius surrounded by a voluminous soft-tissue swelling. After a few days, the radial artery required ligation right after its origin from the brachial artery because of enlarging hematoma.\nAfter a short time of apparent stability, the patient was admitted once again to our emergency department because of active bleeding from the surgical site which required urgent evacuation of the hematoma. Although the specific source of the hematoma was undetectable, the hemostasis was achieved using surgical glue devices. A surgical reduction of the brachial artery's diameter was also necessary. The hospitalization was complicated by two events of severe anemia which required blood transfusions.\nDuring the follow-up, because of chronic anemia and worsening of the forearm lesion, the patient was readmitted to our department. A Doppler US was performed; however, detailed characterization of the mass required further imaging with computed tomography (CT). Because of high suspicion of malignancy (spread vascular enhancement and pathologic fracture of the radius), a bone biopsy of the fractured radius was required, which then confirmed the presence of epithelioid sarcoma. A total-body CT scan was performed with evidence of enlarged ipsilateral axillary lymph nodes.\nAfter a consultation with the oncologist and the radiotherapist, considering the extension of the lesion, comorbidities, and scarce compliance of the patient, chemo and radiotherapy were ruled out and a surgical approach was favored. The patient was then submitted for left arm amputation (above elbow). The hospitalization was complicated by Clostridium difficile infection treated with oral vancomycin and Proteus mirabilis urinary tract infection treated with intravenous meropenem. Four months following amputation, the patient was found to have metastatic disease to both lungs, the left iliac wing, and the duodenum. Five months later, the patient died. |
The patient was a 76-year-old man who came to the office in 2014 looking for possible treatments of his fractured central incisors. Nothing was found relevant about his medical condition. The patient shows a high risk for caries and also eccentric bruxism. He has partial edentulism in the superior left quadrant and multiple decay and fractured teeth. The initial approach was conservative aiming to keep the upper front by means of composite fillings (Figures and ). Then, the posterior superior quadrants needed to be restored with implants.\nThree years after, in 2017, the patient came back to the office referring pain of endodontic origin in the upper left canine. New and secondary subgingival caries were found in the six front teeth. The conservative prognosis was considered poor due to the subgingival depth and extent of decay presented by the lesions from canine to canine. After having discussed the treatment options, especially the surgical lengthening of the front teeth or the orthodontic extrusion, the patient decides to replace the residual teeth with a new implant-supported bridge similar to the recently performed prostheses of the posterior areas that were judged by him as a highly satisfactory treatment. The patient preferred not to involve these restorations in the present anterior treatment and limited it to place only two implants in the lateral incisors' positions ().\nThe treatment was carried out in a staged approach. Briefly, first, we extracted the lateral incisors, using the SST, and placed two immediate implants. The four residual teeth were then prepared to be used as abutments of a temporary bridge for the purpose of maintaining the aesthetics and function of the patient during the early osseointegration period. In a further step, the four remaining teeth were also extracted using the SST, and the initial provisional bridge was replaced by the second provisional screwed on the uncovered implants. Only one out of the four abutment teeth used for the temporization of root canal treatment was needed due to a periapical infection.\nWhen placing the two immediate implants into the alveolus of the lateral incisors, a section of the buccal part of the root (about the two middle thirds) was left in place and no biomaterial was used at all. An impression of the implants was taken to have the second temporary bridge available in the second surgery. Healing abutments were then attached with the proper height for the soft tissue to cover them but at the same time facilitating the uncovering. Finally, a temporary acrylic bridge was cemented onto the four abutment teeth 13-11 and 21-23 ().\nThree months later, the implants were uncovered, the four abutment teeth were extracted, again with the SST—partial extraction of the roots—but this time no more implants were placed in these sockets. The first provisional cemented onto the teeth was then replaced by a second acrylic bridge screwed onto the implants though temporary abutments ().\nThe partial extraction of the canines, aiming to leave a buccal slice of the root, was so hard to perform, and further instrumentation would lead to the socket destruction that a decision was intraoperatively made and a greater portion of the root, including the apex, was finally left. As the locations of the canines did not involve the implant sites, any potential complication could be addressed efficiently.\nOne month later, the prosthodontic phase was undertaken. Little if any differences in the buccal tissue volume and no noticeable aesthetic impact could be found after the multiple extractions (). The desired position of the incisal border was determined by various try-ins, and five months after implant surgery, the definitive prosthesis was placed. The final clinical aspect can be appreciated in the pictures (Figures and ). |
A girl aged seven years and eight months was referred to our observation because of left peripheral facial palsy, causing the inability to close the left eye and dropping of the corner of the mouth. A first peripheral facial nerve palsy occurred when she was three years and one month old, with complete regression after corticosteroid treatment. At the age of three years and nine months, she was diagnosed with pure red cell hypoplasia, manifested as severe anaemia (haemoglobin: 3.00 g/dL; red blood cells: 1,000,000/mm3) with an extreme lack of erythroid precursors in the bone marrow, but high growth of them in culture, probably caused by anti-EPO antibodies. The detection of anti-EPO antibodies, however, is not routinely performed in a clinical setting. The autoimmune hypothesis was postulated on empirical bases, since haemoglobin levels did not increase after recombinant human EPO administration, but normalized after corticosteroid therapy, and the addition of autologous serum to the erythroid precursor culture inhibited EPO growth. When she was 4 years and 4 months old, the patient presented with a second episode of left facial palsy, combined with the acute onset of a strength deficit on the left side of the body. Mingazzini I and II were positive for the left limbs. The imaging assessment showed a haemorrhagic stroke corresponding to the anterior portion of the right putamen and of the external capsule with perilesional oedema, involving the anterior limb of the internal capsule. Blood pressure measurements performed during the hospitalisation revealed high diastolic blood pressure values. These findings suggest a central rather than peripheral involvement of the facial nerve. Three weeks after their beginning, the symptoms had completely regressed. At the age of five years and six months, a third episode of left peripheral facial palsy occurred. Brain magnetic resonance imaging (MRI) was repeated, showing gliotic evolution of the previous haemorrhagic insult without new lesions. The patient was treated with corticosteroids, with a good regression of symptoms. On the last episode, the patient had initially visited a first level emergency room, where laboratory tests, as well as ophthalmologic, neurologic, and otoscopic examinations and a head computed tomography (CT) scan performed were normal. When admitted to our department, the neurologic examination showed complete peripheral left facial palsy (House–Brackmann grade V). Physical examination showed the presence of a furrowed tongue as a synchronous anomaly. No active herpetic mucosal and skin lesions were found. The patient was started on a tapering dose of prednisone for 30 days and vitamin B group supplementation was added. The clinical course was favourable. Three months after, at last follow up, neurological impairment had clearly improved. Facial palsy gradually resolved after the third week of treatment. |
A 32-year-old multiparous woman was admitted at 37 2/7 weeks for induction of labor for abnormal antenatal testing. She had a history of a prior cesarean delivery for arrest of active labor at 7 cm and after extensive counseling chose to undergo a TOLAC. The initial cervical exam was 2 cm dilation and 50% effacement. Her labor was induced with oxytocin and amniotomy was performed at 5 cm dilation with clear fluid noted. She progressed from 2 cm to 5 cm over the course of 10 hours; interval time to progression to 6 cm was 3.5 hours. The patient then began to have a moderate amount of vaginal bleeding with associated minimal fetal heart rate variability and variable decelerations that did not improve with intrauterine resuscitation. She was taken to the operating room for repeat cesarean delivery due to concern for a uterine rupture and/or a placental abruption. Upon entry into the abdomen, there was no uterine rupture or dehiscence, nor was there evidence of a significant placental abruption. She delivered a male infant with a weight of 2659 g and Apgar scores of 9 and 9 at 1 and 5 minutes, respectively; arterial cord pH was 7.26. No extension of the hysterotomy was noted following delivery of the infant. Following repair of the hysterotomy, the bladder was noted to be distended and edematous, despite the presence of a patent Foley catheter. This finding prompted a vaginal exam to assist in evaluating the integrity of the lower uterine segment behind the bladder due to concern for an occult uterine rupture or dehiscence. The vaginal exam revealed a spontaneous detachment of the anterior rim of the cervix from approximately 9 to 3 o'clock. The avulsed portion of cervix appeared necrotic () and there was no bleeding noted at the site of cervical detachment. The cesarean delivery was completed, and an attempt was made to repair the site of the detachment vaginally, at which time the entirety of the cervix completely detached. No excessive bleeding was noted and placement of compression sutures at the site of detachment helped ensure hemostasis. Her recovery and postpartum course were otherwise unremarkable, and she was discharged on postoperative day #3. The patient was examined at a six-week postpartum visit. No cervix was seen on speculum exam and on digital exam the cervix was flush with the vaginal vault. The pathology report for the detached cervix showed diffuse hemorrhage and vascular congestion; there was no pathologic evidence of placental abruption. |
A 48 year old male patient presented to the emergency department with a one hour history of epigastric pain, vomiting and profuse sweating. The patient's medical history was significant for long standing hypertension and chronic heavy cigarette smoking as well as recurrent attacks of chest pains related mainly to exertion and relieved by rest.\nClinical examination revealed an obese restless patient with a blood pressure of 90/60 bilaterally and a regular pulse at 110 beats per minute. The jugular veins were congested with a venous pressure of 15 mmHg above the sternal angle and positive Kussmaul's sign. Cardiac examination revealed normal first and second heart sounds and an S3 gallop but no murmurs or pericardial rub. Chest examination revealed bilaterally equal air entry with normal vesicular breathing and no rhonchi or crepitations.\nElectrocardiogram was performed in the emergency room and revealed Q waves and ST segment elevation in the inferior leads as well as tall R wave and ST segment depression in lead V2 as shown in figure . Right chest leads showed ST segment elevation in lead V3R and V4R as shown in figure . The clinical picture together with electrocardiographic finding suggested a diagnosis of acute transmural infero-posterior associated with right ventricular myocardial infarction.\nImmediately after admission to the emergency room, the patient's conscious level ran a downhill course and he went into deep coma with a GCS of 3/15 and pinpoint pupils. A computed tomography of the brain was performed and revealed no abnormalities. This deterioration was presumed to be due to acute ischemic stroke not yet evident in the initial CT scan. Taking into consideration this sudden worsening of his conscious level and a calculated NIHSS score (National Institute of Health Stroke Scale) of >25 indicating a massive cerebral infarction, it was decided not to administer thrombolytic therapy. We also decided not to undergo primary percutaneous transluminal coronary angioplasty because of the bad prognosis of the patient. The patient was treated conservatively with antiplatelets, anticoagulant therapy and inotropic support for cardiogenic shock.\nLaboratory investigations revealed evidence of myocardial damage with elevation of serial cardiac enzymes and troponin. The kidney functions showed evidence of renal hypoperfusion with a blood urea of 126 mg/dl and serum creatinine of 3.2 mg/dl. Echocardiography was performed and revealed left ventricular systolic dysfunction with an ejection fraction of 35% and a severely hypocontractile right ventricle with a diameter of 4.15 cms in diastole as shown in Figure . There was no evidence of a left ventricular or right ventricular thrombus. The bubble test using agitated saline confirmed the absence of a PFO.\nOn the second hospital day, a follow-up CT brain confirmed the presence of a massive infarction involving the vertebra-basilar territory leading to bilateral occipital associated with brain-stem and cerebellar infarction as shown in figure . The patient then succumbed to severe cardiogenic shock resistant to all resuscitative effort. |
Our patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. ().\nRadiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement (). Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.\nThe patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding soft tissue. The mass was encircling the ulnar neurovascular bundle with mass abutment over the radial bundle as seen in pre-op assessment. The mass was dissected freely from its attachment to those bundles preserving both radial and ulnar structures. The mass was then excised en-bloc having a dimension of 3.5 × 4x2.5 cm (). Histological assessment showed a lesion with fasciitis like features, myofibroblastic proliferation and scattered foci of osteoid formation that was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining and no evidence of malignancy (). The resected margins were however, positive for residual lesion with difficulty in obtaining negative margins due to the extensive nature of the mass. Post-operatively, the patient had an un-eventual course. She was informed about the need for close follow-ups for both clinical and/or radiological signs of lesion recurrence, pending early surgical intervention (see ). |
A 22-yr-old male, farmer by occupation was referred to our tertiary cardiac care institute for management of abnormal ECG changes mimicking acute coronary syndrome. He had sustained accidental electric burn injury (240V) while carrying out some work at home 2 hours prior to admission. He was thrown to the ground following an electrocution and was found to have brief period of loss of consciousness for few seconds with spontaneous recovery. He was immediately attended at a local hospital where ECG changes were noticed and referred to our institution for opinion and further management. He had no prior history of cardiac illness. There was no history of chest pain, palpitation or neurological deficits. There was no history suggestive of sudden or premature cardiac death in his family. He was not on any medications.\nOn physical examination, patient was conscious alert and had deep electric burn entry wound over the dorsum of left hand and an exit wound over the left ankle. The arterial blood pressure and heart rate were 120/80 mmHg and 78 beats per minute, respectively. Cardiovascular assessment was normal. Other systemic examinations were normal. Surface electrocardiogram done immediately following injury demonstrated a sinus rhythm with RBBB with coved ST segment elevation with negative T wave in V1 mimicking type 1 Brugada pattern and saddle back ST segment with upright T wave in V2 mimicking type 2 Brugada pattern with early repolarisation (). QTc was normal. Echocardiographic assessment revealed a normal left ventricular size and function, and no valvular pathology. Routine laboratory tests, including blood urea, serum creatinine, serum electrolytes and cardiac biomarkers were normal. Repeat ECG at 2 hours showed disappearance of above mentioned Brugada type pattern with persistent early repolarisation. Patient was observed in the ICU for rhythm disturbances for 24 hours. Repeat ECG after 24 hours was normal pattern. Since patient had no family history of sudden cardiac death and family members showing normal ECG and clear precipitating event that can result in above mentioned ECG changes he was not subjected for further investigations like induction with class I antiarrhythmics or electrophysiological studies. |
A 63 year-old gentleman presented to the emergency department with non-specific periumbilical pain and nausea. He denied any vomiting, changes to his bowel habits, weight loss, fever or history of similar pain episodes. He was otherwise healthy and had no previous abdominal surgeries. On physical examination, there was some mild lower abdominal tenderness, but no mass was clinically palpable. A computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast was done and revealed a heterogeneous appearing mass like lesion in the midline of the pelvis measuring 11.4 × 6.8 × 6.6 cm. It showed peripheral enhancement with central hypodensity. The mass appears to be intimately associated with multiple segments of small bowel in the lower abdomen with no associated bowel obstruction (Fig. ). The initial radiologist impression was suggestive of a possible gastrointestinal stromal tumor. A CT scan of the chest was performed as well and there was no evidence of metastatic disease in the abdominal or thoracic cavities.\nThe case was discussed in multidisciplinary tumor boards and the consensus was to proceed with surgical resection of the primary tumor. The patient was therefore taken to the operating room for a diagnostic laparoscopy, laparotomy and resection of the mass which was not found to involve the small bowel. During laparoscopic exploration, we did not identify any liver metastases or peritoneal deposits. The mass was occupying the middle portion of the lower abdominal cavity. We elected to convert to an open procedure due to concerns of disrupting the integrity of the tumor during laparoscopic dissection given its large size and weight. It was connected to the greater omentum with a vascular pedicle and slightly adherent to epiploic appendages of the sigmoid colon. An intraoperative flexible sigmoidoscopy was performed and was unremarkable. The mass was not invading any intra-abdominal structures and there was no evidence of metastatic disease. It was resected en bloc with adequate margin on the omental pedicle. The patient had an uneventful recovery and was discharged home on postoperative day three.\nPathology revealed an SFT arising from the omentum. It was described as a finely encapsulated bosselated mass with a rubbery texture and weighed 225 g (Fig. ). Microscopic examination showed a cellular lesion that was not invading the thin capsule with areas of necrosis, which likely represents infarction with a focal histiocytic reaction. The lesion was composed of plump spindled or slightly epithelioid cells in a small, storiform pattern. Nuclei appeared mildly atypical and relatively monomorphic. The mitotic count was less than 4 per 10 high-power fields and no abnormal mitoses were seen, so the lesion did not meet the criteria for a malignant SFT. However, given the fact that mitoses are not rare, it was best considered of unknown biological potential. The lesion was relatively vascular with abundant capillaries and background larger, thin-walled vessels (Fig. ). The pedicle was identified arising from the omentum and showed no evidence of tumor invasion. Immune histochemical staining demonstrated the tumor cells are negative from CD31, ASMA, S100, AE1/AE3, calretinin, desmin and CD117. The tumor was positive for vimentin, BCL-2 and CD34 (Fig. ). CD31 develops the vessels in the background. The very rare tumor cell was positive for epithelial membrane antigen (EMA).\nGiven the benign nature of the tumor histopathology and the completeness of the resection with negative margins, adjuvant chemo- or radiation therapy was deemed not indicated in multidisciplinary discussions. At 6 months follow-up, the patient remains asymptomatic with no clinical or radiologic evidence of recurrence or metastatic disease. The team agreed that routine surveillance may not be required and imaging and other investigations could be done as needed if the patient develops concerning symptoms or signs on examination. |
The 62-year-old male patient in this case report had a smoking history of more than 30 pack-years and a medical history of hypertension and diabetes. He had had a percutaneous coronary intervention 6 years previously due to angina and had noticed a cold and numbing sensation in the extremities of both hands for the previous 3 years. Two years previously, the patient's fourth finger on the left hand had experienced blue discoloration, with extreme pain of greater than 90/100 mm on the visual analogue scale (VAS), followed by ulceration. After a few tests at the orthopedic clinic, the patient had been diagnosed with Buerger's disease. He had been referred to the pain clinic for conservative treatment one year previously. On the patient's upper extremity angiography, greater than 80% stenosis was observed in the first and third finger artery in the area of radial artery and palmer arch, and greater than 90% stenosis was also observed in distal ulnar artery.\nAt the time of referral, the patient had been taking oxycodone 40 mg twice a day, as well as limaprost 5 µg and gabapentin 300 mg 3 times day. Even with an increase in opiate dose and several chest sympathetic block and stellate ganglion blocks, the analgesic effect was temporal. The pain and ulcers on the fingers worsened, and a finger amputation was planned as arterial bypass surgery was not a valid method for this patient. Although a number of treatments were tried, the patient complained about extreme pain, 90/100 mm on VAS, and there were severe gangrenous ulcers progressing on the fourth finger of the left hand and the index finger of the right hand. The patient was very much against the amputation even though he was under extreme pain and had been referred to the pain clinic several times. Hence, the decision was made to attempt spinal cord stimulation prior to amputation.\nThe blood pressure, heart rate, oxygen saturation, and electrocardiography were monitored, and, with the patient in the prone position, local anesthesia was performed at T2-3 intervertebral space. A 15-gauge Tuohy needle was used for the paramedian approach with a C-arm fluoroscopic image. After ensuring the needle was positioned in the epidural space, the guidewire was inserted for easy insertion of the electrode, and the electrode was positioned in the posterior epidural space using the C-arm fluoroscopic image. The guidewire was removed, and the octrode electrode lead (Advanced Neuromodulation System Inc, Plano, Texas, USA) was placed 2 mm left of the radiological center. The distal electrode was placed at the bottom of the cervical spine ().\nThe electrode was connected to the test stimulator, and the stimulation was profound in the areas with pain. After the test stimulation, the pain was reduced by 50%. During 1 week of test stimulation, the patient's pain was maintained to within 20-30/100 mm on VAS, and the use of opiate analgesics was decreased by 50%. Hence, the permanent spinal cord stimulation insertion procedure was carried out. The Genesis IPG (Advanced Neuromodulation System Inc, Plano, Texas, USA) was buried under the lower left-side clavicle, and stimulation was well controlled with 3-4+ electrode combination, 4.0 V amplitude, 240 msec pulse width, and 34 Hz frequency.\nAfter the spinal cord stimulation insertion, the ulcers on both hands began gradual recovery and were completely recovered after 6 months. The pain was maintained within 30/100 mm on VAS, and the use of opioid analgesics was decreased more than 50% compared with the pre-procedure stage (). |
An 87 year old woman patient reported to the outdoor department of our hospital with a history of having sustained a fall in her bathroom. The patient complained of tenderness and pain in the right hip and thigh. The extremity was externally rotated and shortened. Movement elicited pain in the area of the right hip. Radiographs of the right femur revealed a transverse fracture of the right subtrochanteric region. On assessing the trabecular pattern of the trochanteric region the patient was found to have Singh's grade one porosis with near absence of the trabeculae in the femoral head and neck.\nThe patient was put on traction and advised to undergo surgery in view of the nature of the fracture and the requirement of early ambulation. Dual X-ray absorbsiometry showed a T score greater than 2.5 standard deviations below normal.\nIn view of the extremely thin cortices of the femur, it was felt that the oft required schanz pin assisted reduction, needed for guide wire insertion in interlocking nailing, could damage the cortices at the insertion site. Besides this the possibility of cut out precluded the use of dynamic hip screw fixation. The DCS along with cancellous screws was chosen to circumvent these problems.\nThe fracture was reduced on a traction table after opening the area. Fixation was held with a dynamic condylar screw [DCS] and 95 degree barrel plate. In view of the tenuous nature of the cortices the plate was affixed with four cancellous screws on either side of the fracture.\nPost operatively the patient underwent supervised physiotherapy over a period of six weeks. At ten weeks the fracture had united and the patient was allowed full weight bearing. The patient simultaneously was put on treatment with bisphosphonates for the underlying osteoporosis which was primarily of the senile variety.\nAt the last follow-up [3 years post operative] the patient was pain free with full range of motion of the hip joint. The patient's cortex thickness had also improved at this time as seen on radiographs. The patient was advised as to the potential complications of removal of hardware after which she chose to avoid removal of the implant. |
A 56-year-old lady presented with a 6 month history of rectal bleeding, passage of mucus and a change in bowel habit to more frequent stools. She had no abdominal pains and her weight was maintained. The patient had been born with bladder exstrophy and had multiple surgeries culminating in a cystectomy with ileal conduit formation at 5 years of age. She had suffered with recurrent urinary tract infections for most of her childhood and adult life but was otherwise well with no other major co-morbidities or risk factors for colorectal malignancy and had no family history of colorectal disease.\nColonoscopy revealed two large sessile polyps in the sigmoid colon in close proximity to each other and adjacent to a diverticulum-like structure (Fig. ). Each polyp was approximately 3 cm in size and both exhibited a type IV pit pattern with areas of irregularity suggestive of focally advanced disease. Histological examination confirmed both polyps were adenomas comprising both low and high grade dysplasia, without submucosal invasion (Fig. ). On closer inspection the mucosa around the diverticulum was also atypical but not adenomatous. The remainder of the colonoscopy was unremarkable with no other evidence of diverticular disease or polyps elsewhere.\nEndoscopic resection was considered as a therapeutic option however in view of the above characteristics as well as difficult endoscopic access surgery was preferred. Furthermore, radiological imaging had initially raised the possibility of invasive disease in view of sigmoid thickening. The patient underwent high anterior resection and an open approach was chosen because of suspected intra-abdominal adhesions following extensive pelvic surgery. An end colostomy was formed at the patient’s pre-operative request. At laparotomy the right fallopian tube was adherent to the sigmoid colon and adjacent to this a blind ending tube was noted to emerge from the anti-mesenteric border of the colon. This was marked for pathological identification.\nOur patient went on to have an uneventful recovery and her quality of life following surgery was good. Her wish to have a permanent colostomy stemmed from the fact that she had always suffered from an erratic bowel habit and that she was already knowledgeable with regards to stoma care in view of her pre-existing ileal conduit. |
An 80-year-old woman presented to the Breast Clinic with a left breast mass. The patient reported previous benign excisional biopsy of a breast lump around age 50 with no breast-related concerns since that time. About two years ago, she noticed a lump in the left breast that appeared to increase in size over time. Around the same time, she had a single episode of spontaneous bloody discharge from the left nipple. Due to various personal reasons, she delayed her own care and had not sought breast evaluations until the size of the mass had reached a point that prompted her to have it assessed. She had not experienced any pain, discharge, or skin breakdown in her breast, other than some discomfort related to the fullness. She had no family history of breast or ovarian cancer and no risk factors for breast cancer other than her age.\nClinical examination revealed a large left breast mass measuring ∼20 cm involving the inferior and medial left breast. The overlying skin was bluish-purple in color, with a lateral deviation and distortion of the nipple (Fig.). Upon palpation, the mass measured ∼20 × 15 cm with thickening of the nipple. The patient also had a small mass on the left upper anterior chest that had remained unchanged for several years.\nBreast imaging work up included mammography, ultrasound, and magnetic resonance imaging (MRI). Diagnostic mammography revealed a large mass in the left breast and a few scattered coarse calcifications (Fig.A). Ultrasound examination demonstrated a complex vascular mass with a large homogenous fluid component occupying the majority of the left breast with features suspicious of malignancy (Fig.). Bilateral MRI was performed to further characterize the mass, revealing a 13 × 11 × 13 cm mass with both cystic and enhancing solid components abutting the chest wall and the lateral aspect of the mass demonstrating skin involvement (Fig.). Additionally, the small palpable mass on the superior left chest wall was consistent with a lipoma.\nImaging features were suggestive of malignancy and the differential diagnosis included locally advanced breast cancer, papillary cancer, angiosarcoma, intracystic papilloma or hematoma secondary to a lesion. In order to facilitate breast biopsy, the radiologist performed an aspiration of the left breast mass removing 600 cc of brown-gray fluid; cytology negative for malignancy. An ultrasound-guided core-needle breast biopsy was performed with biopsies taken from the mass at the subareolar location and at 10 o'clock position, posterior depth against the chest wall. Both revealed sclerosing papilloma with focal usual ductal hyperplasia and minimal focal cytologic apocrine atypia (Fig.). A prominent left axillary lymph node was subject to fine needle aspiration biopsy and was negative for malignancy.\nThe patient underwent left total mastectomy. The mastectomy specimen was finely sliced at 4–5 mm intervals throughout and the firm areas were submitted for microscopic examination (Fig.). Pathology revealed a giant papilloma in the subareolar left breast with multiple dark red mural papillary nodules lining the cyst wall. The postoperative phase was uncomplicated and the patient was advised routine follow-up care. |
A 44-year old male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.\nA multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.\nAfter induction of anaesthesia, arterial lines were placed in the left radial and left femoral artery. A right infraclavicular incision and a right groin incision was made this was to establish peripheral arterial cannulation access to the right axillary and right femoral artery. An 8 mm dacron graft was anastomosed to each vessel for indirect cannulation. Median sternotomy was performed to access the mediastinum and expose the heart and aorta. Following heparinisation cardiopulmonary bypass (CPB) was established with venous return from bi-caval cannulation. The body temperature was cooled to 25 degrees Celsius. The right superior pulmonary vein was used for venting. Once the cross clamp was applied, complete cardiac arrest was achieved using Custodiol 25 ml/kg crystalloid cardioplegia via a retrograde cannula through the coronary sinus. A further top up of cardioplegia was given once the aorta was opened through direct cannulation of the coronary ostia.\nThe aortic root, valve and ascending aorta were excised. The coronary ostia were fashioned as buttons from the native aortic root. The coronary ostia were noted to be significantly displaced, with distorted anatomy due to the patient’s disease process. Therefore, 8 mm dacron grafts were attached end-to-end to each ostia, with view to performing the modified Cabrol technique later following replacement of the root. The heart was then retracted in a cephalad position to access the posterior pericardium. A vertical incision was made to expose the descending thoracic aorta (DTA). An end to side anastomosis was formed with a 20 mm dacron graft to the DTA (Fig. ). This graft was then routed posterior to the inferior vena cava (IVC) and anterior to the right inferior pulmonary vein (RIPV), adjacent to the right atrium (RA). Root replacement was then performed with a 25 mm biological valved-conduit, as this was favoured by the patient over a mechanical prosthesis, despite the risk of a difficult redo procedure in the future. The 8 mm dacron grafts attached to the coronary ostia were anastmosed to the root conduit as neo coronary ostia. The distal part of the valved-conduit was anastomosed to the proximal arch under selective antegrade cerebral perfusion (SACP). Finally, an end to side anastomosis was fashioned between the 20 mm extra-cardiac graft (attached to the descending thoracic aorta) and the ascending portion of the valved-conduit. Valve-sparing root replacement was not considered in this patient due to the grossly abnormal aortic anatomy.\nFollowing rewarming and deairing the patient was successfully weaned off CPB. The bypass time was 160 min, the cross-clamp time was 120 min, and the SACP time was 40 min. Haemostasis was achieved and thereafter a routine closure of all incision sites. The patient remained in ICU for less than 48 h, and made excellent progress on the ward. Minimal anti-hypertensives were required and the patient was discharged on 8th day post operatively neurologically intact and independent. At 3 months follow up the patient underwent a repeat CTA scan which showed complete patency in the extra-anatomical graft and resolution of the collateral arterial network (Fig. ). |
A 62-year-old female patient was treated in 1991 for a giant cell tumor of the right distal medial femoral condyle with curettage and allograft bone grafting. In the same year, she presented with a local recurrence and had a repeat curettage and cementation of the lesion with polymethylmethacrylate. The patient remained symptom-free for 20 years until she presented to our clinic with increasing knee pain and functional impairment secondary to degenerative change within the knee joint.\nOn physical examination, she had a longitudinal anteromedial knee scar with a 10-degree varus deformity. Range of motion was from 15° to 90° of flexion. Plain knee radiographs showed a large bolus of cement occupying the medial femoral condyle, extending superiorly into the metadiaphyseal junction. The joint space showed significant narrowing. There was no evidence of loosening of the cement or tumor recurrence ().\nThe patient was offered a total knee replacement. Different reconstruction options were considered and included a modular oncologic prosthesis and allograft prosthetic composite. However, taking into consideration the good quality of the cement bed, a standard total knee replacement was planned. We had a modular tumor prosthesis available as a backup option.\nAt surgery, severe articular cartilage wear was noted especially in the medial compartment; however, the cement had not yet worn completely through into the joint. The femoral medullary canal was initially opened using a combination of a drill and burr to accommodate a standard intramedullary guide rod. The distal femoral cut was done using a standard saw cutting through the cement without difficulty. The remainder of the femoral cuts were completed after appropriate sizing of the distal femur. The cement remained well interdigitated to the host bone throughout the femoral preparation with no evidence of loosening or fragmentation (). Due to the presence of the cement, a cruciate retaining femoral component was selected in order to avoid further cutting into the cement for the box of a posterior stabilized femoral component (). The proximal tibia was prepared using standard techniques. The patella was resurfaced. After trialing, final cementation of the definitive components consisting of a Stryker Triathlon size 4 CR femoral component, size 5 tibial baseplate, 9 mm CR insert, and 27 mm patella was completed (all components manufactured by Stryker Orthopaedics, Mahwah, NJ). Postoperative radiographs at a 3-year follow-up showed good component fixation and alignment (Figures and ). The knee was stable and had a range of motion of 0–100 degrees of flexion. |
A 72-years-old female was brought to psychiatry outpatient department, relatives reported that for last 1 month, she is complaining, she is not in her home as she often says that she should be taken to her own home. She was not able to move about freely due to her impaired vision, weight and diabetic neuropathy. She had to be helped for activities of daily living due to impaired vision. She would often say that there are people around her whom she does not know. She was also hearing voices of some persons crying and would ask her daughter-in-law about it. She said she could see a few children eating from her plate when she is eating her meals and she would ask them to be removed. She said there are 3-4 children of 6-8 years age who are eating from her plate. She could see monkeys in her room. At times she would say that she is being taken in an ox-cart, she could see the desert and ruins of a building. She would repeatedly say that she can see many persons around her and they should be removed from there, or she should be taken to her own home. She remained irritable due to the presence of unwanted persons around her. At times, she also said that someone has carried out black magic on her, though on examination, it was not a firmly held belief. On mental status examination her cognitive functions were intact. She had auditory and visual hallucinations. She was troubled by auditory and visual hallucinations and lacked insight.\nShe was a diagnosed case of diabetes and hypertension since 1999. She also had diabetic nephropathy and neuropathy. She was on injection Insulin twice a day 18 units and 12 units, morning and evening.\nIn March 2009, she had an ophthalmic examination. She had proliferative diabetic retinopathy and ocular hemorrhage. She had complete vision loss since March 2009 (2 months) and had to be helped for activities of daily living. She was taking tablet alprazolam occasionally for last 1 year. Her appetite was normal, but sleep was disturbed.\nShe was started on Tablet Aripiprazole 10 mg/day, later increased to 15 mg/day. However, there was no improvement after 2 months and in June 2009, tablet Risperidone was started initially 2 mg/day, increased to 4 mg/day. She was also given tablet lorazepam 2 mg/day. There was no improvement in any of her symptoms. A computed tomography scan was suggested but due to her difficulty in walking and obesity, relatives expressed inability to get it done.\nIn June 2010, she had her ophthalmic checkup. She had mature cataract in both eye, it was not possible to examine her retina. A decision was made to perform cataract surgery in both eyes simultaneously, as it was difficult to bring her to hospital repeatedly. After cataract surgery her psychotic symptoms resolved completely within 1 week. Her risperidone was stopped; she remained symptom free until her death in September 2011. |
This is a case of a 25 years old Malay girl with learning disability and no significant past medical history, who started noticing a sacral mass since August 2015. The mass was painless and gradually increasing in size. The family members of this patient brought her to a traditional healer. They did not seek any medical treatment until late 2017. By this time, the mass over the sacrum was extremely large. Family members claimed the mass was preventing the patient from lying down flat supine. The patient was also unable to ambulate for the past 2 years. Hence, she was bedbound most of the time. It was difficult for her to sit on the wheelchair. She also felt tired to move because the mass was quite heavy. The family members claimed when the patient was lying down flat, she had to flex her hips and knees to achieve a more comfortable position. In addition, she often slept either in prone position or in supine with multiple pillows below her body. The mother also claimed over the last 2 months, the patient’s body had been getting thinner despite her physical weight was increasing due to the increase in size of the sacral mass. The patient had been passing stool and urine in pampers. There was no past medical history and no family history of cancer. Socially, the patient lived with her mother and siblings. The mother was the main care taker. Her father passed away 10 years ago because of heart attack. The patient previously attended a special needs school, but she stopped going to school since 2015 after developing the sacral mass.\nThis patient was managed in the Southern Region referral centre for Orthopaedic Oncology in Malaysia. On clinical examination in the Orthopaedic Oncology ward, the patient appeared cachexic, she had slightly pale conjunctiva, but she was not dysmorphic. Vital signs were Blood Pressure 142/90, Pulse Rate 98 beats per minute and Temperature 37 degrees Celsius. There was a large mass 40 cm × 30 cm × 20 cm over the sacrum. The mass was firm to hard in consistency and involved both buttocks and the gluteal fold (Fig. ). Dilated veins were noted under the skin overlying the sacral mass. Neurological exam of bilateral lower limb was normal. However, there was generalized wasting of all muscles over the bilateral lower limb. Anal tone was intact.\nLaboratory investigations taken were unremarkable. Computed Tomography of the Pelvis showed a large destructive sacrococcygeal mass measuring 43 cm × 38 cm × 27 cm with extension into the presacral space resulting in anterior displacement of the rectum, urinary bladder and uterus and posterior extension into the dorsal soft tissue with involvement of the gluteus, piriformis, and left erector spinae muscles (Figs. and ). Superior margin of the sacral bone involvement was up to S2. The mass was predominantly of fluid density with internal enhancing septation and calcifications which suggested primary chordoma more likely (Figs. and ). Magnetic Resonance Imaging done showed similar findings. Skeletal Survey Radiograph did not show any distant metastasis. A Trucut biopsy of the mass was done. Histopathological analysis showed tumour cells with “physaliphorous cells” positive for pancytokeratin, EMA, Vimentin and S-100 immunohistochemistry stainings with minimal mitotic figures and mild nuclear pleomorphism (Fig. ). Brachyury immunohistochemistry staining was not available in our centre. However, the clinical history, morphology of tumour on microscopy and immunohistochemistry staining available were consistent sacral chordoma.\nThe diagnosis of Sacral Chordoma was confirmed. Multidisciplinary team discussion done among Orthopaedic Oncology, General Surgery, Obstetrics and Gynaecology, Blood Bank, Anaesthetic and Plastic Surgery teams. A family conference was done. The family’s aim was for removal of the sacral mass to allow the patient lie supine on bed and sit on the wheelchair.\nSubsequently, the patient undergone Wide Resection and En Bloc Sacrectomy. The Posterior-Only Approach was used with a “Mercedes Star” 3 limbed incision. Duration of surgery was 8 h. The patient was supported with blood products transfusion during surgery. Intraoperatively, the sacral tumour had eroded the sacral bone from S2 to S5 (Figs. , and ). Sacrectomy was done at the level of S2. Sacral nerve roots S2-S5 were all infiltrated by the mass and therefore were unable to be preserved. The mass and surrounding gluteal muscles invaded by the tumour were also all resected. All resection margins were less than 1 mm from the tumour. Primary closure was done without any distant or local flap as per consultation with Plastic Surgery team. The tumour weight was 25 kg (Figs. , and ). Post operatively, the patient was monitored in Intensive Care Unit for 3 days. The patient developed neurogenic bowel and bladder post sacrectomy requiring enema and long-term urinary catheter. In addition, the post-operative course was complicated by wound breakdown and surgical site infection requiring wound debridement. Dressing was done as per local protocol until wound bed granulating well. Split Skin Graft was done about 3 months post wide resection once the tissue culture results were free of significant infection.\nThe patient also required extensive rehabilitation for transfer, ambulation and bowel and bladder care. Rehabilitation was difficult because the patient had learning disability and she had been habitually keeping her hips and knees flexed because of the sacral tumour for the past 2 years. During the last review 5 months post operatively, patient was able to sit on the wheelchair comfortably. The surgical wound was healing well with good uptake of the Split Skin Graft (Fig. ). |
A 69-year-old man fell from a stepladder with a height of about 3 m, and a sprinkler head penetrated the posterior part of the right auricle. His Glasgow Coma Scale was initially 15, and no obvious motor paralysis or sensory impairment was observed. He had abduction disorder of the right eye, paralysis of the right facial muscles, and decreased perception of the right face.\nComputed tomography revealed that the body had penetrated the petrosal bone [], and traumatic subarachnoid hemorrhage [] and acute cerebellar tent area. Subdural hematoma was observed [], the internal auditory meatus was also deviated [ and d]. and the body was close to the sigmoid sinus []. Digital subtraction angiography (DSA) showed no major artery damage. However, the sigmoid sinus was deviated, compression or damage due to the presence of foreign matter was suspected []. The patient subsequently underwent emergency surgery on the same day.\nThe operation was performed in the lower-left lateral position. The skin incision was designed in 2 pieces because we were able to rotate over a wide area to observe the vicinity of the middle fossa and sigmoid sinus []. First, the skin was cut from the temporal bone side above the foreign body. The skull was exposed and a rectangular craniotomy was performed above the foreign body to expose the middle skull base. From there, the bone was excised toward the foreign body, and the condition of the site where the tip of the foreign body had invaded was confirmed. However, it was difficult to identify the point of the damaged sigmoid sinus, and the foreign matter remained fixed to the surrounding bone. Therefore, a skin cut was added in the direction of the sigmoid sinus, and the approach was performed from the back of the foreign body. The mastoid air cell around the foreign body was scraped with a steel bar to dig up the foreign body. No damage to the skin of the auditory canal was evident. The sigmoid sinus body was not exposed and bone was removed. Bone removal was continued, and when the stability of the foreign substance was completely released, the foreign substance was removed with care. After removing the foreign matter, no clear bleeding from the sigmoid sinus or leakage of spinal fluid from the skull was observed. During the first operation, no obvious damage resulting in cranial nerve palsy was observed. The abdominal fat was filled in the mastoid air cell that had been removed to prevent cerebrospinal fluid leakage after the operation of closing the wound, and it was adhered with fibrin glue [].\nPostoperatively, broad-spectrum antibacterial drugs (CTRX and VCM) were administered for 2 weeks to prevent meningitis. He also had continuous lumbar drainage for 1 week to prevent cerebrospinal fluid leakage. There were no apparent symptoms of it.\nAfter surgery, the right hearing was completely lost in the examination. Three weeks after the operation, he was transferred to a rehabilitation hospital. |
This previously healthy 67-year-old man was admitted with chin to chest deformity in February 2011. The deformity had progressed rapidly from mild difficulty in keeping the head up to head drop over a period of 5 months (). Upon admission, he could maintain his head up with extreme effort only for about five minutes. However, he was able to correct the deformity passively with his hands and the deformity could be relieved spontaneously in a supine position. He denied any other weakness in his extremities or difficulties in chewing and swallowing. The dropped head position had severely impaired the patient's activities of daily living and withdrawn him from social contacts. He used to wear a collar for outdoor activities such as shopping but he preferred to stay home most of the times. For most of his activities and for having a meal, he used to hold his head with the left hand instead of the collar. This type of correction was repeated several times in a day. Neurological examination showed normal parameters. Cervical spine radiographs revealed degenerative changes and flexion deformity of the neck (). MRI revealed cervical spondylotic changes with mild compression of the spinal cord (Figures and ). Clinical diagnosis of isolated neck extensor myopathy (INEM) was suspected. This was confirmed through neurophysiological evaluation with needle electromyography which revealed myopathic changes in the muscles of the neck and open biopsy of paravertebral muscles showing muscle fibers of variable size or atrophic compatible with myopathy ().\nRoutine laboratory studies, such as serum creatine kinase (CK) and lactate dehydrogenase (LDH), were normal. Thyroid function tests, parathyroid hormone, acetylcholine receptor antibodies, and tumor markers were negative.\nAs he refused to undergo surgery, he was advised to wear a cervical collar to improve his neck posture and social interactions. However, according to his wife, he rarely wore the collar.\nOver a period of two years and in particular during the last season, he exhibited mild but progressive weakness of all his extremities with difficulty in buttoning or unbuttoning his shirt and mild difficulty in walking owing to an unsteady gait. He also experienced tingling in both hands. These new difficulties along with the chin to chest deformity impaired his activities of daily living more than before and forced him to seek medical advice. This time, he could keep his head up for only one minute.\nHis neurological examination revealed spastic quadriparesis with positive Hoffman's sign, hyperactive reflexes, and equivocal extensor planter response in both sides.\nCervical plain radiographs in dropped position disclosed osteoporotic cervical spine with severe kyphosis as well as instability with forward subluxation at C3-C4, C4-C5, and C5-C6 levels (). Flexion extension radiographs confirmed reducibility of the deformity (Figures and ). In neutral position radiographs, the plumb line dropped from the basion to the posterior to the manubrium (). New MRI, compared with the previous one which was taken in 2011, showed significant progression of spondylotic changes as well as myelopathic changes at C3-C4 level ().\nOne stage circumferential surgery was decided with respect to the osteoporosis. Therefore, a three-level anterior cervical discectomy fusion with cage at C3-C4, C4-C5, and C5-C6 was accomplished initially. Anterior procedure was followed with C3 to C6 laminectomy from C2 to C7 screw-rod stabilization. With the application of this strategy, simultaneous decompression of the spinal cord and correction of the deformity could be achieved. Postoperative course was uneventful and he was discharged in three days. Postoperative radiographs disclosed normal position of the neck (). Two months after surgery, his neurological exam was nearly normal except for some brisk reflexes. He was satisfied and was thankful that surgery had significantly influenced his daily activities and interactions.\nBut surprisingly, four months after surgery, his head has tendency to drop again, X-ray revealed recurrence of flexion deformity of the neck and out-pulling of both pedicle screws from the body of C7 (). Redoing surgery in order to extend the construct to the upper thoracic vertebras was suggested which was accepted by the patient.\nWith the patient in prone position the site of previous surgery was reopened and the rods and subsequently the screws of C7 were removed. Pedicle screws from T1 to T4 were inserted and the construct was extended from C2 to T4. Finally, the nuts were tightened with the head in normal position. Postoperatively, the patient was discharged after 3 days in Minerva collar, whereas the control radiographs were quite satisfactory (). Now 18 months after revision surgery, the normal head and neck posture is preserved and he has a dramatic improvement in his quality of life, enabling him to perform the daily activities (). |
A 50 year old male with the diagnosis of idiopathic osteoporosis was experiencing pain especially in the thoracolumbar area. He was taking NSAIDs for pain relief for the last few months. He was referred for bone scintigraphy upon exacerbation of his symptoms to rule out the possible micro fractures. The bone scan was obtained at 4th hour following the injection of 925 MBq of technetium 99m methylene diphosphonate (99mTc MDP). The images were obtained with low energy high resolution collimator with a 20 % window set at a 140 keV energy peak. The bed speed was 9 cm/min for continuous acquisition. There were not any significant focal activities indicating micro fractures in the skeleton. But, interestingly diffuse 99mTc MDP uptake was noticed bilaterally in the kidneys ().\nThe patient anamnesis and the patient files were investigated for the possible differential diagnosis of the observed diffuse renal uptake. There was not a history of an oncologic or chronic disease. There was not any history of chemotherapy, radiation therapy or antibiotherapy. There were not any complaints of urinary tract obstruction or symptoms of urinary tract infection. The patient was normotensive. The only medication the patient intakes was diclofenac (75 mg, 2x1 po.) for some months. So, the probability of acute kidney injury as the reason for the bilateral diffuse renal uptake of 99mTc MDP was reported. The intake of the NSAID was also noted as the possible reason for the acute kidney injury (AKI).\nRenal function tests and urine microscopy were ordered by the clinician. The blood urea nitrogen (BUN) and the creatinine values were found to be high (). On clinical evaluation, there was not any known underlying renal disease and there were not any signs and symptoms of dehydration to explain the increased values detected on renal function tests. The patient was normocalcemic. On urine microscopy, squamous epithelial cells, some reactive urothelial cells and a few cellular casts were observed. Some apoptotic cells were also observed. There was not any sign of inflammation and eosinophilia on urine microscopy. Although the urine microscopy results were most probably related with acute tubular injury, the possibility of tubulointerstitial nephritis could not be ruled out with the given findings. The therapy with the NSAID was discontinued. The BUN and creatinine values dropped gradually on the following days () and the renal function tests returned to normal limits upon resolution of the tubular injury. The final clinical diagnosis was nonsteroidal anti-inflammatory drug (NSAID) induced acute kidney injury.\nLiterature Review and Discussion\nIn the presented case we observed an abnormally and diffusely increased MDP uptake in both kidneys. The incidence of diffuse renal uptake on bone scintigraphy was reported to be less than 1 % (). One of the proposed mechanisms for the diffuse symmetrical increase is the renal injury of any kind that acts by adversely affecting the renal secretory and glomerular functions () or by the production of intracellular calcium in ischemic kidney (,). The overload of iron, by altering the distribution of bone seeking agents and decreasing the renal excretion, was also proposed to cause diffuse renal uptake on bone scan (,). The literature was reviewed for the bilateral diffuse renal uptake of bone seeking agents and the causative factors (,,,,,,,,,,,,,) were given in a table (). In one case report, Watanabe and his coworkers confirmed an exercise induced ATN in a young patient with renal biopsy which was diagnosed on bone scan ().\nThe presented patient did not have any oncologic and chronic disease. So the effects of chemotherapeutics and antibiotics as well as the chronic diseases causing iron overload were excluded. He was normotensive and normocalcemic which made the diagnosis of metabolic and vascular pathologies unlikely. The most probable cause for the visualization of the hot kidneys was AKI secondary to the use of a NSAID. AKI is a sudden decrease of the renal function manifesting with an increase in BUN and serum creatinine. The causes of AKI is divided in 3 categories and given in the table ().\nTing and his coworkers described a case of AKI presented with diffuse renal uptake on bone scan secondary to use of significant amounts of NSAIDs (). As far as we know this is the second case in the literature which demonstrates a diffuse and marked MDP accumulation in kidneys secondary to the use of NSAIDs. Interestingly, a patchy and multiple increased renal uptake on bone scan in addition to the diffuse uptake, secondary to the use of analgesics was also described in the literature (). So the hot kidneys were described both in a diffuse or patchy form secondary to the use of analgesics.\nThe medications causing renal failure act with several mechanisms. A hemodynamic renal failure may be caused by COX-2 selective inhibitors and ACE inhibitors/angiotensin II receptor blockers. Some antiviral drugs cause direct proximal tubular epithelial toxicity. Some other drugs like methotroxate and sulfonamides can cause ARF via deposition of crystals (crystal nephropathy) in the kidneys (). The renal side effects of NSAIDs are very rare. NSAIDs, either they are selective or nonselective cyclooxygenase inhibitors, result in some acute effects (AKI, hypertension, edema, congestive heart failure, hyponatremia and hypokalaemia and tubulointerstitial nephritis). The chronic effects (nephritic syndrome, analgesic nephropathy, chronic papillary necrosis and urologic cancers) and acute papillary necrosis were only reported with nonselective COX inhibitors ().\nDiclofenac is a selective COX-2 inhibitor. The risk of renal toxicity increases with the drug dose (). The COX inhibitors decrease the synthesis of cyclooxygenase-derived prostaglandins and inhibit the major role of prostaglandins which is to preserve renal function whenever the physiologic processes were compromised (). This is also true for the COX-2 selective inhibitors. The COX-2 selective inhibitors like diclofenac cause hemodynamic renal failure by reducing prostaglandins and decreasing renal blood flow and glomerular filtration rate (). The selective COX inhibitors have equivalent nephrotoxicity as nonselective ones (). The other mechanisms for the adverse renal effects caused by NSAIDs are the vasoconstrictor effect of thromboxane and reduction of prostacyclin synthesis (,). The renal side effects reverse in days, after discontinuing of the drugs ().\nWe did not perform a renal biopsy or a repeat bone scan for ethical reasons because the microscopy of the urine specimen was compatible with acute tubular injury and the renal functions returned to normal levels within a few days following the withdrawal of the drug.\nNSAIDs are widely used. Although rare, they may induce AKI which may proceed to chronic renal insufficiency if not recognized earlier. The nuclear medicine specialist must consider the possibility of NSAID induced AKI in cases with diffuse bilateral renal uptake of MDP. |
Our patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. ().\nRadiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement (). Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.\nThe patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding soft tissue. The mass was encircling the ulnar neurovascular bundle with mass abutment over the radial bundle as seen in pre-op assessment. The mass was dissected freely from its attachment to those bundles preserving both radial and ulnar structures. The mass was then excised en-bloc having a dimension of 3.5 × 4x2.5 cm (). Histological assessment showed a lesion with fasciitis like features, myofibroblastic proliferation and scattered foci of osteoid formation that was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining and no evidence of malignancy (). The resected margins were however, positive for residual lesion with difficulty in obtaining negative margins due to the extensive nature of the mass. Post-operatively, the patient had an un-eventual course. She was informed about the need for close follow-ups for both clinical and/or radiological signs of lesion recurrence, pending early surgical intervention (see ). |
A 58 year old lady sustained posterior dislocation of right elbow following a fall at home. She underwent closed reduction for dislocation elsewhere, and above elbow slab application (,). She was referred to our hospital three days later with complaints of severe pain, swelling around the right elbow and numbness of fingers. As per the treatment notes there was no obvious neuro vascular injury and radialartery pulse was felt immediately after reduction of elbow dislocation. On examination, We noted that the elbow was swollen, there were superficial blebs, forearm was tense, and there was mild stretch pain. Vascular examination showed good capillary refill with palpable radial artery pulse and decreased sensation over fingers. We evaluated the patient using X-ray of the right elbow -which showed well reduced dislocation and no evidence of fracture. To rule out any vascular injury, arterial doppler scan was performed which showed -large hematoma causing extrinsic compression over distal end of brachial artery with minimal monophasic flow in distal arteries. We took the patient for brachial artery exploration to clear-the hematoma under general anesthesia. A two cm vertical incision was made over medial aspect of lower arm and hematoma was removed. We were surprised to note a pulsating tubular structure with occluded lumen, which led to our suspicion of a complete brachial artery rupture. Immediately, the patient was referred to a vascular surgeon for CT-angiography and for further management. CT angiography showed complete right brachial artery transection five cm above the elbow with thrombus in both ends and significant blood flow in distal arteries through collateral circulation (). The patient was further treated with excision of injured segment of vessel and right transbrachial proximal and distal thrombectomy. The artery was reconstructed by interposition repair of right great saphenous vein graft and forearm fasciotomy () in anticipation of compartment syndrome and reperfusion injury. The elbow was immobilized in above elbow slab. Patient was administered with antibiotics, analgesics and anticoagulants as a post-surgical procedure. Sutures were removed on 15th postoperative day; and skin grafting was done for fasciotomy wound after three weeks. Three weeks after immobilization, the patient was advised with elbow range of motion exercises. |
A 110-kg 28-year-old male was admitted to the Emergency Department for subtrochanteric fracture of the right thigh following a road traffic accident. Besides the injured thigh, there was no complaint of pain at any other site. There was no associated injury and any other comorbid conditions. The patient was obese with a body mass index of 37 and no other comorbidities. He had no history of veno-occlusive disease, and all the preoperative laboratory evaluations were normal. Antegrade interlocking nailing was planned as a treatment strategy. He was taken into the operating theatre within 48 h of the trauma after adequate resuscitation. The surgery was carried out under general anaesthesia, with epidural analgesia. The patient was positioned on a fracture table. The well leg was placed in hemilithotomy position in 70° flexion and 40° abduction, and it was placed on a leg holder. The patient was maintained in this position throughout the procedure. Following closed reduction of the fracture, nailing was attempted. But the failure to obtain acceptable reduction initially increased the surgical time; the intraoperative plan was changed and fixation with a dynamic condylar screw (DCS) was performed (fig. ). The total surgical time was 2 h and 30 min. There was 650 ml of blood loss and 1 unit of whole blood was transfused intraoperatively. The patient's arterial blood pressure was maintained by the anaesthetists at 94/60 mm Hg or above throughout the procedure as a preventive measure to reduce bleeding at the operative site. The intraoperative traction was released after 2 h for 5 min. When the procedure was nearing completion, a dose of epidural analgesia was given to relieve the patient of any possible postoperative pain. The patient was shifted to the ward after the completion of surgery.\nIn the postoperative rounds, the distal pulses of the operated extremity were palpable and any neural deficit could not be assessed as the patient was under the effect of epidural analgesia. The well leg was not examined by the surgeon and the nurse. Four hours after the end of surgery, the patient complained of severe pain in the well leg. A tense and firm swelling was found and stretch pain was present (fig. ). On physical examination, there was paraesthesia on the lateral aspect of the foot. A diagnosis of well-leg compartment syndrome was made. An urgent radiograph of the well leg was taken to exclude any bone injury which might have been missed. The radiographs revealed no bone injury, and the patient was treated with an immediate fasciotomy. A double-incision fasciotomy was performed. Vacuum-assisted closure suction was applied over the fasciotomy wound (fig. ). His wounds healed without difficulty and he regained normal strength and sensation in the lower extremity. The patient was discharged on the 20th postoperative day. The fracture united both clinically and radiologically at the 12th week. At the last follow-up at the end of 1 year, the patient had resumed his occupation. |
A 44-year old male was referred following investigation for chest pain and dyspnoea. He had no pre-existing co-morbidities. Physical examination revealed feeble femoral pulses and he was found to be hypertensive with marked differences between the upper and lower limbs (systolic blood pressure upper limb 190mmmHg, lower limb 75 mmHg, with an ankle brachial index (ABI) of 0.39). Electrocardiogram revealed evidence of severe left ventricular hypertrophy. This was confirmed with echocardiography which also demonstrated a tricuspid aortic valve with significant aortic regurgitation in the presence of an aortic root aneurysm of approximately 9 cm. Left ventricular function was preserved. Computerised tomography angiography (CTA) was performed to evaluate the aortic pathology in further detail (Fig. ). The scan noted an aortic root aneurysm (8.8 cm), in addition to the presence of severe aortic coarctation, with subtotal occlusion and a lumen less than 6 mm in size. The coarctation was just distal to the left subclavian artery, at the aortic isthmus. There was clear evidence of collateral circulation to the descending thoracic aorta via the subclavian and intercostal arteries. Coronary angiography confirmed a right dominant coronary system with no significant coronary disease.\nA multidisciplinary team meeting took place and a consensus was agreed to proceed with a two staged hybrid approach, with the first phase involving an endovascular approach to stent the coarctation, followed by a second stage to perform the surgical repair of the aortic root aneurysm. The first stage to stent the coarctation was unsuccessful via the femoral approach, as the guidewire could not cross the coarctation. Assessment through angiography via the left brachial artery showed complete obstruction at the aortic isthmus. The decision was then made to proceed to a single stage surgical approach to treat both lesions.\nAfter induction of anaesthesia, arterial lines were placed in the left radial and left femoral artery. A right infraclavicular incision and a right groin incision was made this was to establish peripheral arterial cannulation access to the right axillary and right femoral artery. An 8 mm dacron graft was anastomosed to each vessel for indirect cannulation. Median sternotomy was performed to access the mediastinum and expose the heart and aorta. Following heparinisation cardiopulmonary bypass (CPB) was established with venous return from bi-caval cannulation. The body temperature was cooled to 25 degrees Celsius. The right superior pulmonary vein was used for venting. Once the cross clamp was applied, complete cardiac arrest was achieved using Custodiol 25 ml/kg crystalloid cardioplegia via a retrograde cannula through the coronary sinus. A further top up of cardioplegia was given once the aorta was opened through direct cannulation of the coronary ostia.\nThe aortic root, valve and ascending aorta were excised. The coronary ostia were fashioned as buttons from the native aortic root. The coronary ostia were noted to be significantly displaced, with distorted anatomy due to the patient’s disease process. Therefore, 8 mm dacron grafts were attached end-to-end to each ostia, with view to performing the modified Cabrol technique later following replacement of the root. The heart was then retracted in a cephalad position to access the posterior pericardium. A vertical incision was made to expose the descending thoracic aorta (DTA). An end to side anastomosis was formed with a 20 mm dacron graft to the DTA (Fig. ). This graft was then routed posterior to the inferior vena cava (IVC) and anterior to the right inferior pulmonary vein (RIPV), adjacent to the right atrium (RA). Root replacement was then performed with a 25 mm biological valved-conduit, as this was favoured by the patient over a mechanical prosthesis, despite the risk of a difficult redo procedure in the future. The 8 mm dacron grafts attached to the coronary ostia were anastmosed to the root conduit as neo coronary ostia. The distal part of the valved-conduit was anastomosed to the proximal arch under selective antegrade cerebral perfusion (SACP). Finally, an end to side anastomosis was fashioned between the 20 mm extra-cardiac graft (attached to the descending thoracic aorta) and the ascending portion of the valved-conduit. Valve-sparing root replacement was not considered in this patient due to the grossly abnormal aortic anatomy.\nFollowing rewarming and deairing the patient was successfully weaned off CPB. The bypass time was 160 min, the cross-clamp time was 120 min, and the SACP time was 40 min. Haemostasis was achieved and thereafter a routine closure of all incision sites. The patient remained in ICU for less than 48 h, and made excellent progress on the ward. Minimal anti-hypertensives were required and the patient was discharged on 8th day post operatively neurologically intact and independent. At 3 months follow up the patient underwent a repeat CTA scan which showed complete patency in the extra-anatomical graft and resolution of the collateral arterial network (Fig. ). |
A 69-year-old right-handed female was admitted to our hospital because of a pulsatile mass at the right side of the neck, below the angle of the mandible. The patient reported that she had noticed the mass for the first time 13 years ago and has been followed up regularly. There was no history of any infective lesion, trauma, or any family history of aneurysm disease. There was no palpable lymphadenopathy. Initially, she has treated conservatively and due to the appearance of the symptoms such as enlargement of the size of the mass and dyspnea on exertion. She had been managed with endovascular treatment as parent vessel occlusion 4 years ago []. There was shrinkage of the size of the mass and improvement of the symptoms. Over the past 6 months, the size has again started to enlarge and also the appearance of the symptoms and its pulsatile nature became more evident. Clinical examination showed a pulsatile mass on the right side of the neck. No neurologic symptoms occurred in the patient. Examination of the cranial nerves showed no anomalies. A computed tomography (CT) angiography followed, verifying the presence of a fusiform giant aneurysm of the right ICA, measuring 5 cm in diameter. To further define the right EICA and the remaining cerebral circulation, CT angiography was performed with three-dimensional (3D) reconstruction. The 3D reconstruction confirmed a fusiform aneurysm arising from the proximal right EICA []. Despite the patient had undergone endovascular management 4 years ago in the form of parent vessel occlusion, we could see the minimal flow in the EICA which may be due to recanalization. No intracranial aneurysmal disease was identified. The aneurysm measurements were 25 mm × 30 mm, with a cranial-caudal length of 50 mm and a wide neck. An aneurysm extended from 2 cm after the carotid bifurcation nearly to the base of the skull. The patient elected for surgical correction, as she was finding her symptoms troublesome and was keen for a “definitive” solution. Since the patient had undergone endovascular management and still there was enlargement of an aneurysm and causing symptoms, the plan of surgical exploration was made. The procedure was performed under general anesthesia through an incision in the neck along the anterior border of the sternocleidomastoid muscle. The arterial wall was atherosclerotic, and there was a large intraluminal thrombus. She underwent arteriotomy and evacuation of the thrombus and ligation of the EICA []. Postoperative recovery was uneventful without neurologic dysfunction. Postoperative neurologic examination was without anomalies. Surgical pathology of the specimen confirmed the hyalinized thrombus. The biopsy from the wall showed intimal fibromuscular dysplasia which is compatible with the aneurysmal wall and CD34 immunohistochemistry showed the vasa vasorum []. |
An 18-year-old man was admitted to our department showing the symptoms of blurriness. A 1-year history was reported on blurriness and visual indistinctness that had progressively worsened over the past 2 weeks. He has a record of tuberculosis and takes anti-TB drugs on a regular basis. Neurologic examinations at the time of admission revealed no focal neurologic deficits except for oculomotor paralysis. Magnetic resonance imaging (MRI) indicated that the diameter of intracranial segment in the left internal carotid artery was significantly dilated, the inner diameter was approximately 14 mm, the left anterior cerebral artery, and the starting point of the MCA were slightly dilated as well, and the structure of the left cavernous sinus area lacked clarity. There was a circular liquid signal shadow spotted under the inner wall of the left maxillary sinus, the diameter of which was about 16 mm (Fig. ). Further cerebral angiography indicated that the left internal carotid artery GSA was about 48.61 mm × 23.40 mm in size, 4.65 mm in diameter of proximal vessels, and 3.16 mm in diameter of distal vessels (Fig. ).\nHis family was informed of these conditions and signed a consent form prior to the operation. The balloon occlusion test conducted previous to surgery indicated that the anterior communicating artery was open and the contralateral internal carotid artery had a good compensatory blood supply, as a result of which direct trapping of the parent artery was taken as an alternative method. However, ipsilateral MA has a potential of further growth which could lead to paralysis of facial nerve compression, which is due to higher blood flow to the external carotid artery. His family members rejected this traumatic treatment method and thus the insertion of stents was chosen to reconstruct the original structure of the vessel. Therefore, the following surgery was performed: antiplatelet therapy (100 mg aspirin + 75 mg clopidogrel daily) was carried out at least 3 days prior to the operation, and he underwent surgery after being diagnosed with anesthesia. Firstly, a LEO (6.5 mm × 75 mm) stent was put through an Echelon-10 catheter located in the MCA, and then the stent was released at a slow pace and completely through the GSA. Meanwhile, the head was anchored at the distal end of the parent artery. Subsequently, the trans 300 floppy guidewire was switched to the marksman on the MCA. The Tubridge flow diverter (6.5 mm × 45 mm) was easily placed into the designated position where it was attached to the LEO stent that was well anchored before. With the assistance of X-ray, the Tubridge flow diverter was slowly released to overlap with the LEO stent wall and the aneurysm neck was completely covered. Ultimately, digital subtraction angiography (DSA) revealed obvious retention of contrast agent in GSA, and three-dimensional vascular reconstruction demonstrated that the walls of the parent artery were reconstructed by both Tubridge and LEO stent (Fig. ). Then, the guide catheter to the external carotid artery was replaced, liquid glue (50%, 1.5 ml) was injected, and three coils were released through the microcatheter. Finally, the right femoral artery with an 8F Angio-Seal vascular occlude was blocked. The patient needed to avoid stent thrombosis by taking aspirin for a long period of time, although the thrombo-elastography (TEG) test indicated that arachidonic acid inhibition rate (AA%) and inhibition rate on ADP receptor of clopidogrel (ADP%) were within the normal range. After a follow-up observation for 1 year, DSA revealed that the aneurysms were almost completely occluded and the abnormal serpentine channels disappeared. Meanwhile, the MA disappeared as well. The two stents overlapped in the parent artery with excellent adhesion, and no stenosis or displacement was discovered. Three-dimensional revascularization indicated a significant reduction in aneurysm volume, and the mass effect was reduced as shown by CT scan (Fig. ). |
A 42-year-old multiparous female case was admitted due to a palpable itching mass in the genital region that caused difficulty in walking and difficulty in sexual intercourse. It had been reported in the history of the case that she had been circumcised by a village midwife at the age of 7, who was brought by her mother, and then she got married at the age of 16. She delivered through vaginal delivery 3 times at home; the small papillary formation that is present at her left inguinal region that has caused itching from time to time since her puberty has grown rapidly in recent years, eliciting pain in the genital region and difficulty in sexual intercourse. She presented to the obstetrics and gynaecology clinic compulsorily at the request of her husband and, furthermore, she has not had a child for the last 5 years due to the problem in sexual intercourse and she stated that this situation affected her family life. On the evaluation of the case, a 4 × 3 × 2 cm sized, regularly contoured, mobile, sensitive mass was visualized, which was covered with normal skin, including a cystic structure, at the left vulvar inguinal region that caused difficulty in walking and sitting. In the detailed assessment of the case, it was observed that the mass had a cystic component and there was a previous type 2 genital circumcision scar close to the border of the labium majus on the skin of the left inguinal canal (). The routine complete blood count, complete urine analysis, and biochemistry parameters were within normal limits, and the case was evaluated as a benign appearing mass of cystic nature without lobulation and septation on the performed superficial tissue ultrasonography. The case underwent an elective total mass excision operation. Perioperatively, a 4 × 3 cm sized cystic mass, filled with keratinous material in the slices, of off-white colour, was observed (). On microscopy, squamous epithelium consisting of a cyst wall and keratinous material inside the cyst lumen (H&E 40) were detected (). Epidermoid cyst was reported on the histopathological examination of the patient, who had no other trauma and surgery history other than genital circumcision in the vulvar region. The patient had no problems in the postoperative period and the 3rd month control was stated to be normal, and it was also stated that she did not have any anatomical and functional problems and that they had no problem during sexual intercourse and, therefore, she and her spouse were feeling happy. |
A 59-year-old male was transferred from a general hospital to the tertiary psychiatric hospital in August 2011 after treatment of heart failure. He had been "healthy" and functioning well premorbidly and had multiple medical conditions such as hypertension, diabetes mellitus and hyperlipidaemia. He was first admitted to the cardiology unit of a general hospital in January 2011 after he collapsed during jogging. Following basic cardiac life support he was rushed to the emergency room of the general hospital. He was diagnosed to have acute myocardial infarction secondary to triple vessel disease and was arranged for coronary artery bypass surgery when his physical condition was stabilised. The electroencephalography and computerised tomography (CT) scans of the brain done on the day of admission in view of his fall were normal but the magnetic resonance imaging of the brain 10 days later showed mild generalized involutional change and disproportionate atrophy of basal ganglia and hippocampus. He regained full consciousness about 5 hours after the admission and was noted to have resting tremors and mild cogwheel rigidity before the administration of any psychotropic medications. He showed mild impairment in both retrograde and anterograde memory, which was greater for short term than long term memory. Subsequently, he was observed to have fluctuating conscious state and agitation but no localised motor or sensory neurological deficits. Laboratory investigations, which were performed including full blood count, renal, liver, thyroid function tests, and infective screen did not reveal any abnormalities. He was then discharged to a unit for cognitive rehabilitation in April 2011 and he was receiving oral haloperidol 2.5 mg daily for his agitation. For the next two months at the rehabilitation centre, he remained disoriented to time, place and person and can be emotionally labile at times.\nIn June 2011, he underwent his scheduled coronary artery bypass surgery. Intra-operatively he did not have any complications related to the surgical procedures or anaesthesia. However, postoperatively, he continued to be agitated and more disoriented to time, place and person, which persisted for the next 3 months. A month after his cardiac procedures, he was transferred to a residential facility for further cognitive rehabilitation and he was receiving oral haloperidol drops 3 mg daily for his agitation. He was subsequently re-admitted twice to a general hospital after he punched a nursing home staff on both occasions. In order to control his agitation, aggression and perceptual abnormalities, many antipsychotic medications were tried. His psychotropic medication was finally changed to olanzapine 2.5 mg daily as he exhibited extrapyramidal side effects attributable to the haloperidol and risperidone and orthostatic hypotension to quetiapine. The treating team also tried mood stabilisers but he developed adverse drug reactions such as maculopapular rash with lithium, sodium valproate and Steven Johnson syndrome with carbamazepine. As he also assaulted a staff nurse in the general hospital, he was transferred to a tertiary psychiatric hospital for further management of his neuropsychiatric condition.\nAt the psychiatric facility, his disorientation to time, place and person continued. He was agitated frequently, which needed rapid tranquilization and brief periods of minimal physical restraint for his safety. Formal cognitive assessment was attempted using Mini Mental State Examination (MMSE) and clock drawing test, but could not be completed owing to his uncooperative behaviour. The repeat CT scan of his brain revealed increased generalized volume loss of his brain. The nurses noted "sun downing effect" as he tended to become more disoriented and agitated towards the latter part of the day. He had impaired sleep wake cycle in that he was noted to be sleepy during the day time and more alert and disturbed at night. He also insisted on being only attended by female staff and even requested for alcohol in the ward although he was a teetotaller. As he continued to exhibit high risk of agitation, he was transferred to a high dependency psychiatric care unit for closer observation and management.\nDuring his four weeks' stay in the high dependency psychiatric care unit, he continued to have cognitive deficits in orientation, attention and concentration, memory which mainly worsened at night. Gradually his agitation responded to sulpiride 800 mg daily which was chosen due to the lower tendency for extra pyramidal symptoms. He could repeat sentences but was unable to recall the names of his close family members. Formal cognitive testing was attempted several times but to no avail due his uncooperativeness. Repeated laboratory investigations including full blood count, renal, liver and thyroid function tests, serum calcium and magnesium levels and cardiac enzymes were normal and his electrocardiogram showed sinus rhythm with left ventricular hypertrophy. Since his cognitive functions did not improve, he was referred to a psycho-geriatrician and subsequently transferred to the psychogeriatric ward for further management.\nIn the psychogeriatric ward, his clinical status remained the same for another few months. Nine months after the index cardiac event, the delirious features including disorientation to place and person, impaired attention and concentration, altered sensorium, perceptual disturbances such as visual and auditory hallucinations, emotional lability and psychomotor disturbances slowly improved. The altered sensorium, perceptual and psychomotor disturbances finally completely resolved with residual short term and long term memory deficits. He needed assistance for all his basic activities of daily living including toileting and feeding. He became more cooperative with the formal cognitive testing scoring 14 out 30 on MMSE. Input from the multi-disciplinary team involving psychiatric nurses, occupational therapist, physiotherapist, speech therapist and psychologist was sought to manage and improve his functional status. His social issues were addressed by the medical social worker. He was also reviewed by the visiting geriatrician on a regular basis for the management of his underlying medical conditions and he was prescribed clopidogrel 75 mg daily, frusemide 20 mg daily, perindopril 2 mg daily, simvastatin 40 mg daily and gliclazide 20 mg daily for his medical conditions. Overall, he was diagnosed with dementia which was secondary to cardiac arrest related HIE and complicated by prolonged delirium-which started following the incipient episode of cardiac arrest in January 2011 with further exacerbation after the cardiac bypass surgery. The other possibility of depressive episode resulting in cognitive deficits such as "pseudo dementia" was ruled out, as there was no clinical evidence to suggest a depressive episode that preceded the cognitive disturbance in this patient.\nAt the time of writing this case report, the patient still remained confused with significant impairment in short term and long term memory, although there was no fluctuation in consciousness or perceptual abnormalities. He needs assistance in all his basic activities of daily living and he displays aggressive behaviour in the ward on and off. |
Subsets and Splits