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A 12-year-old boy presented to the emergency department with headache and scalp swelling. His left parietal scalp had swelled immediately after his elder brother pulled his hair during a quarrel. He denied any direct impact on his scalp. No medical illness was found in the patient's personal history. Scalp swelling on the left parietal region was observed on brain computed tomography (CT) without any intracranial lesions (). He returned home without any medical intervention.\nHe visited the neurosurgery clinic 2 days after the trauma. The scalp swelling did not change, and his headache subsided. He did not have a history of easy bruising or bleeding. He and his mother were encouraged that the course of SGH would be benign and resolved spontaneously in a couple of weeks, and they returned home. He visited the emergency department again in the evening of the next day (trauma day 3). His scalp swelling expanded throughout the scalp (). The CT angiography on the head was taken for detecting any associated vascular abnormalities in the scalp. No pathological findings were revealed (). His mother denied any further trauma, known coagulopathy, or history of taking aspirin or other anticoagulants. The patient was transferred to the general ward. No further maneuvers, such as an elastic bandage, were applied.\nIn the next morning, he did not complain of aggravation of the scalp swelling or headache. Catheter cerebral angiography was performed, and no blood leakage was noted (). He suddenly complained of severe headache and right eye pain in the evening. Proptosis of the right eye was observed, and the eye did not close completely. He complained of blurred vision in the right eye and diplopia. It deviated downward and was limited for the upward gaze. His left eye was normal. There was no relative afferent pupil defect (RAPD) in either eye. Needle aspiration for the SGH from the frontal scalp (250 mL) and supraorbital region above the medial eyebrow (110 mL) was urgently performed. His proptosis improved slightly, and complete eye closure was achieved. An elastic bandage was wrapped around the head. An oval hematoma in the right superior orbit was found on the sagittal CT image ().\nIn the laboratory test at admission, the blood hemoglobin was 14.0 gm/dL, hematocrit 40.3%, and platelet 289,000 /uL. The prothrombin time (PT_INR) was 1.02, and activated partial thromboplastic time was mildly prolonged at 57.6 seconds (27.7–44.2 seconds). Laboratory workups for coagulation abnormalities were also performed. And then, 10 mg of vitamin K was injected intramuscularly, and 2 pints of fresh frozen plasma were transfused. The blood hemoglobin level decreased to 12.0 mg/dL 1 day after the aspiration.\nThe aPPT was corrected to 43.8 seconds in the plasma mixing test. This meant that the deficiency of coagulation factors existed. For the coagulation factor assay, factor IX was 7% (60–140), and factor VIII was 51% (60–140). A marked deficiency of factor IX was revealed, and hemophilia B was diagnosed. His eye was protected with an ointment and an artificial tear. The intraocular pressure of the right eye was 13 mmHg, and proptosis was 7 mm compared to the left eye on exophthalmometry. His mother informed us that his male cousin on the mother's side was recently diagnosed with hemophilia. The cousin was not receiving any special medical treatment until now. A total of 850 mL of hematoma was aspirated during the following 3 days, and the blood hemoglobin dropped to 10.2 gm/dL. The boy was transferred to a specialized center for pediatric hematologic diseases after hemophilia was confirmed in the laboratory test. He underwent surgical evacuation for IOH at another hospital. The patient recovered completely from SGH and IOH without any complications. |
A 61-year-old woman presented to our outpatient clinic complaining of an indolent, firm, hard subcutaneous nodule on her left thigh. She believed that she had a sebaceous cyst as she had an abscess on the contralateral thigh few years previously. In addition to the removal of a malignant melanoma 25 years ago, her past surgical history included a hysteroadnexectomy for endometriosis and a drainage of a suppurating sebaceous cyst on the right thigh. She also suffered from endometriosis, abdominal chronic pain, and chronic constipation.\nIn 1989, she was diagnosed with malignant melanoma, which was located on the middle third of her left calf. It was excised with a wide margin and the pathological report from the excisional biopsy revealed a “superficial spreading melanoma with epithelioid cellular morphology, median mitotic rate, low inflammatory infiltrate throughout the tumor or along it, Clark level III, and Breslow 1.4 mm.”\nAt the time of the excision, there was no evidence of distant metastasis or pathological regional lymph node spread, and no other atypical melanocytic lesions were observed. Subsequently, the scar was excised with an additional margin and no residual tumor cells where found. No further therapy was planned, and she underwent regular follow-up for 10 years without any signs of relapse and no other cutaneous neoplasms were noted during physical examination. The treatment she underwent was in line with guidelines at that time as it was a complete excision with negative histopathological margins [].\nThe characteristics of our patient's primary melanoma were similar to those related to lesions with late metastasis. She was a female, with an extremity located superficial spreading melanoma and intermediate (1.0 to 3.0 mm) thickness, Clark's level III. She presented with Stage I disease (in the pathological report there was no sign of ulceration), and the recurrence was regional []. A secondary melanoma manifesting as a confined subcutaneous lesion was highly unlikely given their extremely low prevalence and poor prognosis [].\nA fine-needle aspiration of the newly discovered lesion was promptly performed, and the cytological examination revealed a malignant tumor compatible with a subcutaneous localization of a malignant melanoma. Immunohistochemistry findings demonstrated positive staining for Melan A and HMB 45. A complete excision of the lesion with a narrow margin was performed in accordance with the guidelines.\nThe final pathological reports described a “subcutaneous localization of melanoma, with necrotic areas, a mitotic index of 15/mm2, and an angiolymphatic invasion”; the immunochemistry staining showed HMB 45+, Mel ARED+, and MIB 1 40%. The immunohistochemical profile along with the morphological appearance agreed with the diagnosis of metastatic melanoma. Furthermore, the genetic analysis reported a BRAF codon 600 mutation in exon 15.\nThorough investigation, including a total-body PET-CT, failed to reveal any other primary melanoma or metastasis. For our patient, we discussed the choice of not performing SLN biopsy in our multidisciplinary tumor board and subsequently scheduled nevus mapping and radiological exams.\nThe patient was referred to an oncologist and had yearly clinical and dermatoscopic follow-ups. The latest was in 2019. She was not started on any adjuvant therapy.\nAs an incidental finding, a contrast enhancement of the right superior lobe of her thyroid was also discovered during the staging CT for which she was referred to her general practitioner. She has until now not shown any recurrence of her disease. |
A 14-years-old boy came with pain in lower lumbar region lasting for 5 months. One month before presentation, pain had referred to right thigh. He also complained of mild anorexia and weigh loss of about 3 kg. There were no gastrointestinal symptoms, fever and sweating in that period. Physical examinations revealed that he suffered only mild to moderate tenderness on sacral region with a very mild bulging with firm consistency. Muscular force in the proximal of lower extremities was normal while there was a moderate weakness in left foot muscles. Plain radiography of the pelvis and lumbosacral region revealed a large sclerotic lesion with ill defined borders in the first sacral vertebral body, with extra skeletal extension. MRI of this region revealed a large destructing bone lesion in sacrum ().\nComplete blood counts and serum biochemistry showed normal profile except increased serum level of Lactic Dehydrogenase (LDH=886) and Alkaline Phosphatase (ALP=1893).\nChest radiography was normal and whole body bone scintigraphy revealed an increased uptake only in sacral region.\nOpen biopsy of the lesion was done and pathologic study performed. In microscopic evaluation sarcomatous neoplasm was seen with foci of tumoral ossification composed of branching woven bone trabeculas as well as foci of poorly differentiated hyper cellular regions and extensive areas of chondroblastic differentiation with small areas of mixoid tissues. Grading of tumor was estimated 2 out of 4 and final pathologic diagnosis was chondroblastic osteosarcoma grade 2 ().\nAccording to the site of origin and large volume of the tumor it was surgically unresectable; therefore the patient took chemotherapy plus radiotherapy.\nChemotherapy regimen consisted of 2 drugs of cisplatin and doxorubicin; after 4 courses of this regimen pain subsided dramatically and patient received radiotherapy which was delivered with cobalt-60 teletherapy unit with dose of 6000 centigray in 30 fractions during 7 weeks to the gross tumor with a 3 to 5 cm margin in all directions. After completion of radiotherapy, chemotherapy continued for extra 3 courses of the same regimen.\nAt the end of treatment and until the last follow up at 48 months later, the patient was completely asymptomatic with normal performance status and there was not any evidence of active loco regional tumor or distant metastasis.\nThe last pelvic CT scan revealed that sclerotic lesion of the sacral vertebrae with its soft tissue extension remained without any progression. |
A patient, 35-year-old female, came to our clinic because of severe vertigo and paroxysmal headaches for about 2 years. She mostly suffered from vertigo at night with multiple vomiting spells and bilateral tinnitus, which would last the entire night. During the period of vertigo, she also had a headache at the right temporal site, which was present a kind of pulsatile pain and could last several hours; this caused nausea and the inability to fall asleep. Prior to the onset of the vertigo and headache, she also had a visual aura with wave sight that lasted 10 min. Approximately 10 of these attacks were trigged by loud noises or bright lights, accompanied with symptoms such as chest tightness, tachypnea, and blushing. The migraine attacks were mostly accompanied by vertigo, becoming more severe during vestibular episodes. Those symptoms continued to worsen over the next week from the initial onset. During this time, the patient suffered from vertigo for several hours daily, and also suffered from repeated vomiting, numbness on the right side of the face, and tinnitus in the ear. The attacks of vertigo had no connection to changing body position. The headache occurred on the right side with visual aura expressing as fortification spectrum during vertigo. Physical examination found dysesthesia around the right side of the forehead and unsteady gait.\nThe patient’s clinical history revealed a more frequent occurrence of migraines during the period of pregnancy. The headache was usually a throbbing, unilateral temporal pain for 20 min each time. It would result in nausea and vomiting, which led to functional limitation in daily activities and led to bed rest to alleviate her symptoms. Meanwhile, the patient also had a visual aura with waves of light that lasting approximately 10 min. She had no family history regarding her illness, history of drug use, allergy, smoking, or drinking.\nA neurological examination showed clockwise rotary nystagmus when she gazed to the left side, and an abnormal finger-to-nose test at the right side. The patient had normal muscle tone and muscle strength, and no appearance of the Babinski Sign. Vestibular system tests including Dix-hallpike, Roll-test as well as a head thrust test were all negative as well.\nLaboratory test showed the HbA1C was 5.1%, and plasma homocysteine was 9.5 μmol/L. The autoimmune antibodies including pANCA、cANCA(−)、MPO、PR3、ENA、ACA-IgA、ACA-IgG、ACA-IgM、ANA、ds-DNA、DNP were negative except for the AECA(++). Thrombophilia markers were also tested, including protein C activity (130%)、von Willebrand factor activity (109%) 、free protein S activity (76%) as well as antithrombin III activity (109%). Other tumor markers regarding lung cancer and colon carcinoma were all negative and thyroid gland function was also normal. The routine test of cerebrospinal fluid (CSF) was normal, while the aquaporin (AQP) 4 antibodies were negative in both plasma and CSF.\nThe electro-audiometry test revealed a mild hearing impairment in the right ear. Other Neuro-electrophysiology tests, including brainstem auditory evoked potential (BAEP)、visual evoked potential (VEP)、electromyogram (EMG) as well as nerve conductive velocity (NCV) were all normal. The cardiac and carotid ultrasound exams were both negative. The diffusive weighted imaging showed subacute infarction in the right lateral medullar on January 8th (Fig. a, b). The digital subtraction cerebral angiography (DSA) indicated a left intracranial aneurysm on the next day (Fig. c). The infarction and intracranial aneurysm were located on separate sides of the brain, which suggested that the Wallenberg syndrome might not be caused by the intracranial aneurysm. DSA imaging showed that the communicating artery between anterior and posterior circulation of cerebral arteries was not open, and ipsilateral posterior inferior cerebella artery could be seen clearly (Fig. d). We administrated antiplatelet treatment as well as Flunarizine immediately. The patient’s vertigo symptoms diminished just in a few days, with the patient being discharged three weeks later with oral medication, including Betahistine Mesilate 6 mg tid, Dihydroergotoxine 2.5 mg bid, Aspirin 100 mg qd and Flunarizine 5 mg qn. At the patient’s 3-month follow-up, she said she had only once been affected by vertigo and the migraines were less common and less intense than she was previously experiencing. |
A 42-year-old female who was apparently healthy with no known allergies presented to the undergraduate clinic at the dental school of King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia, for endodontic treatment of her lower right central incisor (tooth #41). The patient was given an inferior alveolar nerve block, a rubber dam was applied, endodontic access was achieved, and the pulp was extirpated. The student irrigated the canal using a total of 12 cc of 3% NaOCl. During irrigation, the student noticed increased bleeding from the canal, and the instructor advised her to continue irrigation to stop the bleeding.\nThe patient reported severe pain and a burning sensation, and the student immediately stopped the treatment and removed the rubber dam, at which point she noticed extensive swelling of the lower lip and chin related to the treated tooth (). The emergency response team in the dental school was summoned and, upon arrival, they found that the patient’s vital signs were stable and her oxygen saturation was 100%. An intravenous line was started immediately, and a dose of 100 mg of hydrocortisone was administered through the intravenous line. The patient was transferred to the emergency department for observation.\nThe swelling in the chin and sublingual area continued to progress rapidly during the next 4 hours, involving the lips and the submental and sublingual spaces and resulting in elevation of the floor of the mouth. At that point, the patient started to exhibit signs of upper airway obstruction, with stridor, labored breathing, and declining oxygen saturation.\nThe patient was transferred to the intensive care unit (ICU), where a decision was made to intubate her using an oral endotracheal tube, which was inserted without difficulty, and the patient was placed on a mechanical ventilator. During her stay in the ICU, she was treated with 1,000 mg of cefazolin and 8 mg of dexamethasone every 8 hours. She remained intubated for 72 hours, during which the swelling started to slowly decline and the floor of the mouth became soft and nonraised ().\nThe patient was extubated after exhibiting positive cuff-leak test results and other ICU extubation criteria. At that time, intraoral examination revealed a 2 cm ×1 cm ulcer in the lower anterior vestibule, extending in depth to the bone (). The patient denied any paresthesia or altered sensation of the inferior alveolar nerve or mental nerve branches.\nThe patient was transferred to the ward and observed for another 24 hours, during which the oral wound was monitored for signs of infection. She was seen by an immunologist to rule out an allergic reaction using the following immunological tests: antinuclear antibody, double-stranded deoxyribonucleic acid antibody, complement-3, complement-4, total immunoglobulin (Ig)E, Phadiatop (IgE against common inhalant allergens), thyroid peroxidase antibody, thyroid thyroglobulin antibody, IgG, IgA, and IgM. All of the allergen tests were negative, and the antibodies were within the normal limits. A skin patch test was negative for NaOCl hypersensitivity.\nThe patient was discharged from the hospital on a short taper of prednisone. She continued to be followed up as an outpatient, and during this period, the intraoral wound was monitored. Healing of the ulcer occurred through secondary intention, and it completely healed without a significant scar or nerve deficit after approximately 3 weeks. The patient refused to return for completion of the planned dental treatment.\nThe differential diagnosis of the case includes an NaOCl accident and an allergic reaction to the rubber dam or NaOCl. The patient did not exhibit the typical signs of an allergic reaction, such as itching or rash, and the allergic testing for NaOCl was negative. In addition, the needle used for irrigation was a regular needle, not an endodontic one, and the solution may have been applied under pressure, resulting in perforation into the apical region and extravasation into the tissue. Therefore, a diagnosis of NaOCl accident was established. |
A 43-year-old male with a history of uncontrolled hypertension was admitted to our neuroscience intensive care unit form an outside institution with a diagnosis of a Hunt & Hess grade 4/Fisher grade 3 SAH (). An EVD was placed on admission and a digital subtraction angiography (DSA) was performed which demonstrated presence of the right vertebral artery fusiform aneurysm with the posterior inferior cerebellar artery (PICA) arising from the base of a focal dilatation from the fusiform aneurysm segment (). After consideration of all the treatment options, endovascular treatment was elected in view of poor grade SAH and patients' cardiopulmonary status. He underwent coil embolization along with placement of a PED across the aneurysm. A 6-French guide catheter was used to selectively catheterize the right vertebral artery. A microcatheter was subsequently placed into the vertebral artery with coiling of the focal dilatation arising off the aneurysm along with deployment of a 3.75×18 mm PED completely covering the fusiform vertebral aneurysm for vessel remodeling. A Raymond class II occlusion of the focal dilatation arising from the fusiform aneurysm was achieved (). The patient was loaded with aspirin and clopidogrel during the procedure. The EVD was converted to a ventriculo-peritoneal shunt before the patient was discharged home in a good neurological condition. He was alert and oriented with no focal def icits at discharge except presence of right sided sixth cranial nerve palsy. Dual antiplatelet agents were prescribed for 6 months following the procedure. Routine follow up angiography done at 6 months as per our institutional protocol showed coil compaction and enlargement and regrowth of both the focal dilatation and the fusiform aneurysm without migration of the pipeline stent (). Even though the patient was asymptomatic, considering significant enlargement of the aneurysm with a prior presentation with SAH, he was taken back to the neuro-interventional suite with placement of three overlapping PED's (3.5 mm×18×2 and 3.5×14 mm) to increase the overall coverage area and further reduce the shear stress which possibly caused the aneurysm to continue growing despite treatment with a single PED on presentation. The post procedure course was uneventful and he was discharged home with no new neurological deficits. A follow up angiography was performed at 3 months which showed no residual aneurysm () with no neurological deficits on clinical examination. |
A 3-day-old boy from Kosovo, weighing 2.4kg, was admitted to our hospital with severe dyspnea and cyanosis. Transthoracic echocardiography revealed d-TGA with intact ventricular septum, left aortic arch and a 4mm patent ductus arteriosus. Medical therapy with prostaglandin E1, dopamine, oxygen and antibiotics was initiated. The following day, owing to hemodynamic instability, urgent corrective cardiac surgery was necessitated. The intra-operative findings included the following. The sinus 2, according to the Leiden convention [], presented two coronary ostia: one giving off a branch as the right coronary artery, and the other one originating at a long left main coronary trunk and passing directly backward in close relation to the pulmonary artery, then curving around its posterior aspect to reach the atrioventricular groove, from whence it bifurcated into the left anterior descending and circumflex arteries. An additional branch originated from sinus 1 as a conal branch, giving rise to the septal branches. Translocation of the coronary arteries was performed. The new pulmonary trunk was reconstructed to avoid compression of the coronary artery and distortion of the great arteries. Immediately after surgery, the patient was unstable hemodynamically, as demonstrated by left ventricular (LV) failure and persistent pulmonary edema requiring inotropic support and mechanical ventilation. Transthoracic echocardiography revealed the presence of an anomalous accelerated Doppler flow localized at the left side of the heart, precisely at the aortic arch level. This Doppler image gave rise to our suspicion of an anomalous shunt between the systemic and pulmonary circulation. The hemodynamic study demonstrated a unique supra-aortic anomalous vessel originating from the left subclavian artery. The anteroposterior projection demonstrated an anomalous vessel originating from the inferior wall of the left subclavian artery, from whence it divided into two branches supplying both lungs as BAs (Figure ). The anomalous BA originating from the left subclavian artery was the principal cause of a pulmonary hyperperfusion with consequent pulmonary edema and congestive heart failure. There were no BA originating from the T5-T6 segments. The anomalous vessel was successfully occluded proximally to its bifurcation in the catheterization laboratory with a 5-French catheter (Terumo Europe, Leuven, Belgium) and two Gianturco coils 3×3-French (William Cook Europe, Bjæverskov, Denmark) inserted through the left subclavian artery (Figure ). The closure of this anomalous systemic pulmonary communication was associated with significant improvement of the hemodynamic and clinical status of the newborn, permitting successful extubation and decrease of the inotropic support. The patient’s post-operative course was uneventful, and the baby was discharged to home 30 days later in excellent clinical condition. |
A 46 year-old woman presented in our centre with a three day history of multiple red colored skin lesions which were progressive and were associated with itching and burning sensation. On taking the detailed history, it was revealed that the patient had been suffering from type II diabetes mellitus for the past three years and was being managed with tablet metformin 500 mg twice daily, but one week prior to the onset of skin lesions the patient was also started on tablet Sitagliptin 50 mg/day by her physician in view of the poor glycemic control. After the sixth dose of Sitagliptin, patient noticed multiple circumscribed, reddish lesions over the lips and hands which were associated with burning sensation, which over the next two days progressed to involve the trunk and lower extremities. There was no history of any other drug intake prior to the eruption or any similar lesions in the past. On muco-cutaneous examination, multiple circumscribed erythematous and hyperpigmented round macules were present over the lips, trunk and the extremities whereas the oral and genital mucosae showed the presence of well defined erosions (Figure ). Nails and hair examination revealed no abnormality. Laboratory tests, including full blood count and biochemistry profile including liver and renal functions, were within normal limits, except for blood glucose, with a value of 167 mg/dl. A skin biopsy was performed and the histopathological examination revealed a dense band like lymphocytic infiltrate, perivascular inflammatory infiltrate, eosinophils and increased pigment incontinence suggestive of fixed drug eruption (Figure ). At this junction, a diagnosis of FDE was made and all the drugs were discontinued and the patient was started on Prednisolone 40 mg/day and Glimepride. Five days after initiation of oral corticosteroids, the lesions subsided with residual hyperpigmentation. Two weeks later, oral provocation was done, after taking informed consent, and initially metformin was given in full therapeutic dose but no recurrence was observed. After another two weeks, patient was administered Sitagliptin 50 mg and within six hours of administration, there was recurrence of lesions in the form of itching and erythema over the residual pigmented lesions (Figure ). The patient was again started on a short course of oral corticosteroids and antihistamines which led to clearance of lesions. Causality assessment was carried out using the Naranjo’s scale and the World Health Organization (WHO)‑Uppsala Monitoring centre (UMC) Criteria after which we came to a conclusion that Sitagliptin was the “probable” (Naranjo’s score 6) cause of this adverse drug reaction [,]. Keeping in view her medical history and the nature of lesions, a diagnosis of FDE secondary to Sitagliptin was made and the patient was counseled regarding further avoidance of the drug. |
A 51-year-old female patient was transferred to our institution in May 2011 with a known carcinoid tumor, progressive dyspnea (NYHA III) and progressive peripheral edema for the last two years. The neuroendocrine tumor of the ileum was first diagnosed in 2008. Midgut resection was performed in 2008 and liver metastases were verified by CT. Sandostatin therapy was induced postoperatively. Significant coronary artery disease requiring intervention was ruled out by angiography. The TTE revealed a severe tricuspid valve insufficiency and a pressure gradient of the pulmonary valve of 13/8 mmHg. Diagnosis of Hedinger’s syndrome was confirmed and tricuspid valve replacement was performed in June 2011 with a Medtronic Hancock® (27 mm). At time of discharge the tricuspid bioprosthesis presented a regular function and clinical condition showed significant improvement with dyspnea NYHA I and no peripheral edema. In September 2011 the patient was transferred again to our institution due to recurrence of dyspnea and peripheral edema. The TTE presented a regular function of the tricuspid valve bioprosthesis but a severe insufficiency and a moderate stenosis of the pulmonary valve with a pressure gradient of 23/12 mmHg. After recompensation the patient could be discharged. In June 2012 the patient presented again with right heart failure. Leading clinical symptoms were dyspnea, peripheral edema and additionally severe ascites. The echo now revealed a moderate insufficiency of the tricuspid valve bioprosthesis and the pulmonary valve was severely insufficient and moderately stenotic. The right heart function was reduced (Tricuspid annular plane systolic excursion [TAPSE] of 8 mm). Implantation of a Medtronic Melody® valve through right heart catheter was terminated due to a rather small annulus diameter of the pulmonary valve (23 mm). In December 2012 re-tricuspid valve replacement and pulmonary valve replacement were performed. Intraoperatively no early degeneration of the tricuspid valve was seen. The insufficiency was a result of a compromised leaflet due to a papillary muscle. The pulmonary valve was replaced with a Medtronic Freestyle® 25 mm. Additionally a patch plasty of the pulmonary artery bifurcation was done to avoid stenosis of the distal anastomosis. The postoperative echo showed a regular function of both prostheses. Unfortunately the patient died in January 2013 due to a complication during TACE procedure. Computed tomography 10 days prior to the TACE procedure presented a stenotic distal anastomosis of the pulmonary valve conduit with a diameter of 14.8 mm (Figure ). |
A 13-year-old boy presented to the surgical OPD (outpatient department) with history of a scrotal swelling on right side since 3 years, pain in right hemiscrotum for 10 days, and fever for 3 days. The patient started with a gradually increasing swelling of the right hemiscrotum for 3 years. 10 days before his presentation, he developed pain over the swelling which was dull aching and continuous in nature associated with fever which was mild and continuous. There was no precedent history of any trauma or exercise. On examination the patient had swelling of the right hemiscrotum with edema and erythema of the scrotal skin. Blue dot sign was absent. On palpation local temperature was raised, skin was tender, and testis was not palpable separately. Left side scrotum and testis were normal. On investigation hemoglobin was 12.8 g/dL, total leukocyte count was 12140 per microliter, and other blood parameters were within normal limits. A thick walled septated collection was found in the right tunica vaginalis testis with floating internal debris on ultrasonography (). Both testes, mediastinum testis, and the cord structure were normal (). Scrotal skin appeared thickened and edematous. Doppler study revealed an enlarged right epididymis with increased vascularity with a normal flow pattern into the right testis. On the basis of clinical findings and investigation a provisional diagnosis of right epididymitis with right pyocele was made.\nEmergency exploration was done which revealed a large cyst of approximately 5 × 3.5 × 3 cm in size with a stalk which was arising from the upper pole of the testis (). Torsion of the cyst was evident at the stalk (). Content of the cyst was gangrenous haemorrhagic fluid with early features of gangrene evident in the wall. Cyst was excised along with the stalk () and sent for histopathological examination. Scrotal wound was closed with an open drain. Recovery was uneventful in the postoperative period and he was discharged after removal of the drain. Histopathology report revealed haemorrhagic infarct with organization and fibroblastic proliferation secondary to torsion without any evidence of neoplastic degeneration. On followup, patient is doing well. |
The patient is a 97-year-old Caucasian female with a past medical history pertinent for dementia and normal pressure hydrocephalus with a right-sided ventriculo-peritoneal shunt placed over a decade prior to admission who presented to our facility for swelling and erythema over the right side of her neck. General physical examination demonstrated non-tender swelling and erythema over the right side of the patient's neck with no pain on movement. On admission, the patient’s complete blood cell count was within normal limits and she was afebrile. The patient was taken for revision of the shunt and intraoperative findings were consistent with signs of a disrupted shunt. The patient tolerated the procedure well and was discharged home. Cultures taken from shunt aspirate did not yield any microorganisms. Cerebrospinal fluid (CSF) analysis did not demonstrate white blood cells, red blood cells and glucose was normal at 68 mg/dL. The patient was readmitted for drainage from the surgical site three days after discharge and the decision was made to externalize the shunt pending completion of blood and wound culture. Prior to surgery, the patient was afebrile and blood serum chemistry was within normal limits. The patient was started on empiric antibiotics with vancomycin and cefepime. CSF analysis again failed to demonstrate white blood cells, red blood cells and glucose was elevated at 80 mg/dL. Initial cultures demonstrated acid-fast bacilli and growth on media implied it was a rapid grower mycobacterium. The patient was started on empiric treatment for atypical rapid growing mycobacterium with azithromycin, imipenem and zyvox. Serial CSF analyses were performed to ensure negative gram stain and culture prior to internalization of the VP shunt. Once sterilization of the CSF culture was complete and shunt was internalized, the patient was discharged home on levofloxacin and clarithromycin while awaiting final identification and sensitivity of the organism. The patient completed a total of 15 days of IV antibiotics before being transitioned to an oral regimen. Final identification illustrated M. abscessus. |
Patient's consent was obtained to the anonymous use of his clinical data for research purposes.
A 63-year-old man with a medical history of myocardial surgical revascularization was admitted to our hospital for a COVID-19 pneumonia, which required ventilatory support until the need to wear a continuous positive airways pressure (c-PAP) mask up to 60% FiO2 at day 4. Therapy with hydroxychloroquine 400 mg twice a day, lopinavir/ritonavir 400/100 mg twice a day and antibiotic coverage with ceftriaxone 2 g daily and azithromycin 500 mg daily was set up, according to the internal protocol. Moreover, a 4 French catheter (BD Medical™) was placed in his right radial artery for the arterial blood gas analyses, without any troubles. Then, he received a single dose of tocilizumab 640 mg and started methylprednisolone (40 mg twice a day). The respiratory function progressively improved until a complete weaning from the c-PAP in day 10. The radial artery catheter was removed after 8 days in day 12 without any complications, and local compression was applied to the wrist. However, on day 14 a painful tumefaction in his right wrist, which extended to the forearm was found. The upper limb was warm, motility and sensitivity of the hand were preserved, and both radial and ulnar pulses were palpable. Doppler ultrasonography showed the presence of edema of the forearm extending to the arm, and the regular patency of the arterial and venous axis of the right upper limb, with regular flows and without any hematoma surrounding the artery, which had a regular caliber. A slight compression of the upper limb was then applied with a bandage.
However, on day 16 the clinical picture worsened (Figure ) and the patient complained of continuous pain of his forearm with initial impairment of the sensitivity and the motility of his right hand. Doppler ultrasonography was repeated, showing the presence of a small aneurysm of the radial artery at the wrist. The patient then underwent a |
A 15-year-old female patient with recurrent abdominal pain for the previous 2 years presented to our hospital. The patient had obvious inducement of left upper abdominal pain throughout the last 2 years that was progressive and radiating towards the waist and abdomen. This pain was relieved after lying flat. The patient was referred to the hospital owing to aggravation of abdominal pain, particularly in the afternoon. The patient did not have a fever, was not vomiting, and did not have yellowing of the skin or sclera, breathing difficulties, or other accompanying symptoms. The family history was negative for these malformations.\nA physical examination of the patient showed a large, soft mass located in the right lower abdomen with an impalpable lower pole accompanied by tenderness and without rebound tenderness. Murphy’s sign was negative and no other obvious abnormalities were found. Laboratory tests, including a blood cell count, electrolytes, and liver function, routine stool and occult blood test, tumor-related markers, serum protein electrophoresis, and a neurological examination were normal. Multi-detector computed tomography (CT) showed that the spleen was not in its normal anatomical position and was located in the hypogastrium/pelvic cavity (). The maximum cross-sectional area was approximately 19 × 15 × 8 cm. Computed tomography angiography (CTA) showed tortuosity and varicosity of the splenic vessels () and chronic splenic congestion. These abnormal appearances were further clarified by abdominal magnetic resonance imaging (MRI), which showed the relationship between the spleen and peripheral organs (). Color Doppler flow imaging (CDFI) showed that the spleen and its internal blood flow were not present in the left upper abdomen, but in the pelvis instead (). Surgery was performed because the patient had aggravation of abdominal pain and this may have been associated with torsion of the spleen.\nDuring surgery, the spleen was observed in the right lower abdomen. The spleen reached the pelvic cavity and was approximately 20 × 15 × 7 cm in size with no adhesion. Varices were observed in the gastric fundus and the gastric corpus. The splenic pedicle was separated and dissected. The splenic artery and vein were carefully ligated and the spleen was placed into an extractor and completely removed from the incision. Postoperative pathology confirmed an ectopic spleen and chronic congestive splenomegaly (). The patient was discharged postoperatively within 10 days with no complications. The patient’s pain did not reoccur during follow-up. |
Our patient is a 61-year-old 90 kg 177.8 cm male with a history of coronary artery disease and amyotrophic lateral sclerosis who was admitted to the intensive care unit for ventilator support. On arrival to the emergency department he was profoundly hypoxic and was emergently intubated. He was subsequently transferred to the intensive care unit. On initial evaluation the patient was alert and was able to follow commands and communicated via writing. His overall strength was poor, 2/5 in both his hands and feet with minimal ability to lift his proximal arms and legs. His cranial nerves were all grossly intact. His level of function prior to admission was heavily dependent on assistance for activities of daily living. He was, however, able to talk and swallow without difficulty and was receiving no respiratory support.\nSubsequent to his admission to the ICU he met parameters for extubation during a trial of spontaneous breathing, and the endotracheal tube was removed. He failed spontaneous ventilation and was reintubated within 2 hours following extubation. Over the next three days, multiple attempts were made to wean the patient from the ventilator; however, he failed multiple trials of spontaneous breathing and could not be extubated. The decision was made among the ICU team, the patient, and the family to proceed with tracheostomy insertion. The Oral Maxillofacial Surgery (OMFS) service was then consulted. See for the preoperative chest X-Ray (CXR).\nThis patient was taken to the operating room by the OMFS service. An open tracheostomy was performed with placement of a 6.0 cuffed Shiley tracheostomy tube, under flexible fiberoptic tracheoscopy (FFT) assistance, without difficulty. It was noted in the operative report that the patient had hardening and calcification of the first, second, and third tracheal cartilages. It was also noted that he had a short neck and a posterior trachea. No tracheal abnormalities were observed during FFT after tracheostomy insertion. Within a few hours of the patient returning to the ICU a cuff leak developed. The OMFS service was consulted and he was emergently taken back to the operating room a second time with a concern that the tracheal tube might have become displaced. Intratracheal placement of the leaking tube was confirmed by FFT. Again no tracheal abnormalities were observed. A Cook Exchange Catheter (CEC) was placed through the tracheostomy tube and the damaged tube was withdrawn. A 6.0 cuffed endotracheal tube was placed over the CEC. Verification of tracheal placement was confirmed with both end tidal CO2 and FFT.\nPlacement of a longer 6.0 cuffed Shiley was attempted but aborted due to difficulty in placement. A reinforced 6.5 endotracheal tube was then placed over the CEC. Tracheal placement of the reinforced endotracheal tube was confirmed by ETCO2 and FFT with no noted tracheal abnormalities. The patient was returned to the ICU.\nTwo days later the patient was noted to have gurgling at the tracheostomy site and was taken to the operating room a third time. The 6.5 reinforced ETT was removed over a bougie and a 6.0 cuffed Shiley with proximal extension was placed and sutured to the skin. Good ventilation was confirmed. During FFT, no tracheal abnormalities were noted. Later that same day gurgling was again noted and our patient returned to the operating room a fourth time to replace the leaking tube. The tube was exchanged over a Pediatric Cook Exchange Catheter. Examination of the cuff of the removed tube revealed a leak from the left anterior aspect of the cuff. During this procedure the OMFS surgeon explored the wound further to attempt to delineate a cause for the multiple cuff leaks. In order to gain access to trachea, Army-Navy retractors were down in the surgical site. With further exposure of the surgical site with a Debakey forcep, a 10 mm by 4 mm piece of sharp calcified cartilage was discovered protruding into the tracheal lumen in a location consistent with the previously noted cuff damage. The team was not able to obtain an image of the protruding cartilage. Additionally, the ruptured cuff was tested for bubbles in an emesis basis intraoperatively, though images were not obtained. The cartilage was excised, and an 8.0 Bivona adjustable tracheostomy tube was placed without further difficulty. The patient returned to the ICU. On POD #5 a Neck Soft Tissue CT, which was obtained in order to rule out complications from the repeated tracheostomy attempts, demonstrated increased diffuse tracheal calcification (see ). He experienced no further complications with the tracheostomy tube during his hospitalization and was subsequently discharged for further rehabilitation. |
A 45-year-old man was transferred to our facility for the management of recurrent cholangitis and pancreatitis due to impacted intrahepatic biliary stones. Approximately 15 years prior, the patient sustained a Grade III liver laceration while serving in combat for the US military and was managed nonoperatively.\nApproximately 6 years after the initial liver injury, the patient developed right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. A CT of the abdomen revealed intrahepatic ductal dilatation with intrahepatic bile stones in the right hepatic lobe, isolated to Couinaud segment 7 []. He was admitted for ascending cholangitis and gallstone pancreatitis, and underwent an open cholecystectomy with bile duct exploration and t-tube placement.\nHis recovery was uneventful until 2 years later, when he presented with RUQ abdominal pain and nausea, and was found to have choledocholithiasis and intrahepatic bile duct stones on CT. He was treated with an ERCP with stone extraction and sphincterotomy that cleared the common bile duct (CBD) stones. There was no report of intrahepatic stones identified or treated. A post-procedural magnetic resonance cholangiopancreatography was performed and reported no obvious obstructive stones remaining in the CBD.\nFour years later, he presented again with RUQ pain and was diagnosed with recurrent ascending cholangitis and gallstone pancreatitis, and underwent repeat ERCP with stone extraction. Symptoms recurred 2 years later, and the patient underwent percutaneous transhepatic biliary drain (PTBD) placement by an interventional radiologist. Attempts to extract the stones at that time through percutaneous access using fluoroscopic guidance were unsuccessful.\nFollow-up MRI of the abdomen after PTBD placement demonstrated diffuse biliary duct dilation with recurrent intrahepatic stone formation in the right posterior liver and in the CBD, complicated by acute pancreatitis []. He was transferred to our tertiary care center for further evaluation by gastroenterology and interventional radiology (IR).\nRepeat ERCPs were first attempted that were successful in removing multiple stones from the CBD through mechanical lithotripsy and basket retrieval []. However, the intrahepatic stones were not identified at endoscopy. After a multidisciplinary discussion, the patient was referred to IR for percutaneous transhepatic choledochoscopy. Following the induction of general anesthesia, a cholangiogram was performed through the patient’s existing percutaneous access demonstrating an enlarged biliary duct in segment 7 containing multiple filling defects consistent with impacted stones. This duct was not accessible through ERCP due to its peripheral location, variant biliary anatomy, and presence of the indwelling biliary drain.\nA 10 French peel-away sheath was placed through the tract into the liver, without need for dilation, through which a 9.5 French LithoVue Single-use Digital Flexible Ureteroscope (Boston Scientific, Marlborough, MA) with a two-way deflection scope was advanced into the intrahepatic biliary tree without insufflation []. The abnormal branch in segment 7 was quickly identified containing numerous stones. A 2.4 French Zero Tip Nitinol Retrieval Basket (Boston Scientific, Marlborough, MA) was used to extract the stones percutaneously []. Several additional stone fragments were swept into the duodenum with a compliant balloon catheter. Stones larger than the 2.4 French basket were not encountered. If present, they would have been fragmented using laser lithotripsy. If the basket was stuck with a stone, the stone would have been abandoned and left in the biliary system, with the biliary drain left in place. At the completion of the procedure, an internal-external biliary drain was left in place. Only a single session was performed. The patient was admitted to the hospital post-operatively, where his cholangitis resolved on broad-spectrum antibiotics, before being discharged home on post-operative day 8 with no further antibiotics as an outpatient.\nThe percutaneous biliary drain was removed 6 months later. The patient has remained asymptomatic at the time of this manuscript nearly 2 years later. |
An 80-year-old retired veterinary surgeon presented to his general practitioner (GP) in March 2016 following a 2-month history of ‘chest discomfort’ under the nipple on the right hand side of the chest, which he felt on the interior of the chest. He described this pain as 3–4/10, lasting for approximately 15 min each time and increasing in frequency. He noted that at the time of presentation to his GP they were occurring every 2–3 days. These episodes occurred both at rest and upon exercise, though he did note that they were particularly more prominent when on his bicycle or in times of stress.\nHe did not complain of any symptoms associated to his discomfort, specifically no shortness of breath, palpitations, dizziness, or loss of consciousness.\nHis medical history included neither history of cardiac disease nor any other significant ongoing disease. He does experience nocturia for which he takes solifenacin and has undergone some surgical interventions. He had a transurethral resection of the prostate in 2007 with no complications. He also underwent a laparoscopic bilateral inguinal hernia repair in the same year with no complications. In the 1990s, he had a procedure to remove varicose veins of the right leg and underwent a rigid cystoscopy for haematuria in the 1970s with no underlying abnormality noted.\nHe was sent by his GP to the Rapid Access Chest Pain Clinic at his local district general hospital on 18 March 2016. Examination was unremarkable with normal observations and heart sounds. He was advised that due to the nature of his symptoms, he should attend the emergency department with a diagnosis of unstable angina. In the emergency department, he also complained of some right thumb numbness associated with the right-sided chest pain. After the administration of glyceryl trinitrate spray in the emergency department, he felt that the discomfort had slightly diminished.\nUpon initial examination by the medical team, the cardiovascular system was entirely unremarkable. Heart rate was 70 b.p.m., while pulse was regular with normal volume, oxygen saturation was 99% in room air, auscultation of the heart demonstrated normal heart sounds with no additional sounds audible, and peripheral pulses were present and of good volume. Peripherally, there were no stigmata of cardiovascular disease and no peripheral oedema. Respiratory and gastrointestinal examinations were similarly unremarkable. Normal observations and body mass index were noted.\nBiochemical investigations demonstrated a troponin-I within normal range as well as otherwise entirely unremarkable full blood count and urea and electrolyte panels. A 12-lead electrocardiogram showed no ischaemic changes at rest (Figure ), and his chest X-ray showed no acute abnormalities. His cardiovascular risk profile was limited; he is an ex-smoker with mild hypercholesterolaemia and a family history of late-presentation acute coronary syndrome.\nHe was referred to the cardiology team who admitted him to undergo coronary angiography. This was performed without complications and demonstrated normal coronary arteries. He was subsequently discharged with plans for further investigations as an outpatient. Outpatient echocardiography demonstrated normal biventricular structure and dimensions and preserved ejection fraction with mild-to-moderate tricuspid regurgitation (Figure ).\nA 24-h Holter test displayed no abnormalities. Incidentally, discontinuation of solifenacin for detrusor instability improved his symptoms, but his chest pain did not settle entirely. He was subsequently followed up with stress cardiac MRI. This demonstrated a round-shaped mass in the right ventricular free wall (Figure ), but tissue characteristics were not compatible with known benign or malignant masses. Cardiology multidisciplinary team suggested cardiac computed tomography to assess the mass and mediastinum in full.\nComputed tomography demonstrated that the round mass was actually an artefact from a small metallic object incorporated into the right ventricular free wall measuring 2 × 3 mm (Figure ).\nIn hindsight, it had been visible on fluoroscopic imaging (Figure ) during angiography. Chest radiography performed did not display the object clearly.\nIn summary, there is a small metallic object within the free wall of the right ventricle, which is likely to have been causing chest discomfort. The patient cannot explain how this could have become imbedded in his myocardium. |
A 37-year-old male patient applied to our clinic with a complaint of a neck mass that had enlarged approximately within 3 months on the left lateral side of the neck. He had no additional complaint. The mass was semimobile, smooth in consistency, and painless which was located anterior to the left sternocleidomastoid (SCM) muscle. There was no other palpable mass on examination of the neck. His medical and family histories were unremarkable. Other otolaryngologic and endoscopic examinations were normal. Fine needle aspiration biopsy (FNAB) of the mass was doubtful with no malignant cells. There was no palpable mass on the neck of the patient, except only the lateral cervical cystic mass.\nNearly 6 cm cystic mass that was filled with fluid was detected on contrast enhanced magnetic resonance imaging (MRI) (). Near the cyst approximately 1 cm in diameter 2 lymph nodes that were relevant with reactive nodes were also detected. An approximately 6 cm large cystic mass on the left lateral side on the neck was extirpated ().\nCervical cystic mass was initially diagnosed as branchial cleft cyst, but then the postoperative histopathological examination of the mass was revealed as papillary thyroid carcinoma metastasis (). Thyroid function tests were normal. Ultrasonographic (USG) examination of the thyroid gland showed that the left lobe of thyroid gland had 3 solid nodules with 4, 6, and 12 mm in largest diameter, respectively, but no nodule was found in the right lobe and also in the isthmus of the thyroid gland. FNA biopsies were performed to suspected nodules, but no malignant cell was detected except in one 6 mm nodule, which was suspected having malignant well-differentiated cells. Contrast enhanced computerized tomography (CT) was also performed to disclose mediastinal lymph node metastasis if it exists. Total thyroidectomy was performed to the patient, and postoperative histopathological examination of biopsy material's result showed two papillary thyroid carcinomas with dimensions of 4 and 6 mm, respectively (). Nevertheless, 12 mm sized dominant nodule had no malignancy. The patient underwent a radioactive iodine (RAI) ablation therapy 7 weeks after the operation, with planning of thyroid hormone replacement therapy thereafter. Laboratory measurement values of TSH and thyroglobulin with laboratory reference values just before radioactive ablation therapy were 68.90 μIU/mL (0.27–4.2) and 0.72 ng/mL (1.6–59.9), respectively. The patient has been free of disease for more than 1 year. |
A 27-year-old G2P0010 at 33 weeks and 4 days by last menstrual period was brought in by Emergency System to the hospital on June 25th 2014, with complaints of severe abdominal pain of 1 hour duration. Patient was without medical or surgical history and had a termination of pregnancy before. Abdominal pain was generalized, 10 out of 10 in severity, and associated with vomiting. She denied any diarrhea, vaginal bleeding, or leakage of amniotic fluid. She had recently migrated from the Dominican Republic in May 2014 with no record of prenatal care.\nOn examination, patient was in visible pain with elevated blood pressure, maternal tachycardia, and bilious emesis. An abdominal examination revealed generalized tenderness with guarding and rebound and a fundal height of 34 cm. The fetal heart rate was category III with absent variability and repetitive late decelerations. A vaginal examination revealed a bulging pouch of Douglas with the presenting part deep in the pelvis: a short, firm, and closed cervix displaced anteriorly behind the pubic symphysis.\nOn the way to the operating room limited bed side sonogram revealed fetus in cephalic and a questionable placental location. A tentative diagnosis of uterine rupture versus concealed placental abruption was made proceeding with immediate abdominal delivery.\nAt the time of laparotomy, meconium stained amniotic fluid was seen upon entry to the peritoneal cavity. A fetus was located outside of the endometrial cavity covered only by the uterine serosa on the right side with a placenta attachment to the serosa of the uterus. The left ovary was unremarkable in appearance and an anatomical distortion of the right adnexa was appreciated. A large opening was noted on the posterior aspect of the serosa where the amniotic fluid was leaking.\nAn incision was made on the protruding serosa and a viable female infant was delivered via cephalic presentation with Apgar score of 9/9 at 1 and 5 minutes with weight of 2362 g. The uterus and placenta were exteriorized after delivery due to massive bleeding and distortion of the anatomy (). On further inspection of the placenta, it was noted to invade the pouch of Douglas and lower part of the sigmoid colon and the right uterine serosa.\nA massive hemorrhage protocol was initiated and an emergency back-up team was called. A general surgical consult was requested due to involvement of bowel. The decision was made to proceed on hysterectomy and removal of the placenta tissue due to continuous bleeding. The patient underwent supracervical hysterectomy and excision of the placenta tissue occupying the right side of the pelvic floor. Adhesiolysis from the sigmoid colon was performed by surgery with minimal damage to the serosa.\nIntraoperatively, the patient received 6 units of packed red blood cells, 4 units of fresh frozen plasma, and one unit of platelets. Estimated blood loss was 3000 mL. The patient was then transferred to the ICU for further observation and extubated the following morning.\nShe was discharged home with the baby on day 4 after surgery. There was no evidence of anomaly documented in the baby. Mother and baby are doing well and currently being followed up closely.\nA pathology report revealed that placenta with a segment of trivessel umbilical cord marked old infarct at fetal and maternal surfaces. Attached to the maternal surfaces are fibrous tissues with smooth muscle and dilated vessels. Focal endovasculopathy with luminal occlusion, focal amnion with squamous metaplasia with an attached stretched ovary and fragment of mostly chorionic villi.\nThe uterus was described as intact and weighed 300 g measuring 9.5 cm in length, 11 cm from cornua to cornua and 6 cm anterior posterior diameter with thick endometrial, decidual changes and focal autolysis, no chorionic villi or trophoblast are seen in the endometrium. |
A. D. a 78 year-old right handed Caucasian male, a retired physician, had experienced, for the 3 years prior to his hospital admission, recurrent episodes of transient visual symptoms. These consisted exclusively in the occurrence of colorless mesh-like flickering lights in his right homonymous visual fields. These photopias were not induced by any particular stimulus, showed no movement, but their light intensity pulsated in a rhythmic pattern. These were not associated with auditory phenomena, nor were they preceded, associated with or followed by headache. These episodes lasted for 1–2 min and cleared spontaneously only to recur after variable periods of time. Because these episodes were not associated with any change in his visual acuity nor with the perception of a visual field defect A. D. did not seek, during that period of time, an ophthalmological evaluation. Only when the patient's wife reported some personality changes consisting in sleepiness and unusual sudden mood changes together with a mild gait imbalance, a cerebral MRI with Gadolinium was done and demonstrated an intraventricular meningioma in the right lateral ventricle, associated with edema in the right parietal lobe ().\nThe patient was admitted to a neurosurgical referral center. There his general physical and neurological examinations, including visual field testing by confrontation, detected no abnormalities. A chest x-ray, EKG, complete blood count, electrolytes, BUN, creatinine, liver function tests, and coagulation profile were all within normal limits. He was then brought to the operating room where a right posterior parietal craniotomy was performed in the prone position. A transcortical approach to the right lateral ventricle with image guidance assistance was carried out and a Vycor tubular retractor was positioned into that tract. Under the operating microscope the tumor was visualized and a biopsy was taken that revealed a meningioma grade 2. The tumor was debulked with the aid of an ultrasonic aspirator and it was eventually completely removed. A few veins attached to the tumor capsule were coagulated but no significant bleeding occurred throughout the procedure.\nPost-operatively the patient reported a left homonymous hemianopia, a marked worsening in a preoperatively existing mild bilateral hypoacusia, together with some gait imbalance. His follow-up course showed a gradual improvement in his gait and the hypoacusia eventually returned to its preoperative baseline, but the homonymous hemianopia persisted. A Goldman visual field test confirmed an incomplete left homonymous hemianopia ().\nFor the first 2 months after the surgery the homonymous hemianopia manifested itself simply by the lack of vision in the affected areas of the visual hemi fields. Thereafter, AD reported that some visual activity developed in the form of visual hallucinations that presented spontaneously, with no obvious triggering stimulus and were not associated with any change in his mental status. According to the patient's description, these visual hallucinations presented only within the hemianopic visual fields, lasted for a short period of time and disappeared spontaneously, only to recur after variable periods of time. These were experienced by the patient as clearly unreal and caused him no anxiety nor other emotional effects. Consequently, these could be considered to be pseudo hallucinations. According to the patient these presented in three different formats which seemed to follow each other in a certain sequence. Initially they consisted of the vision of geysers of vapor, constantly growing or shrinking, and changing their position and direction. These were monochromatic in a light gray tone and lasted for a few seconds at a time, only to recur after minutes or hours. This format persisted for 5 days after which it eventually disappeared, not to reappear again. It was followed by a second type of visual activity which consisted of the vision of a small colorless bright dot of light, a phosphene, which appeared at any point within the affected visual fields. During each episode, the visual dot did not change in size or location, it would last for a few seconds before it disappeared. It could reappear after variable periods of time in a different location but with identical characteristics. Its occurrence gradually decreased in frequency and it was eventually replaced by a black dot. This one did not seem to change in size or position between episodes and rather than a pseudo hallucination it appeared to represent a sequelae of the damaged visual pathway. It has persisted unchanged up to the time of this writing.\nFinally a third type of visual phenomena started to occur about a month after the ones already described. It consisted in the simultaneous visual replication, within the hemianopic visual fields, of the image been visualized in the unaffected visual fields. This momentary photocopy [Allaesthesia ()] would rapidly disappear. This transient visual phenomena was polychromatic, its colors matching exactly the ones present in the scene been seen by the intact visual fields. This type of visual phenomena could recur at various times during the day and persisted for about a month, after which eventually subsided and has not recurred since. Neither one of these three types of visual phenomena was associated with any simultaneous auditory phenomena. The timing of their presentation and their apparent sequence would suggest that these phenomena might have been the effect of the ongoing cortical and subcortical healing process in the affected areas. Furthermore, the fact that all these visual phenomena, including the preoperative photopias, completely subsided within a relative short time after the surgery, suggests an epileptic basis for them.\nA CT scan with contrast infusion done 4 months after the surgery, confirmed the complete resection of the meningioma. |
A 62-year-old man, affected dysphagia, was endoscopically diagnosed with lower esophageal cancer confirmed squamous cell carcinoma on biopsy, and was reffered to our hospital (Fig. ). He had no medical history. His lifestyle has included 1500 ml beer consumption per day and 40 cigarettes per day for the past 40 years. Computed tomography (CT) showed thickening of the wall in the lower esophagus as the primary lesion was demonstrated and the tumor formed a mass with the solitary metastatic abdominal lymph node, and invaded pancreas body and gastric body (Fig. ). No other distant metastasis was detected on CT. He was diagnosed with lower esophageal cancer cT4 N1 M0, with pancreatic invasion, cStage IIIC according to 7th edition of the Union for International Cancer Control system []. At first, we considered definitive chemoradiotherapy. However, radiation oncologists evaluated that the tumor was less candidate for chemoradiotherapy because of the risk of gastric mucosal damage. For the purpose of definitive therapy, radical esophagectomy with distal pancreatectomy was planned. As neoadjuvant chemotherapy, CF therapy (cisplatin and 5-fluorouracil therapy; cisplatin was dripped 80 mg/m2 plus 5-fluorouracil was infused 800 mg/m2 on day 1 through 4 continuously) was started according to standard therapy of localized advanced esophageal cancer []. However, after once administration, he could not continue chemotherapy for the exacerbation of dysphagia, and underwent radical surgery. Preoperative evaluation of tumor was similar to initial findings on endoscopy and CT.\nIn findings on laparotomy, abdominal lymph node was infiltrated directly to pancreas body. As the radical surgery, Ivor Lewis esophagectomy with distal pancreatectomy and splenectomy, followed by reconstruction of gastric conduit. Two fields lymphadenectomy was performed according to the treatment strategy of the abdominal esophageal cancer. Reconstruction of gastric conduit was possible although the lymph node was adherent to lesser side of gastric body, which was resected when reconstruction of gastric conduit. In addition, partial resection of lung was performed simultaneously owing to involvement of bilateral pulmonary ligaments to the primary tumor (Fig. ). The operative time was 528 min. The estimated blood loss was 2850 ml, and the patient was transfused 4 units of red blood cell concentrates.\nThe patient had an uneventful postoperative course and was able to take orally. He was discharged 16 days after operation with tube-free. After discharge, he underwent two courses of CF therapy as adjuvant chemotherapy. At present, he is still alive and has no recurrence for 7 years after surgery.\nIn the resected specimen, the primary lesion was observed from lower esophagus to esophagogastric junction, and metastatic lymph node was fixed to stomach and pancreas body (Fig. ). Pathological examination revealed that primary lesion was not infiltrated to lung (Fig. a, b). Massive metastatic lymph node (over 5cm) was observed in the lesser curvature of stomach, and infiltrated to pancreas and gastric wall with extranodal extension (Fig. c, d). The tumor was diagnosed with squamous cell carcinoma, moderately differentiated type. The vascular and lymphatic invasion was confirmed. The surgical margin was negative. The pathological stage was ypT4 N1 (1/61) M0 (metastatic lymph node invasion into pancreas), ypStage IIIC. The histopathological response of chemotherapy was grade 1a, which was equivalent that proliferable cells were 2/3 or more, in 7th edition of the Union for International Cancer Control system []. |
A 61-year-old man visited our hospital with the chief complaints of chest pain on exertion and an intermittent chest pain that was aggravated when he rested in a left decubitus position. He had risk factors for coronary artery disease: dyslipidemia, hypertension, and diabetes. He also had a history of chest trauma, a left rib fracture that occurred in a traffic accident 15 years previously. An initial evaluation of his chest radiograph showed levoposition of his heart and an unusual cardiac contour with a bulging left ventricle (). An electrocardiography showed an incomplete right bundle branch block and a clockwise rotation in the precordial leads. An echocardiography showed an estimated left ventricular ejection fraction of 50-55%, with regional wall motion abnormalities of the basal to mid inferior and inferolateral walls. It also showed a focal external compression of the basal posterolateral wall. His serum troponin-T level was also slightly elevated (0.023 ng/mL). As he had coronary risk factors including elevation of the serum troponin-T level and complained of chest pain on exertion with echocardiographic regional wall motion abnormalities, we performed early elective coronary angiography without noninvasive testing. The angiogram showed two-vessel coronary artery disease involving the left anterior descending artery (LAD) and left circumflex artery (LCX), with a geographically circumferential phasic diastolic compression of three obtuse marginal branches, right ventricular branches, and the posterior descending artery (PDA) ().\nAt first, we considered stenting the LAD as the significant culprit lesion. However, there was a possibility that phasic diastolic obstruction of the epicardial coronary arteries could have caused the chest pain. This feature was consistent with the echocardiographic findings showing regional wall motion abnormalities of the LCX and right coronary artery territories. In addition, a geographically circumferential phasic diastolic compression of the coronary arteries like myocardial bridging suggested a linear extracardiac constriction like a band strangulating the heart between the basal and the mid-ventricular level. Because he had a previous chest trauma history, there was a possibility that cicatrical changes could have caused extracardiac constriction. We decided against performing percutaneous coronary intervention for the mid-LAD lesion. Therefore, to confirm our assumption, a computed tomography (CT) was done, which showed a left-sided movement of the heart, adherence of the heart to the chest wall, and a partial pericardial defect around the mid-ventricular level with strangulation of the mid-LAD, LCX, and PDA (). There was no specific intracardiac abnormality other than the pericardial defect on cardiac CT. Myocardial single photon emission computerized tomography was also done and it showed a reversible perfusion defect at the mid anterior, entire anterolateral and mid inferolateral walls.\nThe operative findings revealed a partial congenital pericardial defect just around the middle ventricular level. Both ventricles were herniated to the left pleural cavity, and there was no epicardial adhesion or scar change. There were also multiple coronary arteries strangulated on the epicardial surface of both ventricles caused by the thickened hard circumferential pericardial edge (). The anterior portion of this band-like thickened pericardial edge was excised in order to release the external compression of multiple coronary arteries. The posterior portion of the pericardial edge was left to prevent phrenic nerve injury. An off-pump coronary artery bypass surgery (CABG) of the left internal thoracic artery (free graft to ascending aorta) to the mid-LAD was done concomitantly considering the presence of significant stenosis with heavy calcification of the mid-LAD, which can cause ischemia.\nAfter the CABG with partial pericardiectomy, a follow-up coronary angiogram was performed to evaluate the possibility of remaining strangulation by chronic cicatricial changes of the epicardium beneath the thickened hard circumferential pericardial edge, but there was no finding of previous dynamic obstruction of the coronary arteries (). A follow-up transthoracic echocardiography was also done and the regional wall motion abnormalities and external compression which were observed in the previous study were no longer seen. The patient was discharged without complications, and he is currently symptom free. |
A 12-year-old female presented with a rapidly increasing mass located over the lower left chest wall and the abdomen. The mass had first been noted in the year 2000, and was confined to the chest wall, and local excision had been done in the same year. Histology had revealed aggressive firbomatoisis and the child was on follow up for a year, after which she dropped out.\nIn 6 months, the mass made a reappearance in the scar tissue of the previous surgery. She underwent a second excisional surgery in 2003, when the tumor involved the upper part of both recti and excision was accomplished with excision of the anterior part 9th and 10th ribs. The defect was repaired by inserting a prolene mesh, and the skin was closed primarily.\nAfter 6 months, the tumor recurred and the parents started traditional treatment and did not report for follow-up. The mass grew extremely slowly over the next 2 1/2 years, but since then had grown aggressively to reach large dimensions.\nGeneral physical examination was unremarkable. Local examination revealed a 15 cm × 12 cm exophytic nodular mass arising from the lower left chest wall and the contiguous anterior abdominal wall. The mass was hard in consistency, crossing the midline, with scars of the previous surgery visible over the mass. Investigations revealed a normal hemogram, renal functions and liver function. Chest radiograph was normal and a computed tomogram (CT) scan revealed that the mass was arising from the lower chest wall and abdominal wall, and was free from the underlying viscera, including the liver []. With a diagnosis of recurrent desmoid tumor, excisional surgery was planned. Reconstruction of the defect that would result could have been done with a musculofascial flap. However, in view of the two earlier recurrences, the location and size of the defect, the possible need for a microvascular anastomosis and with the history of drop out from follow-up, we decided to use a prosthetic mesh surfaced with a skin graft for reconstruction.\nExcision was accomplished with resections of the anterior portions of the 8th and 9th ribs. The mesh placed previously was removed. The diaphragm was sutured to the 7th rib, closing the thoracic cavity. This left a full-thickness defect on the anterior abdominal wall measuring 14 cm × 12 cm. The omentum was detached from the transverse colon and the right gastroepiploic artery was divided. The omentum was then detached from the greater curvature, keeping the epiploic arcade intact. A prolene mesh was then sutured to the muscles in the margin of the wound, leaving a small gap superomedially through which the omentum was brought out and spread over the surface of the mesh. The omentum was loosely tacked to the mesh and skin margins and covered with Vaseline gauze and a dressing was applied.\nOn the 7th postoperative day, she was returned to the operation theater and split skin grafts were taken from the thigh and placed on the granulating surface of the omentum. She recovered without any complications and was discharged after 10 days with a well-taken skin graft covering the mesh. Histology revealed a desmoid tumor with clear surgical margins.\nOn follow-up, she had a small nonhealing discharging sinus on the superomedial aspect of the wound that responded to local probing and removal of a suture. She has been on follow-up for 3 years without any evidence of local recurrence or ventral hernia and she is pleased with the outcome []. |
A 39-year-old lady presented to the ED with complaints of periumbilical abdominal pain and bilious vomiting. She had been experiencing similar symptoms intermittently for the past 6-8 months. Pain aggravated after food intake. She had regular menstrual cycles and has one child born of normal term delivery. She was evaluated elsewhere for the same and all her investigations were reported to be normal. She had been managed conservatively for acid peptic disease. On examination she was in severe distress due to pain, hemodynamically stable, the abdomen was mildly distended but soft with some tenderness in the right iliac fossa and right lumbar area. A contrast CT scan of the abdomen was done which showed terminal ileal stricture with wall thickening and significant proximal dilatation of ileum with positive small bowel feces sign (Figure ). She was further evaluated by colonoscopy, which revealed that the ileocecal valve was edematous with hypertrophied Peyer's patches and with partial intussusception of terminal ileum into the caecum. There was a significant narrowing of the distal-most ileum. Biopsies taken from the nodular areas of the mucosa showed only some nonspecific lymphoid tissue. All other tests done including tumor markers were negative. As even after 48 hours, she continued to have pain and abdominal distention, a repeat CT scan was done which showed persistent dilated small bowel loops with terminal ileal obstruction. She then underwent diagnostic laparoscopy which showed dilated distal small bowel loops with suspicious stricturing growth at the terminal ileum and ileocecal valve region (Figure ). In view of strong suspicion of malignancy and nonavailability of frozen section examination, a formal laparoscopic right hemicolectomy with stapled, side to side, ileo-transverse anastomosis was done. Postoperatively, she had an uneventful recovery and was discharged home on postoperative day 4. On histopathology, gross examination showed cecal induration with intussusception of the distal terminal ileum into the cecum with associated obstruction of the ileocecal valve. Serial sections at the level of the cecum and distal terminal ileum showed marked fibrosis along the adjoining wall. The area of fibrosis extended partially along with the ileocecal valve and partially along the cecal wall. On microscopy and immunohistochemistry, there were features suggestive of endometriosis with PAX8 and estrogen receptors highlighting glandular epithelium nuclei and CD10 highlighting the surrounding stromal tissue. |
A 54-year-old Caucasian male presented to the outpatient clinic with the enlargement on the right thyroid lobe noted approximately 2 months earlier. In his medical history he was operated due to clear cell carcinoma of the right kidney three years ago. The pathological examination of the kidney was revealed as pT3N1M0, Grade 2. Then the adjuvant chemotherapy and the interferon treatment were planned but he refused any treatment and he has been followed after the operation by routine examinations such as liver functions (SGOT, SGPT, alkaline phosphatase, GGT, bilirubin levels), urea, creatinine levels, abdominal ultrasonography, bone scintigraphy, chest X-ray.\nDuring that follow up period, the patient had no symptoms and routine tests were within normal limits. The physical examination after three years revealed solitary nodule on the right lobe of the thyroid that were thought to be an adenoma or a nodule of colloidal goitre. A fine needle aspiration biopsy of the thyroid revealed some mildly pleomorphic and hyperchromatic cells and due to this suspicious ctyological finding consistent with malignancy, bilateral near total thyroidectomy was performed.\nThe pathological specimen measured 5.5 × 5 × 3 cm and showed two nodules, each of them located at different lobe and measured up to 2.0 cm in the greatest dimension. A microscopic examination showed the diffuse proliferation of acinary structures and large sheets of neoplastic cells in the adjacent acini with the extension into the thyroid follicular tissue. The neoplastic cells had a moderate amount of clear, vacuolar or mildly eosinophilic granular cytoplasm and pleomorphic, hyperchromatic nuclei with large nucleoli. Many of the cells showed multinucleation, nuclear lobulation and high mitotic activity, as shown on immunohistochemical staining of tumour tissue sections (). CD10 (), vimentin and pancytokeratin positivity, however, in the same tumour areas cells were negative with TTF-1 (), thyroglobulin and calcitonin.\nThe patient was uneventful after the operation, and the adjuvant chemotherapy treatment for the metastatic disease was planned, however, he again refused chemotherapy. Eighteen months after the thyroid surgery, he was admitted to our emergency service with right hemiplegia. Cranial CT revealed a metastatic tumour and he was operated for brain metastases. During operation, the metastasis was removed successfully but he died due to pulmonary embolia 5 days after the operation. |
A 20-year-old lady presented to the emergency room with complaints of pain in the right lower chest and right upper abdomen, after being kicked in the chest by a horse few hours back. Her abdominal pain soon became generalized and she also complained of increased chest pain during inspiration. She gave no history of vomiting. On initial examination, she had tachycardia (98 beats per minute) and her blood pressure was 100/80 mmHg. Her respiratory rate was 20 per minute and decreased breath sounds were present on the right side. A bruise could be seen over her right lower chest and upper abdomen. Her abdomen was tense, tender and distended with absent bowel sounds. A provisional diagnosis of chest injury with liver injury following blunt trauma abdomen was made and resuscitation was started. Two large bore intravenous lines were secured and patient was given Ringer lactate solution. A Foley's catheter was introduced to assess the response to resuscitation.\nA chest X-ray revealed the heart to be normal in position (apex on the left side) along fractures of the ninth and 10th ribs on the right side. There was no evidence of haemo-pneumothorax or any other bony injury on the X-ray (). An ultrasound of the abdomen revealed moderate amount of free fluid in the abdomen with an injured spleen present in the right hypochondrium. Computerized tomography (CT) scan of the abdomen revealed a shattered spleen on the right side with a normal liver and gall bladder on the left side (). The rest of the abdominal viscera appeared to be normal.\nIn view of the altered haemodynamic status of the patient, a decision was taken to carry out an emergency exploratory laparotomy. During laparotomy, 1.5 L of blood was evacuated from the peritoneal cavity and a shattered spleen was seen in the right hypochondrium with active bleeding. The splenic pedicle was intact and an emergency splenectomy was carried out. The liver and the other viscera were reversed in position but normal. The postoperative period was uneventful and the patient was discharged on the sixth postoperative day. Prior to discharge, the patient was immunized against Pneumococcus, Meningiococcus and Haemophilus influenzae. |
A 48-year-old woman with a history of polyarticular arthritis 3 years ago with high ESR and CRP and negative rheumatoid factor and anti-cyclic citrullinated peptide (ACPA) was treated for early arthritis with prednisolone and methotrexate but after the second visit due to a good response the patient discontinued all medications and did not show up for the next follow-up visits. In subsequent years the patient had some arthralgia, after that using only NSAIDs.\nA month prior to admission she developed left eye pain and photosensitivity so the patient was referred to ophthalmologists and received some topical treatment without any good response. Gradually the pain increased and the patient developed blurred vision and a pussy discharge from the eye. So with the impression of severe left eye scleral melting and necrosis and with diagnosis of pan-uveitis the patient was referred to a rheumatology clinic for further examinations and aggressive treatment. On admission the patient had a history of one week of increased arthralgia, productive cough and dyspnea at night not responding to oral antibiotics. On examination the patient had a temperature of 37.9°C (oral measurement), chemosis and ulceration with pussy discharge of the left eye (), normal lung examination and bilateral MCP and PIP signs of arthritis. Chest CT scan revealed multiple cavity formations. Serum showed c-ANCA antibodies and daily proteinuria was found (440 mg/day). The diagnosis of GPA was established and methylprednisolone pulse 1 gram for three consecutive days was started and also cyclophosphamide (intravenous route) every two weeks for 3 doses and then every 3 weeks was followed in the OPD clinic of rheumatology and ophthalmology.\nAfter 2 months the patient had mild improvement of data but still there was activity of eye involvement and the patient was scheduled for a scleral graft. So we decided on treatment with rituximab (intravenous infusion 1 gram, repeated after 15 days). After 5 months the patient was treated with azathioprine 50 mg per day and 7.5 mg prednisolone with good response () and at the 6th month after the first cycle of rituximab the patient because of flare of pan-uveitis received the second dose of rituximab and remains with a good response. |
A 40-year-old male who complained of pain in the right inguinal region underwent abdominal ultrasonography, which revealed a 6-cm sacciform tumor in the right lower abdomen. The patient had no medical history including surgery, trauma, or inflammatory disease, and he was referred to our hospital for further evaluation. Enhanced computed tomography (CT) showed continuity between the cystic tumor, which measured 66 mm×72 mm, and the right external iliac vein (EIV) (). Further, vascular ultrasonography indicated that the mass was a section of the ectatic vein. The mass was diagnosed as a right EIV aneurysm without stenosis or obstruction of the proximal flow. Although the patient did not present with any symptoms, 99mTc-macroaggregated albumin scintigraphy revealed a pulmonary thromboembolism in the inferior lobe of the right lung. Venography revealed a large saccular aneurysm of the EIV with flow stagnation (), whereas arteriography of the common iliac artery did not indicate any sign of an arteriovenous fistula. Preoperative anticoagulant treatment with warfarin was initiated, and aneurysmectomy was recommended to prevent disastrous complications, such as massive pulmonary embolism and rupture.\nOne month after the aneurysm was diagnosed the patient underwent resection to treat the right EIV aneurysm. With the patient under general anesthesia, the aneurysm was exposed via a retroperitoneal incision in the right lower quadrant (). The aneurysm did not adhere to the surrounding tissue and did not have feeding vessels. The border between the normal venous wall and the aneurysm was easily detectable. An abnormal venous wall occupied more than one-third of the circumference of the vein; therefore, compared to venorrhaphy, patch plasty was considered suitable to preserve the lumen. Following the intravenous administration of heparin (7,000 U), the proximal and distal portions of the aneurysmal sac were clamped, and longitudinal venotomy was performed. The excess vein wall was resected and did not show an adherent mural thrombus. The vessel wall was reconstructed using a saphenous vein graft patch taken from the opposite side, and sutured with continuous Nespylen 6-0 thread using the parachute technique. After the clamps were released, the patch was wrapped in the remaining wall of the aneurysmal vein (). On histopathological examination, the three layers of resected venous wall were preserved and did not display signs of inflammation or fibrosis.\nAfter the 8-h surgery, anticoagulation was started with intravenous heparin: 15,000 U/day, with activated partial thromboplastin time (APTT) of 36.2 s. However, on postoperative day (POD) 1, bleeding from the retroperitoneal drain was aggravated, and anticoagulation therapy was stopped. After a 2-day intermission period, on POD 3, heparin was re-started along with warfarin. Ascending venography, which was performed on POD 6, revealed that the right EIV was completely occluded and there was good collateral flow into the common iliac vein without thrombosis in the vein below the inguinal ligament. On POD 13, venous ultrasonography revealed a hyperechoic thrombus of the EIV alone, which indicated organization and a lower risk of thromboembolism. The patient remained asymptomatic and was discharged on POD 14. Throughout the hospitalization period, the patient did not use either elastic compression stockings or an intermittent pneumatic compression device because we were apprehensive about promoting bleeding due to increased venous pressure.\nAt the 1-month follow-up interval, the patient appeared to be in good condition, ultrasonography did not show the development of a thrombosis, and there was no change regarding thrombotic obstruction in the right EIV. The patient performed manual labor and requested that the anticoagulant therapy be discontinued due to apprehension about trauma. Subsequently, anticoagulant therapy with warfarin was stopped because the risk of thromboembolism was considered to be low. |
A 31-year-old man was admitted to our hospital, complaining of hematochezia which had lasted for 1 month. His past history involved a high anterior resection of the rectum in our hospital due to intussusception caused by Peutz-Jeghers polyposis (Fig. ). He was hospitalized for 1 month after the procedure. Unfortunately, details of the surgical procedure that had been performed and the reason for his extended postoperative hospitalization were unknown, because clinical records from his previous admission were not available. He was followed up for 3 years after the procedure, during which he had no abdominal symptoms. He remained symptom-free until the month prior to readmission when he began to suffer from hematochezia. On this admission, hematochezia was his only symptom and there were no abnormal abdominal findings on physical examination. Blood test results, including levels of tumor markers, were all within normal limits. Colonoscopy revealed a hemorrhagic tumor with a smooth surface protruding from the anastomosis of the previous high anterior resection, at a distance of 10 cm from the anal verge; a second examination 4 days later revealed that the tumor had disappeared (Fig. ). The biopsied tumor and other small polyps were histologically diagnosed as adenocarcinoma and hamartomatous polyps, respectively (data not shown). We performed a low anterior resection of the rectum, including the anastomotic site with the adenocarcinoma, combined with a resection of the ileum for strong adhesion. The patient was discharged from our hospital 42 days after the operation.\nGross appearance of the resected rectum showed a defect of the rectal mucosa with a smooth edge and a mucosal bulge located at the anastomotic site (Fig. ). Cut surfaces demonstrated a submucosal tumor mainly occupying the proper muscle layer under the defect (Fig. ). Microscopically, the submucosal tumor comprised an adenocarcinoma and a bone lesion at the anastomotic site (Fig. ). The surface of the tumor was covered with granulation tissue (Fig. ). The bone lesion not only included the carcinomatous glands but also normal glands in the bone tissue (Fig. ). In addition, we identified the incorporation of the normal mucosa in the submucosal fibrosis at the anastomotic site (Fig. f). |
A 70-year-old woman with interstitial pneumonia suddenly lost consciousness. She was taken to a local hospital by ambulance. Emergent brain CT and magnetic resonance imaging (MRI) scans were normal and one hour later she walked to her car. However, 15 min thereafter her consciousness declined again. She arrived at our hospital by ambulance 5 hr after the initial symptom onset, 45 min after her consciousness decreased for the second time. Neurological examination showed left hemiparesis and she was comatose. Her body temperature was 38.2°C and she was coughing. Blood test revealed a white blood cell count of 10.80 × 103/μL and C-reactive protein of 1.89 mg/dL. Emergent brain CT images revealed air inflow in the cortical veins in the bilateral frontal and parietal areas (Figures and ). MRI scans were performed 30 min later. T2-weighted images showed tortuous air inflow in the bilateral frontal areas; it was less than what had been observed on the CT images (). DWI revealed the cortical areas with restricted diffusion near the air (). On a chest CT scan there was air in the right ventricle and the left external jugular vein and there was a giant bulla (8 cm in diameter) with septa in the left upper lobe (). A diagnosis of CAE was made and she was treated with edaravone. Hyperbaric oxygen therapy could not be delivered because she was too unstable for transfer to a facility with a hyperbaric chamber.\nShe gradually regained consciousness and the air had disappeared on brain CT scans obtained 12 hr after her admission. Six days after her admission the high intensity area on DWI scans had spread and become clear. Aspergillus flavus was examined with sputum culture and serous antibodies to it were determined. A chest CT scan obtained 10 days after her admission showed collapse of the bulla with fluid collection and thickening of the septa (). Under the hypothesis that the alveolar changes were due to aspergillosis, she was treated with voriconazole and the infection abated. A transthoracic echocardiogram was normal. Although her consciousness level improved gradually and she was able to speak, her left arm and leg remained hemiplegic. She was transferred to a rehabilitation hospital two months later. |
Our patient, a 16 year old female had a repair of tetralogy of Fallot at the age of 14 months following a severe cyanotic spell. At operation the ventricular septal defect was closed with a Gortex patch and infundibular resection was carried out together with a trans-annular patch. She was left with a small residual ventricular septal defect which closed spontaneously, pulmonary regurgitation and mild residual infundibular stenosis. Postoperatively echocardiography demonstrated a dilated main pulmonary artery and narrowing of the origin of the RPA with marked turbulence on colour flow mapping and peak Peak Doppler gradients were up to 60 mm Hg.\nFifteen years after surgery, balloon angioplasty was carried out fro bilateral branch PA stenosis. The right had two levels of stenosis: main pulmonary artery (MPA) to distal right pulmonary artery (RPA) gradient 22 = mm Hg) and the left was tightly stenosed at its origin: MPA to left pulmonary artery (LPA) gradient = 30 mm Hg. The procedure did not produce any significant amelioration in gradients or angiographic appearance.\nA further intervention was carried out at a later date with the intention to place stents to the origins of both PAs. Access to the LPA was from the right femoral vein and the RPA from the left femoral vein and a superstiff wire was used on each side.\nAs the LPA stenosis was complex and severe, it was decided to predilate with a high pressure balloon prior to stenting ().\nTwo separate Mullins sheaths sizes (11F on the left side and 12F on the right side) were introduced in the PAs distal to the stenosis ().\nTwo 59 mm Genesis Cordis stents were used. The RPA stent was deployed on an 18mm Crystal balloon while a 16 mm MaxiLD balloon was used for the LPA stent. Precise positioning of the stents was evaluated by angiography through the Mullins sheath. Simultaneous inflation of the balloons by 2 operators working synchronously led to the deployment of the 2 stents at the same time; this is a crucial part of the technique in order to avoid displacement of one of the stents or occlusion of a PA branch. The anaesthetist provided a short period of apnoea during balloon inflation in order to minimise balloon movement or displacement.\nThe proximal and distal ends of the stents were flared open by inflating the balloon distally and proximally.\nThe gradients across the PAs on this occasion fell from 42 to 10 mm Hg on the right and from 50 to 8 mm Hg on the left. RV pressure fell from 70/- to 32/- following the procedure. There were no complications. |
A 23-year-old right-hand dominant male active duty military service member was initially seen in our orthopaedic hand clinic upon referral by his primary care physician for further evaluation and management of a suspected trigger finger. The patient complained of six months of progressively symptomatic locking of the dominant small and ring fingers with pain over the palmar aspects of the bases of both digits. The patient was unable to recall any inciting trauma. His daily activities included repetitive manual activities involved with military service.\nPhysical exam was significant for painful active triggering of the small finger when brought from a position of maximal flexion to extension as well as palpable nodularity and tenderness to palpation over the palmar aspects of the small and ring finger metacarpophalangeal (MCP) joints. There was otherwise no extensor lag, and the patient was able to make a full composite fist.\nGiven the patient's history and clinical presentation, a cortisone injection was administered to the small finger A1 pulley and flexor tendon sheath. He reported complete pain relief following the injection and was sent to occupational therapy. The patient returned to orthopaedic hand clinic with continued pain relief but persistent triggering of the small finger six months later. With the exception of no tenderness, the exam was otherwise unchanged. Given that his symptoms were refractory to conservative management, he was taken to the operating room for small finger A1 pulley release.\nA standard longitudinal incision was made overlying palmar aspect of the small finger MCP joint from the distal palmar crease to the palmodigital crease distally. The pulley was exposed and upon release a frayed, degenerative-appearing flexor tendon stump emerged (). Interestingly, the patient displayed an anatomic variant as he did not have a flexor digitorum superficialis tendon to the small finger, relying solely on flexor digitorum profundus (FDP). The A1 pulley was completely released, exposing a chronic partial attritional rupture of the flexor digitorum profundus comprising the palmar 70% of the tendon. Given the extent of tendon disruption, the FDP was repaired and tubularized with 3-0 Ethibond suture (). Taking the finger through a full range of motion, the repaired portion continued to engage on the proximal aspect of the A2 pulley; therefore, the proximal 50% of the A2 pulley was subsequently released. At the completion of the procedure, the patient was taken through full range of motion with no appreciable triggering and/or bowstringing of the flexor tendon.\nPostoperatively, the patient was immobilized in a dorsal blocking splint for soft tissue rest for 1 week and subsequently enrolled in early active range of motion with occupational therapy. Follow-up 3 months postoperatively revealed excellent strength and range of motion with no further triggering. |
In May 2011, a 34-year-old male was treated for an ACL rupture using a hamstring graft fixation associated with a partial internal meniscectomy. The hamstring grafts were fixated using a transfixation system in the femur and a biodegradable screw in the proximal tibia. The patient’s post-operative course was uneventful, and he returned to sports without further difficulties. In July 2014 (3 years and 6 months following the initial operation), a tibial cyst suddenly presented and was first treated conservatively, including physical therapy and non- steroidal anti-inflammatory drugs, until it became symptomatic. There were no signs of clinical or laboratory infection. Magnetic resonance imaging (MRI) showed a 10 mm x 25 mm cyst lesion filled with liquid (). In November 2014, an open excisional biopsy and primary closure surgery were performed at a different medical center. The material was sent to a pathology laboratory and resulted in a “ganglion cyst.” 2 months after surgery, a painful mass recurred over the anteromedial proximal tibia measuring approximately 10 mm x 25 mm. A gelatinous substance was suctioned from the mass, in a sterile environment, consistent with a recurrent ganglion cyst. 40 days following this event, the cyst had reappeared and measured approximately 50 mm χ 40 mm (). At that time, the patient was referred to our hospital.\nThe physical examination revealed a stable knee and a complete range of motion. An approximately 50 mm χ 40 mm palpable mass was evident at the anteromedial proximal tibia. MRI images were consistent with a homogeneous, fluid-filled cyst with a connection toward the tibial tunnel ().\nOn April 2015, a second open resection and an exploratory arthroscopy were performed. The cyst was approached through the previous skin incision. The mass was meticulously dissected, with care not to injure the cyst or its stalk. After the cyst was isolated from the surrounding soft tissue, it was brought back to its original placing at the tibial tunnel. The cyst and stalk were then excised altogether. Once removed, the tunnel showed no evidence of communication with the joint and the walls showed signs of sclerosis. Walls were debrided with a rongeur and curette and filled with bone plugs extracted from the lateral femoral condyle. Graft was impacted, and fascia and subcutaneous tissue were sutured. The pathology report revealed a fibrous tissue capsule compatible with a synovial cyst ().\nThe patient remained asymptomatic for 3 months, but when he returned to sport activities, a painful palpable mass was evident again in the same site. Like previous episodes, no clinical or laboratory parameters of infection were found. The X-ray and MRI revealed a new cyst recurrence, with an increase in the tunnel size compared to the previous episode. Bone blocks were evident within the cyst (). A third surgical intervention was performed. After the cyst was isolated from the surrounding soft tissue, the three bone plugs were found inside the tunnel and extracted, and the tunnel walls were filled with fibrous tissue. A proper debridement was performed with a curette, and the space was filled using a cancellous allograft and a cortical allograft table (). The last follow-up at 18 months postoperative has shown the patient asymptomatic, practicing sports regularly, and from an iconographic point of view (), a good integration of the bone graft both at the cancellous and cortical side. As shown in the MRI images, the ACL has still survived with good signal and without any modification since the first surgery. |
A 39-year-old caucasian man was referred to the Dental School of the University Federico II of Naples in 2008. His main complaint was localized pain in region 1.1 and 2.1 during the function, the clinical examination showed that either the two fixed prosthesis elements where of ceramic metal as well as the presence of a secreting fistula in correspondence of the mucosa in the apical area of 1.1. A periapical radiograph was performed and the medical history was documented which has no relevance with regard to the disease in question. Dental history reports that prior treatments and retreatments on these teeth have been completed before the prosthesis.\nThe clinical and radiographic findings showed a probable root vertical fracture of the tooth 1.1 as well as a possible vertical fracture of the tooth 2.1 ().\nFor aesthetic reasons, an alginate impression was taken and a plaster cast was made to construct an interim prosthesis.\nTherefore, a decision was made to place two commercial teeth in a row on a steel wire to construct a prosthesis similar to the Maryland Bridge.\nProbable causes were an inadequate apical seal and/or one or more vertical root fractures that were not captured via periapical radiograph.\nThe periapical radiograph from 1.1 revealed an osteolytic area in the middle third of the root. This osteolytic area also enveloped apical third of the root.\nA beta-lactam antibiotic (Amoxicillin) was given orally 2 gr one hour before the surgery, and a diagnostic flap surgery was planned, which allowed to establish the correct treatment plan.\nPrevious to local anesthesia, a diagnostic flap was opened, respecting marginal soft tissues. The root's vertical fracture of 1.1 was immediately evident, while curettage of the exposed portion of the root of 2.1 also revealed a further fracture in the apical mesial portion of the root. The teeth were gently extracted with particular attention to the preservation of the hard and soft tissues at the sites. The extraction sockets were debrided using piezosurgery devices and alveolar surgical curettes to remove the granulation tissue []. The socket walls were then carefully probed to assess the presence of any fenestration or dehiscence defects []. Atraumatic avulsion was required to maintain the integrity of the vestibular bone, which specifically in the frontal region is as usual particularly thin. The preservation of the buccal bone is extremely important to obtain a good esthetic outcome in the frontal area and medium- and long-term maintenance []. If any trauma were to occur to the buccal bone crest, it would hinder the recovery and cause additional damage. The extraoral view of the roots confirmed the diagnosis. The alveolar bone review showed a defect of 8 mm. According to the conclusion of Darby et al., 2009, a decision was made to adopt a technique for ridge preservation [, ]. In particular, the circumferential gap was filled with granules of bone substitute (Bio-Oss, spongiosa, 0.5 mm). This material has exceptional biological and mechanical properties as well as biocompatibility. Its high porosity provides all the necessary space for angio- and osteogenesis. The microstructure of the Bio-Oss surface promotes optimal proliferation of osteoblasts and particles integrate with the newly formed bone. The slow rate of conversion of Bio-Oss in autologous bone (remodeling) stabilizes the structure of the newly formed to maintain a good long-term bone volume increased () [, ].\nThe Vicryl polyglactin (91, 3/0) absorbable suture was used to close the flap. The interim prosthesis was delivered by using an adhesive system to attach to the adjacent teeth. This prosthesis allows to achieve an acceptable esthetic outcome, as well as a good phonatory function and an initial tissue conditioning for the pontic areas () [].\nThe postoperative therapy requires good oral hygiene, rinsing with mouthwash containing 0.2% chlorhexidine solution twice a day, and an evening application of the same product in gel form, as well as the administration of a nonsteroidal anti-inflammatory aid (Ketoprofen 80 mg) for three consecutive days.\nThe patient was asked to be seen for regular followups for the next three months.\nAt the end of the 3 months, the patient showed remarkable healing of the soft tissues, and the gingiva appeared with an excellent color and texture of the tissue too. It also began to outline the proper and harmonious design of the facial mucosa curvatures, which were conditioned by the interim prosthesis ().\nAt six months, from the socket preservation, a periapical radiograph was taken and showed limited bone loss, which was related to the steel wire of the interim prosthesis ().\nMoreover, radiographically, the bone appeared homogenous and with a good radiopacity to show a sufficient remineralization.\nAn alginate impression with the interim bridge in situ was taken, to construct a surgical template. The patient was satisfied with regard to the esthetic outcome. A thermoplastic vacuum-formed template was then built and two holes corresponding to the cingulum of the maxillary central incisors were performed. The temporary bridge was removed to place two implants. A bone trephine was used to obtain a bone specimen to assess the bone quality and structure. The implant phase, however, was necessary to find the maximum stability in the apical zone []. In the presented case, the extracted roots were 11 mm long, and therefore two 13 mm long implants were placed with a 3,75 mm diameter (Nobel Biocare Branemark System) ().\nAfter the initial surgical phase, two resin temporary crowns were applied leaving a sufficient space to allow for any swelling. Only after three weeks, the interim crowns were modeled with a slight contact to the soft tissue.\nAt six months, the implants were uncovered and a resin screw retained prosthesis was constructed with an emergence profile which was suitable for supporting the buccal soft tissue. It also important to remember to avoid any excessive compression, which could lead to a soft tissue shrinkage in the subsequent months of maturation. The occlusal contacts were verified for the presence of a slight contact during maximum intercuspation using shimstock (Almoreshimstock, 8 mm wide, 8 mm thick) in order to protect the implants from any intense forces. Of course, functional loads resulting from lips, tongue, and food bolus will remain [, ].\nAfter waiting for another 6 months, we proceeded to the prosthetic finalization. The patient has a good soft tissue maturation induced by the design of temporary crowns. A periapical radiograph was taken to evaluate the proper bone remodeling.\nA custom impression of the healed soft tissue, recording and transferring the soft tissue contour with a gingival outline, was taken according to the technique of Hinds, 1997 [].\nTherefore, after trying all the components, the definitive gold-ceramic crowns were delivered with good accuracy as well as a proper emergence profile to support the tissue.\nThe patient was instructed to maintain good oral hygiene by brushing and flossing.\nA year later, the patient was seen to observe overall tissue healing, aesthetics, and radiographic osseointegration of the implants.\nThis type of rehabilitation used integrates in the morphological and occlusal context of the oral cavity. In this way, this procedure, appropriately managed, is capable of producing the desired implant-prosthetic outcome, ensuring comfort and patient satisfaction () [].\nWe recommended the patient a thorough oral hygiene through the use of brush, dental floss, and pipe cleaner.\nThe patient was recalled for a clinical control after a three- and five-year period. A new periapical radiograph was taken which showed an excellent osseointegration of the implants with only a minimal loss of bone height according to the Albrektsson criteria and ICOI Consensus Conference, 2007 () [, ].\nOverall the patient was quite satisfied with the esthetic outcome and had no clinical issues. |
A 34-year-old gentleman presented to the emergency department of a regional hospital with 2 days of left-sided periorbital swelling superior to the eye socket with associated erythema and tenderness. He was assessed to have normal visual acuity and extraocular movements. He had a history of severe ankylosing spondylitis for which he was taking a TNF inhibitor, adalimumab. His blood tests showed a slightly raised C-reactive protein of 82 mg/l but otherwise no abnormality. Magnetic resonance imaging (MRI) was performed on the day of admission and noted significant left frontal sinusitis complicated by a defect of the frontal cortical bone as well as oedema and enhancement consistent with a Pott’s puffy tumour (). There was also an abscess of the periorbital soft tissue. Immediate treatment was given in the form of phenylephrine nasal decongestants and intravenous antibiotics (amoxicillin with clavulanic acid), and the patient was transferred to a tertiary centre with ear, nose and throat surgery capacity.\nWithin 24 hours of arrival at the tertiary centre, an incision and drainage of the soft tissue abscess and periosteal abscess was performed. At the same time the sinuses were debrided via endoscopic approach and a wide maxillary antrostomy and sphenoidectomy was performed. It was discovered that the frontal recess was completely occluded by a bony wall (). A cannula was placed into the frontal sinus for regular irrigation during the post-operative period with the other sinuses irrigated via nasal douche. Intravenous antibiotics and regular irrigation were continued for a further 5 days, and the TNF inhibitor was withheld on the advice of a rheumatologist. After this time the frontal sinus cannula was removed and the patient was discharged home. He was reviewed as an outpatient 6 days later and had a palpable soft tissue collection in the same area, which was promptly drained surgically and appeared to be a mucocele intraoperatively. None of the cultures identified a specific causative organism, although a Gram stain from the original admission showed gram negative bacilli. The patient was planned to have definitive surgery to open the bony occlusion of the frontal sinus and allow proper drainage. The patient was noted not to have any recurrence of symptoms on follow-up 1 year post-operatively. |
Our patient is a 1-year-old Saudi female child who was referred from another hospital after PDA ligation, left inguinal hernia repair, accidental fracture of her right ulna and radius, and prolonged mechanical ventilation for severe respiratory syncytial virus infection complicated by acute respiratory distress syndrome. The patient was sent to our hospital for further evaluation due to ongoing respiratory distress and hypoxemia. Our patient was the third child of nonconsanguineous Saudi parents and was born via cesarean section at 36 weeks gestation due to fetal distress. The child was admitted to the neonatal intensive care unit for 5 days because of respiratory distress and was ventilated for 36 hours. The mother has epilepsy and the father has been diagnosed with Behcet's disease. Since the age of 2 months, the child had multiple lengthy admissions in different hospitals (for 1 to 3 months at a time) for recurrent cyanotic events, respiratory distress, frequent choking with feeding, and significant vomiting. The child had accumulated the following diagnoses: severe gastroesophageal reflux disease (GERD), failure to thrive requiring prolonged nasogastric tube feeding, patent ductus arteriosus, pulmonary hypertension, anoxic convulsions, chronic lung disease with prolonged oxygen dependency, reversible bronchospasm, left external iliac vein thrombosis, and developmental delay. She had two prior prolonged stays at our institution.\nThe first admission was due to rhinovirus infection and clinically diagnosed recurrent aspiration secondary to aberrant right subclavian artery (dysphagia lusoria) with prolonged oxygen therapy. The second admission was for respiratory failure that required prolonged intubation including high-frequency oscillatory ventilation complicated by recurrent lung atelectasis and right lung pneumothorax. She failed multiple trials of extubation and unfortunately died of cardiac arrest due to sepsis while receiving maximal supportive therapy. An initial physical examination during the first admission revealed a baby girl in poor health with the following clinical values: moderate respiratory distress and a respiratory rate of 70/min, heart rate of 144/min, blood pressure of 101/47 with saturation of 95% on 1.5 L/min, body weight of 5.9 kg (below the third percentile), and height of 69 cm (at the tenth percentile).The child had diminished breath sounds bilaterally with a prolonged expiratory phase, wheezing, and scattered crackles posteriorly, mild hypotonia, and significant hyperlaxity. Investigations showed normal sweat chloride level, and immune function testing was normal. A chest X-ray (Fig. ) showed multiple subsegmental atelectasis and areas of air trapping. Computed tomography and angiography of her chest (Fig. ) revealed bilateral lower lobe airspace disease, hyperinflation of the right middle lobe and left upper lobe including the lingual, and an enlarged main pulmonary artery. The sagittal view (Fig. ) showed a right aberrant subclavian artery causing posterior compression to the esophagus at the level of the T4 vertebra and minimal compression in the posterior trachea. An echocardiogram showed no residual PDA or significant evidence of pulmonary hypertension. Barium administration (Fig. ) showed external compression along the posterior wall of the proximal third of the esophagus, which was causing significant narrowing of the esophageal lumen. The pH probe showed no significant GERD. Upper gastrointestinal endoscopy showed there was a narrowed and compressed area located 18 cm into the esophagus at T4, and was identified with marked pulsation. The flexible bronchoscopy showed complete ring and narrowing of the lower third of the trachea. A lung biopsy (Fig. ) showed alveolated lung parenchyma with alveolar simplification, in which alveoli do not show age-appropriate normal architecture, compared with the normal alveolar architecture (Fig. ). There was no magnetic resonance imaging (MRI) of the brain because our patient's condition did not allow it.\nMolecular testing for FLNA-related disorders in our patient showed a new pathogenic variant of one copy of c.3153dupC in exon 21 in the FLNA gene. This variant has not been reported in individuals with FLNA-related disorders but is expected to cause disease. |
A 22-year-old male soccer player came to our clinic complaining of knee pain, swelling, and inability to play soccer without pain. Physical exam revealed pain in the lateral femoral condyle, mild joint effusion, and full range of motion. An MRI demonstrated a grade IV osteochondral injury in the lateral femoral condyle. The patient was initially treated nonoperatively and returned to playing soccer at his preinjury level. However, at 1.5 years from the first visit the patient had a painful forced valgus maneuver, no joint effusion, a stable knee, and range of motion, but inability to play soccer pain-free. The MRI showed the same osteochondral injury and bone oedema in the lateral femoral condyle (). Due to lack of improvement with 1.5 years of physical therapy and activity modification, an arthroscopy was recommended to evaluate and treat the KOL. The basal functional scores of the patient were Lequesne index 3 (in a 0 to 24 scale where 0 is no functional limitation) [], visual analogue scale for pain 5 (in a 0 to 10 scale where 0 is no pain), WOMAC 8/96 (8.3%), IKDC Subjective Knee Evaluation Form 46, and Tegner-Lysholm 60.\nKnee arthroscopy demonstrated a rounded 1.7 cm diameter osteochondral injury in the lateral femoral condyle (). The surgical procedure and postoperative protocol detailed above were repeated for this patient (). As in case 1, the patient had no pain after one week of the operation and this was maintained throughout the postoperative period. At two months, the patient had full range of motion and a follow-up MRI was requested, demonstrating good filling and incorporation of the matrix into the defect. At three months after surgery, the patient had slight joint effusion and quadriceps atrophy. At six months, he still had significant quadriceps tone asymmetry and a follow-up MRI demonstrated an almost complete filling of the defect without still complete maturation but with no other significant associated lesions (). The patient slowly recovered quadriceps tone, and at eight months he was allowed to begin running. One year after surgery, the MRI showed adequate repair of the defect with correct thickness (no overgrowth) and similar signal intensity in the defect compared to surrounding healthy articular cartilage. The patient returned to playing at the same preinjury level 10 months after the surgical procedure. At 20 months after surgery, the patient had the following scores: SF-36 96.4 (physical function 100, physical role 100, pain 100, general health 100, vitality 80, social function 100, emotional role 100, mental health 88, and health transition 100), Lequesne index 0 (in a 0 to 24 scale where 0 is no functional limitation) [], visual analogue scale for pain 0 (in a 0 to 10 scale where 0 is no pain), WOMAC 0/96 (0%), IKDC Subjective Knee Evaluation Form 100, and Tegner-Lysholm 100. |
A 79-year-old man visited our hospital with a chief complaint of erythema around the urethral orifice of the glans, which exacerbated 6 months ago. Visual examination revealed red-brown erosion on the glans penis around the external urethral orifice (). Physical examination showed no definite inguinal lymph node swelling. A diagnosis of penile BD was made with a penile skin biopsy. The patient was referred to our department to evaluate the involvement of BD in the distal urethra.\nVisual examination and cystoscopy revealed no definite tumorous lesions in the urethra or urinary bladder. Urine cytology was negative. No definite BD lesions in the distal urethra were expected to be found in this case; therefore, local tumor resection with skin grafting from the femoral skin was performed (). The superficial region of the glans penis, with a margin of 5 mm from the visual lesions, was resected, together with the external urethral orifice.\nAlthough the peripheral surgical margin of the glans penis was negative, a positive urethral margin of the tumor was revealed upon histopathological examination. Since the degree of urethral involvement of penile BD could not be estimated with any clinical observation, the patient received a glansectomy 2 months after the initial surgery. The decision to completely resect the carcinoma was confirmed by the intraoperative frozen section analysis. Histopathological examination revealed the growth of stratified squamous epithelial cells with nuclear atypia in all layers of the urethral mucosa; hence, the patient was diagnosed with urethral BD. A tumorous lesion in the distal urethra, 7 mm from the external urethral orifice, was found. The patient recovered well, with no definite recurrence of BD up to 13 months after the glansectomy. After the second surgery for limited resection of the penis, the patient could urinate in a normal position.\nDNA was extracted from the paraffin-embedded tumor sample using the Pinpoint Slide DNA Isolation System™ (Zymo Research, Orange, CA), and HPV16 DNA was detected using flow-through hybridization (HybriBio™; HybriBio Ltd., Hong Kong). In addition, the locations of HPV16 DNA in the tumor tissue could be observed with in situ hybridization (ISH) (). Immunohistochemistry demonstrated that p16-INK4a, which is a surrogate marker of oncogenic HPV-E7 protein, was widely expressed in the tumor tissue (). Based on these findings, we diagnosed the patient with HPV16-positive penile BD involving the distal urethra. |
A 27-year-old woman was referred by a neurologist, for ophthalmic consultation. She had a history of headache, visual loss in her right eye and four-limb paresthesia over a period of 10 months prior to presentation. During this period, the patient had developed behavioral and mood changes such as depression, paranoia, and memory loss. The primary diagnosis was multiple sclerosis and she was treated with intravenous methylprednisolone (1 g / day) for three days followed by 1 mg / kg / day of prednisone administered orally for six weeks then tapered weekly over the next four months. The response to the steroid was remarkable for paresthesia, but the visual loss remained. The patient also complained of tinnitus and hearing loss for two weeks, prior to admission.\nMagnetic resonance imaging (MRI) before steroid treatment demonstrated nonspecific periventricular high signal intensity foci in the white matter and a few high signal intensity foci in the corpus callosum [Figures and ].\nCerebral arteriography was normal. Spinal fluid examination revealed a high protein concentration of 250 mg / dL with no cells and no oligoclonal immune globulin. Full laboratory evaluations including tests for brucella, syphilis, and collagen vascular disease were normal, except the erythrocyte sedimentation (ESR) rate, which was mildly elevated as 38 mm / hour. An audiogram showed mild right ear sensorineural deafness at lower frequencies. The patient complained of fluctuating tinnitus and could not be elicited sufficiently during the examination. Based on the above-mentioned findings, the diagnosis of multiple sclerosis (MS) was unlikely and the neurologist suspected Susac's syndrome and referred the patient for an ophthalmic evaluation.\nOn examination, she was awake, but had a blunted affect and was difficult to engage. Motor and sensory examinations were normal. The visual acuities in the right and left eyes were 20 / 30 and 20 / 20, respectively. Slit lamp examination was normal. The funduscopy and fluorescein angiographies were normal in the left eye. The right eye fundus was normal []. Fluorescein angiography of the right eye showed a small superior macular branch artery occlusion and perivascular sheathing near the optic disc []. Perimetry showed a central scotoma with a macular problem []. With the confirmation of cerebral, cochlear, and retinal involvement, a diagnosis of Susac's syndrome was made. After initial corticosteroid treatment, the disease remitted and did not recur on a two-year follow-up. Hence, further treatment was not administered. |
A 28-year old female presented in our center suffering from a long term of recurrent abdominal pain. The chronic recurrent postprandial pain started six years ago.\nThe daily pain localized in the epigastric region, the pain wakes her up in the night and she had no complete relieve on analgesics. No nausea, vomiting or weight loss were recorded. Moreover, no diarrhea or constipation were detected. No previous history for medical or family conditions. Only She had an appendectomy ten years ago and two cesareans, and cholecystectomy five years ago.\nThree upper endoscopies showed normal findings with almost six months between one and another. She has a previous diagnosis of irritable bowel syndrome to explain her recurrent abdominal pain.\nAt admission, abdominal examination, laboratory tests and ultrasound were within normal limits. Multi slice computed tomography (MsCT) revealed a 3.5 cm heterogeneous mass in the tail of pancreas with stenosis up to 40% in the celiac trunk with 45° of angulation ().\nThe diagnosed of DS was probable, and a surgical intervention was proposed to resolve the celiac trunk compression and to resect the pancreatic tumor. Abdominal exploration was performed via midline incision; a 3.5 cm mass in the tail of the pancreas was detected with no metastasis or ascites. Distal pancreatectomy with splenectomy was performed. Liberation of the celiac trunk was accomplished by cutting the median arcuate ligament ().\nThe patients discharged from the hospital three days after surgery in good situation. Follow up after showed a complete relieve for her pain.\nThe pathology result showed neuroendocrine tumor in the tail of pancreas.\nA well-demarcated mass in the pancreatic tail, measures 3cm in the greatest dimension, composed of proliferation of sheets and nests of medium and large cells with eosinophilic and finely granular cytoplasm, nuclei are round with salt and pepper chromatin. Atypical and bizarre cell present with prominent mitotic figures and tumor necrosis. Rich vascular network in the stroma, with fibrotic areas.\nImmunohistochemistry (IHC) revealed that neuron specific enolase (NSE), synaptophysin and CD56 were positive (diffuse), negative chromogranin, focal cytokeratins (CK) and the KI67 was high index (20%). Finally, Diagnosis is a well-differentiated neuroendocrine tumor, Grade 3 (). |
A 46-year-old female patient visited the hospital, complaining of a headache. No abnormal findings were observed on the first neurologic examination, while other medical examinations also showed normal findings. Findings on brain computed tomography (CT) examination showed a slightly high-density intra axial mass lesion measuring approximately 2.5 cm lateral sides on the right sylvian fissure. It showed no edema around the mass, iso-density and strong enhancement without calcification inside (). According to findings on a three-dimensional CT angiogram (3-D CTA) examination, the mass was diagnosed as a saccular aneurysm in the right MCA bifurcation (). T2 weighted images from a brain magnetic resonance image (MRI) examination showed a high signal in the aneurysm and a heterogeneous peripheral low signal. At the back of the aneurysm sac, M2 branches were advanced and deviated toward the medial side. A T1 weighted image showed a low signal in a part close to the Circle of Willis and an iso signal far from it. Like the CT image, it showed a slightly low signal with dense contrast enhancement and difference in filling in the aneurysm sac (). In addition, SAH was not found on the CT examination; however, a small amount of SAH was noted around the aneurysm and along the sylvian fissure. In the right internal carotid artery (ICA) angiogram (three-dimension subtraction image) posterior to anterior view, an aneurysm measuring 21.6 × 20.9 mm in the right MCA bifurcation was observed in a lateral direction. It formed a broad neck along an inferior branch of M2 and several perforating branches were observed around the neck (). It is specific in the angiogram that the filling of the aneurysm in the early arterial phage was not partially performed. Filling of the aneurysm in the later arterial phage was completed, without excretion up to the capillary phage. This is referred to as a slow filling and delayed excretion (). The patient underwent surgery after approximately ten days. Direct clipping in the operation field was difficult; therefore, the operation was completed after wrapping the ruptured portion using surgical glue. The patient was discharged from the hospital without complications. According to findings on the MRI examination performed approximately months after discharge, a target sign that appeared as a high signal, and a low signal in a slightly inner portion and a high signal again in a central portion, was seen around the aneurysm on the T1 image (). An examination after 19 months showed that the size of the aneurysm had decreased considerably (). Finally, according to findings on the angiogram and MRI examination (which were performed after three years and eight months), there was no trace of the mass in the sylvian fissure due to the considerable reduction in the size of the aneurysm and almost everything in the M2 branch was intact (). |
A 35-year-old male patient, with persistent AF refractory to the pharmacologic treatment underwent RFA in our hospital. As a routine practice in our centre, the patient was assessed pre-procedurally by transesophageal echocardiography (TEE) on the day of procedure to delineate anatomy of pulmonary veins and left atrium (LA) and to exclude LA appendage thrombus. During RFA procedure all four PV were individually isolated under guidance of intracardiac echocardiography. RF energy was delivered using a conventional 4 mm and 8 mm tip ablation catheters and a power setting of 30 W, 50 °C around a circular decapolar catheter located at the pulmonary veins ostia. Application of the RF was immediately interrupted when microbubbles were detected by the intracardiac echocardiography (ICE). After a curative ablation therapy patient was kept on aspirin to prevent pulmonary venous or arterial thrombosis and recurrence of AF. Ambulatory follow-up cardiac computed tomography (CT) angiogram was done 3 months following RFA and showed approximately 60% left superior PVS but no intervention was performed because the patient was asymptomatic and he was kept on oral anticoagulation ().\nTwo months later, the patient developed cough associated with hemoptysis, mild intermittent fever, mild left-sided pleuritic chest pain and shortness of breath on exertion. He visited the primary health centre close to his residency where chest radiography was done and showed left upper lobe poorly marginated opacities and minimal left pleural effusion. Further laboratory studies were done to rule out pulmonary tuberculosis (TB) which were within normal limits. A definitive diagnosis was not made and the patient was given broad spectrum antibiotics and referred to pulmonology clinic in our hospital for further investigation.\nPatient presented to our hospital 6 months after ablation without improvement in the symptoms. Non-enhanced CT was done and showed increased parenchymal attenuation and multiple peripheral patchy consolidations in the apico-posterior and anterior segments of left upper lobe associated with minimal left pleural effusion (). Cryptogenic organizing pneumonia (COP), chronic eosinophilic pneumonia (CEP), fungal infection (pulmonary aspergillosis), lung cancer and primary pulmonary lymphoma were suggested as differential diagnosis and ultrasound-guided aspiration of the left-sided pleural effusion was carried out and the obtained specimen was fluid of serous nature. Besides that, lung biopsy was also performed and the histopathologic examination revealed surprisingly intimal hyperplasia associated with multifocal haemorrhagic infarction due to PVO and hypertensive pulmonary arteriopathy. After that contrast-enhanced CT scan was performed with 3D reconstruction and manifested clearly an occluded left superior pulmonary vein (LSPV) (). Occlusion was confirmed by conventional angiography. Ventilation/perfusion scan demonstrated absent perfusion of the involved lung parenchyma and left upper lobectomy was warranted. |
A healthy 21-year-old man was admitted to our hospital after being referred from another medical institution because of worsening left eye (LE) uveitis. He was treated 3 weeks earlier with oral acyclovir and topical steroids because of suspected LE herpetic anterior uveitis as serological tests revealed positive immunoglobulin M to herpes simplex virus-1. Initially he responded to treatment but 2 weeks later, his vision declined from 6/9 to counting fingers (CF), resulting in his referral to our center.\nThe patient denied any relevant past medical history. However, he mentioned that a month earlier he was examined for LE discomfort and diagnosed with allergic conjunctivitis following minor blunt trauma from a tree branch.\nOn examination, visual acuity (VA) was 6/6 in the right eye (RE) and CF at 1 meter in the LE. Intraocular pressure was 14 mmHg in both eyes. RE anterior and posterior segments were normal. There was a remarkable LE anterior chamber reaction with dust-like keratic precipitates, cells (4+), flare (2+), and some iris nodules. Fundus assessment was not possible because of dense vitritis. B-scan and high-frequency ultrasound did not reveal any intraocular foreign body. Aqueous tap was performed and the sample was sent for culture and polymerase chain reaction analysis. It was negative for all herpes viruses and for 16S rDNA. Meanwhile, with oral steroids and valacyclovir, the patient showed signs of improvement and LE VA improved to 6/15. Despite the remarkable improvement, it was insufficient as the patient continued to have marked anterior uveitis and vitritis. A white shadow was noted in the peripheral temporal retina of the LE which again could not be assessed properly due to vitreous opacities (). The patient eventually underwent pars plana vitrectomy and laser retinopexy was performed around the white peripheral temporal lesion, which was later believed to be the site of penetrating injury by a thorn on the tree branch from the previous trauma described by the patient. Gram staining of the undiluted vitreous samples showed gram-positive cocci. 16S rDNA was positive for S. epidermidis, and blood agar and chocolate agar cultures confirmed the result with moderate growth.\nThe patient was treated with intravitreal antibiotics (vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL) and intravitreal dexamethasone 400 mcg/0.1 mL as well as intravenous (IV) vancomycin (1 g twice/day), and oral prednisone was continued.\nAfter 48 hours of treatment, the patient showed remarkable clinical improvement. LE VA was 6/12. There was no need to administer more intravitreal antibiotics.\nAfter 5 days of IV antibiotic treatment, the patient was discharged on topical and a tapering regimen of oral steroids.\nAfter a follow-up period of 3 months, LE VA was 6/6 with complete resolution of the infectious process (). |
We present a 64-year-old Hispanic male with Rai Stage II, IgH mutated, and trisomy 12 positive CLL, diagnosed 13 years prior to admission. He was initially observed for 3 years and then received first-line fludarabine, cyclophosphamide, and rituximab (FCR) for 3 cycles with good response. He remained on observation for 4 additional years and then received an additional 4 cycles of FCR followed by 5 cycles of maintenance rituximab. Five years later, he was found to have 17p deleted recurrent disease and he was started on ibrutinib with good response. He presented to an outside facility with acute onset altered mental status after stopping ibrutinib 2 months earlier due to financial constraints. Cerebrospinal fluid (CSF) analysis was initially concerning for CLL infiltration of the CNS with neoplastic-appearing lymphocytes identified by cytomorphology; however, serological tests for West Nile virus indicated acute infection based on positive IgM and negative IgG; however, PCR could not be performed. The patient received therapy for presumed CNS involvement by CLL with intrathecal methotrexate along with intravenous rituximab and methylprednisolone before being transferred to our institution. On admission, his complete blood count revealed leukocytosis with a normal differential and thrombocytopenia, after reviewing the patients' historical trends, we could discern that the platelet count had been within normal limits in the past and had likely decreased due to the acute illness; additionally, we can appreciate the increasing trend in WBCs until the start of treatment around 10 years prior to this admission (). Peripheral blood smear showed normal platelet morphology and moderate leukocytosis with lymphocytosis with coarse, block-like chromatin pattern concerning for prolymphocytoid transformation which had not been present previously. Bone marrow biopsy revealed hypercellularity with diffuse infiltrate of the medium to large-sized mononuclear cells with irregular nuclear contours and prominent nucleoli similar to that seen in the peripheral blood smear (). Repeat CSF studies at our hospital showed lymphocytes accounting for 49% of total events per flow cytometry, positive for CD19, CD20, CD5, and CD23, with lambda light chain restriction, and negative for CD10 and FMC-7 (). The morphology of lymphocytes in CSF was consistent with neoplasia; however, given the admixture of reactive lymphocytes and the presence of known CNS infection, it was deemed that this most likely represented peripheral blood contamination and reactive infiltration of neoplastic lymphocytes.\nHe was treated supportively during his hospital stay and improved without any further CNS-directed therapy. Ibrutinib was later reinstated after the resolution of thrombocytopenia and BTK mutational testing proved negative. The patient continued to improve during outpatient follow-up, prolymphocitoid morphology disappeared from peripheral smear, and brain MRI showed no evidence of CNS disease. |
A 21-year-old Malay female of middle socioeconomic status, first presented with acute pulmonary oedema at 23 weeks of gestation when she was admitted to the intensive care unit for four days for non-invasive ventilation. She had a BMI of 32.9kg/m with hypertension documented during pregnancy. Further assessment also revealed presence of gestational diabetes. She was investigated for Cushing’s syndrome as she had facial acne, purplish abdominal striae, skin thinning and easy bruising (). She had elevated 24-hour urinary cortisol and mildly elevated morning serum cortisol detected. However, her diagnosis of Cushing’s syndrome was never confirmed as she defaulted her follow-up and was subsequently managed in multiple hospitals due to logistic reasons.\nAt 27 weeks of gestation, she was readmitted for acute pulmonary oedema () with hypertensive crisis. She required non-invasive ventilation during this admission and blood pressure was controlled with intravenous infusion of magnesium sulphate. A bedside echocardiogram showed an ejection fraction of 55% with presence of pericardial effusion at the base of the right atrium measuring 1.1 cm with presence of right atrial systolic collapse. In view of her unstable cardiac condition and hypertensive crisis, the collective decision between the obstetrician and cardiologist was to proceed with emergency caesarean section. A 1.1 kg baby girl was delivered prematurely at 27 weeks and 3 days period of gestation and was subsequently admitted to NICU for further care.\nFollowing delivery, her condition improved with diuretics and blood pressure was controlled with 3 oral antihypertensive agents. Unfortunately, her hospitalization was prolonged due to dehiscence over her caesarean section surgical wound. Despite being discharged well after delivery, she was admitted for 2 further episodes of acute pulmonary oedema with hypertensive crisis, in which both episodes required ICU admission and ventilation. The first episode occurred two months after delivery, and again two weeks later. She received furosemide and BP lowering medication. Her diagnosis of ACTH-independent Cushing’s Syndrome was only confirmed in between the two acute pulmonary oedema admissions during the postpartum period. She had unsuppressed serum cortisol after overnight and low-dose dexamethasone suppression test with suppressed ACTH ().\nDuring her clinic review at 4 months postpartum, she complained of severe lower back pain which corresponded to T9 to L1 osteoporotic compression fracture (). She required multiple analgesic medications to relieve her severe pain and she was given an immobilization brace. The pain resulted in her being home-bound and dependent on wheelchair for ambulation.\nShe also defaulted her follow-up during the postpartum period on several occasions resulting in a delay in her adrenal computerized tomography (CT) scan. Adrenal CT scan was only performed at 6 months postpartum which revealed a right medial limb adrenal adenoma measuring 3.1 x 1.9 x 2.9 cm with pre-contrast HU of 31 and 96% absolute contrast washout ().\nAfter much deliberation and counselling, she finally agreed to surgery. She received a short course of metyrapone preoperatively to control her cortisol and underwent an uncomplicated right open transabdominal adrenalectomy in July 2019. Intraoperative findings noted a right adrenal gland measuring 3 x 3 cm in size. Histopathological examination of the right adrenal gland revealed a cortical adenoma.\nDuring the postoperative period, she was started on oral hydrocortisone as cortisol replacement. Bisphosphonate (zoledronic acid) and cholecalciferol were also initiated for the severe osteoporosis. Her anti-hypertensive treatment was significantly reduced from 5 agents to only a single agent during her postoperative period. |
An 82 years-old man was admitted to our hospital because of ongoing low back pain not responsive to pharmacological therapy. Symptoms, which started 7 months before admission, consisted of low back pain, fatigue and weight loss of around 15 kg in the absence of fever, neurological deficits and night sweats. The patient had a history of Pott’s disease of the lumbar spine which had been treated medically 50 years before and prostatic adenocarcinoma which was surgically excised 5 years earlier. Up until the most recent hospital admission the patient was considered free from both conditions. Two months before the current admission, the patient had been admitted in another hospital complaining of epigastralgia irradiated to the lumbar spine. During the hospitalization the patient underwent several investigations including full blood count, EGDS and colonoscopy which were all normal, as well as a lumbar spine MRI which showed a lytic lesion centered around the L2-L3 disc space (). In consideration of the patient medical history, a reactivation of Pott’s disease was suspected. Nevertheless, further studies including sputum examination for mycobacteria, hemoculture and sierological testing for HIV, HBV and HCV and PCR test for atypical mycobacteria were negative. A CT-guided lumbar biopsy was thus performed but the final histological exam was non diagnostic, characterized by a fibrous tissue with lymphocytic infiltration and bone spicules with no signs of neoplasia. The patient was therefore treated with broad spectrum antibiotics (Piperacillin/ Tazobactam for two weeks followed by Rifampicin and Levofloxacin for additional six weeks) and was discharged afterwards with a rigid lumbar brace for pain comfort and mobilization. Because of severe worsening of the lumbar pain and an increase in the inflammatory markers (ESR and PCR) the patient was admitted to our hospital. A new contrast-enhanced lumbosacral MRI was obtained which revealed a worsening of the destructive lesion at L2-L3 with a destruction of the posterior wall of L2 and involvement of the anterior epidural space and the left nerve root canal in addition to the extension of the osteolytic lesion at the level of L3-L4 and to both of the ileopsoas muscles (). After a wash-out period of the antibiotic therapy, a repeat CT-guided bone biopsy was performed at L2-L3 level but it was once again non diagnostic. Broad spectrum antibiotic therapy was thus continued with Ertapenem and Teicoplanin for four weeks leading to a decrease in the inflammatory markers. Nevertheless, due to further worsening of the low back pain, an open vertebral biopsy of L2-L3 disc space was performed through standard posterior approach. The histological examination highlighted the presence of a chronic gigantocellular inflammatory granulomatous process, with no cellular atypia. At this stage, because of the non-conclusive diagnosis, standard antitubercular therapy with Isoniazide, Rifampicin, Ethambutol and Pyrazinamide was started and showed some positive effect of patient’s low back pain. After eight weeks of anti-tuberculosis therapy, repeat CT and lumbosacral MRI () scans were performed because of the onset of bilateral muscular weakness in L2 and L3. Imaging studies showed the extension of the disease also to the L1 vertebral body. Therefore, a surgical procedure of decompression, curettage and posterior biopsy at the L2-L4 level was performed. Histological examinations excluded an ongoing tuberculosis process and documented the presence of findings compatible with metastatic melanoma. The definitive diagnosis was subsequently obtained through immunohistochemistry: anti-melanoma antibodies HMB-45, S-100 protein which were strongly positive. Life expectancy of the patient was calculated in less than 6 months due to the involvement of more than 3 spinal levels and the presence of extraperitoneal involvement. After careful discussion of the available options with the patient, decision was made not to pursue any further surgical therapy. The patient received adjuvant radiotherapy and immunotherapy and died four months afterwards due to liver metastases and the development of acute liver failure. |
A 53-year-old male patient with a history of stage C colon cancer complained of painless diminution of vision in his right eye of acute onset and stationary course for 3 days. He underwent a hemicolectomy for his colon cancer 5 months before and had been receiving chemotherapy in the form of 5-fluorouracil, oxaliplatin, and folinic acid every 2 weeks for 4 months. He had a past medical history of hypertension, which was controlled by medication. He had no previous history of ocular problems.\nExamination revealed a corrected distance visual acuity of 20/ 400 in the right eye and 20/ 80 in the left. Color vision was 2/ 10 in the right eye and 10/ 10 in the left using Ishihara plates. Examination of the pupil revealed a right relative afferent pupillary defect. Intraocular pressure was 16 mmHg in both eyes. Extraocular motility was full. Anterior segment examination revealed nuclear cataract in both eyes. Fundus examination showed bilateral optic disc elevation with multiple superficial nodular swellings over both optic discs. There were also multiple flame-shaped hemorrhages over the right optic nerve head with an anomalous left retinal vasculature (\n).\nA computed tomography scan of the brain and orbit was performed which revealed no cerebral pathology but suggested the presence of bilateral ODD more on the left side (\n).\nRight NAION on top of bilateral ODD was suspected and fundus fluorescein angiography was subsequently performed to confirm the diagnosis (\n).\nB scan ultrasonography was also performed to confirm the presence of ODD and revealed bilateral buried drusen (\n). Visual field testing revealed an altitudinal field defect in the right eye involving the inferior hemifield. A final diagnosis of bilateral ODD with right NAION was made and diminution of vision in the left eye was attributed to the presence of nuclear cataract and ODD. Follow-up of the patient a few months later revealed right optic disc pallor with no improvement in visual acuity. |
A 55-year-old male patient reported with mild swelling and pain in the left zygomatic region. The history of present illness revealed that the patient had noticed the swelling in the last few weeks and it also had an associated intraoral ulcer. The patient was a known diabetic who was under medication. He had a habit of smoking cigarettes for the past 15 years. He smoked almost 15 cigarettes per day. The clinical examination revealed a firm swelling in the left zygomatic region measuring approximately 3 cm to 5 cm. It was mildly painful on palpation. The left maxillary region had significant paresthesia, nasal obstruction, and episodes of pain. A palpable left submandibular lymph node was present, which was also tender and fixed. The cervical lymph node on the left side was also palpable (Figure ). The intraoral examination revealed an ulceroproliferative growth measuring 4 cm to 6 cm in dimension.\nThe lesion was extending in relation to teeth 23, 24, and 25. The ulcer was covered with necrotic slough. Purulent discharge and bleeding were present in the lesion. The other teeth in the quadrant were missing (Figure ). A panoramic radiograph revealed extruded teeth 23, 24, 25.\nThere was increased radiopacity in the left maxillary sinus (Figure ). Water’s view showed the opacification of the entire left maxillary sinus.\nAn intraoral extension of this mass was also evident. The inferior, posterior, lateral, and medial walls of the left maxillary sinus appeared to be destroyed (Figure ). A computed tomography (CT) scan showed a lesion extending into the maxillary space and the nasal cavity. A heterodense soft tissue lesion showing heterogeneous contrast enhancement in the left maxillary sinus and hard palate with the destruction of the posterolateral wall, medial wall, and floor of the left maxillary antrum, extending into the adjacent retro maxillary space and medially extending into the left nasal cavity, obliterating all meati with the destruction of nasal turbinates. It was also inferiorly extending into the oral cavity. The CT was suggestive of carcinoma antrum. The CT was sufficient to understand the extensions of the lesions and the destruction of nasal turbinates. Further radiological investigations were, hence, not considered.\nConsidering the patient history and clinical features and the fact that patient was experiencing paresthesia, a biopsy was deemed mandatory (Figure ). On microscopic examination, the given hematoxylin and eosin (H&E)-stained soft tissue section showed dysplastic epithelial islands arranged in sheets and nests, invading fibrovascular stroma.\nAs shown in Figure , the dysplastic epithelial cells exhibited an increased nuclear-cytoplasmic ratio, individual cell keratinization, and increased mitotic figures.\nKeratin pearl formation was also evident, suggestive of well-differentiated squamous cell carcinoma. The patient was referred to the maxillofacial surgery department and briefed on surgical and chemotherapeutic treatment modalities. As the patient was from a poor socio-economic background and had also reported at an advanced stage, he declined treatment and was advised palliative management. The palliative treatment mainly concentrated on the pain relief and nutritional needs of the patient. The patient was treated with acetaminophen and, later, with stronger medications like opioids to manage pain. A feeding tube was inserted into the stomach through the throat since the patient was having extreme difficulty in swallowing. Sadly, the patient succumbed within a few weeks. |
A 37-year-old male presented with history of injury in left eye during a fight years ago. His vision decreased but he did not use any medications. On examination, vision in right eye was 6/6 and in the left eye it was PL positive, PR accurate. Right eye examination was within normal limits. Left eye showed trace conjunctival congestion, there was diffuse corneal scarring with central descemetocoele. Anterior chamber view was hazy and there was total cataract. He underwent optical penetrating keratoplasty with extracapsular cataract extraction with intraocular lens implantation under local anesthesia in left eye. The post-operative period was uneventful and at last follow-up his vision in the left eye was 20/400.\nFour patients in this series had presented as ulcerative keratitis and one as post-traumatic corneal ectasia. Two of the four patients, diagnosed as stromal keratitis, underwent deep stromal scrapings, which demonstrated microsporidial spores. The diagnosis was made on observing oval refractile bodies in the corneal scrapings, both within cells as well as in extracellular location. The Gram (figure ) and Giemsa stained smears revealed variable staining of the parasites. The oval body had a dark polar nucleus. The parasite was acid fast and appeared as red oval structure on smears stained with 1% acid fast stain (figure ). Corneal scrapings stained with calcofluor white showed oval fluorescent bodies in clumps. Bacterial and fungal cultures from these cases did not reveal any organisms except in one case (case 4) that showed a significant growth of Staphylococcus epidermidis.\nThree cases were initially treated medically based on the findings of smear examination. In case 1 the treatment was started with fortified cefazolin and fortified gentamicin even though oval bodies were seen in the smear examination. In other two cases where scraping was performed the treatment was started with oral itraconazole 100 mg twice daily and topical ciprofloxacin 0.3%. The infiltrate resolved with medical therapy in one case. Even this case developed progressive thinning for which tissue adhesive and bandage contact lens was applied. Penetrating keratoplasty was performed in four cases. The indications were non-responding keratitis in three cases and thinning with ectasia in one case. Postoperatively all cases were managed with corticosteroids (Prednisolone acetate 1%). The graft was clear in all cases with no evidence of recurrence of infection. |
A 16-year-old boy with no urological or medical history presented to his general practitioner with a six-month history of strangury, poor flow, suprapubic discomfort, urinary frequency and urgency. He had also noticed one recent episode of visible haematuria. There was no family history or congenital abnormality noted. Blood tests revealed a normal renal function. An ultrasound of his urinary tract had been ordered in the community, which had shown two large polypoidal masses arising from the right and left lateral walls of the bladder, measuring up to 2.1 cm and 2.5 cm, respectively. The remainder of the urinary tract was unremarkable, and there was no significant post-void residual volume ().\nThe patient was referred urgently to be seen by the urology team. Following further discussion in clinic with the patient and his parents, a decision was made to proceed directly to cystoscopy under general anaesthetic for further evaluation and possible resection of these lesions. A urine cytology was sent which showed a few inflammatory cells but no overtly malignant cells to be present. Serial urine cultures had revealed no growth and he had no history of previous urinary tract infections. On cystoscopic examination, following dilatation of a tight urethral meatus from 14Ch, the two large polypoid lesions were identified on either side of the bladder neck that they were partially obstructing, resembling malignancy in some areas and inflammatory masses in others (). The remainder of the urethra was normal. Neither ureteric orifice was visualised. Both lesions were resected using a 17Ch resectoscope, and a small red area on the posterior wall was biopsied. A decision was made to remove the majority of the lesions from around the bladder neck, leaving as much normal or non-polypoid tissue as possible to reduce the risk of bladder neck stenosis. The patient was kept overnight for bladder irrigation, and the catheter was removed the following day with no postoperative complications.\nHistological examination of the resected tissue revealed florid cystitis cystica and cystitis glandularis in all three specimens. Muscle was included in two of the three specimens. No intestinal metaplasia was seen, and no evidence of dysplasia or malignancy was identified (). The patient subsequently underwent an MRI scan of the pelvis which showed no other abnormalities in the pelvis (). The LUTS symptoms had subsided one month post-operatively and flow rate returned to normal. Following discussion in our multidisciplinary meeting, a recommendation was made for repeat cystoscopy in six months time. |
A 45-year-old, gravida zero para zero, female presented with a one-week history of a fluctuant mass and erythema in the right superior breast. She had a history of seat belt injury to the right breast seven years prior, and had felt stable masses in the breast for two years prior to presentation. After admission to the hospital, intravenous antibiotic therapy was initiated for symptoms of infection. No family history of breast cancer was noted at that time. The work-up for presumed mastitis began with a bilateral diagnostic mammogram. The provided patient history included a possible diagnosis of cellulitis with imaging to rule out an abscess of the right breast. The ordering physician also emphasized the history of seat belt injury. The admission diagnostic mammogram revealed heterogeneously dense breasts, as well as the presence of fat necrosis in the upper outer quadrant of the right breast at the 12 o’clock position (Figure ).\nNo significant masses, calcifications, or abnormalities were noted in the left breast at that time. Ultrasound of the right breast demonstrated edema with no evidence of malignancy. The patient was diagnosed with cellulitis of the right breast and discharged with antibiotics.\nTwo weeks later, the same patient returned with exacerbated erythema, hardness, and tenderness in the right breast. In addition, she also noted a new lump in her left breast which she had not noticed before and mentioned this for the first time to the radiologist while ultrasound is being performed on the right side. The right breast showed redness, induration, and tenderness in the upper outer quadrant. Subsequent diagnostic ultrasound of the left breast revealed an irregularly shaped hypoechoic mass with microlobulated margins. The mass measured 21 x 18 x 14 mm and was located at the 3 o’clock position, 3 cm from the nipple (Figure ).\nUltrasonography of the right breast revealed only fat necrosis and edema consistent with the patient history. Overall, the imaging was given a BI-RADS assessment of 4C, which is a moderate concern for malignancy.\nUltrasound-guided biopsy of the left breast revealed invasive ductal carcinoma, a moderately differentiated nature, and a grade of two with components of ductal carcinoma in situ. Follow-up mammography was performed, showing proper placement of a marker in the clinically observable mass (Figure ).\nThe patient's care was transferred to an outside facility following a definitive diagnosis. The patient ultimately received bilateral mastectomies with sentinel lymph node dissections and adjunctive chemotherapy. |
A 71-year-old male with a history of chronically implanted ICD (6 years) was initially admitted to electrophysiology (EP) suite for an ICD lead extraction and replacement upgrade of the system to a biventricular functional system. During an ICD pulse generator replacement (Medtronic Viva XT CRT-D, model DTBA1D1) 2 months earlier the coronary sinus lead was noted to have a fracture due to insulation break so it was cut and capped at that time. The model of this particular implanted Left Ventricular Coronary sinus lead was Medtronic StarFix unipolar active fixation, model 4195 (implant date 6 years ago). Patient had history significant for class III congestive heart failure with underlying LBBB.\nCardiac fluoroscopy was performed to demonstrate normal position of the ICD pulse generator in the left subclavian area. The right atrial and ventricular leads tracked normally while the coronary sinus lead was noted to be fractured within the pocket with the lead remnant in the ICD pocket. Cardiac silhouette motion was normal and no evidence of pleural effusion was noted. Local anesthesia was infiltrated to the right and left groin. An 18 g arterial line was placed in the left femoral artery with good waveform. #7f and #9f venous lines were placed in the right femoral vein. Through the #9f, an intracardiac echocardiographic (ICE) probe was advanced to the level of the right atrium and ventricle. No evidence of vegetation or pericardial effusion was noted. The left subclavian area was prepped and draped. Local anesthesia was administered to the left anterior chest wall prior to opening the pocket. The pulse generator was removed from the pocket and leads were dissected to the level of the anchoring sleeves. There was a cap present over the abandoned lead remnant and this cap was removed. Tie-down sutures were removed. Leads were dissected to the level of the anchoring sleeves to free them up from posterior scar tissue. The anchoring sleeve of the coronary sinus lead was removed and gentle traction initiated; however, it was heavily scarred into position at the distal branch of the lateral branch of the coronary sinus. All 4 splines were deployed. The head of the lead was cut off and a Liberator locking stylet was advanced and locked at 1 cm from the tip of the lead. With continuous traction, a 12-French laser sheath was advanced over the lead to break up heavy fibrosis near the left brachiocephalic vein and down to the superior vena cava. The lead became dislodged situating itself at the proximal area of the coronary sinus. Continuous gentle traction of this area and laser at the ostium of the coronary sinus lead dislodged the lead in its entirety from the coronary sinus and it was removed without difficulty. There was a substantial amount of scarring at the level of the coronary sinus insertion site and around the splines before they became dislodged.\nAt this time, the patient's blood pressure became labile. Cardiac silhouette motion was decreased and ICE probe showed pericardial effusion consistent with pericardial tamponade. A subxiphoid pericardiocentesis needle was inserted and 60 cc of blood was aspirated. The patient's blood pressure responded and, however, subsequently started to decrease again. Cardiothoracic surgery was called to the EP suite, and patient was intubated and requiring massive hemodynamic support, which deteriorated into cardiac arrest requiring cardiopulmonary resuscitation. While in the EP suite, open chest sternotomy and evacuation of hematoma from the pericardium was performed. Large amount of clot was removed from behind the heart and hemodynamics stabilized despite continued bleeding. Patient was transferred to the operating room.\nIntraoperatively, the patient was immediately placed on cardiopulmonary bypass to explore cardiac structures and injury. Several injuries were noted including a large amount of bleeding from the posterior portion of the heart due to total disruption of the distal coronary sinus and large degloving injury of posterior portion of the heart with large first obtuse marginal branch bleed. In addition, the innominate vein had a large hematoma overlying a tear where it crossed the aorta. At least 2 puncture injuries to the heart were noted likely associated with pericardiocentesis.\nAfter the patient's status stabilized, electrophysiology recommended replacement of biventricular ICD pulse generator to his remaining right atrial and ventricular leads without any further manipulation of the leads with intention to eventually upgrade to a biventricular device. The procedure was successfully completed. |
A 22-year-old woman referred to the Ardabil Dental Faculty Clinic, Ardebil, Iran, with a chief complaint of pain in the upper first molar area. The patients’ medical history revealed that she was a known case of β-thalassemia minor. She had undergone splenectomy five years ago without any history of blood transfusion. Due to high platelet counts, aspirin was recommended by an oncologist to reduce the risk of thromboembolism.\nThe intraoral examination revealed the transposition of the left maxillary canine that erupted mesial to the third molar (). The distal slope of the canine was in contact with the mesial marginal ridge of the lower left third molar. The crown of the transpositioned canine was well-formed with a prominent cingulum ().\nThe left maxillary first and second molars as well as the right and left mandibular first and second molars were missing. Furthermore, major occlusal plane discrepancies were observed due to the mandibular posterior teeth lost. The right canine was also missing. The patient interview revealed that the mentioned tooth was impacted and already surgically extracted by an oral and maxillofacial surgeon. The upper and lower dental midlines did not coincide, and there were spaces between the lower anterior teeth.\nThe right and left deciduous maxillary canines were retained. The rare occasional finding in this patient was the transposition of the left canine that erupted mesial to the third molar (). The left first and second molars were absent. The patient did not remember anything about these teeth.\nThe patient underwent radiological examination. The panoramic views revealed the enlargement of marrow spaces with widened trabeculae in both the maxilla and mandible (). The soft tissue drapes had normal color and contours. The only abnormal finding in soft tissue examination was macroglossia ().\nTo determine an appropriate treatment plan, an impression was made of both dental arches. The stone casts were mounted on a semi-adjustable articulator by the means of a facebow. The analysis of the mounted casts showed a severe occlusal plane discrepancy as well as over-erupted right second premolar and first molar that had contact with the lower edentulous ridge.\nIn this condition, the prosthodontic treatment modality necessitates administration of extensive orthodontic and surgical interventions to create adequate space for the replacement of the missing tooth. However, due to economic issues, the patient did not accept any prosthodontic treatment and only received endodontic therapy for the maxillary first molar. |
A 13-year-old Caucasian girl, who was otherwise healthy, presented with intermittent swelling, erythema, tingling and numbness of the palmar aspect of her left hand. The nature of the pain was described as dull and shooting. These symptoms lasted for 7-10 days, even though regular analgesics were used.\nOn examination, the patient was found to be in excellent physical condition. Left hand pulses were easily felt. She had a slight functional limitation of her left hand grip due to pain and stiffness. The left hand was slightly cold to touch compared with the right hand. On examination, the patient was found to be in excellent physical condition. A positive Tinel test and elevated arm test was noted in the clinically affected arm. There was no asymmetry of clavicles noted. There was no muscle atrophy identified.\nIn view of these symptoms, neurovascular TOS was considered. X-ray of her cervical spine revealed an anomalous first rib that was fused to the second rib []. Magnetic resonance imaging of her brain, cervical spine and brachial plexus was normal. She also had a nerve conduction study, which interestingly revealed bilateral ulnar sensory and motor conduction abnormalities as well as early bilateral median sensory nerve conduction changes.\nIn view of the neuropathic nature of the intermittent pain, she was started on amitriptyline and gabapentin. This had a variable effect on her pain. Following a surgical opinion, a left-sided supraclavicular approach for exploration was undertaken. During the surgery, there was no apparent bony structure compressing the brachial plexus, nor was there any fibrous band. On moving the arm around, it was evident that the brachial plexus was entirely free. The scalenus anterior itself was impinging on the brachial plexus; hence, she underwent left anterior scalenectomy. She showed good response following the surgery. This was evident from the reduction of her symptoms of pain, swelling and tingling. Postoperative sensory and motor nerve conduction studies in the median and ulnar nerves were normal. |
A 51-year-old African-American woman with a history of sickle cell anemia presented for the evaluation of significant bilateral shoulder pain that was interfering with her activities of daily living and requiring narcotic medication for pain control. The pain and disability had been increasing progressively over several years and was recalcitrant to physical therapy. Radiographs and magnetic resonance imaging (MRI) confirmed AVN of her humeral heads without joint collapse ().\nStaged surgery was then performed approximately 4-month apart using the identical technique on both shoulders. Our standard perioperative protocol for sickle cell patients was utilized. This consists of admission the evening before surgery to the internal medicine service with acquisition of routine blood work, intravenous hydration, and preoperative blood transfusion as indicated based on hemoglobin level []. Surgery was performed in the beach chair position with the c-arm coming in perpendicular to the patient. Diagnostic arthroscopy was performed to evaluate for intra-articular pathology and confirm that there was no significant chondromalacia, which would negate the benefits of the joint preservation procedure. In this case, arthroscopy revealed small partial thickness articular sided supraspinatus tears that were debrided but no visible chondral damage was present. Upon probing, the cartilage was quite soft over the areas of AVN noted on MRI. Under fluoroscopic guidance, a guide wire was directed into the center of the region of AVN, which was done via a small deltoid splitting approach laterally. The arthroscopic probe was placed in the center of the most depressible cartilage region on the head and utilized fluoroscopically to guide pin placement. Once the guide wire was in the center of the defect, an expandable reamer was utilized and the necrotic bone was removed (). The arthroscope is critical in this stage to allow complete extraction of necrotic subchondral bone while ensuring no penetration of the cartilage. After full decompression was performed, synthetic bone graft (PRO-DENSE, Wright Medical) was injected under fluoroscopy and direct visualization. Given the immediate structural integrity of the graft, maximal removal of necrotic segments was attempted. Care was taken under fluoroscopic guidance not to penetrate the articular surface and no cartilaginous defects were encountered. For both procedures, the standard sickle cell protocol was followed with overnight admission for intravenous hydration followed by discharge with 2 weeks of deep venous thrombosis (DVT) chemoprophylaxis. She was allowed activity as tolerated and physical therapy initiated 2 weeks after each surgery. At 8-month follow-up from the index procedure, she is asymptomatic with a full range of motion on the first shoulder and some mild residual stiffness in the second shoulder (4-month follow-up). Radiographs demonstrate incorporation of the bone graft without evidence of joint collapse or further AVN (). |
An 18-year-old male patient from Greece was admitted to our department due to chronic nonspecific knee pain (for the last 3 months) for a plain X-ray and an MRI examination.\nClinical examination two weeks prior to MRI revealed pain at the medial compartment and a meniscal tear was considered the most probable diagnosis, as the patient was also a semi-professional footballer. Physical examination revealed no skin stigmata, orbital pathology or other pathologic conditions. There was no history of previous trauma and his medical history was unremarkable. Laboratory findings were also unremarkable. No medication at the time of the examination except occasionally anti-inflammatory agents. The patients did not smoke or drink. From family history, and according to information from patient’s father, his mother died 3 years ago (at the age of 42) from an ovarian cancer and his little brother at the age of 3 from a brain tumour (no more data were available).\nPlain X-ray () revealed a geographic lytic lesion at the medial aspect of the proximal tibia with no evidence of soft tissue mass or internal calcifications. Small periosteal reaction demonstrated at the lower aspect of the lesion. CT examination () confirmed the findings of plain X-ray and showed a lytic geographic lesion with wide zone of transition at its lateral aspect causing slight expansion and thinning of the cortical bone, scalloping of the endosteum, no soft tissue extraosseous mass. Internal amorphous calcifications were demonstrated inside the lesion. MRI contrast enhanced examination () revealed a lesion of fairly homogenous low signal intensity at T1-weighted sequences, mainly cystic lesion with fluid-fluid levels at T2-weighted images. After contrast agent administration () enhancing viable tissue was detected mainly at the periphery of the lesion. CT of the lungs, MRI examination of the rest of the tibia and bone scintigraphy was negative. Biopsy of the lesion showed telangiectatic osteosarcoma. The patient underwent initially chemotherapy followed by resection of the proximal tibia with prosthesis implantation. As far as the authors known, the patient had not been investigated for possible germline mutations of the tumour suppressor gene TP53. |
A 16-year-old girl presented with drooping of the left upper eyelid and diplopia in primary position, which was worse in right gaze. Both eyes had visual acuity of 20/20, intraocular pressure of 16 mmHg, and normal slit lamp and fundus examinations. The response to color vision testing using Ishihara plates was 12/12 in both eyes. The video shows the ocular motility findings, and depicts the results of the visual field examination []. Results of magnetic resonance imaging of the brain are shown in Figures and . The parents did not accept to perform any further work-up.\nHerein, we address two questions regarding the above-mentioned case to three experts in the related field.\nQuestion 1: What are the possible causes of these findings?\nQuestion 2: What is your treatment plan for this patient?\nFirst I would like to discuss possible causes of the condition based on the examination, prior to obtaining the MRI scan. This girl has findings most consistent with partial left CNIII palsy. There is ptosis, together with adduction, elevation and depression deficit. It is hard to tell if the pupil is involved on the video. It appears that the optic nerve and the 6th nerve are intact, and we lack data on the 4th and 5th cranial nerves.\nWe are also unaware whether the onset of the condition was sudden or slowly progressive. If the palsy was sudden onset, an aneurysm at the junction of the internal carotid and posterior communicating artery would be at the top of the list of the differential diagnoses except in very young children. Another cause in a young person is ophthalmoplegic migraine. In an older person with vascular risk factors, an ischemic peripheral third nerve palsy is most common. If a slowly progressive CNIII palsy is present, a structural lesion with compression of the nerve is more likely.\nOnce we have the MRI in this case, we see a lesion in the orbital apex extending to the anterior cavernous sinus. Based on the appearance on the current images, differential diagnoses would include mainly a cystic schwannoma or a venolymphatic malformation. The bright T2 and dumbbell shape is consistent with a schwannoma.\nI would consult oculoplastics/orbital specialists and neurosurgeons. A diagnosis would be made by biopsy, but one must be careful about bleeding if the lesion appears to be vascular. Resection of the lesion might be tried but could be difficult because of the potential for visual loss or other cranial neuropathies from operating at the orbital apex or anterior cavernous sinus. If surgical removal is not feasible and deficits are progressive or if the lesion grows significantly, I would consider highly focused radiotherapy for either schwannoma or venolymphatic malformation. If the lesion turns out to be a venolymphatic malformation, partial cauterization to shrink the lesion might also be considered.\nIf the deficit is longstanding and the lesion remains stable on sequential MRIs, then the option of observation without intervention may also be considered, since optic nerve function is normal.\nThe clinical features of the patient are compatible with partial third nerve palsy with aberrant innervation. Aberrant innervation is seen with parasellar mass lesions, trauma, or congenital lesions. Based on the history, the cause of the condition might be a parasellar lesion. The MRI depicts an orbital apex or superior orbital fissure lesion with a signal similar to CSF, i.e., hypointenseon T1 and hyperintenseon T2 without significant enhancement which is compatible with a cystic lesion. Differential diagnoses include the following: Arachnoid cyst, orbital encephalocele, perioptic cystic lesion, infectious cyst (hydatid cyst) and orbital meningocele.\nThis is a 16-year-old girl of likely Indian origin whose clinical examination seems consistent with partial left third nerve palsy. Involvement of the pupil has not been described in the synopsis of the case or demonstrated in the video. Brain MRI depicts a cystic lesion at the left orbital apex. She does not appear to have involvement of 4th nerve, 6th nerve, or the optic nerve.\nThe orbital apex refers to the posterior aspect of the orbit adjacent to the superior orbital fissure and optic canal, and freely communicates with the inferior orbital fissure and pterygopalatine fossa. The orbital apex is an important landmark where several neurovascular structures enter the orbit from the cranium. These include structures that exit within and external to the annulus of Zinn. An orbital apex syndrome may present with ophthalmoplegia due to involvement of the oculomotor (3rd) nerve, trochlear (4th) nerve, or abducens (6th) nerve, or can cause optic nerve dysfunction. Involvement of the ophthalmic branch of the trigeminal nerve may also occur.\nThere are a variety of lesions that can affect the orbital apex and manifest with the orbital apex syndrome. These include neoplastic lesions, vascular lesions, inflammatory lesions, infectious processes and traumatic lesions. In this particular case, the lesion seems to involve the orbital apex and cavernous sinus. It is a smooth, elliptical, cystic lesion and has a dumbbell shape. It does seem to involve the internal carotid artery. The lesion is hypo-intense on T1 weighted MRI, and hyperintense on T2 and STIR sequences. Contrast enhanced images are not available. The lesion does not seem to be a meningioma, lymphoma or metastasis. Such lesions are not common at this patient's age. Schwannomas are slow growing tumors that can develop from the myelin sheaths of peripheral nerves. They can affect the orbit and involve the intraconal or extraconal space or the orbital apex. They can conform to the surrounding structures and can assume a dumbbell shape if they extend into the cranial vault within the superior orbital fissure. They are isointense to the brain on T1 and hyperintense on T2 and can show homogenous enhancement. This lesion could be a schwannoma arising from the oculomotor nerve. However, contrast enhanced images have not been provided. Another possibility is a neurofibroma. Other cystic processes should also be considered.\nThe clinical and imaging features do not suggest an inflammatory lesion. However, infectious process such as tuberculoma cannot be entirely excluded although cavernous sinus tuberculoma is exceedingly rare.\nThe imaging features do not meet the criteria for a vascular lesion such as a capillary or cavernous hemangioma, caroticocavernous fistula or other compressive lesions such as a subperiosteal hematoma, mucocele and fibrous dysplasia.\nDetailed laboratory testing for infection and inflammation is mandated in every orbital apex lesion. This should include inflammatory markers namely erythrocyte sedimentation rate and C reactive protein, complete blood count with differential, complex metabolic panel and autoimmune work-up including anti-nuclear antibody and anti-neutrophil cytoplasmic antibody. In this case, one should consider testing for tuberculosis with purified protein derivative or quantiFERON-TB Gold test and a chest X ray. Lumbar puncture may also be required. Suspicion for sexually transmitted diseases remains low in this case.\nBiopsy of the lesion may be the most definitive way to establish the diagnosis. A multidisciplinary team involving a neurosurgeon, ENT surgeon and oculoplastic surgeon may be needed for surgical excision of the lesion. Surgical approach should be undertaken with the understanding that the patient may be left with diplopia post-operatively. It is also possible that she may have improvement.\nThe diplopia can be temporarily be overcome by patching one eye. However, for a more definitive treatment, prisms may be required. Surgical correction for misalignment may be required eventually. She may need more than one surgery which should be undertaken only when the misalignment has been stable over a period of 6 to 9 months. This patient should be periodically evaluated at the neuro-ophthalmology or pediatric ophthalmology clinic. |
A 37-year-old woman was admitted to emergency services with complaints of left-sided abdominal pain which had persisted over two weeks, as well as a mass which had increased in size for several days. The patient was not receiving any specific medication and her medical history did not suggest any major disease. Nor was there any history of alcohol usage or trauma. Physical examination revealed the presence of a huge mass in the upper left quadrant of the abdomen, but without tenderness or rebound tenderness. Laboratory findings were all within normal limits. The abdominal X-ray examination showed no presence of intestinal gas in the upper left quadrant and the normal location of the intestines was pushed toward the right, indicating the presence of a mass in the upper left quadrant (). An abdomino-pelvic computed tomography (CT) scan demonstrated a 15 × 10 cm, hypo-dense, well-capsulated and huge cystic lesion of unknown origin in the upper left quadrant ().\nA surgical procedure was decided upon because of compression symptoms and the possibility of the mass being malignant. Under general anesthesia, a median incision was performed in the upper abdominal region. The spleen appeared normal, while the presence of a mass was confirmed, firmly attached to the pancreatic tail. The mass was hard and uneven with tubercles of varying sizes. To perform en bloc resection of the mass, mobilization of the spleen was deemed necessary. Both the splenorenal and splenocolic ligaments were detached from the retroperitoneum to mobilize the spleen. After removal of the pancreatic tail and the spleen from the abdominal cavity, excision of the mass and the pancreatic tail, as well as splenectomy, were performed to ensure en bloc resection (). No other abnormalities were found inside the cavity after the procedure. The peritoneal cavity was irrigated thoroughly with normal saline solution and Jackson-Pratt drains were placed in the left subdiaphragmatic area and in the pelvis.\nThe removed mass had a clearly distinguishable outer membrane, a smooth, polished surface, and signs of swelling due to the liquid it contained (). The sectioned specimen contained mildly bloody serous liquids and a large swollen cyst. Small multiseptated cystic masses of various sizes were also seen situated along some of the thicker portions of the cystic wall. Pathologic findings showed that the mass was comprised of a number of multiseptated cystic masses of varying sizes that were wrapped with flat lymphatic endothelial cells. Some lymphatic infiltration was found in the mass. However, no connection with the pancreatic main duct was observed despite the firm attachment between the mass and the pancreas ().\nAt immunohistochemistry, the endothelial cells that made up the cyst showed a strong positive reaction to CD31 and D2-40 and a mild positive response to CD34. Based on the results of the microscopic and immunohistochemical findings, a diagnosis was made for a cystic lymphangioma consisting of lymphatic endothelial cells ().\nThe patient recovered uneventfully and was discharged on the 9th postoperative day. At the follow-up examination 3 months after surgery, she was doing well. |
We present the case of a 66 year-old woman with history of intense smoking (pack years of 50), diabetes mellitus detected a prior year and COPD (Chronic obstructive pulmonary disease) diagnosed 8 prior months. She came at the emergency department to receive medical attention by presenting fever, loss of weight and dyspnea. During the initial evaluation was performed a thorax CT scan that showed lymph nodes enlargement and subsequently by presence of abdominal pain was performed an abdominal and pelvis CT scan that showed a right kidney tumor of 4 × 5 cms besides of abdominal lymph nodes enlargement. A radical right nephrectomy was designed, prior to surgery we performed an spirometer study that revealed a moderate obstruction pattern. The surgical procedure included lymph nodes remotion. Histopathology study revealed Hodgkin's lymphoma involving right kidney, abdominal lymph nodes, ureter and liver. Immunostaining showed positiveness for CD15, CD30 and LMP-1 while CD3, EMA and ALK were negative. Histological study also reported a clear renal cell cancer, degree II, involving only the right kidney without extension to any other structure. Surgical resection was complete and margins were negative for cancer, diffuse glomerulosclerosis also was found. After surgical procedure we did a bilateral bone marrow biopsy that was negative for lymphoma. Staging studies showed an IV b stage and 4 unfavorable factors (stage IV, hemoglobin 7,2 g/dl, albumin 3.2 g/dl and lymphocytes <0.6) at diagnosis. We performed an echocardiography study that revealed light enlargement of right cavities, diastolic dysfunction and moderate pulmonary hypertension. The patient received chemotherapy with a protocol called EVA (etoposide, vinblastine and doxorubicin). After third cycle we documented complete response, fact that was obtained after completed the chemotherapy scheme. At present she continues asymptomatic without evidence of disease activity. We present a figure that shows in the panel A and B a tumor involving the right kidney, measuring 4 × 5 cms while panel C shows the CD 30 immunostain being positive in the neoplasms cells and panel D shows a transitional area between renal cell cancer and Hodgkin's lymphoma. |
A 34-year-old man was admitted to the emergency room with sudden mental deterioration, dysphonia, and limb weakness. He had no relevant past medical history such as hypertension, chronic hyperinsulinemia, or diabetes. His blood pressure, light reflex, and blood tests related to coagulopathy were normal. His level of consciousness was drowsy at initial presentation, but subsequently worsened to stupor. He showed sudden respiratory difficulty, so underwent endotracheal intubation. Because a stroke was suspected, a brain computed tomography (CT) was performed. The CT scan revealed a hemorrhagic lesion in the central pontine area. The amount of bleeding was estimated to be approximately 5 mL (). He was admitted to the intensive care unit (ICU) and received conservative treatment because surgical intervention was impossible. Hemostatics, antihypertensive agents, and anticonvulsants were administered. The hemorrhagic lesion in the pons was reduced in size on subsequent brain CT scans, and his mental status also improved. His mental status was restored to the alert level and self-respiration was possible without mechanical ventilation 7 days after ICU admission. After he recovered his mental status, he complained of hearing difficulty. He said that he could hear speech sounds, but could not understand them at all. Physical examination of both ears revealed normal tympanic membranes. His average hearing threshold by pure tone audiometry was 26 dB HL in the right ear and 32 dB HL in the left ear (), but his speech discrimination score was zero for both ears. Further hearing tests were performed to reveal the cause of hearing loss. Transiently evoked otoacoustic emission (OAE) and distortion product OAE showed robust responses for both ears, but the auditory brainstem response (ABR) showed only a broad wave I at 100 dB nHL click stimuli (, ). Based on these results, he was diagnosed as having auditory neuropathy. Follow-up hearing tests were performed 6 months after the initial hearing tests, and the OAE and ABR tests showed the same results, including robust OAE responses and no waveforms in the ABR test. His hearing thresholds had not changed but his speech discrimination scores improved to 44% in the right ear and 60% in the left ear. At present, he can easily communicate verbally with familiar people with aid of speech reading. |
A 5-year-old boy had multiple pelvic fractures and right femur fracture after a road traffic accident. He was unable to pass urine and there was blood at meatus. After resuscitation, his femur fracture was repaired along with suprapubic cystostomy for urinary diversion elsewhere. No attempts were made to catheterize the child per urethra. The child had uneventful recovery.\nAfter 3 months of his trauma and initial orthopedic procedures, the child was referred to us for definitive management. At presentation, the child had a suprapubic catheter for urinary diversion and complete disappearance of penis from its normal position with only penile skin visible at that area without any palpable corporal bodies. The child also had a small sinus-like wound in the right inguinal region with occasional urine dribbling through the wound []. A cord-like structure was palpable in the right inguinal region. Both the testes were normal.\nUltrasound evaluation of the local area was inconclusive. Magnetic resonance imaging (MRI) study of the pelvis revealed the presence of an intact penis with normal corporal bodies in the subcutaneous plane of the right inguinal region [ and ]. Urinary bladder, proximal urethra, and both the testes were normal.\nSurgical exploration was performed by incising the penile skin ventrally till the penoscrotal junction. Penile shaft was exposed and had dislocated to the right inguinal region. Penile glans was embedded in the subcutaneous plane and a small cavity had been formed around the glans []. This cavity communicated with the wound over the right inguinal area. Penile shaft was mobilized from the surrounding soft tissue and glans was separated from its cavity. Both corpora were normal, and urethra was easily catheterized with no evidence of urethral injury. The penis was detached from its suspensory ligament attachments and brought into its normal anatomical position. The previous penile skin was used to cover the mobilized penis partly, augmented by inner prepucial skin for the distal shaft [].\nThe child had an uneventful recovery with good cosmesis and normal phallic length at 6-month follow-up. |
A 77-year-old man with a past medical history of type 2 diabetes, hypertension, and ESRD underwent deceased donor renal transplantation. Two months following his renal transplant, the patient was admitted for an acute kidney injury discovered on routine follow-up laboratory testing. From a baseline creatinine of 1.3 mg/dl after the transplant, he was noted to have a creatinine of 2.7 mg/dl and a renal biopsy was obtained. Histopathology was suggestive of mildly active cellular rejection and acute tubular injury but with no concerns for antibody-mediated rejection. The patient received three days of methyl-prednisolone 250 mg daily intravenously and was subsequently transitioned to high-dose oral prednisone with a taper.\nThe patient was readmitted within three weeks of his renal biopsy with worsening renal functions, now with a creatinine level of 3.8 mg/dl. At this time, he was on prednisone five mg daily, tacrolimus four mg twice daily, and mycophenolate 500 mg twice daily. His family reported poor oral intake and that he had been taking furosemide at home. He received intravenous (IV) normal saline and diuretics were held. However, as his renal functions did not improve beyond a creatinine level of 2.1 mg/dl, the decision was made to perform a repeat renal biopsy. During ultrasonography for the renal biopsy, concerns were raised for a possible renal artery aneurysm. An ultrasound of the right lower quadrant and transplant kidney subsequently showed a 3 cm x 3.4 cm x 4 cm aneurysm proximal to the renal artery anastomosis to the right external iliac artery (Figure ). The right external iliac artery to renal artery anastomosis was patent and the renal vein was noted to be patent as well. No peri-transplant kidney fluid collections were noted and no hydronephrosis was seen.\nSubsequently, a pelvic arteriogram was performed, which showed patent pelvic and iliac arterial flow. However, a large pseudoaneurysm arising directly off the right external iliac artery was re-noted and the renal transplant artery was noted to be filling from the distal side of the aneurysm and remained patent, although with sluggish flow (Figure ). A second known renal transplant artery was not seen and was presumed to be thrombosed.\nWhile the interventional radiologist considered closing off the pseudoaneurysm by stent placement, the origin of the aneurysm was noted to be too close to the anastomosis to allow for stent placement. Hence, transplant surgery was consulted. The patient was taken to the operation room for a re-exploration of his transplanted kidney and revision of the arterial anastomosis. The patient underwent exploratory laparotomy, and intraoperatively, significant inflammation and scar tissue surrounding the hilum of the transplanted kidney was seen. Once the pseudoaneurysm was entered, necrotic tissue and purulence within the pseudoaneurysm were noted. It was felt that the arterial flow to the transplanted kidney could not be restored and, therefore, a decision was made to proceed with the resection of the infected pseudoaneurysm and transplant nephrectomy. The transplanted kidney was explanted. A portion of the pseudoaneurysm was sent to pathology for further characterization, and a portion was sent to microbiology for culture. The explanted kidney was also sent to pathology for further analysis. The patient was transferred to the intensive care unit (ICU) postoperatively for further management and close monitoring. During the surgery, the patient received crystalloids and multiple blood products.\nOn arrival to the ICU, the patient had temporary dialysis access placed and started on continuous renal replacement therapy (CRRT). Given concerns for an infected pseudoaneurysm, he was empirically started on renally dosed vancomycin, piperacillin-tazobactam, and fluconazole. All immunosuppressive agents were discontinued at this time. Due to persistent vasopressor requirements while in the ICU, the patient was switched to vancomycin, meropenem, and micafungin. The infectious disease team was consulted for recommendations. Blood bacterial and fungal cultures remained negative. However, fungal cultures from the pseudoaneurysm grew Aspergillus flavus on three separate samples. The patient was then transitioned to IV isavuconazonium 372 mg every eight hours for six doses, followed by 372 mg daily with a plan to continue for at least six weeks. Vancomycin and meropenem were discontinued. The pathology of the explanted kidney showed transmural necrosis of the renal artery, no evidence of rejection, and scattered micro-abscesses within the parenchyma. As the patient improved clinically, he was transitioned from CRRT to intermittent hemodialysis. He was subsequently transferred out of the ICU in stable condition. His hospitalization was complicated by colitis secondary to Clostridium difficile for which oral vancomycin was initiated. Preparation was made to discharge him to an acute rehabilitation facility; however, a day prior to discharge, he was found to be unresponsive by his nurse and despite prolonged resuscitation attempts for cardiac arrest, could not be revived. The exact etiology for this sudden demise could not be determined. |
A 66-year-old right-handed Caucasian female with a past medical history of hypertension and depression was transferred to our facility for a possible stroke after presenting to an outside hospital ED with acute right facial droop and diplopia. She reported that the facial droop was new but the diplopia was not. Once in our facility, an extensive history was gathered by the neurology team, including questions about fatigue, dysphagia, ptosis, or any other focal or lateralized weakness; these symptoms were denied by the patient. She did admit to a generalized weakness but denied any diurnal worsening of this weakness or any of her other symptoms. The physical examination determined that she had a right upper and lower facial weakness and no active diplopia or ophthalmoparesis, even after sustained upward gaze. The computerized tomography (CT) angiogram of the head and neck along with the remainder of her stroke work-up were also unremarkable. A magnetic resonance imaging (MRI) of the brain was performed with and without contrast to evaluate for any brainstem lesions and was unrevealing. The levels of thyroid stimulating hormone and skeletal muscle enzymes were normal. She was diagnosed with right BP and started on acyclovir and steroids, and discharge orders were placed.\nBefore being discharged, she began to develop slurred speech, hoarseness, and an increase in her right facial weakness which was now accompanied by mild ptosis. She was admitted and underwent a bedside swallowing evaluation, which was abnormal. A modified barium swallow study was performed and suggested poor relaxation and coordination of the upper esophageal sphincter. The ear, nose, and throat (ENT) specialist evaluated the patient and recommended an esophageal dilation with Botox injection. A taste test to evaluate 7th cranial nerve function was performed at bedside and was normal. Concerns for other diagnoses were raised, including MG. The patient underwent a modified Tensilon test using 2 mg pyridostigmine administered intravenously with atropine at bedside for any bradycardia. About 30 s after pyridostigmine administration, the patient's ptosis and dysarthria completely resolved. Her dysphagia also improved, and she drank a few sips of water. All supportive evidence was thus in favor of the working diagnosis of MG. The ENT recommendation for botulinum toxin injections was denied once the Tensilon test was positive. The electrodiagnostic testing (repetitive nerve stimulation and single fiber electromyography) was deferred as a result of the positive Tensilon test and response to pyridostigmine, demonstrating a neuromuscular junction abnormality. Autoantibody lab testing was pending to further confirm MG diagnosis.\nPlasma exchange (PLEX) was initiated for 5 days and the patient responded with a near-complete resolution of the right eye ptosis, facial droop, and dysphonia. She continued to fail the swallow evaluation initially but was able to pass for a puree diet after PLEX. A chest CT revealed no evidence of a thymoma or any residual thymic tissue. The patient was educated on aspiration precautions and discharged. Two weeks later, the acetylcholine receptor antibody levels (anti-AChRs) were found to be elevated, confirming the diagnosis of MG (AChR binding antibody: 5.11 [normal 0–0.24]; AChR blocking antibody: 66 [normal 0–25]; AChR modulating antibody: 44 [normal <21]). |
A 5-month-old male child presented with recurrent pneumonia. The apex beat was in the right parasternal area, and there was no air entry on the right hemithorax. The skiagram showed an opaque right hemithorax. A contrast-enhanced computed tomography scan revealed a small collapsed right lung being supplied by the pulmonary artery and drained by the pulmonary vein []. The right-sided main bronchus was not identifiable.\nA contrast esophagogram showed prompt delineation of the right bronchial subdivisions. A communication of the lung with esophagus was established at the junction of middle and lower one-third of the intrathoracic esophagus [].\nThe child underwent an exploratory thoracotomy. The preoperative findings were confirmed. The bilobed lung was nonaerated and had a liver-like consistency []. There was a direct communication between the esophagus and the lung across a short bronchial stump [].\nThe communication was taken down, and the defect in the esophagus was repaired with interrupted 5-0 Polyglactin sutures over a 10 Fr nasogastric tube. The child made an uneventful recovery. The histopathological examination demonstrated the presence of respiratory epithelium and confirmed the diagnosis of EL. The child is currently thriving well and is asymptomatic after 18 months of the operation.\nMost of these patients have other associated congenital malformations, mainly esophageal atresia or cardiac anomalies.[] It closely mimics pulmonary sequestration (PS) radiologically; however in PS, blood supply is of systemic origin unlike the pulmonary artery in EL as in our case. Being a rare anomaly, a close index of suspicion is necessary for diagnosis. A history of recurrent pneumonia and relevant radiological studies should clinch the diagnosis in the majority of such cases. The clinical images provided are expected to help understand the abnormal anatomy and surgical repair in EL. Management is excision of the involved lobes along with the abnormally communicating bronchus and primary repair of the esophageal defect.\nThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nNil.\nThere are no conflicts of interest. |
A 39-year-old female was brought to our emergency room by a private vehicle after being shot. An evaluation revealed a wound at the lower left back and at the mons pubis. Exploratory laparotomy and resection of the sigmoid colon, left ovary, and fallopian tube with a colostomy was performed. Postoperative deep venous thrombosis prophylaxis in the form of enoxaparin, 30 mg every 12 hours, was given and then changed to heparin, 5,000 units subcutaneously every eight hours, due to worsening renal function. The patient did well until postoperative day 4 when she complained of increased abdominal pain out of proportion to the clinical findings. Her symptoms worsened the following day. A computed tomography (CT) scan of the abdomen and pelvis was obtained, the results of which were consistent with postoperative ileus and raising concerns for right colon ischemia.\nThe patient was managed conservatively, and bedside drainage of the superficial wound infection was done on postoperative day 6 with improvement in abdominal pain. On the following day, a repeat CT of the abdomen and pelvis raised more concerns for bowel ischemia; however, the patient refused reexploration (Figure ).\nA computed tomography angiogram (CTA) of the chest was obtained for worsening pulmonary symptoms on postoperative day 8 and was consistent with lower lobe pneumonia.\nFeculent drainage around the stoma was noticed on postoperative day 9, and an exploratory laparotomy was performed with resection of multiple small bowel ischemic loops, cholecystectomy, and right hemicolectomy. The rest of the small bowel appeared dusky and friable. After multiple visits to the operating room, she was left with only a few inches of the proximal jejunum. A CTA of the abdomen was done on postoperative day 13 from her initial surgery and was consistent with a superior mesenteric artery occlusion (Figure ).\nAdmission platelet count was 281, down to 82 on postoperative day 11 when she tested positive for heparin-induced antibodies. The pre-test probability for HIT score was high (2 for thrombocytopenia, 1 for timing, 2 for thrombosis, 2 for no other cause = 7). The heparin was stopped and argatroban was used. The patient did survive her injury and was referred to a small bowel transplant center. |
A 34-year-old woman (gravid 3, para 1) was admitted to our center because of PPP combined with Rh(D) negative blood type at 37 weeks of gestation. She had a history of vaginal bleeding at gestation age of 3 months, and was diagnosed with state of complete placenta previa. Hereafter, she underwent antenatal cares at regular intervals, and the Rh(D) blood type antibody screening was normal. She had a history of CS because of malpresentation 3 years ago and a history of natural abortion 4 years ago. The PPH volume of last CS was 600 mL because of adherent placenta, but no blood transfusion was needed.\nUltrasonography (USG) and magnetic resonance imaging (MRI) images (Fig. ) revealed placenta completely covered the lower segment of anterior and posterior wall of the uterine, and implanted into the uterus cesarean scar of the lower segment reaching the uterine serosa layer. Rich blood sinus was seen above the internal cervical os, and the length of the cervix uteri was 28 mm. The estimated bleeding volume during operation was large and the patient had a strong desire to maintain fertility. Meanwhile, the patient was combined with a rare blood type that homomorphous type blood resource was insufficient.\nAfter obtaining consent from the patient, CIA balloons were placed in her bilateral CIA before CS. Vascular engorgement was seen in the anterior wall of the uterus and part of the vascular formed to blood sinuses penetrating the placenta during the operation. The balloons in the right and left CIA were filled with 6 and 6.5 mL normal saline immediately after the fetus delivered, respectively. The placenta in the lower segment of the anterior uterine wall was seen adhering closely with uterine muscles, and a 5 × 4 cm district of the anterior uterine wall was only seen a thin serosa layer. Placenta was manually removed, and carefully clipped. The surface of placental separation was locally sutured and the ascending branches of bilateral uterine arteries were ligatured. Then 1-0 absorbable suture was strapped in the lower uterine segment. And 1-0 absorbable suture cerclage was placed in the lower uterine segment via the posterior fornix. After observation of no active bleeding, the occlusion balloons were released and the uterine and abdominal incisions were closed layer by layer. The weight of the infant was 3100 g, the Apgar scores were 10 in 1 and 5 minutes. Time of CIA balloon occlusion was 15 minutes. The hemorrhage volume intraoperation was 1000 mL, and the patient was transfused with 2 units of red blood cells.\nAt 10 am the first day after CS, the patient caught sudden left-side lumbago and backache accompanied with palpitation and shortness of breath when she turned over in the bed. The blood pressure was 92/50 mm Hg, heart rate was 145 bpm, and she was suspicious of being combined with massive bleeding in the peritoneal cavity. The emergency ultrasound revealed a 14 × 9.1 × 5 cm liquid mass in the middle and lower abdominal. Abdominal computed tomography with angiography (CTA, Fig. A) revealed rupture of multiple pseudoaneurysms which extended from the left common iliac artery branch to the external iliac artery. Digital subtraction angiography (DSA) showed extravasation of a little contrast agent 0.6 cm from the bifurcation of left CIA (Fig. B). Endovascular intervention was performed emergently. A 13.5 × 60 mm covered stent was inserted into the proximal part of the left CIA and the ipsilateral internal iliac artery was embolized by coil to prevent endoleak. DSA revealed smooth blood flow of bilateral CIA and the external iliac artery, no extravasation of contrast agent and a good location of the stent.\nThe patient was observed in the intensive care unit (ICU) for another 3 days and USG showed the retroperitoneal hematoma gradually diminished. The reviewed CTA displayed well coverage of the covered stent, smooth blood flow of bilateral common and external iliac arteries with no vasodilation and endoleak (Fig. A). Eight days after endovascular intervention, the patient was discharged in stable condition without other complications. She was followed up by regular clinic visits, and the retroperitoneal hematoma was absorbed completely 6 months after endovascular intervention. One year later, she was admitted to our department again because of subsequent pregnancy. Abdominal CTA (Fig. B) was performed after abortion to recheck the location and shape of the covered stent which showed normal location of the stent, smooth blood flow of bilateral common and external iliac arteries, and formation of the left CIA collateral circulations to supply the left pelvic cavity. She was recovered and discharged from hospital without complications. |
A 40-year-old female was initially admitted into a regional hospital for the left flank pain and refractory hypertension. Ultrasound and computed tomography (CT) revealed severe stenosis in the right renal artery and aneurysm in the left (Figs. and ). The diagnosis of Takayasu arteritis was assumed, but without evidence from either lab tests or images. Endovascular bilateral renal artery stenting was performed, with uncovered stent inserted in the right renal artery and covered one in the left (Figs. and ). A stenosis distal to the covered stent in the left renal artery was noted and could be the potential cause of recurrence (Fig. ). The symptoms ameliorated after the interventional therapy. However, three months later the symptom of left flank pain recurred, and repeated CT showed relapse of the left RAA. Expectant treatment was ineffective, so the patient was transferred to our Urology Surgery Department. The patient complained about fatigue and intermittent dull pain in her left flank. But general condition was moderate. Multidisciplinary consultation was organized following the admission of the patient in our center. The size of the aneurysm (over 30 mm in diameter) and progressive pain gave the impression of a threatened rupture. Given the giant size of the aneurysm, previous covered stent implantation history, and the elusive etiology, immediate radical nephrectomy was considered, however, the left covered renal artery stent stretched into the aorta was a great challenge for surgery (Figs. and ). She was transferred to the interventional radiology suite for endovascular treatment. Written informed consent was obtained. Under local anesthesia, access from the right groin was obtained and a 5F sheath was placed. Angiography showed the bilateral renal artery stent insertion, and the presence of a large aneurysm originating from the distal end of the left renal artery stent (Fig. a). The stent was a covered one and the proximal part of it stretched into the aorta. A 6 × 40 mm balloon catheter (ATB advance, Cook, Bloomington, IN, USA) was placed into the stent through a guide wire (Terumo, Tokyo, japan). Thrombin injection was completed under protection of the balloon dilation (Fig. b). Further embolization with 2 coils placed into the prior stent (10 mm, Boston Scientific, Interlock) successfully occluded the aneurysm, with sacrifice of the left kidney (Fig. c).\nThe one-week post-embolization renal function tests (BUN and CREA) were within normal range. The patient remained stable after the second endovascular treatment and was discharged. However, the patient developed multiple painful subcutaneous nodules in her flanks 20 days after the embolization procedure. Biopsy was performed in the regional hospital and pathological exam revealed undifferentiated sarcoma (Fig. ). Chemotherapy was tried but the patient could not tolerate it. The patient experienced more episodes of hemorrhagic shock which required multiple blood transfusions, and finally passed away 2 more weeks later. |
A healthy 21-year-old man was admitted to our hospital after being referred from another medical institution because of worsening left eye (LE) uveitis. He was treated 3 weeks earlier with oral acyclovir and topical steroids because of suspected LE herpetic anterior uveitis as serological tests revealed positive immunoglobulin M to herpes simplex virus-1. Initially he responded to treatment but 2 weeks later, his vision declined from 6/9 to counting fingers (CF), resulting in his referral to our center.\nThe patient denied any relevant past medical history. However, he mentioned that a month earlier he was examined for LE discomfort and diagnosed with allergic conjunctivitis following minor blunt trauma from a tree branch.\nOn examination, visual acuity (VA) was 6/6 in the right eye (RE) and CF at 1 meter in the LE. Intraocular pressure was 14 mmHg in both eyes. RE anterior and posterior segments were normal. There was a remarkable LE anterior chamber reaction with dust-like keratic precipitates, cells (4+), flare (2+), and some iris nodules. Fundus assessment was not possible because of dense vitritis. B-scan and high-frequency ultrasound did not reveal any intraocular foreign body. Aqueous tap was performed and the sample was sent for culture and polymerase chain reaction analysis. It was negative for all herpes viruses and for 16S rDNA. Meanwhile, with oral steroids and valacyclovir, the patient showed signs of improvement and LE VA improved to 6/15. Despite the remarkable improvement, it was insufficient as the patient continued to have marked anterior uveitis and vitritis. A white shadow was noted in the peripheral temporal retina of the LE which again could not be assessed properly due to vitreous opacities (). The patient eventually underwent pars plana vitrectomy and laser retinopexy was performed around the white peripheral temporal lesion, which was later believed to be the site of penetrating injury by a thorn on the tree branch from the previous trauma described by the patient. Gram staining of the undiluted vitreous samples showed gram-positive cocci. 16S rDNA was positive for S. epidermidis, and blood agar and chocolate agar cultures confirmed the result with moderate growth.\nThe patient was treated with intravitreal antibiotics (vancomycin 1 mg/0.1 mL and ceftazidime 2.25 mg/0.1 mL) and intravitreal dexamethasone 400 mcg/0.1 mL as well as intravenous (IV) vancomycin (1 g twice/day), and oral prednisone was continued.\nAfter 48 hours of treatment, the patient showed remarkable clinical improvement. LE VA was 6/12. There was no need to administer more intravitreal antibiotics.\nAfter 5 days of IV antibiotic treatment, the patient was discharged on topical and a tapering regimen of oral steroids.\nAfter a follow-up period of 3 months, LE VA was 6/6 with complete resolution of the infectious process (). |
A 50-year-old female presented with a four-month history right-sided headaches with occasional bloody otorrhoea. The patient had been treated with a mastoidectomy twenty years previous to chronic suppurative otitis media and a cholesteatoma but had no symptoms following her surgery. Past medical history included a schizophreniform disorder and Barrett's oesophagus under surveillance. Otoscopy revealed a mass within the middle ear and a biopsy confirmed moderately differentiated squamous cell carcinoma. A staging CT scan established that there was no distant metastatic disease and that the tumour was confined to the temporal bone. The TNM staging of the tumour was T3N2M0. A radical right mastoidectomy was performed that involved the removal of posterior and superior canal wall, meatoplasty, and exteriorisation of middle ear. At the time of surgery it appeared that the carcinoma was arising from the middle ear cleft and extending up to an eroded patch of tegmen. This was easily cleared but the eustachian tube orifice appeared widened and biopsy confirmed the presence of squamous carcinoma. In the hope of clearing residual disease the patient was offered adjuvant radiotherapy. The patient exhibited a good response to radiotherapy and showed a complete remission.\nAfter treatment the patient was reviewed regularly at follow-up. Eleven months later the area of irradiated mastoid bone developed osteoradionecrosis (ORN) and periodically became infected. The initial diagnosis was made following a head and neck CT scan with intravenous contrast. The indication for imaging was a two- to three-week history of increasing pain adjacent to the surgical site and it was initially feared that this might have represented recurrent malignant disease. The radiological features included slight erosion and sclerosis of the adjacent temporal bone, no mass lesions, and mastoid opacification. It must be noted that the radiological features of ORN are often challenging to discriminate between malignancies, particularly in patients with a past history of cancer. The ORN was initially treated conservatively with regular local irrigation, analgesia, and antibiotics for episodes of infection. Repeated local cultures and blood cultures did not grow any organisms. After several months a CT head revealed a sequestrum in the temporal bone overlying the facial nerve and the patient suffered intermittent pain in the area of her ear that was treated with various analgesics including Tylex and amitriptyline. In addition a Tri-Adcortyl was inserted and Optomize was instilled into the external ear during episodes of infection. In addition, her mastoid cavity was periodically cleared through irrigation. The patient also suffered from recurrent episodes of labyrinthitis proposed to be caused by an exposed section of a semicircular canal adjacent to the sequestra of bone. These episodes were managed with vestibular sedatives and lasted only a few days. However, she did not suffer any significant hearing loss in either ear and between attacks of labyrinthitis her vestibular function was preserved without any associated symptoms. Stemetil was prescribed and these attacks became less and less frequent over the next 12 months.\nTwo years after the patient's initial surgery the area of necrotic temporal bone developed into penetrating osteomyelitis that lead to the formation of a 2 cm3 cerebellar abscess abutting the area of infected bone. The initial presentation was one of worsening headaches and an urgent MRI head revealed the presence of the abscess. In addition, the MRI revealed the sequestrum within the temporal bone opacification of the temporal bone adjacent to the abscess. No mass lesions were noted on imaging. The patient had no other features of raised intracranial pressure. The temporal bone osteomyelitis and cerebellar abscess were treated with broad-spectrum IV antibiotics and surgical drainage and irrigation through a burr hole. Local wound cultures and peripheral blood cultures were negative but local wound cultures grew fully sensitive Pseudomonas aeruginosa. The procedure was uneventful and the patient made a full recovery without any lasting neurological deficit.\nAt the time of writing the patient has repeated foul smelling otorrhoea. Repeated microsuction and toileting of the mastoid is performed during follow-up appointments every 3 to 6 months. Moreover, antibiotics are given when infections develop including Augmentin. |
The patient, a 58-year-old male, endured vertebral fractures at cervical levels C3–C6 in a motor vehicle accident at the age of 22. The patient did not have any respiratory problem and his stay in the ICU was limited to 5 days. Following the injury, the patient underwent manual motor testing of lower and upper body muscles groups as well as sensory testing. The motor testing involved examination of flexion and extension of upper body (shoulder, elbow, and wrist), and lower body joints (hip, knee, and ankle), and sensory testing involved examination of sensation to pinprick and light touch on both hands and feet. Initially, the patient had no motor or sensory function below the level of injury. Motor and sensory function at the sacral level was also absent, which was tested during the bladder evacuation and catheter placement procedure. This injury is equivalent to an ASIA A (ASIA: American Spinal Injury Association), or a “complete” injury, according to today's ASIA impairment scale (AIS) (Maynard et al., ), which did not exist at the time of the patient's injury.\nSpinal cord stabilization was accomplished with a halo. His rehabilitation regimen consisted of active-assisted range of motion (ROM) exercises of the lower and upper limb performed at home. Lower limb ROM exercise was performed for 30 min, three times a day, and the upper limb ROM exercise was performed for 30 min, two times a day. The exercise was performed at home, assisted by his family members.\nHe experienced slow and progressive neurological recovery that continued for 17 years after the injury. The first neurological recovery, movement of the left big toe (a grade 1 motor function), occurred 6 weeks after the injury. The first recovery of sensation occurred 6 months after the injury in the form of a painful dysesthetic sensation in the pelvis. Eleven months after the injury, the patient was able to perform complex upper body motor functions such as sitting up without assistance. Complex lower body motor functions such as ability to walk unassisted were recovered 15 months after the injury. Concomitantly, the patient recovered autonomic nervous system functions (i.e., a high degree of bladder and bowel functions were recovered up to 64 months after the injury) although many remain abnormal (Table ). Currently, his injury is categorized as ASIA D. His latest AIS evaluation (Figure ) showed that he has regained 94% of motor function in the upper body and 100% in the lower body. The patient manifests incomplete and asymmetric motor recovery in his hands—i.e., his left hand is more functional then the right one. He has also regained 23% of sensory function in the upper body (above the level of T7), but only 10% in the lower body. The patient reports that his walking and functions he performs with his feet depend heavily on visual feedback; he also manifests autonomic dysreflexia. It should be noted that the AIS evaluation of the motor function is based on muscle strength in the extremities, and that sensory function is evaluated based on conscious sensation of light touch and pin prick on the skin, and does not include proprioception. |
A 48-year-old man with a history of alcohol abuse presented to the gastroenterology department for the first time in November 2006. He was suffering from severe epigastric pain and nausea for two days. Because the laboratory findings were suspicious for pancreatitis, the patient underwent computed tomography (CT) (Fig. ). The examination showed an edematous pancreas tail and fluid in the anterior prerenal space and in the anterior, posterior and lateroconal fascia. There were no signs of chronic pancreatitis or vascular complications. In the following months the patient had two similar episodes of acute tail pancreatitis.\nIn September 2009 he presented with vague epigastric pain of several weeks duration. Serum amylase and lipase levels were normal, however the cholestatic parameters were mildly elevated. Therefore, a magnetic resonance (MR) study was performed. The examination demonstrated moderate chronic pancreatitis of the tail with atrophy and irregular bording of the Wirsung’s duct. There were no other abnormalities. Further examinations also revealed a Helicobacter pylori gastritis.\nIn February 2012 the patient presented again to the gastroenterologist with epigastric and left upper quadrant pain. Laboratory findings were not suspect for acute pancreatitis. However, contrast-enhanced CT scan was performed in order to evaluate the known chronic pancreatitis and other causes of pain (Fig. ). This study surprisingly revealed a hypervascular lesion in the pancreatic tail consisting of a conglomeration of small hypervascular spots and blood vessels. Further examinations were performed in order to differentiate a vascular malformation from a hypervascular pancreatic tumor, especially an islet cell tumor or a hypervascular metastasis. Contrast-enhanced MR study showed a focal area of heterogeneous contrast enhancement without an apparent nodular component. The subsequent angiography showed two large feeding arteries in the early arterial phase, followed by a racemose vascular network, an early transient dense parenchyma stain in the early portal phase and early wash-out of the lesion in the portal phase (Fig. ). Based on these findings, a pancreatic arteriovenous malformation was suggested. The patient was treated with a resection of the pancreas tail and postoperative recovery was uneventful. Histopathologic examination revealed sequelae of chronic pancreatitis and numerous dilated blood vessels accompanied by blood clot formation and intimal hyperplasia (Fig. ). The histopathological findings were consisting with a pancreatic AVM. |
The patient was a 57-year-old male, with ESRD secondary to diabetes and hypertension, on hemodialysis for 20 months. He was evaluated to undergo living unrelated donor kidney transplant. The donor was a 54-year-old female with unremarkable past medical history. She was medically and surgically cleared after full assessment. Preoperative computed tomography (CT) angiography for the donor revealed a small complex cyst (Bosniak IIF), a short right renal vein (2 cm), and a right renal artery with an early bifurcation of an upper pole artery. Surgical approach deemed best by the living donor selection committee was to remove the right kidney with the complex cyst via laparoscopic approach.\nThe risks of surgery and potential complications were explained to both donor and recipient. Written informed consent was obtained prior to surgery from both patients.\nA standard hand-assisted laparoscopic living donor nephrectomy (LLDN) was performed to retrieve the right kidney and the right ovarian vein for reconstruction. The length of the donor renal vein was reduced by 10-15 mm due to the standard use of vascular stapler device to control the renal vein stump.\nStatus after procurement upon visualization in the back table is that the length of the donor renal vein was 3 mm. In order to elongate the vein, the donor ovarian vein was dissected and used for reconstruction. It was opened longitudinally, folded over, and anastomosed to the donor renal vein using end-to-end anastomosis with an 8-0 Prolene ().\nThe donor kidney had a renal artery with early bifurcation of an upper pole artery. After mobilization of the inferior vena cava as much as possible, the endovascular stapler was placed after the bifurcation from the renal artery and the length of the vessel was reduced by 10-15 mm. At the back table the donor kidney presented two individual arteries: the main renal artery and the short upper pole arterial branch. Consequently, the recipient IEA was used as an extension graft to perform an end-to-side anastomosis between the upper pole arterial branch and the main renal artery using 8-0 Prolene ().\nThe complex cyst was dissected all the way down into the calyces and substantial margin of healthy parenchyma was removed. Distal margin was sent to pathology to rule out malignancy. The calyces and the renal parenchyma were oversewed with 5-0 PDS and the edges of the defect with U-stitch of 4-0 PDS using pledget ().\nThe extended renal vein and the main renal artery were anastomosed end-to-side to the external iliac vein (EIV) and artery (EIA) respectively, using 6-0 Prolene ().\nWe performed an extravesical ureteroneocystostomy and a Jackson Pratt drain was placed. The warm ischemia time was 33 minutes. Postoperative course was uncomplicated and the patient has maintained adequate renal function with stable serum creatinine (1.32 mg/dl) at 5-month follow-up. The final pathology report and the intraoperative frozen section of the margin were negative for malignancy. |
We present a 64-year-old Hispanic male with Rai Stage II, IgH mutated, and trisomy 12 positive CLL, diagnosed 13 years prior to admission. He was initially observed for 3 years and then received first-line fludarabine, cyclophosphamide, and rituximab (FCR) for 3 cycles with good response. He remained on observation for 4 additional years and then received an additional 4 cycles of FCR followed by 5 cycles of maintenance rituximab. Five years later, he was found to have 17p deleted recurrent disease and he was started on ibrutinib with good response. He presented to an outside facility with acute onset altered mental status after stopping ibrutinib 2 months earlier due to financial constraints. Cerebrospinal fluid (CSF) analysis was initially concerning for CLL infiltration of the CNS with neoplastic-appearing lymphocytes identified by cytomorphology; however, serological tests for West Nile virus indicated acute infection based on positive IgM and negative IgG; however, PCR could not be performed. The patient received therapy for presumed CNS involvement by CLL with intrathecal methotrexate along with intravenous rituximab and methylprednisolone before being transferred to our institution. On admission, his complete blood count revealed leukocytosis with a normal differential and thrombocytopenia, after reviewing the patients' historical trends, we could discern that the platelet count had been within normal limits in the past and had likely decreased due to the acute illness; additionally, we can appreciate the increasing trend in WBCs until the start of treatment around 10 years prior to this admission (). Peripheral blood smear showed normal platelet morphology and moderate leukocytosis with lymphocytosis with coarse, block-like chromatin pattern concerning for prolymphocytoid transformation which had not been present previously. Bone marrow biopsy revealed hypercellularity with diffuse infiltrate of the medium to large-sized mononuclear cells with irregular nuclear contours and prominent nucleoli similar to that seen in the peripheral blood smear (). Repeat CSF studies at our hospital showed lymphocytes accounting for 49% of total events per flow cytometry, positive for CD19, CD20, CD5, and CD23, with lambda light chain restriction, and negative for CD10 and FMC-7 (). The morphology of lymphocytes in CSF was consistent with neoplasia; however, given the admixture of reactive lymphocytes and the presence of known CNS infection, it was deemed that this most likely represented peripheral blood contamination and reactive infiltration of neoplastic lymphocytes.\nHe was treated supportively during his hospital stay and improved without any further CNS-directed therapy. Ibrutinib was later reinstated after the resolution of thrombocytopenia and BTK mutational testing proved negative. The patient continued to improve during outpatient follow-up, prolymphocitoid morphology disappeared from peripheral smear, and brain MRI showed no evidence of CNS disease. |
Case presentation 2: a 21-year-old male suffered isolated mandibular angle fracture following a road traffic accident. Patient in this case wanted early return to the work and also on CT scan a torsional deformation was seen on the fracture fragments. Hence the decision to do open reduction was made. Incision designing and access ad procedure was carried out as described. Access was satisfactory and 2 miniplates were placed and fixation achieved ().\nSurgical procedure: both the above-mentioned patients were treated under general anaesthesia. Thiopentone sodium was used for induction and patients were intubated nasally. Oral cavity was kept free to achieve maxillo-mandibular fixation and achieve the occlusion. Isoflurane and/or sevoflurane were used for maintenance. Surgical site and incision line were marked with a marking ink before commencing the procedure. Thereafter the marked line was infiltrated using lidocaine with adrenaline in 1: 1000 concentrations. Incision remains the key of this approach as aesthetics has been given prime importance to the designing of this surgical access. Care has to be taken that incision follows the curvature of the angle of the mandible and suture line has to be visualized beforehand such that it is hidden completely in the shadow of the angle. Incision can be said to be combination of postramal Hind´s incision and submandibular Risdon´s incision but to the fact that it remains closer to the angle of the mandible, around 1 cm away from the bony landmark completely in the shadow of the mandible. Sharp incision with a 15 number blade is imperative to avoid any jagged incision line. In the first stroke only skin and subcutaneous tissue should be visible and skin flaps hold tightly away with skin hooks, which gives clear view of the subcutaneous tissue. Platysma muscle once seen can be dissected easily with a pair of scissors and blade with care that the superficial layer of deep cervical fascia is left undisturbed.\nFurther careful progression and perhaps the most challenging step is dissecting through the deep cervical fascia which is important because the facial nerve, facial artery and facial vein will be lying deep to the fascia and hence absolute care has to be taken while incising the deep fascia. Immediately after incising the deep fascia, it is of utmost importance to identify the facial nerve with the nerve stimulator and retracting it in the upper flap. Subsequently, facial artery and vein should be identified, and if necessary, should be ligated and retracted to expose the underlying pterygo-masseteric sling. Once the pterygo-masseteric sling is visible then it becomes fairly easy procedure, whereby sharp incision on the sling can be given to expose the mandibular angle and this plane is fairly avascular with not much bleeding. Once the angle is exposed, fracture fragments can be easily manipulated to achieve reduction. Miniplates can be placed thereafter and fixation achieved. After irrigating the surgical site, closure is achieved in layers to define anatomic spaces. Great care was taken to achieve skin closure wherein subcutaneous horizontal mattress suturing was done to achieve the skin approximation which gives excellent post-operative scar. In both the treated cases, no suture tracks were noticed and a linear scar within the mandibular angle shadow was seen which was almost inconspicuous at the conversational distance (, ). |
An 8-year-old girl presented to the orthopedics OPD with swelling and pain in the left knee for the past 6 months (). The swelling had rapidly increased in size in the past 1 month. There was a history of difficult in walking and frequent locking of this knee. No history of trauma or any other joint involvement could be elicited. No similar history was found in siblings or mother. An X-ray of the knee joint was advised which showed a lytic lesion in the proximal tibial epiphysis with peripherally placed sclerotic areas (). X-ray did not reveal any significant joint effusion and in view of marked joint swelling, a magnetic resonance imaging (MRI) of knee joint was done. The MRI showed a heterogeneous lesion in the tibial epiphysis with altered signal intensity and a sclerotic rim (). The lesion involved the tibial spine with a breach of the articular margin. There was evidence of perilesional edema with soft tissue enhancement suggesting a reactive pathology. On the basis of the above two, a differential diagnosis of tuberculosis and chondroblastoma was suggested. The hematological and biochemical work-up of the patient was within normal limits. The joint aspirate was negative for any crystals. Mantoux test read 8 mm. In view of no evidence of tubercular etiology and provisionally neoplastic radiological diagnosis, the patient was taken up for excision of the lesion with bone grafting. The bone graft was taken from fibula. Intraoperatively, the synovium appeared markedly hyperplastic, yellowish in color, and extending into the supra and infrapatellar compartments of the knee (). The lytic lesion was managed by intralesional curettage and packing with allograft bone chips along with excision of the hyperplastic synovium. The curetted material from the lytic lesion and synovial tissue were sent for histopathological examination. Sections from the synovial tissue showed villi-like proliferations of the hyperplastic synovium with expansion of the subsynovium with mature adipose tissue ( and ) and also seen were interspersed chronic inflammatory cells and few dilated vessels. Sections from the curetted tumor material showed a cartilaginous tumor composed of fragments of mature hyaline cartilage, compact polyhedral chondroblasts with well-defined cytoplasmic borders and hyperlobulated nuclei with grooves. A chicken-wire matrix surrounding the chondroblasts was seen ( and ). No nuclear pleomorphism or mitosis identified. A final diagnosis of chondroblastoma with synovial lipomatosis was given. The MRIs were reviewed and it was seen that the soft tissue enhancement was in real the thickened synovium thrown in finger-like projections. Postoperatively, the pain and joint swelling improved drastically and no recurrence is seen till date. |
A 56-day-old full-term male infant [] diagnosed with PRS was referred to the outpatient department with the complaint of difficulty in feeding. The child was born out of non-consanguineous marriage to healthy parents. The attending physician of the Pediatric Intensive Care Unit in a private hospital referred the patient to the Department of Pedodontics because of poor swallowing ability due to which a nasogsatric intubation was advocated. Following a period of using the nasogsatric intubation, the mother was advised to expel the milk into a feeding bottle and then feed the child as the oroantral communication could not facilitate breast feeding. Nasal regurgitation was still evident on bottle feeding; hence, the necessity for dental management arose. Extra-oral examination revealed a retruded chin and ocular lesions. Intra-oral examination of the baby revealed a large median U-shaped cleft of the hard palate that extended to the soft palate with only the alveolus in the right and left side []. The nasal septum and conchae was visible. Since the baby was not scheduled for corrective surgery in the near future, it was decided to construct a feeding obturator following approval from the parents so as to prevent nasal regurgitation or aspiration of milk into the trachea.\nPreliminary impression was done with impression compound using the index finger to mold the impression material. The process of the child's suckling reflex when the index finger was placed also aided in the molding of the impression compound. A special tray [] was constructed using self-cured acrylic resin that was finished and polished to prevent any injuries. The tray was coated with a tray adhesive and the impression was made using addition silicone impression material []. The impressions were made with the infants face held toward the floor, in order to prevent aspiration in the event of vomiting and asphyxiation due to airway obstruction.\nThe feeding obturator [] was constructed using heat polymerizing acrylic resin with two holes for tying a dental floss for handling and positioning the obturator. The infant was made to wear the obturator, with the floss around the ears [Figures and ] following trimming and polishing to correct the extent as well as to prevent injuries due to sharp margins. The parent was made to breast feed the child and as advised review after 24 h, 1 week, and 1 month later. The parent was advised to clean the obturator after every feed. The parent and child showed good prognosis using the feeding obturator and nasal regurgitation of milk was not to be noticed. |
A 42-year-old man made a complaint of restriction of motion particularly in the 4th and 5th fingers of his left hand. He had never been examined before because the restriction of motion had only arisen in the past month. The painless masses were growing slowly and were causing dysfunction of the affected joints. Although all of the MCP joints were covered with these solid and painless masses (), only the 4th and 5th MCP joints exhibited extension loss (20 and 30 degrees, resp., in the left hand). The neurovascular examination was intact. The patient has bilateral arcus cornea, which may be an indication of hypercholesterolemia (). The patient's serum cholesterol level was above normal, and he has a positive family history of early death due to myocardial infarction. There were no abnormal findings observed in the plain X-rays; however, multiple solid masses that were engaged to the extensor tendons were detected in the superficial ultrasound (USG). The severity of engagement was remarkable at the level of the MCP joints of the 4th and 5th fingers. Regarding our findings and the clinical progression, the patient underwent an open excisional biopsy and tenolysis of the extensor tendon at the 4th and 5th MCP joints.\nUnder local anesthesia and tourniquet control, a “V-shaped” excision was used to explore the masses over the extensor side of the 4th and 5th MCP joints. After the retraction of the subcutaneous tissue, 2 × 2 cm and 3 × 2 cm, solid, yellowish masses were detected over the extensor side of the 4th and 5th MCP joints, respectively (). Peritendinous fibrosis were observed as these masses infiltrated the extensor tendons thus restricting the gliding of the tendons. All masses were meticulously dissected from the tendon with devoted attention to maintain the continuity of the tendon by preserving the paratenon. The full range of motion was achieved after excision of the masses and the wound was sutured. Immediate active and passive ranges of motion exercises were started to avoid stiffness. Although the literature mentions wound complications, no issue with wound healing was encountered [].\nA biopsy specimen showed xanthoma cells dispersed between the collagen fibers of the tendon (). After thirty months followup, no recurrence or complications were detected in regard to maintaining a full range of motion of the affected joints. |
A 28 year old male patient presented initially in December 2013 with clinical features of acute osteomyelitis of right tibia. His haemogram was normal and the blood culture was negative for bacterial study. The erythrocyte sedimentation rate was 22 mm/h and C-reactive protein of 34 mg/dl. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. There was no regional or generalized lymphadenopathy. X-ray of the right leg showed an osteolytic lesion of the right tibia within distinct margins, cortical breach, and moth-eaten appearance. Magnetic resonance imaging (MRI) scan done prior to the biopsy was reported as osteomyelitis of tibia. Biopsy report came as inflammatory granulation tissue densely infiltrated by lymphocytes and histiocytes consistent with nonspecific chronic osteomyelitis. Tissue cultures were negative for bacterial or fungal elements. Tumor markers or special strains were not done. The patient was treated with antibiotics and anti-inflammatory drugs. He was then discharged from the hospital once his pain subsided and was kept under close followup.\nHe remained asymptomatic except a diffuse swelling over the anteromedial part of the right tibial shaft. After 6 months, he presented again with complaints of pain and rapidly increasing swelling on his right leg, which increased to a size of 10 cm []. There was no regional lymphadenopathy. X-ray showed a permeative lesion with significant periosteal reaction over the mid-diaphysis of the tibia. We suspected some type of aggressive bone tumors in view of the rapidly increasing swelling and the permeative lesions in the X-ray. Hence, his chest X-ray, computed tomography of chest, and ultrasound abdomen were taken which were negative for any lesion. This prompted us to take a repeat MRI contrast study, which showed (coronal image) altered signal intensity and irregular patchy enhancement lesion involving the marrow of the diaphysis of the tibia. There is enhancing soft tissue component as well []. The sagittal image shows diffuse marrow and soft tissue involvement with posterior cortical irregularity []. Fine-needle aspiration cytology (FNAC) done from the lesion composed of sheets of small cells with high nuclear to cytoplasmic ratio. The cytoplasm was scant and eosinophilic suggestive of Ewing sarcoma []. Due to the disparity in the two Histopathological reports (initial report of non specific chronic osteomyelitis and the present report of Ewing sarcoma), confirmatory biopsy with immunohistochemistry was done. Incision biopsy showed the sheets of medium-sized atypical lymphoid cells suggestive of B-cell lymphoma [].\nImmunohistochemistry showed CD99 negativity (specific of Ewing sarcoma). Then, the immunohistochemistry study of lymphoma was suggested as it is the next possible condition. The CD45 (leukocyte common antigen [LCA]) (for differentiating to lymphomas) [] and CD20 (specific of B-cell lymphomas) [] were positive. Then, the final diagnosis was made as a primary B-cell lymphoma. He was started on combined treatment modality with chemotherapy and radiotherapy. There was no evidence of recurrence at the 15th month followup. |
A 40-year-old female patient presented at the Emergency Department of our institution with complaints of back pain for the last three days that started after moderate physical exertion. The patient referred no pain relief after taking anti-inflammatory drugs and denied respiratory symptoms such as chest pain, dyspnea, or cough. No weight loss, anorexia, or other symptoms were reported. There was no referral of previous surgeries or medications. A different, stronger anti-inflammatory drug was prescribed, but three days later she returned to the hospital, where a lumbar radiograph revealed the presence of a lytic lesion in the L4 vertebra. Due to the nonspecific appearance of the lesion, the patient underwent an MR of the lumbar spine. The exam revealed the presence of a heterogeneous, T1-hypointense mass in the body of L4, causing its partial destruction, and nerve root compression (). A CT-guided biopsy was performed in order to assess the etiology of this mass. The pathology report described the presence of tumor fragments of mesenchymal origin with smooth muscle differentiation that were diffusely positive for estrogen and progesterone receptors. No obvious nuclear atypia or mitotic figures were identified. Ki-67 proliferation index was less than 1%. The final report stated that the lesion was compatible with BML.\nSubsequently, a contrast-enhanced CT was performed to evaluate if other organs were affected: there were several soft tissue density round masses in the thorax, the largest being located in the left lung, measuring 44 mm (). There was a 12 cm mass in the left iliac crest that enhanced after intravenous contrast. This mass had a lytic component and exhibited an intrapelvic bulky element (). There was enlargement of the uterus due to the presence of several leiomyomas ().\nThe clinical conduct included vertebral subtotal tumor removal, laminectomy, and pedicle screw fixation on L3-L5 () to decompress the nerve roots and reduce the symptoms. Oophorectomy and hysterectomy were performed and confirmed the benignity of the leiomyomas. Outpatient treatment consisting of anastrozole, an aromatase inhibitor, was prescribed. At the 6-month follow-up CT examination, the nodular pulmonary and iliac crest masses kept the previous dimensions and no new lesions were observed. Long-term follow-up was recommended in this case.\nRegarding the low back pain, the patient referred a moderate improvement. Despite this, she needed to resort frequently to taking anti-inflammatory drugs after some physical exertion. The patient also reported a sensation of pressure in the pelvic region, especially in the lateral decubitus, most likely associated with the mass of the iliac bone. |
A 62-year-old man, affected dysphagia, was endoscopically diagnosed with lower esophageal cancer confirmed squamous cell carcinoma on biopsy, and was reffered to our hospital (Fig. ). He had no medical history. His lifestyle has included 1500 ml beer consumption per day and 40 cigarettes per day for the past 40 years. Computed tomography (CT) showed thickening of the wall in the lower esophagus as the primary lesion was demonstrated and the tumor formed a mass with the solitary metastatic abdominal lymph node, and invaded pancreas body and gastric body (Fig. ). No other distant metastasis was detected on CT. He was diagnosed with lower esophageal cancer cT4 N1 M0, with pancreatic invasion, cStage IIIC according to 7th edition of the Union for International Cancer Control system []. At first, we considered definitive chemoradiotherapy. However, radiation oncologists evaluated that the tumor was less candidate for chemoradiotherapy because of the risk of gastric mucosal damage. For the purpose of definitive therapy, radical esophagectomy with distal pancreatectomy was planned. As neoadjuvant chemotherapy, CF therapy (cisplatin and 5-fluorouracil therapy; cisplatin was dripped 80 mg/m2 plus 5-fluorouracil was infused 800 mg/m2 on day 1 through 4 continuously) was started according to standard therapy of localized advanced esophageal cancer []. However, after once administration, he could not continue chemotherapy for the exacerbation of dysphagia, and underwent radical surgery. Preoperative evaluation of tumor was similar to initial findings on endoscopy and CT.\nIn findings on laparotomy, abdominal lymph node was infiltrated directly to pancreas body. As the radical surgery, Ivor Lewis esophagectomy with distal pancreatectomy and splenectomy, followed by reconstruction of gastric conduit. Two fields lymphadenectomy was performed according to the treatment strategy of the abdominal esophageal cancer. Reconstruction of gastric conduit was possible although the lymph node was adherent to lesser side of gastric body, which was resected when reconstruction of gastric conduit. In addition, partial resection of lung was performed simultaneously owing to involvement of bilateral pulmonary ligaments to the primary tumor (Fig. ). The operative time was 528 min. The estimated blood loss was 2850 ml, and the patient was transfused 4 units of red blood cell concentrates.\nThe patient had an uneventful postoperative course and was able to take orally. He was discharged 16 days after operation with tube-free. After discharge, he underwent two courses of CF therapy as adjuvant chemotherapy. At present, he is still alive and has no recurrence for 7 years after surgery.\nIn the resected specimen, the primary lesion was observed from lower esophagus to esophagogastric junction, and metastatic lymph node was fixed to stomach and pancreas body (Fig. ). Pathological examination revealed that primary lesion was not infiltrated to lung (Fig. a, b). Massive metastatic lymph node (over 5cm) was observed in the lesser curvature of stomach, and infiltrated to pancreas and gastric wall with extranodal extension (Fig. c, d). The tumor was diagnosed with squamous cell carcinoma, moderately differentiated type. The vascular and lymphatic invasion was confirmed. The surgical margin was negative. The pathological stage was ypT4 N1 (1/61) M0 (metastatic lymph node invasion into pancreas), ypStage IIIC. The histopathological response of chemotherapy was grade 1a, which was equivalent that proliferable cells were 2/3 or more, in 7th edition of the Union for International Cancer Control system []. |
A 52-year-old male with a 5-week history of severe headaches was admitted after he had a syncopal episode while at home. He found himself down on the ground, and he was unaware of the initiating circumstances. There was no post-event confusion, weakness, tongue biting, incontinence of bowel or bladder, or any reported head trauma after the incident. This was the first such episode he was able to infer that occurred after having found himself on the floor. His headache was worse in the left temporal region and radiated through his neck, progressively increasing in severity over time. His headaches were described as severe, especially when he turned his head to the left. Over the past several months, he noted occasional drenching night sweats and a 40-pound unintentional weight loss over 6 months. Past medical history is significant for smoking 2 packs per day for the past 30 years, but otherwise he has no chronic diseases and takes no medications regularly.\nWhile in the emergency department, he had several episodes of bradycardia noted on telemetry and had accompanying hypotension with values reaching as low as 60/31 mm Hg at one point. He was dizzy during these episodes, and both his blood pressure and heart rate responded to 0.5 mg of intravenous atropine. An electrocardiogram obtained during one of the episodes showed sinus bradycardia, ventricular rate of 25 beats per minute, with no signs of atrioventricular dysfunction or ischemia.\nPhysical examination revealed a large ulcerative lesion in the left tonsillar area with tenderness in the left submandibular region. No lymphadenopathy was appreciated in the neck. The rest of his examination was grossly normal. His heart rate and blood pressure, measured after an episode had resolved, was 93 beats per minute and 113/61 mm Hg, respectively; vital signs were otherwise normal. Routine laboratory investigation was normal. A computed tomographic angiography of the head and neck showed extensive soft-tissue swelling of the left palatine tonsil and surrounding tissues. Otolaryngology was consulted, and a biopsy of the left tonsillar mass was obtained. The histology of the left tonsillar lesion was consistent with invasive squamous cell carcinoma and was P16 positive on immunostain. A subsequent positron emission tomography/computed tomography showed hypermetabolic regions in the posterior tongue extending to the left palatine tonsil, in addition to metastatic involvement of left jugular chain. He was diagnosed with stage IVa squamous cell cancer with nodal involvement of the left jugular chain. Echocardiography failed to show any abnormalities. Interestingly, most of his episodes of bradycardia and hypotension were preceded by changes in neck position (he had repeated episodes of bradycardia when he moved his neck in certain ways), which was initially attributed to a vasovagal response related to pain.\nThe patient continued to have repeated episodes of symptomatic hypotension and bradycardia throughout his stay. He was started on a trial of benztropine (2 mg every 8 hours initially) to help ameliorate these symptoms. After increasing the dose over several days, he continued to have episodes of hypotension and bradycardia and was ultimately started on a dopamine drip. He continued to require dopamine infusions intermittently, and phenylephrine was added on as well. Intravenous atropine continued to be the only treatment to consistently provide relief. After failing to improve on the benztropine, he was started on midodrine (5 mg twice daily) and sertraline (50 mg daily).\nOnce being started on this regimen, he had no further episodes of bradycardia and required no more atropine. Although he had several episodes of orthostatic hypotension, complicated by acute blood loss anemia, he was able to eventually come off the dopamine and phenylephrine drip completely once the bleeding was stopped. Also, he began treatment with high-dose cisplatin 1 week into his stay, and started a course of 35 rounds of radiation therapy 2 weeks into his stay. He remains on midodrine, sertraline, and cisplatin every 3 weeks, and he is over halfway through radiation therapy without any recurrences of syncope.\nThis patient’s picture was consistent with a small number of case reports describing neurocardiogenic syncope secondary to head and neck cancer. In this case, it was thought to be due to irritation of the glossopharyngeal nerve with spread of the cancer to the jugular chain. |
A 7-day-old male infant born of full-term normal vaginal delivery was referred to our Tertiary Care Eye Hospital in South India for an eye check-up. The infant was the second born of a third degree consanguineous marriage. There was no family history of anyone born with similar eye and skin problems or cleft lip/palate.\nOn examination, the right eye had a thin band of tissue 1 mm wide and 6 mm long, stretching from the gray line of the medial part of the upper lid and attached to the medial aspect of the lower eyelid inferiorly. The lower eyelid also had notches along its margin, which appeared as freshly de-epithelized lesions []. The band did not restrict the eye from opening []. The palpebral fissure was equally wide bilaterally. Meibomian gland orifices were present. There was no swelling over the lacrimal sac area and no regurgitation of fluid on pressure over the lacrimal sac, suggesting that there was no nasolacrimal duct obstruction. The anterior and posterior segments of the eye were well visualized and did not show any abnormalities. The left eye did not show any band joining the lids, but both upper and lower lid margins showed notching similar to the right eye []. The anterior and posterior segments of the left eye were normal.\nThe infant had multiple patches of hypopigmentation of the skin over all the four limbs [Figs. and ]. The skin over the face, however, appeared normal. There were no skin erosions over the scalp or elsewhere. There was no cleft lip or palate. There were no structural limb abnormalities and no syndactyly. There were no obvious nail lesions. The child was feeding and thriving well.\nAlthough an initial neonatal checkup by the referring doctor did not reveal any systemic abnormalities, the infant was referred to the pediatrician to specifically rule out cardiac, genitourinary, neurological, and odontological abnormalities and advised to review with us. A simple division of the band as an outpatient procedure was advised. The parents were not willing for the procedure immediately and wished to review back for the same. However, the patient was lost to follow-up. Division of the band and genetic testing were therefore not possible. |
A 70-year-old female with no significant past medical history, Eastern Cooperative Oncology Group performance status 0 and no prior incidence of hypersensitivity reactions, was incidentally found to have a small nodule in the proximal right posterolateral vaginal wall after presenting with post-menopausal bleeding. Subsequent biopsy demonstrated a 9 mm invasive melanoma and the patient underwent wide local excision with confirmed negative margins. 4 months later, she developed a right periclitoral mass. Positron emission tomography/CT scan at that time demonstrated focal uptake in this area but no regional/distant metastases (). Excision demonstrated a large submucosal mass of atypical epithelioid cells with evidence of melanin synthesis, consistent with malignant melanoma. Breslow depth was 9 mm (3 mitoses/mm2) with a positive deep margin, and there was no evidence of lymphatic invasion. Her case was presented at a multidisciplinary tumour board and either additional surgery or radiation therapy was recommended to the patient. Owing to the significant morbidity anticipated with additional surgery, the patient opted for radiation therapy. Given the high risk of both local and regional/distant failure, concurrent chemotherapy was proposed. Owing to the historically poor response rates with standard chemotherapy, an immune pathway targeted agent was considered. This non-standard approach was actually initially proposed by the patient. After being thoroughly explained the current standard of care, in addition to the pros and cons of pursuing concurrent radiation and immunotherapy, the patient chose to proceed with combination immunotherapy and radiation treatment. Several studies have demonstrated that local radiotherapy primes and/or enhances an immune response through cytotoxic T lymphocytes. Concurrent immunotherapy may then further enhance the activity and/or duration of the downstream immune response. Given the historically low efficacy of our current treatment paradigms in this disease, as well as the preclinical/clinical rationale to combine radiation and immunotherapy, a strategy of pursuing a combination of ipilimumab with radiation was felt to be reasonable.\nRadiation was planned with intensity-modulated radiation therapy (IMRT) to the vulva and vagina (no elective nodal radiation to the groin) to an initial dose of 45 Gy (1.8 Gy/fraction over 25 fractions), and was to be followed by an electron boost to a total dose of 63 Gy (1.8 Gy/fraction over 10 fractions) at the site of the positive margin (). A thermoluminescent dosimeter was placed on the vulva at the start of treatment to measure the skin dose and read as 1.78 Gy [95% confidence interval (1.66–1.90)], confirming that the planned dose was accurate on the skin. The patient received her first cycle of ipilimumab (3 mg kg−1) 7 days after the start of radiation, and the second cycle was delivered 3 weeks later when the patient was at a dose of 36 Gy. Around this time (3 weeks post ipilimumab cycle 1), she began to develop non-painful erythema in the vulvar and perianal area, as well as a pruritic, grade 2 cutaneous eruption that morphologically showed distinct erythematous papules that coalesced into thin plaques over the upper arms, chest, back and face/ears (all toxicities were graded using Common Terminology Criteria for Adverse Events version 4.03). She did not experience any fevers or other systemic symptoms. By 48.6 Gy dose (10 days post ipilimumab cycle 2), the patient developed a grade 3 skin reaction () that was characterized as a moist desquamation with significant oedema, erythema and pain in the vaginal/vulvar/perianal region and was restricted to the radiation field (). A timeline of these events is illustrated in . After proper consent, a 4 mm punch biopsy of the affected skin was performed and histopathological examination demonstrated spongiotic and interface dermatitis with a perivascular inflammatory infiltrate consisting of numerous eosinophils, consistent with a fixed drug eruption.\nRadiation and ipilimumab were held given the severity of the moist desquamation, and the patient was referred to a dermatologist for evaluation of the ipilimumab-associated cutaneous eruption. It is noted that the patient had no existing risk factors or hypersensitivities predisposing her to an enhanced skin toxicity. The patient was started on 0.1% topical triamcinolone cream along with a methylprednisone dosepak. Given only mild improvement after 1 week, she was started on prednisone 60 mg daily (tapered over 7 days) with oral diphenhydramine for pruritus as needed. This resulted in significant improvement in her cutaneous eruption and pruritus. She then received a third cycle of ipilimumab (4 weeks after cycle 2) and resumed her periclitoral radiation boost without further issues after a 1-month break from radiation treatment. She went on to receive a fourth cycle of ipilimumab after completion of radiation without any complications.\nAt follow-up 8 months post completion of radiotherapy, she had complete resolution of the in-field toxicity and improvement of her ipilimumab-associated cutaneous eruption (). Clinical examination and positron emission tomography/CT imaging 10 months after completion demonstrated no evidence of disease recurrence. Most recently, at her 15-month follow-up, she remains disease- and symptom-free ().\nAt each follow-up visit, the patient has repeatedly expressed satisfaction with her decision to pursue immunotherapy rather than standard chemotherapy to complement her radiation treatment. She admits the initial side effects and intensity of the treatment course were difficult, although she is very pleased with the outcomes and would make the same decision if asked to do so again. |
A 50-year-old male patient was referred to a private dental clinic with the complaint of a nonhealing ulcer on his right posterior ventrolateral portion of the tongue in relation to 30 and 31 tooth region (universal system) for the past 3 months. The patient revealed a habit of cigarette smoking for the past 30 years. There was no gross facial asymmetry noticed on extraoral examination. On intraoral examination, an ulceroproliferative lesion, measuring approximately 2 cm × 2 cm with indurated margins, was seen on the right posterior ventrolateral portion of the tongue extending from 30 to 31 tooth region. The surface of the ulcer appeared erythematous with irregular borders and was tender on palpation. Lymph nodes on the right cervical region were palpable, nontender and firm in consistency. Based on the above findings, a clinical impression of carcinoma of the tongue was made. Incisional biopsy was performed, and the specimen was sent for histopathological examination.\nGrossing showed two grayish white soft-tissue specimens, firm in consistency with irregular surface. On histopathological examination, the surface epithelium was dysplastic, infiltrating into the underlying connective tissue stroma []. Two distinct components were noticed in the connective tissue, which were in close proximity with each other: the superficial squamous component and the deeper glandular component []. Squamous component revealed malignant squamous epithelial cells arranged in solid nests and islands, resembling typical well-differentiated squamous cell carcinoma with few areas of the island showing keratin pearl formation and individual cell keratinization []. The glandular component revealed squamous cells arranged in ductal pattern with few areas of the ducts showing amorphous eosinophilic intraluminal content []. Special staining with periodic acid–Schiff (PAS) and mucicarmine showed positivity for the intraluminal content and confirmed the secretory nature of the glandular component [Figures and ]. With the above characteristic histological findings, a final diagnosis of ASC was made. Immunohistochemistry was done as an adjunct on the tissue specimen for markers such as pancytokeratin and Ki-67. The tumor cells revealed strong positivity for pancytokeratin in both squamous and glandular component and a low Ki-67 index [Figures and ]. |
A 65-year old male patient with early gastric cancer was transferred from Aruba to our institution. He had a 3-year history of black stools and anemia. His past medical history included multiple comorbidities: diabetes, chronic renal failure, alcoholic cirrhosis Child A, complete heart blockade and thrombocytopenia of unknown etiology. An upper endoscopy and biopsy revealed a well-differentiated intestinal type adenocarcinoma in the antrum. Endoscopic ultrasonography showed a hypoechoic, 3.2 cm neoplasm, without muscularis externa infiltration and reactive ganglia (). Endoscopic mucosal resection was chosen due to tumor size, stage and comorbidities of the patient. The tumor was fully resected without complications. At the end of the procedure the anesthesiologist had difficulty with ventilation and abdominal distention was observed (). He had a 128/91 mmHg blood pressure and 70 bpm heart rate. An endoscopic revision was done before finishing the procedure, without identification of any macroscopic perforation. A nasogastric tube was placed and therapeutic strategies to improve abdominal-wall compliance were instituted (changes in ventilation parameters, nasogastric suction, change to a supine position and removal of any strap over the abdomen). A plain abdominal radiography in the operating room showed a massive pneumoperitoneum (). Decision of a nonsurgical management was conducted and the patient was taken to the intensive care unit (ICU) for monitoring. The IAP measured by a trans-bladder catheter was 33 mmHg. Six hours after ending the procedure the patient developed dyspnea and anuria. The diagnosis of an abdominal compartment syndrome was established. Given the worsening status, interventional radiology evaluated the patient. A CT scan confirmed the massive pneumoperitoneum without intraperitoneal extravasation of contrast (a & b). A percutaneous decompression guided by CT scan was performed with a pigtail catheter G14 (c & d). Air was immediately released under pressure. Immediately after the procedure, the patient's symptoms and hemodynamic status improved. Diuresis returned after a few hours. The pigtail catheter was closed the first day after placement and taken out at the third postoperative day. Control CT scan revealed no evidence of pneumoperitoneum. Pathology report confirmed the resected specimen had free malignant cell margins and areas of high-grade and low-grade dysplasia. The patient was discharged from ICU at postoperative day 2 and discharged from hospital at postoperative day 5 without further complications. |
We report a 43-year-old male who presented with an amputated right hand (). After clinical and radiological examination of the amputated hand and the stump, the patient was consented for hand replantation. Careful dissection and debridement of the neurovascular structures both proximally and distally and a 1-cm bone shortening of both bones on the amputated hand side was done. Afterward, both forearm bones were fixed by four K-wires. Meticulous repair of the radial and ulnar arteries and the cephalic vein was accomplished followed by repair of the three nerves of the forearm. Finally, tendons repair and skin closure was achieved. The patient tolerated the procedure well and 2 months later showed a progressive improvement in motor and sensory functions ().\nThe cephalic vein was the only vein repaired because the rest of the veins of the hand were either too small or badly damaged. While this replanted hand survived on a single-vein repair, Weiland described that a ratio of 2 veins to 1 artery repair is required to improve the outflow and increase the chances of the hand survival. Also, other authors recommended to repair more than a single vein. The cut end of the two bones on the amputated hand side was ragged and sharp so about 1 cm of the two bones was resected. Bone shortening facilitated the neurovascular structures repair without grafts. The distal radio-ulnar joint was about 3–4 cm away from the trauma site so integrity of the joint was preserved. Regarding the outcome of the sensory and motor function recovery, several reports have revealed favorable results following hand replantation, including of Hoang, who reported five consecutive hand replants in young male patients with clean-cut injuries at the level of radiocarpal joint resulting in 70%–80% of total active motion in the digits and thumb and 8–12 mm of static two-point discrimination. The best results have been seen in children with the recovery of as much as 90% of total active motion and 5–7 mm of static two-point discrimination. In our patient, the follow- up period is 2 months, so complete assessment of the sensory and motor function recovery is not feasible at this time period. However, the patient has started to exhibit flexion and extension movements at the wrist, metacarpophalangeal and interphalangeal joints and signs of initial sensory recovery, such as crude touch.\nWe conclude that in our procedure, single-vein repair was sufficient for survival of a replanted hand; however, we recommend utilizing more than a single-vein repair, if possible, for a better chance of survival of the hand.\nThe Ethical Committee approval was sought for this article. |
A 60-year-old man with a 45-year history of perianal fistula who had recently been suffering from mucinous discharge, pain and perianal induration was referred to hospital for treatment. Two years before, he had undergone surgery at another institution for incision and drainage of recurrent perianal abscess. Physical examination revealed an indurated, ulcerative lesion 7 cm in diameter with an external anal fistula opening (fig. ). The internal opening of the fistula was indicated at the right side of dentate line. There was no tumor in the rectum on digital examination. Histological examination of a biopsy specimen taken from the induration revealed mucinous adenocarcinoma. Magnetic resonance imaging (MRI) demonstrated a large demarcated tumor at the level of the anorectal junction with extension to the right side of the ischiorectal fossa and presacral space (fig. ). No enlarged pelvic lymph node was observed, nor was there evidence of distant metastasis. Neither colonoscopy nor barium enema showed any evidence of mucosal lesion in the colon or rectum. Laboratory data showed renal dysfunction caused by pyelonephritis, and the carcinoembryonic antigen serum level was extremely elevated to 40.8 ng/ml (normal <5 ng/ml).\nTo increase resectability and decrease the rate of local recurrence, preoperative radiotherapy was proposed without chemotherapy because of the renal dysfunction. Preoperative radiotherapy was given with 40 Gy in 25 fractions for 5 weeks through posterior and bilateral portals. After radiotherapy the tumor was markedly shrunk (fig. ) and carcinoembryonic antigen serum level gradually decreased to 13.0 ng/ml.\n8 weeks after radiotherapy the patient underwent radical resection. An APR with lymph node dissection was performed. The skin surrounding the tumor was excised with adequate tumor-free margin. The resected specimen revealed that the tumor had developed in the ischiorectal fossa, but there was no evidence of cancer extension to the mucosal surface of the anal canal and rectum (fig. ). Histological examination of the excised specimen showed foci of mucinous adenocarcinoma involving the lower internal and external anal sphincter muscles, and the resected margins did not show any residual tumor (fig. ). According to the UICC TNM staging criteria, the treatment outcome with preoperative radiotherapy revealed minimal response (grade 2). Metastases to the lymph node were not detected. After the operation, the patient died due to renal failure. |
The patient in this study was a 37-year-old right-handed male. He had a university education and had worked as a public officer before the onset of his cerebrovascular accident.\nHis medical history showed a record of arrhythmia in the past but it did not require any special cure in the department of cardiology. He had a right hemiplegia and suddenly could not speak during an exercise session on the eighteenth of October, 2008. At this time, he was diagnosed with an infarction in the left middle cerebral artery ().\nDrooling at the right side of the mouth was observed during the first week after onset, but it improved over time. He was lucid and conscious during neurological examination and scored 29/30 points on the Korean version of the Mini-Mental State Examination. On the manual muscle test, the flexor and the extensor of the right shoulder joint were found to be at a Good(-) level, while the flexor and the extensor of the elbow joint were at a Fair level, and the flexor and the extensor of the wrist joint and the knuckle joint were at a Fair(-) level as well. Moreover, the flexor and the extensor of the hip joint were at a Fair(-) level, the flexor of the knee joint was at a Fair(-) level, the extensor of the knee joint was at a Fair level, and the flexor and the extensor of the ankle joint were at a Poor(+) level.\nThe language evaluation was performed because of frequent articulation errors that were found on the 10th day after the onset of symptoms.\nOn the Korean version of the Western Aphasia Battery, the information content and fluency of spontaneous speech were recorded at 9/10 points each. Correct responses were shown on the conversation task. The length of utterance was normal, and correct sentence was recorded on the picture explanation task.\nAll responses were correct on the yes-no questions task, auditory word recognition task, and on the sequential commands task of the auditory comprehension section. Some phrases, especially those with long sentences, were omitted and trial-and-error groping articulatory movements was shown on the repetition task. In the naming section, the object naming task, the word fluency in controlled association task, and sentence completion task, all responses were correct, except for the incorrect response [ʥəŋɲjaŋ] for [səŋɲjaŋ].\nConsequentially, the result for fluency was 9/10 points, comprehension (10/10 points), repetition (8.5/10 points), and naming (9/10 points). The Aphasia Quotient was 92.8 points, which showed that there were no symptoms of aphasia. Furthermore, all responses were correct under oral instruction in the praxis task. Thus, the patient was diagnosed as having no buccofacial apraxia.\nThe oral function evaluation and articulation test were performed for detailed speech movement evaluation. Oral recording was assessed by the Praat (ver. 5200, Amsterdam, Netherlands) program. This was worked using 44,100 Hz sampling rate and 16 bit quantization, which used a head-worn microphone, Shure WH20 XLR (Shure Radio company, Niles, lllinois, USA) and the external sound card, Sound Blaster SB04090 (Creative Labs, Milpitas, California, USA). The movement of tongue, lip, velum, and jaw were normal for oral function results.\nThe recorded contents list consisted of the respiratoryphonation test, diadochokinesia (DDK), the increased word articulation test, the same word repetition articulation test, and the paragraph reading test. A printed sheet of the recorded contents list was shown to the patient, which he read.\nOn the respiratory-phonation evaluation result, the maximum phonation time (MPT) was 32.11 seconds and the voice intensity was 74.43 dB. No problem was diagnosed for respiration because the MPT was maintained for 20 seconds with appropriate loudness of voice.\nDDK consisted of sequential motion rate (SMR, /pʌtʌkʌ/) and alternating motion rates (AMRs, /pʌ// tʌ//kʌ/). Each rate was measured three times and the averages of these measurements were calculated. The method for counting syllables was applied to SMR such as AMRs in order to keep time standard.\nThe results were SMR/pʌtʌkʌ/=12.3, AMR/pʌ/=19.3, AMR/tʌ/=17, AMR/kʌ/=19.6. These results show that the articulations made at the same place would be faster than those at different places.\nIn the result of the increased words articulation test, the target word [ɕin - ɕinbaɭ - ɕinbaɭʥhaŋ] was twice found as a correct response, but the target word [iʨhɨŋ - iʨhɨŋʥiphʨhaŋ - iʨhɨŋʥip¬ʨhaŋmun] was found as an in correct response showing [iʨhɨŋ, iʨhɨŋʥip¬ʨhaŋ, iʨhɨŋiʨhɨkiʨhɨk, iʨhɨŋʥip¬ʨhaŋmun, iʨhɨŋiʨhɨm, iʨhɨŋʥip¬ʨhaŋ, iʨhɨŋʥip¬ʨhaŋmun]. Similar to this example, almost all target words were changed to other phonemes, and this is known as the phonemic paraphasia phenomenon. Several self-correcting trials were attempted to amend for these errors. The voiceless pause in a word was observed as [ʥinxɯk¬thaŋ__dɨɭģ'iɭ] in the target word [ʥinxɯk¬thaŋģ'iɭ].\nWhile repeating the same words in the articulation test, difficulties were found in first syllable utterance such as [phun, phun, phuŋɕən, phuŋɕən, phuŋɕən] for the target word [phuŋsən]. The subject substituting the plosive phoneme for the fricative phoneme was observed as well as repetition of syllables such as following example: [swomdathaŋ, swomphaswomsaʨhaŋthaŋ, swomphashomsaʨaŋthaŋ, swomswomdathaŋ, swomsathaŋ, swomsathaŋ] for the target word [swomsathaŋ].\nThe patient responded [kəmkjəŋʨhaɭɡwan, kjəŋʨhaɭɡwan, kjəŋʨhaɭɡwan] for the target word [kjəŋʨhaɭɡwan]. This may be due to the semantic paraphasia phenomenon, because the printed letter of the target word may remind the patient of 'kəmsa (prosecutor)' in the brain. |
We report a case of a white phosphorus burn that has a unique mechanism of injury involving a 40-year-old woman with her 7-year-old daughter who were collecting rocks on a beach in Tel Aviv. Upon returning home, the daughter washed the rocks of sand with tap water and immediately wrapped them in a paper towel. According to her anamnesis, the daughter presented her mother an unusual appearing, yellow translucent colored rock covered by a wet paper towel. As she commenced unwrapping the paper towel, white smoke emanated from the rock that was followed by ignition of flames and accompanied by a severe burning sensation in her hands. Subsequently, she dropped the rock which made contact with her right calf and then landed on her right foot that was covered by a sock and ignited. The patient then proceeded to put out the flames in the bathroom shower. Upon return to the living room, the piece of white phosphorus had ignited the couch which took hold and the entire apartment was gutted with fire. Both mother and child were safely evacuated from the apartment with no further injuries sustained.\nUpon arrival at the Emergency Department, within 1 h of the burn injury, the patient presented as conscious and talking with no evidence of an inhalation injury. Assessment revealed chemical burns from contact with what was suspected to be white phosphorus. No adequate first aid was administered at the time of the injury. First aid was commenced and the burns underwent decontamination, irrigation and debridement of devitalised tissue. Her wounds were thoroughly irrigated with water and then covered with saline soaked pads and was subsequently admitted to our Burns Center for further treatment.\nDigital photography with written informed consent from the patient pertaining to the use for treatment and teaching and learning purposes were taken on admission to the Emergency Department []. As this was a retrospective case report the ethics committee of Sheba Medical Center Helsinki Committee does not require ethics approval to be sought for this case report.\nScattered partial thickness burns were sustained on bilateral hands to the dorsum and palms aspects of 0.5% Total Body Surface Area (TBSA), deep dermal burns to her right medial calf of 1% TBSA and full thickness burns were sustained to her right foot dorsum aspect calculated to be 0.5% TBSA (see Fig. ). Due to the small surface area involvement and our Department’s experience with conservative non-surgical approach for minor burn care, the patient’s burns were treated with mafenide acetate (Sulfamylon) on the right medial calf and dorsum of foot and Flaminal Forte for the palmar wounds. Vital signs were all within normal limits, bloods were unremarkable and electrocardiogram abnormalities were not observed.\nThroughout the hospitalization period, blood tests were routinely taken twice weekly. The phosphorus level increased gradually from 2.90 mg/dL on day 1 to 4.40 mg/dL on day 14 (normal range 2.5–4.5 mg/dL). C-reactive protein (CRP) levels increased throughout the first 5 days and reached 122.21 mg/L, then gradually decreased to normal parameters (normal range 0–5 mg/L). During the admission period, occupational therapy and physiotherapy were provided to facilitate full range of motion to the hands and right leg. The patient was discharged 22 days after admission and followed up in the outpatient clinic. Pressure garments were provided however; hypertrophic scars began to develop on the dorsum of her right foot. Silicone sheets were provided under the pressure garment and the patient was educated on the importance of adherence to burn care therapy. The patient was again followed up 7 months post injury where digital images were once again obtained with the consent of the patient (see Fig. ).\nDue to the unusual appearance of the burn in this case report, the patient’s clothes were sent for examination to a forensic specialist. Consequently, the police and military investigators confirmed the nature of the chemical agent as white phosphorus crystals to permit preventive measures and announcements were made in the media. It is not known exactly how the piece of white phosphorus came to be on the beach in Tel Aviv however, the most probable explanations could be that the it may have fallen of a passing cargo ship, migrated from distant industrial factories or power station, remnants from naval training exercises or even an old incendiary bombshell that has been carried away by the sea currents. |
A 60-year-old male presented with chronic right side heart failure which had started around 2 years before. He had been diagnosed with chronic traumatic AVF at the right thigh due to a 30-year-old shotgun wound. Initially, CVI of the right leg had slowly developed. Two years before he had symptoms of right side heart failure, including leg swelling and liver congestion. These symptoms persisted and progressed into severe congestive heart failure (CHF). His echocardiography showed severe tricuspid regurgitation, mild mitral regurgitation, mild pulmonary regurgitation, and pulmonary hypertension.\nA physical examination showed swelling of his right leg with hyperpigmented skin around the ankle. Pulsatile varicose veins in the right thigh and groin were observed. A CT angiogram showed one large AVF between mid-SFA and SFV together with multiple AVFs along the external iliac artery and vein, the common femoral artery and femoral vein, and the distal SFA and SFV. There was a 5 cm aneurysmal change in the proximal right external iliac artery and vein. A venous aneurysm (3 cm in diameter) was found next to the largest AVF site ().\nAt first, the authors planned to close all AVFs in this patient, but it was impossible because of multiple AVFs along the external iliac artery to the distal SFA level. Since the authors had an experience of postoperative DVT in the venous aneurysm in case 1 after closure of the chronic AVF, the authors closed only the largest AVF, which would facilitate a decrease in his cardiac return. This would ease his cardiac failure condition but still allow some arterial blood flow to prevent acute thrombosis in the venous aneurysm. This was carried out by resecting the dilated AVF segment, and then arterial and venous bypasses were performed using an 8 mm Dacron graft individually (). Immediately after the authors clamped the AVF, the patient suffered reflex bradycardia (the Branham effect). The patient's heart rate dropped below 40 beat per min and his blood pressure decreased to 80/40 mmHg, so the anesthesiologist used a subcutaneous pacemaker to control his heart rate to 60 bpm, thereby increasing his blood pressure to around 100/60 mmHg.\nAfter the operation his right side heart failure condition improved. His leg was less swollen and his cardiac pumping function improved. He was weaned off the percutaneous cardiac pacemaker within 1 week of the operation. He had no DVT or thrombosis of either the external iliac artery aneurysm or the external iliac vein aneurysm. He was able to return to work within 3 weeks of the operation but still needed surveillance ultrasound for venous aneurysm progression. |
A 67-year-old Caucasian male with a past medical history significant for a liver transplant on prednisone and tacrolimus, heart failure with preserved ejection fraction, atrial fibrillation on apixaban, hypertension, and type 2 diabetes mellitus was admitted to an outside hospital 4 months prior to presenting to our hospital with a chief complaint of painful and necrotic ulcerations of the left first metatarsal and fifth toes. During this hospitalization, he was diagnosed with bilateral pulmonary emboli, subclavian clots, and thrombocytopenia. Skin biopsy was performed due to worsening necrotic ulcers, which showed intravascular clots and shaggy perivascular deposits of C4d. He was diagnosed with tacrolimus-induced TMA and was treated with 7 sessions of plasmapheresis with resultant improvement in thrombocytopenia and some of his lower extremity ulcerations; however, he did require amputation of his left great toe. Due to concern for tacrolimus-induced TMA but concomitant need for immunosuppression, he was switched to cyclosporine and later to everolimus due to thrombocytopenia associated with cyclosporine. Two weeks later, the patient was admitted to our hospital with worsening necrotic lesions and ulcerations of the left first metatarsal and fifth toes with significant spread to his bilateral lower extremities.\nOn examination, the patient was in mild distress. His temperate was 99.3 °F, the blood pressure was 103/73 mm Hg, the pulse rate was 117 beats per minute, and the oxygen saturation was 94% on 6 liters of O2 via nasal cannula. Jugular vein dilatation was noted. Effort and breath sounds were normal with no wheezes. No murmurs were appreciated. There was no abdominal tenderness or organomegaly. He had bilateral lower extremity edema. The left foot was cool and dusky with edema and the first left great toe was amputated-pulses present ( and ). The amputation site was dry and black and the tip of the third toe was black (). Large open wounds were present on bilateral shins ( and ). The left lateral leg ulcer measured 8 × 3 cm with an unknown true depth (). The wound base was moist, yellow, and black with no drainage. The right medial leg had an ulcer measuring 6.5 × 5.5 cm at the skin level with a dry and black wound base with no drainage or odor (). Bilateral arms had ecchymosis with a left arm ulcer measuring 3 × 1.5 × 0.2 cm (not shown). The wound base was moist and yellow with scant discharge.\nLaboratory studies showed low hemoglobin at 9.0 g/dL (reference range: 13.5-18 g/dL; reference range is provided in the parenthesis in the following laboratory studies), platelet count at 30,000/µL (150 000-400 00/µL). Creatinine 1.33 mg/dL (0.66-1.25 mg/dL), prothrombin time 17.9 (9.9-13.1 seconds), international normalized ratio 1.6 (0.8-1.2), partial thromboplastin time was 27.2 (25.6-38 seconds), haptoglobin 463 mg/dL (30-200 mg/dL), and lactate dehydrogenase (LDH) 407 U/L (122-225 U/L). Autoimmune, vasculitic, and antiphospholipid antibody syndrome workup was negative. Hexagonal phase phospholipid and platelet neutralization phase were elevated but could not be interpreted as positive due to anticoagulation use. Inflammatory markers C-reactive protein 192.7 mg/L (<8.0 mg/L) and sedimentation rate 49 mm/h (<20 mm/h) were elevated.\nOn admission, the patient was continued on oral prednisone 30 mg twice daily along with everolimus 1 mg by mouth twice daily. Computed tomography angiogram of the bilateral lower extremities revealed <50% stenosis in tibioperoneal artery on the right side, suggesting that his ulcerative lesions were unlikely to be due to major vessel pathology and more likely due to small vessel disease. Skin biopsy from his left lower extremity wound showed tissue hemorrhage ( and ) and fibrin thrombi ( and ) with immunofluorescence showing antibodies against immunoglobulin (Ig) G, IgM, IgA, C3, and fibrin, suggestive of immune-mediated vascular injury. His hospital course was complicated by acute hypoxic respiratory failure requiring mechanical ventilation secondary to cytomegalovirus (CMV) and Pseudomonas aeruginosa pneumonia, which was treated with a 14-day course of piperacillin/tazobactam. CMV quantitative DNA polymerase chain reaction was elevated at 835 IU/mL, and although suspicion for organ-invasive CMV disease was less likely given his immunocompromised state, he was empirically treated with intravenous IV ganciclovir for 14 days. Remaining infectious workup including blood, sputum, urine, and fungal cultures was negative.\nWorkup for thrombocytopenia and normocytic anemia with peripheral blood smear showed rare schistocytes. LDH and haptoglobin were elevated and not indicative for overt hemolysis and direct coombs test was negative. ADAMTS13 activity level was normal at 94% and did not support the diagnosis of thrombotic thrombocytopenic purpura. His prothrombin time, partial thromboplastin time, and international normalized ratio were within normal limits and not suggestive of disseminated intravascular coagulation. Due to his ulcerative cutaneous lesions, thrombocytopenia, and prior improvement of his skin lesions at the outside hospital with plasmapheresis, he received 4 more sessions of plasmapheresis. There was initial concern for the possibility of antiphospholipid syndrome and his steroids were increased to IV solumedrol 125 mg daily and he was started on a heparin drip. While on high-dose steroids, his platelet counts only increased from 30 000 µL to 57 000 µL; however, there was no improvement in his lower extremity ulcerations.\nGiven his overall worsening necrotic low extremity skin lesions suspected to be secondary to small vessel ischemia, significant thrombocytopenia, and acute kidney injury, there was concern for DITMA secondary to tacrolimus. Due to limited improvement with drug withdrawal, steroids, and plasma exchange, he was given IV eculizumab, 900 mg 2 times 7 days apart. The patient had significant improvement in several of his lower extremity ulcerations (Figure 1I-L) and had a sustained creatinine within normal limits. His platelets showed dramatic response and quickly normalized after just one infusion and LDH and haptoglobin levels both normalized.\nPrior to eculizumab infusion, the patient was offered below knee amputation of his left leg and transtarsal amputation of his right foot due to the extent of his necrotic lesions. The patient was interested in a second opinion for potential amputation and was transferred to an outside hospital. His total hospital stay was 22 days. |
A 71-year-old hypertensive man presented to hospital with a 1-day history of chest pain and dyspnea. Enhanced computed tomography (CT) revealed type B aortic dissection. He was transferred to our hospital for further investigation and care. His medical history included medically managed hypertension, untreated diabetes mellitus, and a 50-year smoking habit (Brinkman index: 1500).\nOn presentation, blood pressure was controlled below 120 mmHg with nicardipine. The patient complained of back pain. Abdominal and peripheral pulse examinations revealed no abnormality. Enhanced CT showed dissection and coagulation in the false lumen from distal to left subclavian artery at the renal artery level. Contrast-enhanced CT and echocardiographic findings did not reveal any congenital heart defects such as right-sided aortic arch or cardiac malformation. Two arterial anomalies were observed. The right subclavian artery arose from the aortic arch posterolateral to the origin of the left subclavian artery. The right vertebral artery arose from the right common carotid artery (). All aortic branches including the aberrant right subclavian artery arose from the true lumen.\nUpon admission, antihypertensive and analgesic treatment with bed rest were initiated. The symptoms were gradually ameliorated; therefore we performed rehabilitation in accordance with the type B acute aortic dissection rehabilitation protocol utilized by our hospital. Contrast-enhanced CT was performed on hospitalization days 2, 4, 7, and 12 to assess the aortic condition. No changes such as dilation or emergence of ULP were noted. After the rehabilitation protocol was completed, the patient was discharged. Hypotensive drugs were prescribed to control blood pressure, and the patient was scheduled for outpatient follow-up aortic imaging.\nOn day 11 after discharge (day 25 after onset), the patient visited our hospital for outpatient follow-up. Contrast-enhanced CT findings revealed a ULP (). We determined that the patient had complicated type B dissection, and an urgent operation was required. After the necessary presurgical checkups, we performed endovascular repair under general anesthesia, with tracheal intubation for mechanical ventilation. The right brachial artery was accessed, and a pigtail catheter was positioned in the ascending aorta for contrast enhancement. The left common femoral artery was exposed and used as the access route for stent graft placement.\nContrast-enhanced CT imaging of the thoracic aorta was used to visualize the ULP in the descending aorta. We confirmed the origin of the right subclavian artery that had arisen as the fourth aortic branch. The diameter of the proximal landing zone was 30 mm and the diameter around the ULP was 27 mm. The treatment length was 150 mm, which was between the position of just distal to ARSCA and 50 mm distal to the ULP. A guide wire (Amplatz Super Stiff wire) was inserted from the left common femoral artery to the ascending aorta and used as a guide for the stent grafts (Relay plus 26∗26∗10, Bolton) that were placed to cover the ULP. Care was taken to place the bare stent in a sufficiently peripheral site to prevent the tip from contacting the aortic arch. Furthermore, the stent was positioned 2 cm medially to the medial part of the ULP.\nFor Proximal part, we selected a stent graft that was considered appropriate for long-term treatment, at the aortic diameter (Valiant 32∗32∗10, Medtronic). We placed the second stent graft in the descending aorta from the region distal to the origin of the ARSCA. Angiography using a pigtail catheter confirmed that the ULP had disappeared on contrast-enhanced imaging and that no occlusion existed in the fourth branch of the aortic arch ().\nNo postoperative complications, including cerebral infarcts, paraplegia, or right upper limb claudication, were observed. On hospital day 5, the patient was discharged in ambulatory condition. At postoperative day 12, contrast-enhanced CT findings revealed that the ULP had disappeared, and no other abnormal findings such as occlusion or stenosis of the arch branch were observed (). |
A single breast amputation was performed on a 45-year-old woman with unifocal, unicentric breast cancer without affection of lymph nodes breast cancer and without any signs of disease generalization. Postoperative pathology revealed a poorly differentiated, grade 3 tumor with highly proliferative cells. Following tumor parameters were additionally determined – estrogen receptors were positive, Herceptin test was negative. No data exist about estimation of progesterone receptors and Ki-67 antigen. The patient received six courses of doxorubicin and cyclophosphamide chemotherapy, followed by local radiotherapy. No hormonal treatment was used. At 12 months after the breast amputation, radical hysterectomy and adnexectomy were performed. At 2 and 3 years after breast amputation, tumor markers were within the reference range for healthy individuals.\nAt 4 years after mastectomy, the patient began to complain of pain in the right ilium. Anteroposterior pelvic X-ray revealed an osteolytic lesion in the right iliac bone localized above the acetabular roof. Carcinoma Antigen 15-3 and Carcinoembryonic antigen tumor markers in the blood were increased significantly. Bone scans confirmed that the lesion was active and probably metastatic; however, similar abnormalities were not detected in the remaining skeleton. The right ilium was irradiated with 20 Gy radiotherapy. After 3 months, computed tomography (CT) was performed and a bone scan of the pelvis repeated. CT revealed a closed osteolytic lesion in the right iliac bone, ~15 cm3 in volume without cortex penetration (). The bone scans demonstrated increased osteoblastic activity with high metastatic potential despite the radiotherapy.\nBased on the clinical state of the patient and the results of imaging, the interdisciplinary team, consisting of an orthopedic surgeon, pathomorphology specialist and oncology specialist, devised the therapeutic strategy, presented it to the patient and obtained written consent. The therapy was based on an open biopsy of the lesion, with the expectation of tumor-positive intraoperative pathology and planned administration of doxorubicin into the bone.\nThe patient underwent surgery in the supine position; the highest and most anterior possible site of bone penetration in the supraacetabular region was chosen, allowing the drug to be administered precisely without contact with surrounding tissues or the possibility of leakage from the administration site (). Fluoroscopy was used to identify the operated area []. The diameter of the osteotomy site was 1 cm and the roof of the bone was preserved for closure of the resected area. The intracystic material was removed. Pathomorphology analysis confirmed the presence of tumor cells and 5 mg doxorubicin liquid (2.5 ml; suspended in a solution of sodium chloride and hydrochloric acid) was applied to the defect (). The cavity was closed with the piece of bone cortex obtained during osteotomy (). The tightness of the cavity was checked intraoperatively using contrast liquid (). Drainage was applied.\nPostoperative CT was performed during the hospitalization period (). During the postoperative period, no local or general complications occurred. The sutures were removed and the patient was discharged 10 days after the surgery. Tumor markers decreased to normal levels 3 months after the surgery.\nDuring the following 6-month observation period, the patient had no signs of recurrence. No pain was reported, only mild discomfort within the first 6 weeks after the surgery, and her gait was normal. After 6 months, a second operation was performed on the same area of the bone and intraoperative pathological analysis for the presence of tumor cells was negative. The defect was reconstructed using bone allografts. The metastatic region was radiologically evaluated by CT at 4 and 14 months after the second operation, revealing complete healing of the bone allografts ( and ). |
A 67-year-old male was referred to the Maxillofacial Unit after presenting to the Emergency Department with a facial swelling. Medically, the patient was fit and well, with a history of smoking 20 cigarettes per day and 20 units of alcohol per week. There was a soft, erythematous swelling of the right cheek measuring 3 × 3 cm. It was painful, without a discharging punctum and had features of an infected sebaceous cyst. The patient was not complaining of dysphagia and was systemically well. Intra-oral examination showed chronic periodontal disease and carious teeth but no sign of acute infection (Figs and ).\nA diagnosis of an infected sebaceous cyst was formulated and arrangements made for incision and drainage under local anaesthesia. Unfortunately, the patient then left the department before treatment was undertaken. He returned 1-week later with the same complaint, when the lesion was drained and a review appointment made. A review at 1 week found the erythematous area to have increased in size, with the incision site now having an exophytic, indurated appearance. An urgent biopsy was undertaken and ultrasound scan arranged.\nHistology showed a high grade adenocarcinoma with appearances unlikely to represent a primary adnexal carcinoma. The immunoprofile of the specimen suggested a metastatic deposit of a tumour originating in the gastrointestinal tract or pancreatico-biliary system. In light of this, a CT abdomen, thorax and pelvis was undertaken whilst a referral was made to a gastrointestinal surgeon. CT showed a large tumour of the lower oesophagus with multiple metastatic lymph nodes, bony metastasis in vertebrae L2 and lung metastases. Oesophageal biopsies confirmed an invasive adenocarcinoma, just superior to the gastro-oesophageal junction. Spinal decompression and stabilization was undertaken, in order to maintain quality of life, and he was discussed at the UGI MDT where it was decided that treatment would be palliative in nature. Radiotherapy involved five fractions to the lumbar spine and right cheek, before referral to a medical oncologist for palliative chemotherapy. The cheek mass had responded well to radiotherapy and the patient was placed on a course of epirubicin, oxaliplatin and capecitabine (Xeloda, Manufacturer Hoffman La Roche) for the oesophageal tumour. On review, a CT scan showed progression of bony disease and lung metastases along with a collapse of C4, and at this point the oncologist estimated survival to be that of 3–6 months. The patient died soon after. |
A 71-year-old female patient reported to the outpatient department with the chief complaint of pain in the lower jaw. There was a history of extraction of lower front teeth 31, 32, 33, 41 and 42 5 months back because of continuous pain, which was resistant to analgesics.\nOn intraoral clinical examination, an irregular, mild diffuse swelling was noted on the buccal aspect of the anterior mandible. The overlying surface of the swelling was normal in color and showed no associated color changes or gingival inflammation. On palpation, no rise of local temperature was noted. The swelling was nontender and firm in consistency with no pulsations evident. Submental lymph nodes were palpable but nontender [].\nPanoramic radiograph showed an irregular osteolytic lesion measuring about 6 cm × 3 cm involving the anterior mandible extending from the mesial aspect of 42 regions up to the mesial of 33 regions anteroposteriorly. No diversion or root resorption was noted. All remaining teeth were vital [].\nTo assess the exact boundaries and invasion into the adjacent areas, cone-beam computed tomography (CT) and chest radiograph were advised. Distant metastasis was ruled out with no other lesions of the major or minor salivary glands. Routine hematological investigations were normal [].\nOn correlating the history and clinical findings, a provisional diagnosis of an odontogenic cyst/tumor or an aggressive osteolytic lesion was considered. Differential diagnosis of intraosseous malignancy, minor salivary gland tumor like MEC, ACC were postulated.\nOn performing incisional biopsy, histopathology revealed moderately collagenous stroma lined by strands of cells forming multiple ductal tubule-like structures with pale eosinophilic mucinous material within the lumen. A focal stromal area shows the presence of numerous ducts such as tubules and pseudocysts mimicking a cribriform pattern in most of the areas. The high-power view revealed cuboidal cells with prominent hyperchromatic nuclei and minimal cytoplasm lining the duct-like tubules. A few cells show clear cell changes as well. The stroma shows the presence of abundant plump fibroblasts, numerous blood vessels and few lymphocytes interspersed among fine moderately fibrillar collagen bundles. No clear perineural invasion was seen. Majority of the areas (>70%) showed a cribriform pattern; hence, the diagnosis of ACC was made [Figures and ].\nFocal positivity for periodic acid-Schiff was noted for the eosinophilic material within the lumen of the ductal tubules. Tumor cells showed diffuse immunopositivity with respect to S100, calponin and CD117 [Figures –].\nPostoperative radiotherapy was given. Follow-up after 15 months since the initial diagnosis showed no sign of recurrence. |
A 49-year-old male was admitted electively for a TL resection of a vestibular schwannoma. He had symptoms of a left sensorineural hearing loss and pain in the distribution of the trigeminal nerve, for seven months, prior to the diagnosis of a left intracanalicular vestibular schwannoma. The patient underwent an uneventful procedure. On the fourth day after the operation he became confused with mild dysphasia. A computed tomography (CT) of his brain showed a hypodense collection in the left temporal lobe (Figures -). Further investigation with magnetic resonance imaging (MRI) of his brain demonstrated a fluid collection within the substance of the left temporal lobe and significant oedema of the surrounding temporal lobe with mass effect, but there was no evidence of haemorrhage or abscess formation (Figures -). In addition there was evidence of pseudomeningocele formation in the subcutaneous tissues adjacent to the previous wound. The patient showed further worsening of his confusion and speech disturbance and the decision was made to proceed to the operating theatre.\nAt operation the pseudomeningocele was evacuated; a 2x2 cm craniotomy was performed over the squamous temporal bone. After elevation of the bone flap, a small dural tear was noted over the inferior temporal lobe and the temporal lobe was bulging against the dural margins. Bipolar cortectomy was performed and the cavity identified on MRI was entered with egress of clear CSF under high pressure. The temporal lobe immediately appeared relaxed and was seen to be pulsating normally. A cystosubdural shunt (CSS) was fashioned from two 5 cm pieces of a 1.9 mm diameter external ventricular drain. Both were inserted into the cystic cavity with the other ends placed in a subdural pocket and secured to dura with sutures. Haemostasis was achieved and copious washout of the surgical site was followed by layered closure with absorbable sutures and nylon and staples to the skin. After reversal of anaesthesia and extubation, the patient showed some improvement in his confusion. A CT scan of the head 24 hours postoperatively showed resolution of the cystic collection and improvement of the mass effect (Figures -). He was continued on anti-seizure medications prophylactically for seven days postoperatively. Over the next few days his confusion and speech improved rapidly and he was referred on for further rehabilitation. |
A 21-year-old boy who has been evaluated in emergency service with abdominal pain was referred to our outpatient clinic because of the reason that there was seen edema and inflammation around the ileal wall and some collection regarding the initial diagnosis of inflammatory bowel disease in the CT scan performed to exclude acute abdomen. The patient has no family history of any cancer. In his physical examination, mildtenderness has been detected in the right lower quadrant and periumblical site of the abdomen. His bowel sounds were normal and in his rectal examination, there was a formed stool without blood. In his laboratory results, pathological results were as follows: CRP: 25; ESR: 22 and fecal occult blood test was positive. In his CT/CT enterography there was seen free subhepatic and pelvic abdominal fluid; asimetric thickening in the sigmoid colon walls; derangement of bowels and peritoneum. According to these findings the radiologists pointed that it must be evaluated not only for inflammatory bowel disease but also for the diseases involve peritoneum. Then colonoscopy and gastroscopy were performed and while there was no pathological sign in gastroscopy, an obstruction in sigmoid colon has been detected by colonoscopy (Figures , and ). The biopsies were taken. Before the pathological investigation has been completed, patient was presented with subileus according to the obstruction of sigmoid colon. Placement of a metal stent to the sigmoid colon was tried but it was not successful according to the hardness of the tumour. Biopsy results were reported as signet ring cell carcinoma of sigmoid colon (). Signet cell carcinoma cells were also seen in the abdominal fluid which we have obtained after the pathological diagnosis. Afterwards, the PET/CT scan was performed and it also showed peritonitis carcinomatosa with a significant omental cake. As the patient was accepted as inoperable with an advanced stage, patient underwent the surgery for the palliative colostomy. FOLFOX regimen which includes 5 Fluoruracil, calcium folinate, oxaliplatin, and bevacizumab (FOLFOX + Bevacizumab) has been started with the diagnosis of metastatic colon cancer. The patient is still undergoing treatment. |
A 7-year-old boy known to have homocystinuria since the age of 2 years and 10 months presented to the pediatric emergency department with abdominal pain and bloody stools. The child was born full term by cesarean section delivery with a birth weight of 2.7 kg. He was born to healthy consanguineous parents and has 5 brothers and 3 sisters. The child was growing normally except for delayed speech development. At the age of 2 years he started to have recurrent focal seizure alternating from one side to the other and associated with a disturbed level of consciousness. Electroencephalogram (EEG) showed focus of sharp waves on the right centroparietal and temporal regions. Computed tomography of the head was performed and reported as being normal. The patient was started on different antiepileptic medications which partially controlled the seizures.\nTen months later, the patient developed right-sided hemiparesis. Computed tomography of the head showed a hypodense area on the left thalamic region. Magnetic resonance imaging and magnetic resonance venography of the brain showed left thalamic hemorrhagic infarction and thrombosis of both the internal cerebral vein and vein of Galen. Following the magnetic resonance venography, the child developed deep vein thrombosis extending from the right femoral vein up to the common iliac vein. Anticoagulation therapy (heparin followed by warfarin) was started along with the antiepileptic medication. Further investigations revealed positive urine and blood for homocystinuria. Eye examination demonstrated bilateral downward lens dislocation. Sibling screenings were positive for homocystinuria for 1 brother and 1 sister. Vitamin B6, folic acid and betaine were added to the treatment and 8 weeks later warfarin was discontinued and dipyridamole was added.\nThe child improved gradually and showed signs of complete recovery. He started to walk and talk normally 8 weeks following the event. However, the child was not compliant with the treatment and did not attend the outpatient follow-up regularly. Despite the lack of compliance, the child became seizure-free and antiepileptic medication was stopped at the age of 51/2 years.\nAt the age of 7 years he had symptoms of upper respiratory tract infection with vomiting. An oral antibiotic was prescribed by his family physician. Several days later he showed up in the emergency room with crampy abdominal pain and bloody stools. Physical examination showed normal vital signs with no signs of dehydration or infections. He was admitted to the hospital for further investigations. During his stay, the child continued to have progressively worsening abdominal pain with lower GI bleeding; he was therefore transferred to the surgical side. Doppler ultrasound of the abdomen showed superior mesenteric vein and middle colic vein thrombosis. The patient underwent an emergency exploratory laparotomy which demonstrated a 120-cm ischemic black small bowel approximately 50 cm distal to the duodenojejunal junction. Resection with end-to-end anastomosis was performed and anticoagulant therapy was commenced after the procedure. A few days later the patient started to tolerate oral fluid and vitamin B6, betaine, folic acid and methionine restriction were added. He was discharged in a good general condition. Homocysteine and methionine levels on admission were 24 and 739 µmol/l, respectively, while on discharge corresponding values were 11 and 265 µmol/l (normal range: methionine 10-40 µmol/l, homocysteine not detected). The discharge medication included vitamin B6, betaine, folic acid, and warfarin. The child and the family were advised to be compliant with treatment and clinic appointments. With subsequent visits he was noted to be compliant with the medications and the follow-up as well as his affected siblings. |
A 16-year-old young Egyptian female presented with progressive shortness of breath over a period of five years. The dyspnea was gradual in onset, at times precipitated by stress, but most of the time there was no precipitating factor. It was associated with severe nonproductive cough and bilateral headache. There was no significant past medical history. There was no history of fever, night sweats, and wheeze or chest pain. Also, there was no hoarseness of voice or hemoptysis. The patient sought medical advice at a private health center when the patient's daily activities gradually started getting affected. The patient was prescribed Salbutamol inhaler which gave her temporary relief. At the same time, the patient was diagnosed to have hyperthyroidism and was started on carbimazole. The patient took these medications for about 4 weeks and discontinued them against medical advice as she experienced lethargy and easy fatigability due to the sideeffects of the prescribed drugs.\nAfter a brief period of relief of symptoms, the patient again started to have dyspnea and presented to the Cardiothoracic Unit in our hospital for evaluation. Baseline investigations were done, which included complete blood count, renal function tests, and liver function tests; all were within the normal range. Chest X-ray showed a well-demarcated right upper lobe mass close to hilum (). Chest computed tomography (CT) scan showed bilateral thyroid nodules and a large well-defined heterogeneously enhancing mass measuring 11 × 6 cm with a central hypodensity at the right upper lobe with significant compression to the superior vena cava (). There was no evidence of significant lymphadenopathy or pleural effusion. Complete surgical removal of the tumor along with safety margins was done and sent for histopathology examination. The biopsy report revealed ill-defined neoplastic growth showing biphasic pattern comprising epithelial and mesenchymal components consistent with pulmonary blastoma (Figures and ). The surgical margins were free of tumor. CT abdomen and bone scintigraphy showed no evidence of distant metastasis. The patient was referred to Radiation Oncology Department for possible intervention, but due to lack of established evidence of the role of radiotherapy in controlling local recurrence, the patient did not receive adjuvant radiotherapy. Due to the presence of certain poor prognostic factors like biphasic type and tumor size more than 5 cm, it was decided to proceed with adjuvant platinum-based chemotherapy comprising of ifosfamide, carboplatin, and VP-16 (ICE protocol). The patient received 6 cycles of the ICE protocol every 3 weeks with prophylactic granulocyte colony stimulating factor (G-CSF) from day 5 to day 12 after each cycle. There was one episode of febrile neutropenia after cycle 4 and the patient recovered completely after treatment with intravenous antibiotics. Reevaluation was done after 3rd and 6th cycle with CT chest which showed no evidence of recurrence. The patient is in complete remission and currently on a 3-month ongoing followup. |
A 35-year-old lady with a known history of controlled hypertension, avascular necrosis of the right hip, lupus nephritis status post cadaveric renal transplant in 2014, with chronic graft rejection, and a history of abdominal pain that was attributed to an abdominal wall hematoma diagnosed previously by ultrasound (US) abdomen, presented to an outside facility with severe 10/10 stabbing chest pain radiating to the back that started suddenly while the patient was sitting down; she also complained of some abdominal pain that was mild as compared to her chest pain. At the outside facility, the patient was noted to be hypertensive. Serial electrocardiograms (EKGs) and troponins were done, and they were unremarkable. The patient was later found to have acute kidney injury with a creatinine of 7.4 and her last known creatinine was around 4.2. Given the patient’s acute kidney injury, computed tomography (CT) abdomen without contrast was done to evaluate the renal graft, which eventually came back unremarkable. The patient was then transferred to our facility due to the availability of transplant services in our hospital with a working diagnosis of acute on top of chronic kidney disease secondary to worsening chronic graft rejection.\nUpon initial presentation to our hospital, the patient had a blood pressure reading of 214/89 as well as an episode of chest pain. The patient's pain and blood pressure slowly improved after receiving 1 mg of hydromorphone hydrochloride, with blood pressure returning to 130/70 mmHg. The patient's home blood pressure medications were then resumed.\nFrom that point onward, the patient was no longer complaining of any chest or abdominal pain. Her blood pressure ranged around 113/70 throughout her stay. Upon questioning the patient about her blood pressure control, she said that it was always controlled and that it was only high on presentation because of the severe pain she was in. A complete physical exam was done on admission, including bilateral measurements of blood pressure in both arms that did not show any discrepancy. Given the patient's stable clinical condition and lack of any pain, the possibility of aortic dissection was kept low on the differential diagnoses list, and we attributed the chest pain to possible acute coronary syndrome vs pericarditis. The plan then was to trend troponin with serial EKGs and a routine transthoracic echocardiogram.\n \nMeanwhile, the nephrology team was consulted and during their examination, they appreciated a possible friction rub that was missed by the primary team, and the priority of the echocardiogram was changed to stat to rule out possible uremic pericarditis. Bedside echocardiogram done by the cardiologist revealed new moderate aortic valve regurgitation, with mild aortic dilatation and possible aortic dissection, as well as mild to moderate pericardial effusion. Given the urgency of the situation, the patient was started immediately on esmolol drip and was transferred to the critical care unit after consulting the cardiothoracic surgeon. The patient had a trialysis catheter inserted emergently in preparation for hemodialysis, and she went for CT angiography. The CT findings reported a type A aortic dissection extending from the aortic root to the abdominal aorta and extended through the left common carotid artery and celiac trunk. It also showed the intimal flap extending into the origin of the left main coronary artery. In addition, an area of rupture with pseudoaneurysm and extravasation of contrast along the ascending aorta left wall was seen, which was causing the moderate to large hemopericardium.\nThe patient was started immediately on esmolol drip to control her heart rate, as her blood pressure was already within the target range. She also got an emergent hemodialysis session and was scheduled for an emergent vascular surgery on the same day.\nPertinent investigations upon initial presentation\n● Troponin I: 0.03 on admission with a minimal rise to 0.06 after three hours\n● Creatinine: 7.4 mg/dl at the outside facility, which increased to 8.33 mg/dl\n● Bicarbonate: 13 meq/L\n● Anti-double stranded DNA (anti-dsDNA): <1/10 normal\n● C3 & C4: 57 (lower limit of normal is 79) and 16 (normal)\n● Erythrocyte sedimentation rate (ESR): 36\n● Potassium: 5.5 meq/L\n● EKG: nonspecific ST changes\n● Chest X-ray (XR): No widening mediastinum, with no radiographic evidence of acute cardiopulmonary process (Figure )\n● Transthoracic echocardiogram after the suspect pericardial rub: Global left ventricular systolic function is hyperdynamic. There were moderate left ventricular hypertrophy and moderate aortic valve regurgitation. A dissection of the aortic root is seen. There were also mild aortic dilatation and a small to moderate pericardial effusion. Echodense material within the pericardial space suggested a clot or fibrinous elements (Figure ).\n● CT angiography (CTA) chest done after confirming an acute aortic regurge on echocardiography: There was a type A aortic dissection extending from the aortic root to the abdominal aorta, which involved the celiac trunk. The ascending aorta was dilated, measuring 4.2 cm. The intimal flap extended down to the aortic valve plane and extended into the origin of the left main coronary artery. There was also an area rupture with a pseudoaneurysm along the left wall of the ascending aorta, which could account for the large amount of hemopericardium present. Contrast was present in the true and false lumen. The dissection extended to the left common carotid artery with a good enhancement of the main three branches of the aortic arch (Figures -).\nOutcome and follow-up\nThe patient had a successful surgery with a median sternotomy and repair of type A aortic dissection, with a 29-mm Gelweave graft (Vascutek, Inchinnan, UK) and a complex resuspension of the aortic valve. The patient was successfully extubated. She was initially maintained on continuous venovenous hemodialysis but then later transitioned to an intermittent hemodialysis regimen. The patient made a good recovery, and she was later discharged with close outpatient follow-up. |
A 64-year-old male underwent cryoablation of all four pulmonary veins for symptomatic drug refractory AF and was discharged home the same day on rivaroxaban and amiodarone for 3 months as well as an event monitor for 3 weeks. Later that night, the patient developed pleuritic chest pain. He was found to be in atrial flutter in the emergency department. A CTA of the chest and abdomen identified esophageal perforation with a fistulous tract to the left atrium (). Echocardiogram at this time showed a moderate to large pericardial effusion with no evidence of hemodynamic compromise.\nMedian sternotomy was performed 5 days post-ablation in order to drain the pericardial effusion of purulent fluid. An esophageal stent was also placed for the treatment of an AEF. Pericardial fluid cultures grew group A Streptococcus and the patient was started on antibiotics. Although he improved clinically, an esophagram revealed a persistent AEF (). The patient was sent to a rehabilitation facility.\nThe patient was hospitalized and found to have intermittent febrile episodes with hypotension and three transient episodes of left-sided weakness. The patient was in AF with rapid response; therefore, he was maintained on amiodarone and a heparin drip.\nA TTE demonstrated a mobile echogenic structure within the left atrium consistent with a thrombus. He underwent sternotomy with removal of the left atrial thrombus and closure of a patent foramen ovale. The patient was transferred to our facility to undergo repair of the newly demonstrated AEF. demonstrates the 2-cm defect in the esophagus (). It was accomplished with surgery consisting of an autologous pericardial patch with suture repair of the esophageal defect and latissimus dorsi muscle interposition flap placement (). The esophagus was circumferentially wrapped with the latissimus flap. The esophageal stent was also removed. He tolerated the surgery well. Heparin drip was started immediately post-operatively. The patient was discharged to a rehabilitation facility. Patient was followed up several months afterwards and has continued to do well post-operatively. |
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