text
stringlengths 746
31k
|
|---|
The patient is a 47 year old Native American female without significant past medical history or known CD risk factors who presented after being critically injured in a motor vehicle accident. During her trauma evaluation and stabilization, a posterior mediastinal mass was noted as shown in . She was taken to the operating room for multiple internal injuries necessitating surgical repair. Visualization of the mass was noted but was not attended to at that time. After a several month recovery, she returned to the thoracic surgeon for follow-up and further workup of the mass. Biopsy was performed via mediastinoscopy and pathology results revealed angiofollicular lymph node hyperplasia, consistent with CD. CT and PET-CT scans were performed which showed the mass to be 5.5 cm x 4.6 cm with a peak SUV of 5.3. Due to the location of the mass and history of recent prior surgery, she was determined not to be a good candidate for complete surgical resection. She was then referred to consider radiotherapy treatment options.\nTreatment simulation was performed in the supine position and immobilization via a vac-lock. Treatment planning was performed on Eclipse External Beam Planning 7.5.51 (Varian Medical Systems, Palo Alto CA). Given the midline, posterior location of the mass, IMRT was utilized to reduce the dose gradient and toxicity to the surrounding normal tissues. The gross tumor volume (GTV) was contoured and expanded 5 mm to create the planning target volume (PTV). The patient was treated to a total dose of 4320 cGy. RT was delivered in nine initial once daily fractions of 180 cGy to a total dose of 1620. She was then placed on a 10 day break followed by re-simulation and treatment planning. She then completed the total 4320 cGy dose prescription without interruption in 180 cGy once daily fractions. Radiation therapy (RT) beam arrangements are shown in . The initial PTV volume was 235.7 cm3 and the re-CT PTV following treatment break was reduced to 120 cm3, a reduction of approximately 50.9%. Cumulative dose volume constraints allowed the mean total lung dose to be limited to 961 cGy and the 20% volume to be limited to 1706 cGy. The heart was limited to a mean dose of 939 cGy, and the expanded cord mean to 1163 cGy. Dose volume histograms of each plan (pre and post treatment break) and a cumulative plan sum are shown in , , and . A summary of mean and max dose statistics is shown in . No acute side effects were noted during treatment.\nAt a follow-up of ten months, the patient has had no disease progression. She did develop RTOG grade III pneumonitis at three months follow-up which was managed by steroids. Follow-up PETCT () showed the mass to be stable at 3.9 cmx 5.1 cm and SUV values to be at background. No late effects have occurred. |
A 45-year-old systemically healthy male patient was treated in Department Of Periodontics, Bapuji Dental College and Hospital, Davangere for root exposure in relation to lower front teeth (31) using the subepithelial connective tissue grafting procedure.\nThe connective tissue graft was harvested using Bruno's technique. Immediately after harvesting SCTG, the palatal donor site showed profuse bleeding. Digital pressure was applied for 15 minutes to control the bleeding and to find its origin. Slight reflection of the epithelial flap at the palate revealed pulsating bleeding with the artery involved. Bleeding was controlled using heat coagulation and later palatal wound was sutured using interrupted sutures and periodontal dressing was given. The patient was kept under observation for another half an hour to check bleeding. Postoperative instructions including oral hygiene maintenance, antibiotics, and analgesics were given and the patient was recalled after 10 days for further evaluation and suture removal.\nTen days postoperatively, periodontal dressing was removed and the surgical site was irrigated using a 5% iodine solution. Debridement of the wound showed an exposed bone with yellowish slough formation at the donor site with surrounding erythema and edema []. Overlying epithelium showed necrosis and the patient complained of moderate pain in relation to the same. After evaluation of the site, it was decided to use PRF to initiate healing along with Kollagen to stabilize the PRF. A written informed consent was taken from the patient for the same.\nThen 5 ml of venous blood was collected from anticubital fossa of the patient and was immediately transferred to a sterile test tube. The blood was centrifuged at 3000 rpm for 10 minutes, following which the platelet-rich fibrin was obtained. A Kollagen membrane containing bovine collagen was rinsed in sterile saline water and then was spread uniformly on a clean glass slab. The platelet-rich fibrin obtained from patient blood was placed over the kollagen membrane and the latter was folded in two folds over PRF [] and was further cut to the size of the palatal wound.\nThe palate was anesthesized and bleeding was induced at the site of infection from the surrounding tissues. A layer of platelet-rich fibrin was covered on the wound surface and a Kollagen membrane was further placed over PRF as a scaffold []. Seven days after placement of PRF + kollagen, the palatal stent was removed and the site was evaluated. The clinical examination of wound site showed complete resorption of the kollagen and PRF with reduced erythema, edema, and absence of slough []. Margins of the wound were seen to be merging with the periphery of the wound and the bone was covered with thin layer of epithelium. After 14 days complete epithelization was observed []. The wound margins could not be differentiated from the rest of the palate. No signs of erythema or edema were seen at the wound site. After 21 days the healing site could not be differentiated from the surrounding tissue []. The patient did not present any discomfort. At 1-month palpation of soft tissue in the wound region showed resistance to probe thus depicting formation of new connective tissue. |
A 44-year-old female visited our hospital due to the presence of a painless mass in her parotid region. The patient denied all genitourinary symptoms and was otherwise well. Laboratory studies revealed normal hemogram, urinalysis and blood ureanitrogen results. The results of a complete ear, nose and throat examination were also normal. The head and neck computed tomography (CT) scan revealed a 4×2.5-cm mass in the right parotid region accompanied by an osteolytic destruction of the right mandibular branch (). A roentgenogram of the chest was observed to be normal. Further examination by an abdominal CT scan revealed a 6.5-cm mass in the left kidney, suggesting RCC (), and a mass in the right iliac area accompanied by a slightly osteolytic destruction of the right iliac bone (). A radical nephrectomy was performed. The histological analysis revealed a renal clear cell carcinoma () and confirmed the renal tumor to be the primary neoplasm. The patient was then discharged from the hospital, as she did not accept any further treatment.\nAfter seven months, the patient presented with the mass in the right parotid region that had enlarged to a ball-like size and was causing a difficulty in opening the mouth. On physical examination, positive findings consisted of a firm mass measuring ∼12×13 cm in the parotid region (). The mass demonstrated no tenderness but had local heat. The CT scan revealed that the masses in the right parotid region and the right iliac area had enlarged to 12.5 and 13.5 cm, respectively, and were accompanied by serious osteolytic destruction of the right mandibular branch and the right iliac bone, respectively ( and ). Furthermore, liver metastasis, multiple bone metastases and bilateral multiple metastatic lesions in the lungs were identified. The patient was administered interleukin (IL)-2 and bisphosphonates, and received local radiotherapy to the right parotid region and pelvic cavity. However, after three weeks, oral mucositis occurred. Due to unbearable pain, the patient did not accept further radiotherapy. Therefore, targeted therapy with sunitinib was recommended; however, the patient refused this treatment due to its high cost. The patient was treated with Chinese medicine and supportive care. Further follow-up continues. |
An 8-year-old female with no significant past medical history presented with diffuse erythematous nonpruritic rash anteriorly over both thighs and laterally over the right thigh, which started as a red bump on the night prior to admission. The rash worsened over the course of a few hours progressing to blisters on top of the rash. She reported a few episodes of coughing and runny nose 2 to 3 weeks prior to admission. However, she was not treated with any antibiotics, and at the time of admission she did not have signs or symptoms of respiratory tract infection. She came back from a 10-day trip to California with her family and cousins but denies having any sick contacts. While she reported 1 day of loose stool, she did not take any antibiotics or any other medications in the last few weeks. No dysuria or eye pain was reported.\nPhysical examination revealed normal vital signs, and a tender erythematous rash with diffuse borders, approximated 10 cm by 15 cm on the anterolateral aspect of right thigh and another similar appearing lesion about 5 cm by 5 cm on the anterior aspect of left thigh. Tense blisters were noted over these erythematous areas. Her oral mucosa did not have any lesions. Her lung and cardiovascular examination was also unremarkable. While in the hospital her rash continued to increase in size and blisters worsened with increase in size and number. Initial laboratory examination showed a normal complete blood count and comprehensive metabolic panel.\nSince the rash was worsening and associated with blistering, we sent a skin biopsy that showed normal immunofluorescence studies, ruling out cutaneous autoimmune conditions such as bullous pemphigoid. Histological examination revealed focal epidermal necrosis with perivascular lymphocytic infiltrate suggestive of subacute erythema multiforme-like reaction. Results of blood test for hepatitis A, B, and C viruses, Epstein-Barr virus (EBV), human herpes virus 6 (HHV6), herpes simplex virus (HSV), and cytomegalovirus (CMV) were negative. Her Mycoplasma pneumoniae–specific IgM titer came back elevated at 1823 U/mL (positive > 950 U/mL). She was diagnosed with Mycoplasma-associated bullous erythema multiforme. She responded well to corticosteroids and did not have any mucosal involvement during the entire course of her illness. No antibiotics were given as the patient did not have any respiratory symptoms. She was subsequently discharged after the skin lesions showed improvement. |
A 42-year-old, gravida 4, para 3, patient was hospitalized at 34 weeks’ gestation due to a severe headache and vomiting for 15 days. The patient was admitted to the Xuanwu Hospital and was hemodynamically stable, with bilaterally reactive pupils. The patient’s previous obstetric history included three full-term pregnancies with two vaginal births and one CS. A physical examination confirmed weakness in the faculty of memory, indifference of facial expression and a Glasgow Coma Scale score of 13/15. An MRI scan showed a right frontal lobe tumor with an intratumoral hemorrhage (), causing a significant midline and brain shift toward the left side. Obstetric USG showed a single intrauterine live pregnancy with breech presentation which was concordant with its gestational age. The patient was otherwise healthy and denied any previous history of disease. The laboratory results were within the normal ranges. Due to the presence of an intratumoral hemorrhage, termination of the pregnancy was recommended. Following mannitol and steroid infusion, the patient was taken to the operation room for CS followed by neurosurgical resection of the tumor.\nCS and craniotomy in the supine position were performed under general anesthesia. A healthy 2,450-g female was delivered by CS 5 min after the skin incision. The female neonate had an Apgar score of 9 at 1 min and 10 at 5 min after delivery and was taken to the neonatal intensive care unit for observation.\nTen units of oxytocin were administered intravenously to improve the uterine contraction after clipping the umbilical cord. The obstetrician massaged the uterus regularly to improve uterine tone during the neurosurgical procedure, which was performed uneventfully. At the completion of craniotomy for resection of the brain tumor, the patient was extubated while fully awake in the operating room and then transported to the intensive care unit.\nThe pathology laboratory reported an anaplastic oligodendroglioma, WHO grade III. Immunohistochemistry of the tumor cells revealed positive p53, IDH-1 and Ki-67 (40%) expression and partially positive GFAP, CD34 and EMA expression. The patient was discharged 8 days after surgery. The patient received radiotherapy 25 times and treatment with chemotherapy using temozolomide was administered in another hospital.\nAt follow-up 6 months after discharge, the mother was observed to have an adequate condition and the newborn was observed to be in a good neurological and behavioral state of development. |
A 41-year old man with a diagnosis of metastatic adenocarcinoma of the colon was admitted to the Pain Unit because of severe abdominal pain. He had a progressively increasing epigastric pain radiating towards his back for two months. He was using tramadol 300 mg/day and non-steroidal anti-inflammatory drugs which no longer provided satisfactory analgesia. He was also prescribed transdermal fentanyl 25 µg/h, but did not use regularly because of side effects.\nAfter evaluation, it was learnt that he had undergone surgery 4 years before and had colostomy. He had chemotherapy for a long time but he was now regarded as chemotherapy resistant and no further treatment was planned. A recent computerized tomography revealed multiple metastatic lesions in the liver and enlarged peri-pancreatic, peri-aortic, peri-caval and hepatogastric lymph nodes tending to conglomerate ().\nHe was subsequently hospitalized in Pain and Palliative Care Unit for pain management. A splanchnic neurolytic block was planned and written informed consent was obtained from the patient. The procedure was performed under fluoroscopic guidance in the operating room. He was placed in the prone position with a pillow placed under the abdomen. After establishment of a diagnostic splanchnic block with a local anesthetic mixture of 5 ml of lidocaine 2% and 5 ml of bupivacaine 0.5% using retro-crural technique and obtaining pain relief without motor weakness, a bilateral neurolytic splanchnic block with 10 milliliters of alcohol on both sides was performed. The place of the needles and spread of the solution was confirmed with a contrast medium.\nWhile administering alcohol, sedation with propofol was given to prevent the feeling of pain and movement during injection. He was turned to supine after cleaning and dressing of the injection site of the skin.\nWhen he was transferred to the pain and palliative care service back, it was noticed that he had bilateral motor weakness and sensorial deficit in both legs. On consultation with neurologist, intravenous steroid, oral vitamin B and anti-aggregates were started.\nThe motor block began to improve the next day. The motor strength was assessed as 4/5 in the right leg, 3/5 in the left, and there was patchy sensorial deficit in both proximal part of the legs. The sensorial examination was normal in other dermatomes. The thoracolumbar diffusion magnetic resonance imaging revealed spinal cord ischemia between the corpuses of vertebra T8 and L1 ().\nHe had no epigastric or back pain due to his cancer anymore and was integrated into a physiotherapy program. He was able to walk with a walker one month later, but had still a bladder catheter due to neurogenic bladder which was changed to clean intermittent catheterization at the second month. The motor and sensorial deficits were almost completely resolved at the end of the third month. The patient died because of tumor progression and metastases at the fourth month at home. |
The patient was a 51-year-old man who presented to the Emergency Department with hematemesis. His past medical history was unremarkable and he took no drugs. Physical examination revealed normal vital signs. On abdominal examination, the patient had no masses, muscle guarding, or rebound. Complete blood count revealed anemia with hemoglobin of 9.2. C-reactive protein (CRP) was normal, and the remainder of the serologic and immunologic workup was within normal limits. Gastroscopy revealed a submucosal-like tumor on the posterior wall of gastric angle with superficial ulceration (). There were blood clots on top of the tumor, but no active bleeding existed; therefore we did not perform endoscopic hemostasis technique. Computed tomography indicated a tumor measuring 65 × 50 mm in the stomach, which was suspected to have invaded into the pancreas, but no metastatic lesions were detected (). Magnetic resonance imaging also revealed a mass, having a high signal in the diffusion-weighted image (DWI) in the stomach, and the mass was also growing into the pancreas. At first, we considered the tumor as a malignant submucosal tumor such as GIST in the stomach or NET in the pancreas. General condition after hospital admission was stable, so we decided to perform an operation on suspicion of submucosal tumor, originating in the stomach or pancreas. During the preoperative period, massive hematemesis occurred with bright red blood with hemostatic shock. Emergency distal gastrectomy, distal pancreatectomy, and splenectomy were performed. The resected specimen consisted mostly of a hematoma and some vessel wall but did not have any malignant cells (). We checked preoperative CT angiogram retrospectively and it indicated dissection of common hepatic artery as well as aneurysms of the common hepatic artery (maximum diameter, 8 mm) and bilateral renal artery (maximum diameter, 5 mm) (Figures , , and ). The tumor was close to splenic artery; therefore he was diagnosed with vessel rupture of splenic artery causing retroperitoneal hemorrhage and a hematoma that penetrated into the stomach.\nOn postoperative day 21, he exhibited peritoneal irritation in the form of a rigid board-like abdomen with shock vital signs. Emergency CTA showed a dissection and vessel rupture of aneurysm of common hepatic artery, causing intra-abdominal hemorrhage, so he underwent emergency coil embolization (Figures and ).\nFollow-up was done every 6 months, and CTA one year after the first operation indicated the aneurysms (maximum diameter, 5 mm) of the bilateral renal arteries remained. |
A 9-year-old female patient reported to the orthodontic clinic with a chief complaint of unesthetic appearance due to the presence of a single large upper front tooth. Medical and dental history revealed that she was born full term and had no history of any tooth loss due to caries or trauma. Extraorally, the patient had dolichocephalic, symmetric face with harmonious facial thirds []. The central portion of the upper lip was high with an indistinct philtrum which is characteristic of SMMCI syndrome. On profile examination, the patient had a convex profile with a decreased nasolabial angle and a retrognathic chin.\nOn intraoral examination, the patient was in a mixed dentition stage with one large maxillary central incisor situated exactly in the midline []. Maxillary and mandibular arches were symmetrical with angles Class I molar relationship. The patient had a V-shaped palate and marked midpalatal vomerine ridge. The labial frenulum of the upper lip and incisive papilla were absent. A periapical radiographic examination showed a central incisor having only single root canal [].\nClinical and radiographic examination both confirmed that the child had a symmetrical permanent solitary maxillary central incisor. No caries lesions or restorations were present. The nasal cavity was narrow with slight asymmetric nasal septum which is characteristic of SMMCI syndrome. In terms of other syndrome-associated anomalies, the patient had no intellectual disability or any other developmental anomalies.\nAs the main concern of the patient was esthetics, the only way to achieve this in patients with SMMCI is to provide space for the second central incisor. At appropriate age, space can be created by an orthodontist using expansion appliance to widen the palate, thus providing sufficient space for the SMMCI tooth to be moved to one side of midline and creating space for contralateral missing central incisor to be replaced with prosthesis. After creation of space, the incisor may be replaced using fixed prosthodontic rehabilitation. Among the fixed prosthodontic treatment, options are single-tooth implant, Maryland retainers and bridge. Fixed partial dentures/bridge are not indicated in adolescents. A single-tooth implant is also not indicated unless alveolar growth is complete as it may result in implant position which is different from adjacent normal teeth which keep on growing in adolescents. Maryland retainers with minimal tooth preparation can be used in such cases but are often associated with fracture and failure. A modified removable orthodontic retainer with artificial central incisor is the easiest treatment option available till the time growth is complete and an implant or bridge can be used. After completion of growth (17–18 years of age), SMMCI tooth can be recontoured using a labial veneer to create the anatomical form of appropriate size and shape along with prosthodontic rehabilitation of missing teeth. |
The patient is a 29 year old lady, married and house keeper .she came to our office with an erythematous nodule on back of her right hand and multiple painless subcutaneous nodules that are in linear pattern spread toward the elbow. The patient had a precedent history of a penetrating injury When she was cleaning the fish tank in her house (one centimeter length) just at the site that first nodule appeared. One week later she developed local redness with linear spread toward the elbow at the same hand. She received 200 mg Doxicycllin per day for 14 days. Although redness decreased but nodules size did not have any changes and after that multiple subcutaneous nodules appeared (). In physical examination her general condition was good, vital signs were stable and had not any significant problem but in her right hand in 3rd metacarpofalingial region had a 1 cm superficial wound with an erythematous nodule and multiple satellite papules around it. There were 7 non tender approximately 1.5 cm nodules between wrist and elbow. There were no epitrochlear or axillary lymphadenopathy. She had complaint about itching at the wound site.\nIn past medical history she had cesarean section 7 month ago and hypothyroidism since one year ago that she was on levothyroxin. She had not significant diseases in her family history. On laboratory investigations, the blood, urine and stool were all within normal limits. Gram staining and smear for Leishman-Donovan bodies was negative. Hepatitis B surface antigen and HIV screening were negative and PPD test was positive (20 mm). Chest X-ray was normal. In Gram Stain Gram positive bacilli was seen with many PMN and in Ziehl Nellson Stain Few Acid fast Elements were seen. Microscopy and direct KOH test for fungal spores were also negative. Bacterial culture of blood and wound secretion also had not any significant data. Histopathology of skin revealed acanthosis of the epidermis with dermal lymphocytic infiltrate and few Langhan’s giant cells while fine needle aspiration cytology showed a tuberculous picture. Diagnosis was M. marinum lymphangitis and the patient were treated with the following medications; Ethambotul 800 mg/daily, Rifampicin 600 mg/daily and Doxicycllin 100 mg/bid. After four month patent had not any sign and symptom and treatment were discontinued after 6 months. |
This case is of a 27-year-old African American, right hand dominant male professional basketball player who experienced right middle finger pain and swelling after an injury during competition several days prior. He said he was attempting to grab the ball away from an opponent when he got tangled up and experienced blunt trauma to his hand. He immediately felt a sharp pain. He denied obvious dislocation or deformity of his hand. Since that time he said the swelling and pain have persisted and he rated it a 6/10 in severity. He admitted to a snapping sensation at his knuckle with flexion of his finger. He tried ice and anti-inflammatory medication with some relief. He denied numbness and tingling of his hand. He denied loss of strength but had limited active range of motion with flexion of his middle finger of his right hand. His team’s athletic trainer had placed him in a splint to limit flexion so that he could continue to play basketball as his team was attempting to make the playoffs. He denied significant past medical history. He has had a sports hernia surgery several years ago but denied other surgeries. He has injured his other hand before and said this is similar. At that time, he was told he had a sagittal band rupture which was managed non operatively. His mother, father and one brother are living and healthy. He denies tobacco or recreational drugs and drinks socially.\nThe initial differential diagnosis for an acute athletic finger injury includes fracture and flexor or extensor injuries such as sagittal band rupture, jersey finger, mallet finger, and boutonniere deformity.\nThe workup and treatment of the player included immediate evaluation from the athletic training staff. Radiographs were obtained and negative for osseous abnormalities. He continued conservative management and finger extension splinting to limit the amount of flexion. The goal of the splint was to allow maximum 30 degrees of flexion at the metacarpophalangeal (MCP) joint. He underwent physical therapy and at two weeks his motion was improved and did not experience the snapping sensation anymore. He was able to continue to compete with his splint. Figures - demonstrate the extension splint used to limit MCP flexion. Figures - were taken during follow up and demonstrate increased motion without reported snapping sensation. Swelling is still pronounced and middle finger MCP prominence is demonstrated in panel E which exposes this finger to this injury most often.\nThe final diagnosis for the player based on the location of the injury, negative radiographs, and symptoms of swelling and initial snapping sensation was a sagittal band rupture. |
The patient was a 24-year-old male who experienced difficulty in walking for three months prior to our examination, and complained of dysarthria as well as diplopia. In his personal history, he had undergone laparoscopic sleeve gastrectomy surgery in the department of surgery seven months prior to our examination. At that time, he was in a state of morbid obesity, and he was 190 cm tall, weighed 170 kg, and had a 47.1 kg/cm2 body mass index (BMI). The patient had hypertension and diabetes mellitus for one year before surgery, but no medical history of alcohol addiction, hepatitis, or tuberculosis. After the initial surgery, he had to undergo additional surgery twice due to leakage of gastroesophageal anastomosis. However, the leakage was continuous, so total parenteral nutrition was given for approximately 60 days. Stent insertion was then performed to begin parenteral nutrition. Subsequently, the patient exhibited a confused mental state and symptoms of delirium. The severity of the symptoms was weak, and his general condition gradually improved even with conservative treatment. The symptoms of delirium were considered temporary symptoms that often appear after an operation. Therefore, the patient left the hospital.\nIn the physical examination that was performed when the patient was admitted to the hospital, he presented with alert consciousness without a sign of cognitive deficiency. At that time, his weight was 110 kg, which was 60 kg lighter than before the operation, and his BMI was 30.5 kg/cm2. Judging from these data, his morbid obesity was remarkably improved. Sensory examination was normal both for superficial and deep sensation. However, as a result of a Medical Research Council of Great Britain (MRC) examination, it was found that the muscle strength of both arms and legs appeared to be at a level of 4-4+/5, showing slight muscle weakness. Dysmetria was observed in both hands and feet, which was more serious on the left side of his body compared to the right side. It was impossible for the patient to sit down, stand, or walk independently due to weakness and dysmetria. In addition, he needed assistance in most aspects of the functional evaluation of the activities for daily living. In particular, he showed serious restrictions of delicate actions such as those required for writing a letter. Furthermore, he showed severe dysarthria, and consequently was diagnosed with severe ataxic dysarthria in a speech evaluation. However, signs of dysphagia were not clinically observed, and the patient had normal findings in a video-fluoroscopic swallowing study as well. He complained of diplopia, but there was no restriction of extraocular movement. Left and right horizontal nystagmus was observed in the horizontal gaze, while there was no up and down vertical nystagmus in the upward gaze.\nThiamine levels slightly reduced to 15 nmol/L (20-50 nmol/L) in a blood test. HbA1C (Hemoglobin A1C) was 5.8%, blood sugar levels two hours after a meal were 208 mg/dl, and blood sugar levels with an empty stomach increased to 126 mg/dl. There were no other abnormal findings in the blood test. No specific lesion was observed on magnetic resonance images or angiography that could explain the symptoms (), and the nerve conduction study (NCS), needle electromyography, and somatosensory evoked potentials study were normal.\nAlthough normal findings were seen with neuroimaging and blood tests, the patient showed typical signs of Wernicke's encephalopathy, including ataxia, nystagmus, and diplopia. Furthermore, because he had a medical history of gastrectomy and long-term total parenteral nutrition, we began to administer thiamine immediately. Intravenous 100 mg/day thiamine was administered for 10 days, and then changed to oral administration. One to two days after the start of intravenous administration of thiamine, the patient could stand by himself. One week later, diplopia and nystagmus disappeared, and he could walk a short distance with minimal assistance. After the eighth day of being hospitalized, physical therapy, occupational therapy, and speech therapy were carried out in the department of rehabilitation medicine. As a result, the muscle strength of his limbs and the fine movement of both hands gradually improved. On the tenth day, the muscle strength of the patient's limbs fully recovered to the normal range, and he could do most activities of daily living (ADL) without assistance. On the 30th day after being hospitalized, there remained a slight crawling movement when he walked by himself. Nonetheless, his endurance improved enough to walk more than 20 minutes at a speed of 2.5 km/hour on a treadmill. In addition, handwriting became almost normal. With continuous speech therapy, ataxic dysarthria also improved to a slight case from a serious case. Finally, he was discharged from the hospital. |
A male patient aged 46 years old visited the hospital due to pain in the right buttock and the inguinal area while standing up from a chair. Under the suspected condition of bursitis of the hip, nabumetone (1,000 mg/day) was orally administered to the patient for 2 weeks. However, the pain was not relieved and the symptoms deteriorated upon weight bearing. The patient experienced a limping gait 10 days after symptom expression and depended on a wheelchair. The patient had no previous history of trauma and had been taking medication due to hypertension for 5 years. The patient was relatively healthy except for smoking one pack of cigarettes a day and drinking 3 times a week. During a physical examination conducted upon hospitalization 2 weeks after expression of symptoms, no muscle weakness of the bilateral lower extremities was observed in manual muscle testing (MMT). Limited range of motion of the right hip joint due to pain, a positive right Patrick sign, and pain in the right inguinal area and the buttock were observed. Meanwhile, normal findings were observed in the deep tendon reflex of the lower extremities and the straight leg raising test. In hematologic tests, erythrocyte sedimentation rate was 11 mm/hr (normal range, 0-22), and C-reactive protein was 0.62 mg/dl (normal range, 0.00-0.50). When hip joint MRI was performed, the joint space of the bilateral hip was shown to be maintained, and a lesion, which showed patch low signal intensity with unclear border in a T1 weighted image and non-homogeneous high signal intensity in a T2 weighted image, was found across the right femoral head and neck (). In addition, the joint surface of the femoral head was shown to be maintained, and no circular band of the bone marrow of the femoral head, which is shown in avascular necrosis, was found. In a bone scan test, avascular necrosis was ruled out due to the increased uptake of radioisotopes in the bone marrow of the femoral head. After being diagnosed with transient osteoporosis of the hip, nabumetone administration (1,000 mg/day for 15 days) was discontinued. Subsequently, a single dose of zoledronate (5 mg) was intravenously infused for more than 15 minutes. Weight bearing was minimized by using crutches and a wheelchair. Hot pack, ultrasound, and interferential current therapies were performed on the hip. Normal gait was achieved one week after the treatments. No pain was observed upon weight bearing despite a slight pain in the inguinal area 2 weeks after treatments. However, the patient was asked to use crutches for an additional 2 weeks to minimize weight bearing on the hip joint. No pain in the inguinal area and no pain in the hip joint upon weight bearing were shown 4 weeks after treatments. When MRI was taken 6 months later, previous abnormal findings were completely resolved and no clinical recurrence was found (). |
In October 1983, a 16 year old male basketball player presented to another hospital with a 1 month history of paresthesiae of the index and long finger of the right hand. The patient was diagnosed with tendinopathy of the wrist extensor tendons, and managed for 2 months with physiotherapy, anti-inflammatory drugs and rest. In January 1984, the young athlete presented to the emergency room of our hospital with persistent neck pain after twisting his neck during a basketball game. His initial examination showed contracture of the cervical paravertebral muscles. Neurological examination was unrewarding. Radiographs showed an osteolytic area of the sixth vertebra of the cervical spine (C6) (Fig. ). Myelograms showed compression of the cord. A CT scan showed a mass involving the right side of the vertebra including the body, the lamina, and the lateral mass with its joint. The patient was immobilized in a halo cast, and referred to the senior author (V.D.), who performed a surgical resection of the mass through a staged anterior and posterior approach.\nThe first stage was performed with a posterior approach with the patient prone. At surgery, the tumour was removed posteriorly. The tumour involved the right side of the vertebra including the body, the lamina, and the lateral mass of C6. An intra-operative biopsy was performed, and a histopathological diagnosis of osteosarcoma was formulated.\nA wide resection of the mass was performed. A Roy Camille plate was used on the left side, which was free of tumour. A non-instrumented fusion was obtained on the right side with a bony bar harvested from the ipsilateral iliac crest. The bar was secured by screws onto the lateral articular masses of C4 and T1.\nTwo weeks after the first procedure, the patient underwent a further operation through an anterior approach for complete removal of the neoplasm and fusion. A complete excision of the anterior portion of the vertebral body was performed. After wide resection, the body was reconstructed anteriorly with an iliac crest autograft and a plate with screws (Fig. ).\nThe patient was immobilized in a Halo cast for 4 months, followed by a SOMI (Sternal Occipital Mandibular Immobilizer) brace for 1 year. After surgery, the patient underwent radiotherapy (40 applications). Recovery was uneventful, and the patient returned to his activities of daily living, and qualified as a surveyor. He returned to play competitive basketball in 1989 for 2 seasons.\nIn 1993, the patient started to complain of mild dysphagia, but all the physicians attributed this to post-surgery and post-irradiation adherences.\nIn July 1998, the patient underwent fluoroscopy for the diagnosis of the dysphagia, showing the second screw of the anterior plate being partially extruded (Fig. ). One month later, in August 1998, the patient complained of complete inability to swallow. Radiographs showed the absence of the mobilized screw in the anterior plate (Fig. ), and the screw migrated in the colon (Fig. ). The patient underwent a colonoscopy, but the endoscopist was not able to remove the screw. Two days after the colonoscopy, the patient eliminated spontaneously the screw through the intestinal tract.\nThe patient underwent a first operation for removal of metal work through the same right pre-sternocleidomatoid approach in another hospital. During the operation, removal of the plate was not possible for the presence of much post-surgery and post-irradiation fibrosis.\nIn February 2001, the patient underwent a second operation for surgical removal of metal work through a wide U approach with an ear, nose, and throat surgeon in the same hospital, but it was only possible to remove 1 screw (Fig. ). During surgery, a tracheostomy was performed, and closed after 2 weeks.\nThe patient continued to complain of dysphagia for 1 year, and he lost 15 Kg. In January 2001, the patient returned to the senior author, weighing 45 Kg. The patient underwent total parenteral nutrition for 5 months, and returned to his normal weight of 60 Kg.\nOn July 1st 2001, the patient underwent a third operation, this time performed by the senior author, with another ear, nose, and throat surgeon to tackle any intra-operative oesophageal injury. During the operation, no signs of oesophageal perforation became evident. At surgery, much fibrosis was found. To reach the vertebral plane, MESNA (sodium 2-mercaptoethanesulfonate) (Uromitexan, Bristol) was intra-operatively applied on the fibrous tissue to ease tissue dissection. A modified dissector was used to release the drug locally []. Duration of local application was about 20–30 s; repeated applications were performed during surgery. Average volume of agent used was about 10cm3.\nRemoval of the plate proceeded uneventfully, and a suction drain was left in situ after the procedure. The patient was immobilized in a Philadelphia collar for 2 months. Post-operative recovery was uncomplicated.\nAt 24 year from the first operation, the patient is symptom free. When last reviewed in October 2008 (Fig. ), he had no disability, scoring 0 on the Neck Disability Index []. |
A 41-year-old male patient, with progressive abdominal pain during the previous 48 hours, was admitted to the Department of General Surgery, the Second Affiliated Hospital of Nanjing Medical University. No fever, nausea, vomiting, melena and jaundice were observed during the period. He had a history of subtotal gastrectomy with Billroth II reconstruction for perforation at the site of the duodenum and a mass near the lesser curvature of the stomach at the other hospital. Pathological and immunohistochemical examinations of the excised specimen () revealed that the mass near the lesser curvature of the stomach was poorly differentiated gastric NETs (type III). Serum gastrin content was normal and Zollinger-Ellison syndrome was excluded. The perforation was due to duodenal ulcer rather than a malignancy. The patient was examined regularly with abdominal CT for 2 years after the operation, but no metastasis was detected during the period. No further follow-up was performed during the subsequent 2 years. The patient visited our hospital for sudden abdominal pain and vomited one years ago. CT scan revealed multiple liver metastases located at both the left and right lobes of the liver with coeliac lymph node enlargement. Meanwhile, serum gastrin content was still normal. Owing to the widespread metastasis, liver metastases were treated through trans-arterial chemoembolization (TACE) with 5-Fu 0.5 g, epirubicin 20 mg, and cisplatin 40 mg combined with lipiodol four times rather than surgery. Two courses of intravenous chemotherapy at the Department of Oncology with irinotecan 100 mg and cisplatin 40 mg were given to him owing to elevated serum neuron-specific enolase (NSE) levels. He was discharged from the Department of Oncology when the level of serum NSE returned to normal, which was also allowed by his general state of health.\nOn his arrival at the hospital, he was previously misdiagnosed as intestinal obstruction or acute pancreatitis considering that his vital signs were normal except for a poor mental status. A gastrointestinal decompression tube was immediately filled with about 400 mL black gastric juices that drained out of the stomach. Plain X-ray of the abdomen revealed little free gas in the subphrenic spaces (). Abdominal CT scan showed some free gas in the subphrenic spaces, inhomogeneous iodized oil on the liver and multiple enlarged lymph nodes near the abdominal aorta (). We scheduled laparoscopic exploration in view of the perforation. Hepatomegaly and edema of the small intestines combined with extensive adhesions in the peritoneal cavity were observed. After careful separation of the adhesions, laparoscopic exploration revealed a perforation of 1.5 cm in diameter at the site of previous gastroenterostomy. Gastric juice along with food debris could be seen coming out from the site of perforation when we were conducting the operation. Based on these findings, we decided to close the perforation site directly through the open operation rather than laparoscopic exploration because of severe intra-abdominal adhesions. We successfully repaired the perforation and a drainage tube was placed. The patient had a relatively uneventful recovery except slight intestinal tympany. He was discharged from the hospital 15 day after surgery based on his condition and he remained alive after two months of follow-up. |
A 30-year-old pregnant Caucasian female complaining of severe anal pain and an anal bump was referred to the Colorectal Surgery Office by her primary care physician. She was 8-week pregnant. Her pain started a few days earlier and she noticed a small amount of bright red blood on the toilet paper and coating the stools. She had been constipated. She stated the pain was worse during and after defecation. Her medical history was significant for irritable bowel syndrome, recurrent oral ulcers, and anal pruritis. She denied abdominal pain, nausea, or vomiting. Her family history was significant for inflammatory bowel disease in her maternal relatives. She denied any history of anal intercourse or instrumentation.\nUpon examination there were no significant physical findings with the exception of what appeared to be an atypical fissure with heaped up skin edges and ulceration in the center in the left posterior position. A local block was placed and a steroid injection was performed. Topical lidocaine mixed with diltiazem and high fiber supplementation were prescribed.\nHer pain transiently improved but upon repeat examination two weeks later she was having recurrent pain and there was no change in the appearance of the fissure. She was admitted for pain control, an examination under anesthesia, and a flexible sigmoidoscopy. The differential diagnosis upon admission was new onset Crohn's Disease or a severe anal fissure. Upon admission, her vitals were normal and anal inspection revealed two large skin tags. A digital rectal exam could not be done secondary to severe tenderness. Labs showed normal serum electrolytes, WBC 3900, platelets 133000, Hb 11 g/dL, Hct 31.5, and MCV 91.\nShe was taken to the operating room and examination demonstrated a large deep anal canal ulcer in the left posterior-lateral position (). No obvious fistula or abscess was identified. A sigmoidoscopy was performed and revealed numerous aphthous erosions involving the mucosa of the rectum and sigmoid colon, which appeared consistent with inflammatory bowel disease. The proximal colon was not evaluated endoscopically. Biopsies were taken from the anal ulcer and rectosigmoid mucosa (). An additional steroid injection was given into the ulcer bed. She was discharged home that day and was to follow up the following week.\nIn the following few days, the results of the peripheral blood smear and pathology returned. The smear contained 5% blasts. The biopsy from the anal ulcer depicted squamous mucosa with ulceration and submucosal atypical hematopoietic cell infiltrates suggestive of acute leukemia. Similar findings of discrete mucosal and submucosal aggregates of atypical large and medium-sized hematopoietic cells were noted on rectal biopsies. She was immediately readmitted and a bone biopsy was performed. Her results with flow cytometry showed hypercellularity with 53% blast cells. The abnormal cells were positive for CD13 (58%), CD33 (73%), CD15 (59%), CD45, CD34, CD64, CD4, HLA DR, and MPO markers consistent with acute monocytic leukemia (FAB M5b). Refer to Figures , , and . Subsequent cerebrospinal fluid analysis also showed 30% blasts on flow cytometry. Her cytogenetic evaluation revealed an abnormal female karyotype with Inv (16) (p13q22), and Trisomy 8 and 22.\nShe was diagnosed with acute myeloid leukemia and started on high-dose Idarubicin and cytarabine for induction chemotherapy. Intrathecal methotrexate was also given as there was evidence of central nervous system disease. Her pregnancy was terminated therapeutically before the chemotherapy was started. A repeat bone marrow biopsy nine months later after completing chemotherapy did not show any atypical cells. She clinically has no evidence of disease at this time. |
We report the case of a 63-year-old man who presented to our emergency department with bilateral inferior limb numbness and weakness, mainly to the left leg and complaining of bladder retention. Neurological assessment revealed a 1/5 monoparesis of the left inferior limb and 3/5 monoparesis of the right, as well hypoesthesia and dysesthesia in the same region. Perineal reflexes were absent. The patient was on anticoagulants.\nThree weeks prior to the onset of neurological symptoms, the patient underwent percutaneous VP of L1 and L3 vertebrae, in an oncology institute, for pathological compression fractures, due to secondary localization of a retroperitoneal myxoid liposarcoma, removed several years before. VP was indicated by an oncologist and performed at the above-mentioned institute of oncology. Pathological anamnesis revealed that the patient underwent surgery several times for the removal of a retroperitoneal liposarcoma. In 1997 the patient underwent the first surgical procedure for the removal of the lesion located in the upper left quadrant of the retroperitoneal space. During the same procedure, the left colon was also removed. In 2004 a second surgical procedure was performed for the removal of a local relapse of the lesion as well as for the removal of the spleen. In February 2005 a follow up abdominal magnetic resonance imaging (MRI) showed the presence of another local relapse of the pathology. In consequence, another surgical excision of the lesion was performed, including excision of the pancreatic tail. The procedure was proceeded by the administration of a chemotherapeutic protocol consisting of Antracicline and Ifosfamide. In November 2011 another surgical excision was performed. It included the left part of the diaphragm as well as a portion of the small intestine and the left half of the transverse colon. Furthermore, on November 2013 the patient underwent cyberknife radiotherapy.\nUpon admittance at our emergency department for paraparesis, an emergency spinal MRI with gadolinium was obtained. Results showed the presence of a high signal lesion in the intradural extramedullary space, at the conus medullaris (Figure ). Furthermore, the trajectory of the needle used to perform the vertebroplasty was detected at L1 and L3 levels and it suggested that the needle had passed through the dura into the subarachnoid space and then into the vertebral body (Figure ). An emergency decompressive bilateral laminectomy of L2 and L3 vertebrae was performed. No epidural bleeding was observed. A longitudinal durotomy revealed a blood clot, tightly adherent to the cauda equina rootlets (Figure ). The hemorrhagic lesion was completely removed with the assistance of a surgical microscope (Figure ). After the procedure, neurological symptoms progressively disappeared and 5 d later, the patient completely recovered both motor and sensory deficits, as well as bladder functions. Postoperative MRI documented adequate surgical decompression and removal of the intradural lesion (Figure ). Histological examination confirmed the haemorrhagic origin of the lesion, constituted by clots and fibrin, with no evidence of tumor. |
A 76-year-old man was referred to our facility from his family dentist after two cystic lesions were identified in the right mandible. Panoramic radiography revealed two radiolucent areas at premolar and angle regions of the right mandible (). Cone-beam computed tomography (CBCT) revealed two defects of the cortex on the lingual aspect of the mandible (Figures –). No discontinuity or erosion was seen in the lingual cortex. On intraoral view, the overlying mucosa of the oral floor was normal (). The outflow of saliva from the right sublingual caruncle was scarce, with no discharge of pus. Slight induration was evident when palpating the right floor of the mouth in the premolar region. The tongue showed normal mobility. Magnetic resonance imaging (MRI) with gadolinium contrast showed that both bone cavities were filled with soft tissue. Soft tissue in the mandibular angle seemed to be part of the submandibular gland (). In the premolar region, the soft tissue in the cavity showed identical signals to that of the right sublingual gland (). The right sublingual gland was mildly enhanced compared to the left sublingual gland. On the basis of these clinical and imaging findings, posterior SBD for the bone cavity in the mandibular angle was diagnosed and the decision was made to provide conservative follow-up by radiographic examination. However, as for the premolar region, not only anterior SBD, but also sublingual sialadenitis was suspected. In addition, sublingual gland tumor could not be completely ruled out. Surgical resection to the soft tissue in the cavity of the premolar region was therefore performed under general anesthesia, including the right sublingual gland. Intraoperatively, intrusion of a sublingual salivary gland into the cavity was seen (). No adhesion between the sublingual gland and bone was identified (Figures and ). The pathologic diagnosis was salivary gland with chronic inflammation. Histopathological examination revealed expansion and duct, expansion or atrophy of the acinus in comparison with the acinus to be normal, retention of mucus, and infiltration of lymphocytes into the sublingual gland (). Based on these findings, a definitive diagnosis of anterior SBD was made for the lesion in the premolar region. The postoperative course was uneventful, and no functional disturbance has since been observed. |
A 31-year-old female patient was referred to our general surgical unit by a general practitioner with a large, painless right-sided breast mass which had been growing slowly for the last 10 years. She presented with an ulcer on the same breast that began as a hot porridge scald burn 15 months before. The ulcer had since increased in size and become fungating. During her childhood, she had been of the same stature as her peers. However, her growth had started to lag around the age of 5 years. Around the same age, she had noticed small nodular growths which had begun to appear on the fingers of her right hand as well as angular deformity of the right upper limb and right lower limb. A few months later, she sustained a fracture of her right tibia after a trivial fall as well as another pathological fracture a year later at the shoulder region. Over the rest of her childhood and adolescence, her limb deformity worsened. She was otherwise in good general health. She was right-handed however, the hand deformity did not prevent her from using that hand for daily tasks or writing. She was also able to walk, albeit with a limp and she reported a minimal effect on her work as a subsistence farmer. She had no history of oral contraceptive use and had experienced menarche at the age of 14 years. There was also no family history of breast neoplasms. None of her 5 siblings nor her parents or grandparents were affected by a similar condition of the limbs. Apart from this, her drug, family and psychosocial histories were non-contributary.\nExamination revealed a well-circumscribed, irregularly shaped, firm, mobile breast mass, approximately 15 cm in its transverse diameter and 20 cm in its superior/inferior diameter replacing >90% of the normal breast tissue. There was associated solitary, mobile ipsilateral lymphadenopathy. There was a superolateral fungating ulcer which was friable and surrounded by inflammatory skin changes and downward nipple displacement (). She was of short stature (149.5 cm), with unilateral distribution of bony abnormalities on the right side. She had irregular angular deformity and limb shortening (A and B) of the upper and lower limb, causing a limp favouring the right side as well as shortening and deformity of the thumb and index finger (C) with associated nodularity. She had no facial dysmorphic changes. She also had a pedunculated, soft hyperpigmented mass on the anterolateral abdominal wall, which was 2 × 2 cm in size (A).\nA core needle breast biopsy revealed findings consistent with a tubular adenoma. Because of the breast ulceration and solitary ipsilateral lymph-nodes considered to be suspicious for malignancy, two repeat core needle biopsies were performed and examined by independent pathologists which both confirmed the initial result. The patient was prepared for theatre. Preoperative assessment included a skeletal survey.\nRadiographs of the right hand revealed multiple enchondromas in the phalanges and metacarpals (A), as well as in the long bones confined to the right side, (B–E). Typical “ring and arc” chondroid type calcifications were associated with these lesions. Multiple well defined calcified phleboliths were identified within the soft tissues, and these were indicative of associated haemangiomata. The radiographic abnormalities were deemed classical for Maffucci’s syndrome\nA simple mastectomy was performed for removal of the mass because almost the entirety of the breast tissue was replaced by the tumour. Two enlarged lymph nodes were noted and also removed. The procedure was performed by a junior resident with 4 years of specialised training under the supervision of a qualified, experienced surgeon. Her post-operative course was uneventful, she did not experience any complications of surgery. The mastectomy specimen was submitted for pathological examination. Her pedunculated abdominal skin lesion was also removed and sent for pathological examination as well as core biopsies of the cystic bony masses noted on x-ray.\nPathological examination of the mastectomy sample revealed a large, well-circumscribed breast mass with a well-defined capsule (A). The tumour was 18 cm × 15 cm × 10 cm with minimal, compressed normal breast tissue adjacent to it. The tumour was composed of lobules of bland tubular glands lined by two layers of cells with a surrounding capsule. The trabeculae were dense and fibrous with focal calcifications (A). The overlying skin was ulcerated with an associated dense mixed inflammatory infiltrate and focally acantholytic epidermis. A diligent search was made throughout the tumour for malignancy but none was found. Of the lymph nodes sampled, none showed any tumour, and all showed follicular lymphoid hyperplasia. Pathological examination of the skin lesion (B) noted a dermal lesion composed of cystically dilated blood vessels with marked congestion, thrombosis and focal calcification in keeping with a cavernous haemangioma. Core bone biopsy of the bony lesions noted lobules of benign cartilage encased by spongy bone marrow consistent with enchondroma with no evidence of malignancy seen (B).\nGiven the above pathological features, a final diagnosis of Maffucci’s syndrome with giant tubular adenoma was made. The patient did not wish to have surgery of her bony deformities for cosmetic or functional reasons. Her primary concern had been the large breast mass which had attracted stigma from members of her community and we achieved a high degree of patient satisfaction. On 1-year follow-up, the patient is free of malignant disease and had experienced no postoperative complications. A plan was made for surveillance every year with clinical examination for early detection of occult malignant tumours. A timeline of events is provided in . |
A 34-year-old female was seen in our outpatient clinic in November 2008 for assessment of bilateral hip pain. Her pain began in July 2008, during the end of her first pregnancy, which required an expedited delivery by caesarian section due to the development of eclampsia. She received two intramuscular injections of 12 mg of betamethasone (prednisone equivalence of 75 mg) over a 48 hour period for fetal lung maturity prior to delivery. Her pain developed immediately following the delivery, two days after receiving the first injection. She subsequently developed hip pain, worse on the left side, which was progressive in nature and radiated down her anterior thigh and knee. It was aggravated from weight bearing, with her functional status limited to walking the length of her driveway.\nHer past medical history was significant for hypothyroidism and bilateral ACL reconstruction. She was taking Synthroid and reported no allergies.\nOn examination, she had a notable antalgic gait favouring the left side, with one centimeter of shortening. Range of motion of the left hip was limited from 0-80 degrees of flexion, 0 degrees of internal rotation, and external rotation and abduction to approximately 20 degrees. The left knee exam was normal. The right hip had mild discomfort with full range of motion, aside from a mild decrease in internal rotation.\nRadiographs of the left hip showed collapse and sclerosis of the femoral head with preservation of the joint space, while x-rays of the right hip were unremarkable (Figure ). An MRI of the left hip showed significant osteonecrosis with collapse of the femoral head and abnormal articulation (Figure ). The MRI of the right hip revealed a small area of osteonecrosis in the superolateral head with no collapse. This imaging was in keeping with Ficat Grade 4 osteonecrosis on the left and Grade 2 on the right [].\nGiven her symptoms and degree of immobility, it was recommended that a hemiarthroplasty be performed. This was performed in April 2009 using an Accolade 2.5-132 femoral press fit prosthesis, a minus 4V collar, and with a 49 mm unitrax unipolar ball (Stryker). In addition, debridement of the labrum was performed. She tolerated this procedure well, and there were no complications (Figure ).\nUnfortunately, she presented one year later with recurrent bilateral hip pain, again left worse than right, which was activity related and radiated to her knees. She was taking Meloxicam and regularly attending physiotherapy. On examination, she had symmetric range of motion of both her hips, with no limitations in internal or external rotation. However, she experienced deep anterior pain in her left hip with terminal flexion.\nRadiographs performed at this time demonstrated no interval changes on either side. The stem on the left side did not show any signs of osteolysis, although clinical impression was consistent with arthritic changes over the acetabular side of the left hip. It was recommended that she undergo conversion to a total hip arthroplasty. This was performed in June 2010 using a 48 mm Stryker Trident PSL acetabular component with an X3 28 mm liner and L-fit 28 mm head (Figure ).\nSince her total hip arthroplasty, she has experienced significant improvement in her hip pain bilaterally. Radiographs taken in 2015 at her 5-year follow-up demonstrated the components to be in proper position on the left side (Figure ) and preserved femoral head shape. Minimal degenerative changes in the right hip with no advancement of collapse were seen on MRI performed at the same visit (Figure ). |
In this case presentation, approval from the Nagasaki University Hospital review board was not required and written informed consent was obtained from the patient for publication of this case report.\nA 30-year-old woman was referred to the department of special care dentistry at Nagasaki University Hospital for dental treatment because she had experienced frequent episodes of nausea and unconsciousness during dental treatment after the administration of widely used amide-type local anesthetics at dental clinics. When the patient visited the department of special care dentistry at the Nagasaki University Hospital, a medical examination and screening test were required to identify an available non-allergic local anesthetic through the algorism of clinical guidelines for patients with a history of allergic reactions because the possibility of allergic reaction to local anesthetics could not be completely ruled out. However, as she refused to undergo screening tests using any of the amide-type local anesthetics she had been administered previously, procaine hydrochloride, which is an ester-form local anesthetic, was the only agent tested on her at the department of dermatology. At the completion of the test, she was informed that the test with 1% procaine hydrochloride had not shown any abnormal reaction. After obtaining informed consent, she was scheduled to undergo a drug challenge test using minimum test dose (0.1 mL) for gingival mucosa and dental treatment using 1% procaine hydrochloride under careful monitoring of vital signs.\nBecause of the lack of commercially available prefilled cartridges of the desired agents, we consulted with the hospital pharmacy on the method of preparation of procaine hydrochloride 10 mg/mL with 0.005 mg of adrenaline (adrenaline equivalent to a concentration of 1:200,000). As suggested by the pharmacy staff, we added 1 drop of adrenaline to 1 mL of procaine hydrochloride (10 mg/mL) using a 27-G needle to add 5 μg of adrenaline immediately before administering it. After confirming no side-effects of the drug challenge test using a minimum test dose (0.1 mL) for gingival under mucosa topical anesthesia using ethyl aminobenzoate, 5 minutes later, we provided an infiltrated initial dose of 0.5 mL of procaine hydrochloride into the gingival mucosa for resin restoration of the anterior teeth. Treatment was started after confirming the analgesic effect, and if pain was reported, an additional dose was planned to be added as appropriate. However, dental treatment was completed because the first initial dose of total 0.6 mL provided a sufficient analgesic effect.\nBlood pressure, heart rate, and arterial oxygen saturation were monitored to evaluate her overall general status during the treatment. No abnormalities of the vital signs were evident 10 minutes after inducing local anesthesia. No abnormalities were identified before the end of the treatment, and the sensation of paralysis in the anesthetized region lasted for 55 minutes. The patient was subsequently scheduled for approximately ten treatments under anesthesia with procaine hydrochloride to complete the initial treatment plan ().\nAt the 6-month follow-up of the treatment at the outpatient center of the department of special care dentistry, the patient complained of the failure to conceive as a result of the inability to use local anesthesia for possible surgical treatments. We explained the mechanisms of allergic reactions to local anesthetics and recommended that she undergo another intradermal test at the dermatology department. She understood that amide-type local anesthetics could be used for the allergic screening test because ester-type local anesthetics, such as procaine hydrochloride, which we had used, are generally considered more likely to cause allergic reactions based on medical reports.\nOne year after the initial treatment, the patient requested a screening test using Patch test and scratch testing at the dermatology department of the hospital. Lidocaine hydrochloride (Xylocaine cartridge®; lidocaine hydrochloride 36 mg/1.8 mL with adrenaline [0.0125 mg/mL] 1:80,000) and propitocaine hydrochloride (Citanest Octapressin®; prilocaine 30 mg/mL with feripressin [0.045 unit]) and Methyl 4-hydroxybenzoate showed only mild erythema on scratch testing, but adrenaline did not show erythema symptoms. Therefore she was informed that lidocaine hydrochloride (lidocaine injection as a single agent) without any vasoconstrictor plus preservative or procaine hydrochloride would be safe for her. The dermatologist also pointed out that she showed hypersensitivity to pain because of vagotonia during the test.\nSeven years later, she re-visited our hospital for the treatment of pain in the mandibular right second molar. At the time, an improved form of lidocaine hydrochloride was prepared after removing the preservative methyl-4-hydroxybenzoate (methylparaben) had become available. Therefore, we conducted screening tests for four types of lidocaine hydrochloride among amide-type local anesthetics. All results from scratch and intradermal tests for lidocaine hydrochloride, except prilocaine hydrochloride, were negative. After she acquired sufficient information on the features of each agent, she opted to undergo local anesthesia using mepivacaine hydrochloride. However, infiltration of 7 mL of mepivacaine hydrochloride failed to provide a pain-free condition. After obtaining her consent, we added 2 mL of the new type of lidocaine hydrochloride (ORA injection cartridge®), allowing successful hemi-section of the mandibular right second molar. |
The second case, a 51-year-old Caucasian male, a heavy smoker, complained of abdominal discomfort and an abdominal ultrasound (US) exam performed in June 2004 was significant for a mass in the right kidney, consistent with RCC. He underwent a radical right nephrectomy that was histologically proved to be a chromophobe RCC of nuclear grade Fuhrman 4, stage T1N0. Following regular follow-up with abdominal US in December 2004, a solid mass in his left kidney was revealed, which was again consistent with RCC. He underwent a radical left nephrectomy and the lesion histologically proved to be a clear cell RCC, of nuclear grade Fuhrman 3, stage T1N0. The patient required renal replacement therapy and he started a three times weekly course of hemodialysis. In December 2009 after a regular basis follow-up with abdominal CT scan, an asymptomatic local disease recurrence at the anatomical bed of the right kidney consisting of a solid mass of 34 mm diameter with central calcification, displacing the inferior vena cava and psoas muscle was diagnosed. Sunitinib at 50 mg/day for 4 weeks with a 2-week washout phase was then administered leading to partial disease response. A radical excision of the recurrence was attempted in January 2010, however the surgical margins were macroscopically invaded by RCC. Interestingly, the lesion was histologically proved to be a recurrence of the primary chromophobe RCC. Two weeks after the resection the patient manifested a subacute left temporal-occipital hematoma in brain CT scan which was attributed mainly to a hemostasis disorder induced by the dialysis procedures. Due to postoperative residual disease the patient was treated with a second generation mTOR inhibitor, Everolimus 10 mg/day per os which led to complete response of the disease, without major toxicity. Nine years after the initial diagnosis of RCC he is disease free and leads an active life.\nThe incidence of bilateral RCC either synchronous or metachronous has been reported to be 2–13% []. Patients with RCC are in high risk to manifest a second RCC either in the affected kidney in case of partial nephrectomy or in the contralateral one []. In Rabbani’s et al. study [] the incidence of metachronous contralateral RCC was stable on long-term follow-up; however it was strikingly high during the first 5 years of follow-up.\nAlthough most RCCs are sporadic, several syndromes associated with bilateral RCC have been described [,]. Hereditary renal cancers are usually multiple, bilateral and often occur at a young age. In support of this epidemiologic observation, Klatte et al. [] reported that among patients with bilateral RCC, familial predisposition was found in 14.3% of them. Additionally, the von Hippel-Lindau (VHL) disease was observed in 4.3% of cases. In terms of pathology, the clear cell RCC typically carries the 3p deletion and is associated with VHL disease []. |
A 14-year-old female reported to our clinic with the chief complaint of painless, hard swelling in the gums in relation to the upper front teeth. The swelling was present for 4 years. The patient had consulted a general dental practitioner 2 years back. Details of the treatment availed were not available. But the patient did not notice any improvement after treatment.\nOn clinical examination, a 1 × 1 cm. swelling was noticed in the marginal and attached gingiva in relation to 21. The tooth was slightly lingually placed. Gingiva over the swelling appeared normal and was clinically devoid of inflammation []. The swelling was bony hard in consistency. Mobility was absent. Probing depth of 10 mm was observed near the distolabial line angle of 21. Intraoral periapical radiograph in relation to 21 and 11 was normal []. Orthopantamograph showed haziness between 21 and 22. Since the clinical and radiographical pictures were inconclusive, it was decided to surgically explore the site.\nBlood profile was taken prior to surgery. All the values were within normal limits. Patient was free of systemic illnesses. After obtaining written consent for explorative surgery from the patient, a mucoperiosteal flap was elevated in relation to 11, 21 and 22. We noticed excessive thickening of the labial cortex in relation to 21 extending from the mesial to the distal aspect of the tooth. The thickened labial bone was elevated from the tooth surface, but the height of alveolar bone labially was not reduced. The thickened and elevated labial cortex enclosed an intrabony defect which measured 10 mm on the William's periodontal probe []. The inner surface of the flap contained thick fibrous granulation tissue and that made the gingival over the swelling appear thick. Histopathological examination of the soft tissue and hard tissue was done and was reported as granulation tissue and as normal bone, respectively. Therefore the clinical picture was suggestive of buttressing bone formation.\nTreatment involved osteoplasty in relation to 21 to reduce the thickened labial cortical bone. Cortical demineralised bone graft (Osseo +, Imtec Corp.) was placed in the bony defect []. Prior to suturing, thick fibrous granulation tissue on the inner side of the flap was dissected and removed and the flap was sutured. Patient was recalled after 10 days and sutures were removed. The swelling had reduced but the gingiva still appeared thick over that region. Gingivectomy and gingivoplasty was done subsequently after about a month to enhance the aesthetics in relation to 21. Frenectomy was also done to correct the gingival pull. The follow-up after 3 months and 1 year showed satisfactory esthetics and no evidence of any recurrence []. |
A 63-year-old female patient was admitted to our hospital with intermittent epigastric abdominal pain for the past three months. Results of the physical examination on admission indicated no icteric sclera. The abdomen was soft with no palpable abdominal mass. The patient had experienced a weight loss of about five kg in the past two months and had no history of hepatitis B or C. She had been exposed to dogs and sheep and denied any history of exposure to infected cases from the epidemic area. After admission, CA19-9 was measured and was 796.20 U/mL. No serological examination for echinococcosis was performed because of the limited conditions of our hospital. Test results from pelvic ultrasound indicated menopausal uterus and uterine fibroids. Test results from gastroscopy showed chronic non atrophic gastritis. Colonoscopy revealed multiple polyps in the large intestine (basically removed); intestinal histopathology (cecum, biopsy) showed severe chronic inflammation of the mucosa and adenomatous hyperplasia of the individual glands. Contrast-enhanced computed tomography of the upper abdomen (Fig. A) revealed a more homogeneous thickening of the gastric wall in the antrum. Round unenhanced low-density foci with a diameter of 4.6 cm was seen in the S7 segment of the liver. Nodular calcifications were also observed. No significant dilatation was noted in the intrahepatic and extrahepatic bile ducts. The size and shape of the gallbladder were normal, the wall was not thick, and no significant abnormal density was observed in the cavity. The pancreas, spleen, and adrenal glands showed no significant abnormalities. Test results from computed tomography indicated liver cyst and intrahepatic calcifications. Contrast-enhanced magnetic resonance imaging of the liver and gallbladder (Fig. B, ) revealed a normal size and shape of the liver and proportion of each lobe, and the intrahepatic and extrahepatic bile ducts and flow vessels ran naturally. A long T1 and long T2 cystic signal with a diameter of about 4.7 cm was observed in the right lobe of the liver, with liquid level, short T1 high signal intensity in the lower layer, high signal intensity on diffusion-weighted imaging sequence, and enhancement of the cyst wall on the enhanced scan. Test results from magnetic resonance imaging showed that the space-occupying lesion of the right lobe of the liver had been considered to be more likely a hepatic hydatid cyst. Preoperatively, three-dimensional reconstruction demonstrated the location of the tumor and its relationship with the surrounding vessels (Fig. A).\nThe patient underwent laparoscopic S7 segmentectomy. Intraoperative findings showed that the tumor was located at the S7 segment of the liver and was about 5 × 4 cm in size and partially protruding from the surface of the liver, with an intact capsule and clear boundary with normal liver tissue. The tumor compressed the right hepatic vein and its tributaries and densely adhered to the right hepatic vein (Fig. B). On postoperative pathology, a mass was observed immediately adjacent to the liver capsule, with a volume of 5 × 5 × 4.5 cm. The section surface showed a brown turbid fluid, a smooth inner wall, and greyish red, greyish yellow, and soft section surfaces of other liver tissues. The pathological section showed a low-grade mucinous cystic neoplasm (volume 5 × 5 × 4.5 cm) in the S7 segment of the liver, with steatosis in the surrounding hepatic tissue area, chronic inflammatory cell infiltration in the portal area, and no tumor cell involvement in the margin of the liver resection.\nImmunohistochemistry demonstrated tumour cells CK7 (+), CK19 (+), and CEA (−); stromal cells ER (+), PR (+), α-inhibin (a small amount +), vimentin (+), desmin (+), and actin (+) (Fig. A–C). This study was approved by the Ethics Committee of Yantai Affiliated Hospital of Binzhou Medical University. |
Emergency department presentation
A 76-year-old male patient arrived at the emergency department (ED) as a transfer from an outside hospital. The patient was awake and alert but complained of fatigue and difficulty swallowing. His vital signs were normal. Upon physical examination, the patient had obvious bilateral ptosis of the eyes and diminished chest movement with respiration. Negative inspiratory force revealed an initial reading of 18 cm/H2O and a subsequent reading five minutes later of 15 cm/H2O. The patient and his family were informed of the patient’s impending respiratory failure. They agreed to the treatment plan of intubating the patient in order to protect the airway and provide ventilatory support while awaiting definitive care. He was then admitted to the intensive care unit (ICU) where his endotracheal tube was removed three days later without complication. The patient was awake and alert at the time of discharge, during which he provided further pertinent past medical history.
History of present illness
The patient presented signs and symptoms of a urinary tract infection (UTI) at a local urgent care center 24 hours before his arrival at the ED. He stated he was experiencing urgent and frequent dysuria, and lower abdominal pain. He explained that the urgent care was exceedingly busy, so the provider quickly assessed him. He was given an intramuscular injection of ceftriaxone, and discharged home with a prescription for ciprofloxacin 500 mg twice a day for seven days. The provider was treating for potential multidrug-resistant gram-negative organisms due to the patient’s previous stay in the hospital five months prior. About 15 hours after his antibiotic injection, the patient was awakened at home around 0300 by his UTI symptoms so he took the oral ciprofloxacin. He was symptom free at breakfast the next morning, but by lunchtime, he was unable to swallow his food. He recalled feeling this prior to his first acute myasthenia crisis five months ago, and immediately called his neurologist. The neurologist advised him |
A 40-year-old man presented with gastrointestinal bleeding due to esophageal varices and liver cirrhosis. Review of his records revealed that he had been diagnosed with GSD at the age of two years following a liver biopsy, when he had a distended abdomen due to hepatomegaly. He had problem with weakness from early childhood. In his childhood, he had frequent nose bleeding and easy fatigability. His growth was very slow. He was on no specific therapy and never suffered from symptomatic hypoglycemia. He went into a late puberty at about 17–18 years, but grew very rapidly and became much taller than his parents. During that period, his muscle weakness worsened and he had been in a wheelchair since he became 24 years old. His weakness in his arms also dated back to his puberty. At the time of presentation, he was unable to brush his hair and had to lean forward to eat. He had not had any heart problem. He had not had any sleep problems or chest infections. He suffered from low back pain after sleeping. His diet was high in protein with lots of meat, nuts, eggs, and yoghurt. He had never tried uncooked corn starch. GSD IIIa, for the first time, was confirmed at the age of 28 in the National Hospital for Neurology and Neurosurgery, Queen Square in London, on April 7, 2004. His parents were unrelated, alive and doing well. There was no family history of other muscle disorders. He had no other medical problems. He had normal schooling and studied engineering at university but had to stop in his 3rd year because of the weakness. He was on no regular medication. He was unable to sitting in wheelchair and needed assistance to be transferred. On physical exam, he appeared dysmorphic, thin, disable but intelligent. His vital signs, chest and heart were normal without any evidence of cardiomyopathy. Abdominal examination revealed a firm and enlarged liver, splenomegaly, and ascites. Marked proximal and distal weakness, not involving face, was detected. The patient was unable to lift his arms or legs against the gravity. No deep tendon reflexes were presented. Muscular enzymes were elevated; muscle biopsy performed at age of 30 years. Because of massive upper gastrointestinal bleeding due to grade 4 esophageal varices, ascites, low platelet count, and fatigue, despite sever muscle weakness with weight, height and BMI of 56 kg, 180 cm, and 17.2 kg/m2, LT was performed. On 28th month after transplantation, the patient had normal liver function and metabolic control without any restrictions and some weight gain up to 60 kg. However, he still had muscle weakness with elevated muscle enzymes. He was treated with prednisone 5 mg, mycophenolate 1500 mg, and tacrolimus 4 mg for prophylaxis of graft rejection. |
Mrs B is a 65-year-old, married, white woman with a long-standing history of bipolar disorder type I, who was transferred to our inpatient psychiatric hospital from a general medical hospital in May 2012. She had been treated in the emergency department for mania with psychosis as well as hypertension, hyponatremia, urinary retention with urinary tract infection (UTI), and resulting delirium. Psychosomatic medicine was consulted, and once medically stabilized, she was transferred to an inpatient psychiatric hospital.\nMrs B reported a history of mood symptoms beginning at age 12. Since that time, she noted discrete periods of mania with 4 to 5 days of elevated mood, decreased sleep, racing thoughts, pressured speech, impulsivity, spending sprees, and reckless behavior. She also had previous major depressive episodes but endorsed more periods of mania than depressive episodes. She had multiple psychiatric hospitalizations, typically during times of mania. Her first hospitalization was at age 12, and she required multiple hospitalizations until she began treatment with lithium in her late teenage years.\nHer medical history is significant for type 2 diabetes mellitus, hypertension, dyslipidemia, cataracts, history of secondary hyperparathyroidism, and history of anemia. She had a remote history of alcohol abuse but no current substance use. Family psychiatric history was notable for alcohol use disorder and mood disorders in her brother and both parents.\nMrs B's renal transplant was performed in August 2010 after several decades of lithium treatment. Her renal failure was suspected to be due to lithium nephrotoxicity in the setting of long-standing hypertension and diabetes. At the time of transplant, lithium was discontinued, and she was started on quetiapine 150 mg daily.\nBetween September 2010 and June 2012, she was hospitalized more than 40 times for medical and psychiatric reasons, including medication nonadherence, hypertensive crisis, and multiple episodes of mania with psychosis. The patient was admitted to multiple hospitals during this time, so not all records were available for review. Data from hospitalizations within our system are included in this report. In between hospitalizations, she required nursing home care as her husband was unable to safely care for her at home. A brief account of medication trials, including relative dates are detailed through May 2012 ().\nHer final hospitalization was in May 2012. She was hospitalized from her nursing home for a UTI, elevated blood pressure, urinary retention, mania with psychosis, and delirium. She was treated with fluphenazine decanoate but developed QTc prolongation while medically hospitalized. She was then transitioned back to aripiprazole 15 mg twice daily. Her delirium improved after treatment of her UTI. However, she continued to demonstrate significant symptoms of agitation, violence, flight of ideas, word salad, and clang speech. She then required psychiatric hospitalization. Divalproex sodium delayed release (DR) 750 mg once daily was added without resolution of her mania. She continued to experience functional impairments not consistent with her previous baseline and was not considered safe for discharge by her husband or treatment team.\nThe decision to restart lithium was made in June 2012 by the primary inpatient team after discussion with the patient, husband, primary care physician, renal transplant surgeon, and nephrologist. This decision was based on the patient's previous history of long-standing mood stability with lithium and failed trials of multiple other medications as well as the patient and husband's desire to subvert nursing home placement. Lithium carbonate immediate release (IR) was started at 300 mg daily at bedtime. Within 24 hours, the patient was noted to have improvement in her symptoms. Her dose of lithium carbonate IR was later increased to 600 mg daily, and within 2 days, she had returned to her previous baseline. Prior to discharge, her serum lithium level was 1.0 mEq/L, and her serum creatinine value was 1.0 mg/dL. The discharge plan included follow-up with her primary care provider, geriatric psychiatry clinic, nephrology, and home health care. Complete blood cell count, basic metabolic panel, lithium, and valproic acid level were planned to be drawn 1 week after discharge.\nIn August 2012, Mrs B presented to the geriatric psychiatry clinic for hospital follow-up and intake assessment. Mrs B and her husband expressed the dramatic positive changes noticed since lithium carbonate IR was restarted, which she described as “a night and day of difference.” She felt she had regained her independence in carrying out daily activities with improved clarity of thought and alertness. She progressively required less assistance, which enabled her to live at home with her husband. At that time, she had no significant mood symptoms or psychosis. Her husband felt she was 50% back to her baseline mental status, and the patient felt she was closer to 80%.\nLithium level at that time was 1.2 mEq/L. There was some concern that this lithium level was exacerbating the cognitive impairment, which had previously developed with her ESRD. The lithium carbonate IR dose was reduced to 450 mg daily at that appointment. She was continued on divalproex sodium DR 750 mg twice daily and aripiprazole 30 mg once daily.\nShe was seen frequently over the next several months with ongoing continued stability of mood and denial of any symptoms consistent with psychosis or depression. However, she continued to have complaints of cognitive impairment, and lithium carbonate IR was further decreased to 300 mg daily.\nMrs B was able to reach remission of her symptoms on this medication regimen with minimal cognitive symptoms after the final lithium carbonate IR dose decrease. Her renal function continued to be carefully monitored but was stable over time on this medication regimen. |
This is a case of a 68-year-old male with a history significant for rheumatoid arthritis and a moderate pericardial effusion discovered incidentally on a CT scan of his chest during the initial workup for worsening dyspnea (). Over the next 18 months, he developed increasing lower extremity edema and dyspnea with activity. Symptoms at that time showed modest response to oral diuretics. Serial echocardiograms, during the 18-month evaluation period, were performed periodically to evaluate his worsening dyspnea and generalized edema. Despite his worsening symptoms, the echocardiograms showed no decrement in the systolic or diastolic function with minimal increase in size of the effusion with no end-diastolic chamber collapse, interventricular dependence, or spectral Doppler variation suggestive of tamponade physiology. Physical exam revealed a normotensive male that was not tachycardic. There was a pericardial knock and distended jugular veins. He had coarse breath sounds bilaterally and mild abdominal distention with hepatomegaly. Extremity exam showed deep pitting edema to his thighs and small joint deformities associated with his known rheumatoid arthritis. A directed echocardiogram for evaluation of constrictive pericarditis showed a hyperdynamic left ventricle. Right ventricular collapse was evident along with respirophasic ventricular septal motion. These findings along with bilateral atrial enlargement, in the absence of restrictive pattern on diastolic function evaluation, were suggestive of possible pericardial constriction rather than tamponade.\nThe patient continued to worsen over the next two years. He underwent a diagnostic pericardiocentesis with cardiac and pericardial pressure monitoring. Pericardial pressures were elevated at 30 mmHg prior to drainage of fluid. There was hemodynamic evidence of equalization of diastolic pressures in all chambers. There were a positive Kussmaul sign and significant ventricular interdependence. After pericardiocentesis, pressures in the pericardial space decreased to less than 5 mmHg. Despite this extracardiac change in pressure, there were no changes in the intracardiac pressures (). There continued to be a prominent square root sign on both right and left ventricular tracings. Right atrial pressure tracings now demonstrated a blunted X descent and rapid Y descent (). These findings supported a diagnosis of constrictive pericarditis as the etiology of heart failure in this patient. Pericardial fluid was bloody and revealed no infectious etiology on analysis and cultures including acid fast bacillus, with total protein content of 5.1 g/dL, glucose of 4 mg/dL, LDH 5640 u/L, and a total cholesterol of 211 mg/dL. In view of the patient's significant symptomatology, he was referred for pericardial stripping in a high volume surgical center. Pathology report of the pericardial tissue, obtained from the surgical center where the stripping took place, revealed degenerating blood with focal areas of cholesterol crystal formation. |
A 35-year-old Japanese man with no past psychiatric history, but with a past neurologic history of PKD, was referred by the neurologic department at our hospital to the Department of Psychiatry because of severe anxiety and hyperventilation. When the patient was 16 years old, he was clinically diagnosed as PKD by a neurologist based on characteristic symptoms including involuntary movement induced by voluntary movements and various examination findings, such as test using blood and cerebrospinal fluid, and several image findings. After that, he had been maintained on carbamazepine (CBZ) at 200 mg/day since 16 years of age without any attacks.\nIn February 2013, on a regular follow-up in the neurologic department, the neurologist changed CBZ to topiramate after the patient complained of long-term symptoms of drowsiness and wobbliness, which he thought might be the side effects of CBZ. Two days later, he visited the emergency department at our hospital with chest pain and hyperventilation. Although the neurologist suspended topiramate and resumed CBZ, his anxiety and hyperventilation did not improve as was expected. The following month, the patient was referred to our department, but he stated that he had no anxiety about PKD or any other psychosocial stressors. He presented as a gentle young man without any abnormal affect, but seemed somewhat nervous with an impassive facial appearance. We took time to have a good discussion about his history and symptoms. At last he confessed that, 10 years before this referral, he became aware of a feeling of breakdown in his overall physical functions to what he considered as about 70% of his earlier state. He had then avoided becoming familiar with people out of concern that his physical dysfunctions might be perceived in a negative light. It means that his anxiety symptoms had existed and persisted 10 years before a change of drug, CBZ to TPM, though we could not completely deny it affected these symptoms. Then we began treatment with escitalopram at 10 mg/day, targeting the symptoms of anxiety and depression. Moreover, we added aripiprazole at 3 mg/day and ethyl loflazepate at 1 mg/day (). Both his subjective physical condition and objective expressions subsequently showed gradual improvement. Feelings of chest compression and anxiety entirely disappeared. By contrast, his speed of speech and amount of conversation increased markedly, and he seemed more cheerful in his appearance. He stated, “Amazing! After 10 years’ absence, this feeling came to me! My ability to judge things has been improved and I don’t feel hesitant in starting new things,” “I can perform complicated movements and quick motions. Now I can run and swim!,” “I gained a larger circle of acquaintances and at last I have a girlfriend!.” He himself called this phenomenon “Awakenings”, as an analogy to the well-known movie.\nIn short, escitalopram, aripiprazole, and ethyl loflazepate proved effective in addressing both subjective and objective symptoms (but increased doses of these drugs have loss of efficacy) in the present case. As a result, his quality of life was prominently enhanced as the scope of his activities and friendships rapidly expanded. In addition, increases in plasma monoamine metabolite levels were observed for homovanillic acid (a dopamine metabolite), total 3-methoxy-4-hydroxyphenylglycol (a noradrenaline metabolite), and free 3-methoxy-4-hydroxyphenylglycol, which were analyzed with high-performance liquid chromatography with electrochemical detection. In particular, homovanillic acid level was doubled after this change in pharmacotherapy (). Furthermore, the c.649dupC mutation, which has been found in most Japanese PKD families, was detected in his PRRT2 by direct sequencing after polymerase chain reaction amplification. |
A 28-year-old male patient came to the private clinic with a chief complaint of severe pain in his upper front teeth.\nOn examination, the patient had a full complement of permanent teeth. The maxillary central incisors appeared broader mesiodistally than usual. Right permanent maxillary lateral incisor was placed palatally between 11 and 13, and the left permanent lateral incisor was placed in the normal position between 21 and 23 []. This feature is suggestive of the fusion of permanent maxillary central incisors with mesiodens on both the sides.\nTooth number 11: A groove was present in the labial aspect of 11 which extended from the middle third to the incisal edge. Extensive discoloration was observed around the groove in 11, which was suggestive of deep caries extending into the pulp [].\nTooth number 21 showed a huge crown mesiodistally without any indentations or fissures. In the lingual aspect of 21, there was a deep carious pit with extensive discoloration.\nIntraoral periapical radiograph of maxillary anterior region revealed the presence of two roots and two root canals with a single huge crown in 11. Tooth number 21 revealed a huge crown with fused mesiodistally wide single root with two root canals with a Vertucci's type II root canal configuration []. In both the teeth, the caries was extending until the pulp.\nThe radiographic features are suggestive of incomplete fusion of 11 with mesiodens and complete fusion of 21 with mesiodens.\nOn vitality testing, both thermal and electrical pulp tests revealed no response in 11 and 21 suggestive of nonvital 11 and 21.\nThe treatment plan was to extract 12, followed by endodontic treatment in 11 and 21 and later full coverage ceramic restoration in 11 and 21. Since the patient was not concerned about the esthetic problems due to macrodontia and his only concern was a pain, endodontic treatment was performed to relieve the pain, and the access cavity was restored with a composite restoration.\nUnder local anesthesia, access cavity preparation was done in 11 and 21 conventionally with a triangular outline, and later, the access cavity was modified and extended mesially to accommodate the additional pulp horn and distinct pulp chambers with canal orifices were found. K-file size 10 (Dentsply Maillefer, Ballaigues, Switzerland) were inserted into the orifice and the working length established []. The canals were instrumented using crown-down pressureless technique using rotary NiTi files (Protaper files, Dentsply) up to size F5. Copious irrigation with 2.5% sodium hypochlorite solution was used during the preparation. The canal system was dressed with a nonsetting calcium hydroxide paste and sealed temporarily with Cavit (ESPE, Seefeld, Germany). The canals were obturated with protaper gutta-percha points and AH plus sealer []. |
A 30-year-old Japanese man was admitted to our hospital because of high-grade fever with transient consciousness disorder and double vision. He had no medical history throughout his childhood and adolescence but continued to have repeated fever and productive cough since the age of 25. He also presented with stomatitis and dental caries. His mother had a history of disseminated cryptococcosis and died from chronic hepatitis C virus infection. His younger brother had been clinically diagnosed with CMCD for having recurrent and refractory cutaneous candidiasis although no genetic analysis has been performed on his dissent.\nPhysical examination on the admission revealed that the majority of his teeth were corroded, and that he had white moss throughout his mouth. A nuchal stiffness was noted with right abductor paralysis. His chest computed tomography (CT) showed bronchiectasis and multiple granular shadows randomly distributed in the bilateral lower and middle lobes, thin-walled cysts predominantly in both upper lobes, and consolidation in the lower left lobe (). Cryptococcus neoformans was isolated from his blood and cerebrospinal fluid samples and was also detected in liver and lung biopsies. Accordingly, he was diagnosed with disseminated cryptococcosis with meningitis and oral and cutaneous candidiasis.\nThe patient was treated with a combination therapy of liposomal amphotericin B and flucytosine for 8 weeks. Consequently, his respiratory symptoms and neurological abnormalities resolved. The cryptococcal antigen titers in his cerebrospinal fluid decreased from 1,024 times to 32. His chest CT on day 44 of the treatment showed that the granular shadows and consolidation entirely improved, but the bronchiectases in his right middle lobe and left lingular segment remained. The antifungal treatment was then switched to oral fluconazole, and the disease did not recur for one year.\nThe patient was suspected of having primary immunodeficiency because of the present clinical course and his family history. We sequenced the patient’s CMCD-related genes and found a previously recognized heterozygous missense mutation in the coiled-coil domain of the STAT1 gene (c.820C>T, p.R274W) (, ). The same mutation was also detected in his younger brother. The monocytes of the patient showed hyper-phosphorylation of STAT1 after stimulation with interferon-γ (). Based on these results, the patient was diagnosed with STAT1 GOF.\nAdditionally, the patient presented with low serum IgG and IgA levels [IgG: 2.36 g/L, normal range (NR): 8.61–17.47 g/L; IgA: 0.05 g/L, NR: 0.93–3.93; IgM: 0.92 g/L, NR: 0.33–1.83]. Surface marker analyses revealed that 72.3% (NR: 54.3–81.9%) of his peripheral lymphocytes comprised CD3+ cells with a CD4/CD8 ratio of 32.8 (NR: 24.3–49.7%)/36.2 (NR: 18.4–49.0%), and that 0.1% (NR: 2.9–20.1%) comprised CD19+ cells (). Peripheral blood lymphocyte responsiveness to phytohemagglutinin was normal (Stimulation Index: 281, NR: 254–388). The level of T-cell receptor excision circles was 2.06 x 102 copies/μgDNA [NR: 3.4 ± 3.6 x 102 copies/μg DNA ()], whereas both those of the coding joint and signal joint kappa-deleting recombination excision circles were undetermined. We then investigated the cause of hypogammaglobulinemia and B-cell lymphopenia. The B-cell differentiation was blocked in the stages between VpreB+IgMlow (pre-B1b) cells and VpreB−IgMlow (pre-B2) cells in the bone marrow sample obtained three months after the onset of cryptococcosis (). Human immunodeficiency virus-RNA and Epstein-Barr virus- and cytomegalovirus-DNA were undetectable by polymerase chain reaction. No pathogenic variants in antibody deficiency-causing genes listed in the 2017 Primary Immunodeficiency Diseases Committee Report on Inborn Errors of Immunity were detected using the target panel sequence (). The reduction in the peripheral B-cell counts had persisted even after the patient’s recovery from cryptococcosis (). His prolonged respiratory symptoms did not recur upon regular subcutaneous immunoglobulin infusion to maintain a trough level of >7.0 g/L. |
A 35-year-old male from a remote village in Nawalparasi, Nepal, presented to our Emergency Department following a sudden jolting movement sustained at the back of the neck while he was driving a tractor. He did not report any loss of consciousness and episodes of vomiting. His did not complaint of dizziness, fall attacks, tinnitus, and vertigo. He only complaint of the persistent bulking type of headache, especially in the nape of his neck. A headache was resistant to over the counter analgesics. He had no similar episodes of headache in the past. No significant past other medical or surgical illnesses were elicited. His Glasgow Coma Scale was 15/15. Bilateral pupils were equal and reacting. Neck rigidity was present. His vital parameters were within normal range. There was no nystagmus, and cerebellar signs were absent. His cranial nerves examination was normal. The urgent computed tomography (CT) head scan revealed foramen magnum territory SDH and cisterna magna SAH []. CT angiography performed did not reveal any associated aneurysm in the posterior circulation and showed hypoplastic right vertebral with predominant supply from the left vertebral artery. Their extra cranial course in C1 was normal. The patient was started on tablet nimodipine 60 mg postoperative 4 hourly for preventing vasospasm. The patient was admitted and was rigorously monitored for features of raised intracranial pressure. After 12 h of admission, the patient complaint of severe intolerable headache multiple episodes of vomiting with associated bradycardia. Urgent repeat CT head revealed features of evolving hydrocephalus [], and there was compression in the cranioverteral junction. The patient and his relatives were counseled regarding the high risk of tonsillar herniation and brain stem compression. The external ventricular drain placement was deferred due to the fact that it could predispose to the progression of the upward transtentorial herniation. The patient underwent posterior suboccipital craniectomy exposing up to C2 arch. Dura was opened, and there was evidence of SDH in the CV junction and SAH in the cisterna magna. The hematoma was completely evacuated. Cerebellum was completely lax and pulsatile after the procedure. There was minimal oozing from the hemispheric branch of the posterior inferior cerebellar artery (PICA) which was controlled. The dura was sealed, and the wound closed in layers. The patient was extubated. Postoperatively, there was complete resolution in the headache and repeat scan showed complete evacuation of the SDH and the SAH with resolution in the hydrocephalus []. The patient was discharged home on the 7th operative day. The patient was followed up for 2 weeks later with no symptoms. The dose of nimodipine was tapered off in 3 weeks. |
A 62-year-old female presented to the outpatient department of Wuhan Central Hospital of Tongji Medical College in September 2015with a complaint of recurrent infections in the umbilical region. She reported abdominal pain similar to a burning sensation that accompanied the discharge of faecal matter. These symptoms and signs waxed and waned but lasted for 5years. Our attention was piqued by the fact that the patient’s family described the patient as an individual who cried easily. The patient had no history of diarrhoea, constipation or other abdominal disturbances. No surgical treatment was mentioned in her prior medical history.\nAcoordinated physical examination revealed normal vital signs. An external fistula was located in the umbilical region with redness of the surrounding skin. Morphological examination indicated that fistula secretions mainly consisted of small intestinal juice. The abdominal wall was soft, with no tenderness. Bowel sounds were regular. Escherichia coli and Enterococcus faecalis were detected in the fistula secretion culture. Other findings from laboratory examinations were normal. A CT scan of the abdomen revealed that part of the intestinal wall was adhered to the abdominal wall in the navel region, although no bowel obstruction was detected (Fig. ). A presumptive diagnosis of ECF was reached; this diagnosis was mainly based on digital radiography of the fistulous tract conducted using iopamidol-370 as a contrast agent. This procedure was performed under local anaesthesia and revealed that the distal ileum approximately 40 cm from the ileocaecal junction was entrapped (Fig. ).\nThe patient agreed to surgery after a clear preoperative conversation. She understood the operative risk factors and signed an informed consent. After bowel preparation, the patient received an exploratory laparotomy. The abdominal cavity was completely exposed, and a loop of the terminal ileum (approximately 40 cm proximal to the ileocaecal junction) was found entrapped in the internal hernia ring; this finding was consistent with the preoperative contrast image. The defect in the abdominal wall was less than 1.0 cm, and an extremely small portion of the bowel wall was stuck and could not be retrieved back into the cavity (Fig. ). Nonetheless, this defect resulted in perforation over the loop (Fig. ). Side-to-side ileo-ileal anastomosis was completed by utilizing a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed with plication sutures instead of via mesh repair due to the patient’s small defect and infection risk. The abdominal cavity was thoroughly cleaned with saline solution, and a rubber drainage tube was placed in the pelvis. The scar tissue was removed to improve wound healing; subsequently, relaxation sutures were available to close the abdomen in layers. A final diagnosis of Richter’s hernia presenting as spontaneous ECF was reached. The patient was discharged 2 weeks after surgery without serious complications. No hernia recurrence was observed during 10 months of follow-up. |
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 []. |
An 80-year-old Caucasian man who initially presented with back pain was found to have a 9.8 cm infrarenal abdominal aortic aneurysm on computed tomography (CT). This was suitable for endovascular aneurysm repair (EVAR) but the left common iliac artery (CIA) was short, necessitating the extension of the left iliac limb into the external iliac artery (EIA). The decision was made to proceed with an on table coiling of the left internal iliac artery (IIA) and EVAR. However, a tortuous right CIA made coiling of the left IIA extremely difficult and following a prolonged attempt, the decision was made to proceed with EVAR without coiling the IIA (Fig. ).\nOn a 1-month follow up CT the left limb extension had disengaged from the main body, resulting in a large Type 3 endoleak. The disengagement was presumed to be due to the tortuosity of a heavily calcified external iliac artery returning to its anatomical position on removal of the Meir wire (Boston Scientific). The left IIA remained patent and acted as an outflow for the type 3 endoleak. The left limb was then realigned successfully with termination of the type 3 endoleak.\nOn a follow up CT 1 month post repair, the left IIA remained patent with a large type 2 endoleak demonstrated but the sac size remained static (Fig. ). The failure of the IIA to occlude was presumed due to the cavity created within the aneurysm sac from the type 3 endoleak. Due to the large size of the aneurysm and the relatively large size of the type 2 endoleak the decision was made at multi-disciplinary team meeting to embolise the type 2 endoleak.\nAs antegrade access to the left IIA was not possible due to the presence of the stent graft, an attempt was made to access the internal iliac artery via the buttock. Direct sac puncture was not possible as the endoleak was located within the pelvis and surrounded by bony structures and pelvic viscera. The intention was to puncture the posterior division of the IIA but visualisation with ultrasound was limited and a vessel was punctured, which on subsequent angiography was shown to be the anterior division of the left IIA (Fig. ). The left IIA was embolised using Spirali (Pyramed) coils in a retrograde manner. Due to the absence of a solid structure which to compress the access vessel against, especially as the anterior division of the IIA had been punctured, the arteriotomy needed to be closed using an Angio-Seal (Terumo). Correct intraluminal placement of the Angio-Seal (Terumo) is dependent on backflow of blood into the Angio-Seal (Terumo) sheath from the artery. However, as the left IIA had been embolised, backflow from the Angio-Seal (Terumo) was non-existent. The angioseal was not visualised on ultrasound and therefore a 4 French dilator was inserted within the Angio-Seal (Terumo) sheath through which contrast was injected to directly visualise the tip to the sheath within the artery (Fig. ). The sheath was then withdrawn until just inside the vessel lumen and the plug deployed with immediate haemostasis (Fig. ). This was an off-label use of the Angio-Seal (Terumo).\nA follow up CT 1 month post procedure revealed resolution of the Type 2 endoleak. |
A 60-year-old male patient was being regularly followed up in the Department of Radiotherapy since 6 years. In the year 2010, he presented with a growth on the base of the tongue that had gradually increased in size over the preceding 8 months. He was a chronic smoker (15 pack years) and chewed tobacco. An irregular, friable growth was seen on the right side of the base of tongue measuring 1.5 cm × 1.5 cm × 0.5 cm along with the level I right cervical lymphadenopathy. All the routine laboratory investigations along with X-ray and computed tomography (CT) of the patient's chest and abdomen were within normal limits. Fine needle aspiration cytology smears from the enlarged cervical lymph node showed metastatic deposits of squamous cell carcinoma. We received an incisional biopsy in the Department of Pathology and histological examination showed features of moderately differentiated squamous cell carcinoma of the base of tongue. Thus, a final diagnosis of carcinoma of the base of tongue, stage III (T1N1M0) was made, and the patient was planned for radical radiotherapy. The patient received radiotherapy (dose 66 Gy/33 fractions/6.5 weeks) in the same year and achieved complete response. He was regularly followed up at an interval of 4–5 months with no recurrence for 6 years. He had stopped smoking as well as chewing tobacco. His oral hygiene was good. However, in the last follow-up session in May 2016, he complained of mild pain while swallowing. On examination, an irregular firm growth was seen on the base of tongue. There was no palpable lymphadenopathy. CT scan showed a growth on the right side of the base of tongue measuring 3 cm × 2 cm × 1 cm []. Salivary glands and vocal cords showed hyperechoic echogenicity caused by the fatty tissue infiltration, suggestive of mild radiotherapy-induced changes. There was no evidence of any malignancy or significant lymphadenopathy elsewhere in the body. There was no history of any immunosuppressive condition or immunosuppressant drug intake. Incisional biopsy showed monomorphic tumor cells arranged in diffuse sheets and small clusters infiltrating into the surrounding fibroconnective tissue. The individual tumor cells were round with scant amount of eosinophilic cytoplasm and a round to oval hyperchromatic nucleus. Abnormal mitotic figures (7–8/10 high power fields), necrosis, and crush artifact were also seen [Figure –]. There was no evidence of keratinization. Based on the morphology, a differential diagnosis of poorly differentiated squamous cell carcinoma, small cell carcinoma, nonHodgkin's lymphoma, and Merkel cell carcinoma were considered and an immunohistochemical panel was applied for definite categorization. On immunohistochemistry, the tumor cells showed positivity for neuron-specific enolase, synaptophysin, chromogranin, pan-cytokeratin (CK), and CK7 [Figure –]. The tumor cells were negative for p63, leukocyte common antigen, and CK20 thereby excluding squamous cell carcinoma, lymphoma, and Merkel cell carcinoma, respectively. The tumor showed high Ki-67 proliferation index of 75%–85%. Thus, on the basis of distinct immunohistomorphological features, a final diagnosis of small cell NEC of the base of tongue was rendered. The patient was then planned for wide local excision. |
A 55-year-old male patient reported with a complaint of mobile and broken teeth in the maxillary anterior region. He had suffered from trauma 2 days back. His medical history was noncontributory. On extra- and intra-oral examination, there was no apparent trauma to the soft tissues.\nIntra-oral examination revealed a complicated crown root fracture of the maxillary left central incisor and uncomplicated crown fracture with maxillary right central incisor. The fracture line of 21 was supragingival on the labial side and subgingival on the palatal side. The fractured fragment of 21 was incompletely separated and mobile []. Palatal gingiva and interdental papilla were neither inflamed nor edematous. Evaluation of periodontal status of the patient revealed the absence of periodontitis. The intraoral periapical radiograph showed the fracture line. There was no evidence of periapical pathosis.\nThe adhesive reattachment of the coronal fractured fragment to the remaining tooth structure was planned for 21, to be followed by composite restoration of 11. To improve the tooth resistance and expand the bonding areas involved in the adhesive reattachment technique, placement of a translucent glass fiber post was also planned with 21. The patient accepted the treatment plan.\nThe gingiva was separated on the palatal side, and the fractured fragment was removed using a forceps without incurring any damage. The subgingival extent of fracture was confirmed on fragment removal. The surface of fragment and pulp chamber was debrided and cleaned. The fragment was preserved in saline until reattachment to avoid discoloration and dehydration. Since the patient reported 2 days after the trauma, preservation of the tooth vitality was not feasible. Hence, single visit root canal treatment was performed with 21. An enamel bevel was prepared all around the remaining tooth structure and the fractured margin of the fragment. An additional internal dentinal groove was also prepared within the dentin of the fractured fragment, which would approximate the access cavity prepared for endodontic therapy of the remaining tooth structure []. The post space was prepared using Peeso reamers, leaving apical 5 mm of Gutta percha.\nA glass fiber post of diameter 1.1 mm (Reforpost Glass Fiber, Angelus, Londrina, Brazil) was selected. Coronal part of the fiber post was cut to fit into the coronal fractured fragment and the fragment was aligned with the apical part of the tooth fragment. The prepared post space was acid etched and bonded. The post was then luted with dual-cure resin cement (Multilink, Ivoclar, Vivadent) with 2 mm of its coronal portion extending into the chamber []. Tooth fragment was reattached using resin cement. The beveled part was restored with composite. There was no need of suturing palatal gingiva since it was atraumatically separated during fragment removal. It was followed by direct composite restoration of 11 [Figure and ].\nOne month later, clinical and radiographic examination revealed a stable reattachment of crown fragments. The palatal gingiva showed adequate approximation with the reattached tooth without formation of any pocket. Pulp sensibility testing of 11 using cold and electric pulp tests confirmed the vitality of the tooth. At 1-year follow-up visit, the clinical and radiographic examination showed a stable reattachment and good periodontal health.\nIn the second case, a 32-year-old male patient reported with a complaint of broken tooth in the maxillary anterior region. He had suffered from trauma 1 day back. On intraoral examination, a complicated crown root fracture of the maxillary right lateral incisor was observed. The fracture line of 12 was located supragingivally on the labial side, whereas it extended subgingivally on the palatal side. The fractured part of 21 was not completely separated from the remaining tooth and exhibited mobility. Radiographic examination revealed the fracture line. Reattachment of the fractured fragment to the remaining tooth structure using fiber post was planned. The treatment was carried out in the similar way as that for Case 1. Follow-up visits of the patient revealed successful reattachment of the tooth [Figure and ]. |
A 47-year-old male originally from Mexico presented to our hospital with persistent nasal congestion, sore throat, hoarseness of voice, and dysphagia. His symptoms first started 23 years before while in Mexico. At that time, he reported having had multiple episodes of epistaxis and the presence of an “extra skin” in his nose. He also reported that he had a surgical procedure at initial presentation in which his “nostrils were scraped” and subsequently was put on antibiotics for 6 months (patient unaware of the name of the antibiotics he received). His symptoms improved, only to resurface ten years later. Shortly thereafter, he moved to the USA. He experienced progressive worsening of nasal congestion, difficulty swallowing, and hoarseness of voice and went to a primary care physician for evaluation. He received 3 doses of intramuscular ceftriaxone followed by oral antibiotics. He reported a mild clinical improvement followed by rapid relapse with continued symptoms progression. He presented to our hospital for further evaluation. By the time of hospital presentation, in addition to the above symptoms the patient also noted a mass protruding into the back of his throat. He denied weight loss, fever, or chills. His past medical history was significant for treated pulmonary tuberculosis at the age of 16. He denied any cigarette smoking, drug use, or alcohol intake. His family history revealed that his maternal uncle and his oldest son had constant rhinorrhea and his mother had a mass in her nose, but all affected family members remained in Mexico with limited access to medical care. Physical exam showed an erythematous, irregular soft tissue lesion covering the entire posterior oropharynx with some white exudate (). The mucosa of the nares had a similar appearance, but no discreet mass was appreciated. The remainder of the exam was unremarkable.\nComputed tomography of the neck showed a 21 × 24 × 25 mm mass in the soft palate narrowing the nasopharynx () and a lesion of 15 × 9 mm in the anterior aspect of the left false vocal cord (). There was also an asymmetric thickening of the left tonsil. No cervical adenopathy was detected. An esophagogram did not reveal any evidence of obstruction.\nOtolaryngology was consulted and performed biopsies of the oropharyngeal mass and the left tonsil. Tissue was submitted for pathology and microbiology studies. Histopathology with hematoxylin and eosin (H&E) stain revealed plasma cell infiltrates mixed with foamy macrophages, known as Mikulicz cells (). These findings were consistent with rhinoscleroma. Gomori methenamine silver (GMS) stain was also performed and showed intracellular coccobacilli (). Tissue cultures yielded Klebsiella ozaenae, resistant only to ampicillin. The automated system used to identify this isolate was the MicroScan Walkaway 96 (Siemens, Sacramento, California).\nThe patient was started on trimethoprim-sulfamethoxazole but developed body aches and cramps as side effects. Therapy was subsequently changed to ciprofloxacin and doxycycline, planning to complete a six-to-twelve-month course. Unfortunately, he was subsequently lost to follow-up. |
A 20-year-old Para 1 woman presented with continuous urinary incontinence in spite of normal micturition for one month. Her symptoms followed an unsupervised spontaneous vaginal delivery which lasted for more than 24 h, resulting in foetal demise. The pregnancy and delivery was not attended by a skilled birth attendant and there was no instrumentation during delivery.\nDirect dye test using 300 ml of dilute methylene blue instilled into the bladder showed no dye leak. However, a clear stream of urine was seen spilling from the left ureter (Fig. ). The ureter was catheterized with a ureteral catheter for up to 6 cm. Furthermore, a three swab test confirmed ureterovaginal fistula as the swab near the cervix was soaked with urine but the other swabs were neither dye-stained nor soaked. The diagnosis of left ureterovaginal fistula was made and the patient was prepared for surgery. Her packed cell volume was 34%; HIV was non-reactive; while urea and creatinine were within normal limits.\nThe diagnosis and treatment options were discussed with the patient and she signed an informed consent for left ureteroneocystostomy by vaginal approach.\nUreteroneocystostomy was done via the vaginal route under spinal anaesthesia. An inverted ‘T’ shaped incision was made at the distal border of the left ureter, and the anterior vaginal wall was dissected, taking care to free the distal left ureter over the ureteral catheter. An artery clamp was passed through the urethra and used to pierce the bladder, creating a tiny bladder fistula around the distal margin of the left ureter through which the ureteral catheter was pulled through the bladder and out through the external urethral meatus. The ureter was then reimplanted into the bladder using 4/0 Vicryl at four quadrants by passing each suture from the serosal margin of the distal ureter exiting through the mucosa and then through the mucosa of the bladder exiting the bladder serosa. A second layer of bladder serosa was closed over the reimplanted ureter using Vicryl 2/0 (Fig. ). The urethra was catheterized and post closure dye test was negative, so the vaginal wall was closed with vicryl 2/0 in one layer (Fig. ).\nThe patient had an uneventful recovery and post-operative period, and the catheters were removed after 14 days. The patient was completely continent of urine at discharge and remained continent at last follow up 2 years thereafter.\nThe patient was therefore discharged from follow up after repeated sessions of counselling for prenatal planning, antenatal care and supervised delivery in a hospital to ensure safe subsequent deliveries. |
A 64-year-old female, with chronic kidney disease, hypertension, diabetes mellitus, obesity, and prior right femoral neck fracture treated with dynamic hip screw, presented with a chronic right leg infection. Approximately one year prior to presentation, she sustained a right distal femur fracture treated with retrograde intramedullary nail fixation, which was complicated by early hardware failure requiring revision. She then developed a MSSA infection, requiring removal of hardware and placement of an antibiotic spacer. She completed a course of antibiotics and subsequently underwent total knee arthroplasty, which was complicated by MRSA infection with development of a sinus tract communicating with the distal femur. She underwent three more irrigation and debridement procedures, long-term IV Vancomycin, and replacement of an antibiotic spacer at the most recent debridement. Her sinus tract persisted and she presented for second opinion to discuss alternatives to amputation. On examination, she had a draining sinus tract near the knee, which probed to a depth of 5 cm. Her right lower extremity was 4 cm shorter than the left. ESR was 16 mm/hr and CRP 0.58 mg/l.\nRadiographs at presentation are shown (), and she was taken to the operating room where cultures were obtained and all hardware and antibiotic cement were removed. The femur and tibia were then reamed and an 11.5 mm × 700 mm Smith and Nephew intramedullary nail was placed with gentamicin cement packed around the nail. Intraoperative cultures had no growth and she was placed on IV Vancomycin for six weeks given her history of MRSA and MSSA. Postoperative images are shown ().\nHer postoperative course was complicated by Vancomycin-resistant Enterococcus (VRE) PICC line infection and E. coli UTI, which were treated at an outside hospital. At follow-up, she was noted to have a draining sinus at the distal femur, which was treated with wet-to-dry dressings. Inflammatory markers were then trended and decreased over time off antibiotics.\nTen months later, it was felt that her infection had been cleared when her inflammatory markers reached ESR 10 mm/hr and CRP 0.26 mg/l, and she returned to the operating room for reconstruction. Intraoperatively, frozen sections were negative for acute inflammation and a large Stryker GMRS endoprosthesis was used for reconstruction. A gastrocnemius flap and split thickness skin graft were used for soft tissue coverage. Postoperative radiographs are shown ().\nHer postoperative course was complicated by necrosis and purulence of the proximal portion of the wound requiring repeat IV antibiotics and irrigation and debridement on three subsequent occasions over several months. Operative cultures from these debridements grew various organisms including VRE, Morganella morganii, Acinetobacter baumannii, and coagulase-negative Staphylococcus. A long discussion was held with the patient about her postoperative course when she continued to have drainage from the incision and intermittent wound breakdown despite attempts at antibiotic suppression. She was taken again to the operating room for hip disarticulation two years after her index procedure. |
A 64-year-old female presented to the emergency department secondary to shortness of breath, cough, and associated fever. She had a past history of chronic obstructive pulmonary disease, left upper lobe cavitary lung lesion, and microcytic anemia. The patient was on daily oral steroids for the last several years due to poorly controlled COPD and had recently been released from the hospital two weeks before for a left lower lobe pneumonia. At the time of her prior admission, she was started on vancomycin and aztreonam for her pneumonia and was ultimately discharged on levofloxacin for ten days.\nDuring her emergency department course, her chest radiograph revealed a worsening left lower lobe infiltrate which was later confirmed on computed tomography of the chest. The patient had worsening hypoxia during her course and was eventually placed on BIPAP therapy, and she was started on intravenous vancomycin, levofloxacin, and fluconazole for a presumed hospital-acquired or fungal pneumonia given her recent hospital admission and cavitary lung lesion. Prior to admission, she had no physical exam findings to suggest a fungal infection. She was admitted to the hospitalist service for further evaluation and management.\nWhile hospitalized, the patient continued antibiotic and antifungal therapy, and on day two, aztreonam was added due to a worsening clinical picture. The following day, the patient underwent consultations from infectious disease, pulmonology, and cardiothoracic surgery due to her worsening clinical status and pneumonia with associated cavitary lung lesion. Following consultations, the patient underwent a fiberoptic flexible bronchoscopy with bronchoalveolar lavage which showed a large mucous plug obstructing the left main bronchus but no associated lesions. Cultures from the bronchoalveolar lavage eventually grew Nonomuraea solani, Candida glabrata, and Candida dubliniensis.\nFollowing a protracted hospital course of nine days, the patient was discharged home with cefpodoxime 400 mg twice a day for ten more days and was instructed to follow up with infectious disease within the next two weeks. However, the patient eventually presented to the emergency department one month later with a left-sided empyema status after wedge resection of the cavitary lesion that grew Corynebacterium amycolatum and Staphylococcus hominis spp. on cultures. |
A 15-year-old girl was admitted to the emergency department due to strongest headache, ataxia, vomiting, and progressive somnolence. The complaints had started 24 hours prior to admission, following a three-week period of abnormal fatigue. Four weeks before admission, the patient had started to take an oral contraceptive for family planning purposes, any other medication was denied.\nProgressive somnolence necessitated intubation and assisted ventilation. The initial cCT and successive cMRI scan revealed an extensive cerebral venous sinus thrombosis (CVT) of the straight sinus, left transverse sinus, and the occipital part of the superior sagittal sinus with subsequent congestive infarction of the basal ganglia and thalami (Figure ). During the immediate angiography, a 6 cm venous thrombus could be interventionally removed by aspiration. Mechanical thrombectomy was carried out under general anesthesia. A diagnostic catheter was placed to the left internal carotid artery via the right femoral artery. A diagnostic run was performed confirming CVT of the internal cerebral veins, the vein of Galen, the straight sinus and the proximal part of the left transverse sinus (Figure ). A therapeutic catheter was introduced via the right femoral vein to the left jugular bulb, and advanced to the level of the thrombotic occlusion of the left transverse sinus. Continued aspiration was carried out for 20 minutes within the transverse sinus and secondary within the straight sinus. After aspiration thrombectomy, flow was restored within the transverse sinus (Figure ). However, progressive congestive brain edema required implantation of an intracranial pressure monitor and subsequently an external cerebrospinal fluid drainage and surgical decompression by partial removal of calvarium bone. Intracranial pressure improved continuously, so that drainages and monitor could be removed after 2 weeks. After cessation of ventilation and anesthesia, the girl initially showed a left-sided hemiparesis and a motoric aphasia. She was able to communicate by movements with her eyes and head. A control cMRI 2 weeks post intervention revealed amelioration of basal ganglia congestive infarction alterations (Figure ). During the following rehabilitation, she fully recovered, and on examination 5 months later, she showed no neurological sequelae. The girl returned to school with normal performance.\nImmediately after diagnosis of cerebral venous sinus thrombosis, therapy with unfractionated heparin was initiated and changed to low molecular weight heparin 2 weeks later. After 5 months, anticoagulative treatment was shifted to phenprocoumon. The oral contraceptive had been discontinued instantly after initial hospital admission.\nAn extensive diagnostic work-up regarding thrombophilia including lipoprotein a, prothrombin G20210A and factor V Leiden mutations revealed no abnormal findings. Methylenetetrahydrofolate reductase (MTHFR) gene analysis showed the thermolabile variant c.655C>T (p.Ala222Val) in heterozygous state, but homocysteine in plasma was repeatedly normal. Proteins C, S, and factor XI were abnormal. Of note, AT was persistently low. Subsequently, SERPINC1/AT gene analysis was performed but revealed no abnormal findings. Further evaluation of causes of reduced AT activity revealed an abnormal glycosylation pattern in transferrin isoelectric focusing analysis, indicating a congenital disorder of glycosylation (CDG) type 1 (Figure ). Enzymatic analysis of mannose phosphate isomerase (MPI) in leukocytes displayed absent activity, proving MPI-CDG (Figure ). This was confirmed by MPI gene analysis showing compound heterozygous occurrence of the variants c.655C>T/p.Arg219Trp and c.1178G>C/p.Gly393Ala. The patient's mother carried the variant c.655C>T/p.Arg219Trp in heterozygous state and showed c.1178G as wildtype allele; DNA of the father, however, was not obtainable. Both variants have not been reported in the literature yet but showed an allele frequency of 0.002% and 0.02%, respectively, according to the dbSNP database (entries rs138891630 and rs201815588). They were therefore considered pathogenic. An extensive evaluation of the preceding medical history did not reveal any gastrointestinal, hepatic or endocrine symptoms during infancy, childhood and adolescence (Table ), as they have been frequently reported in other MPI-CDG patients.\nFollowing the diagnosis, a therapy with oral supplementation of D-mannose was initiated at a dose of 0.9 g/kgBW per day in 3 to 4 divided doses. AT, protein C, protein S and factor XI activities almost or fully normalized within 2 weeks (Figure ), and phenprocoumon was discontinued. However, the patient suffered from loose stools and independently reduced the dose to 0.6 g/kgBW per day. Under this regimen, AT activity decreased again, so that the mannose dose was stepwise increased to 0.75 g/kgBW per day divided into 5 to 6 doses. On this mannose dose, AT normalized again (Figure ), without any further gastroenterologic complaints. |
The second case report describes a 65-year-old man with intractable, cold, throbbing, and shooting pain mainly in his left lower limb. He had complained of this neuropathic pain during rehabilitation since undergoing a craniotomy 9 years ago for multiple brain injuries caused by a motorcycle accident. Several back surgeries had been performed over the past few years to correct the cause of this neuropathic pain after it was misdiagnosed as being caused by lumbar spinal lesions. However, after these spinal operations, the patient remained in pain. He was then referred to the neurosurgical department with intractable neuropathic pain. The patient was assessed by a pain specialist, and eventually was diagnosed with central neuropathic pain syndrome caused by the previous traumatic damage done to the sensory pathways of the central nervous system. Testing for SEP revealed prolonged latency in the left tibial nerve above the T12 level. Based on several published reports suggesting that SCS may effectively treat central neuropathic pain syndromes, this modality was proposed to alleviate his significant refractory pain that was resistant to various medications. To maximize pain-control effects, a 5-column Penta lead to the T9 level and a rechargeable neurostimulation system (Prodigy, Abbott, Plano, TX) were surgically placed (Fig. ), and stimulation was delivered to the patient in an alternating pattern between traditional tonic and burst waveform. For tonic stimulation, the pulse width was programmed in the range of 100 to 500 ms, with frequencies typically between 30 and 100 Hz, and at amplitudes producing comfortable paresthesia according to the patient's perception. Through the first 6 months of stimulation, the patient's pain relief was maintained at about two-thirds his prestimulation levels. However, his pain gradually returned to its prestimulation state, and about 3 years after the initial surgery, both stimuli were again used alternatingly, which resulted in about a one-third improvement in the patient's pain. The patient has provided informed consent for the publication of this case report and accompanying images. |
A forty four-year-old woman was referred from a local general hospital for dyspnea and aspiration on eating. She had history of drug intoxication from a suicidal attempt 2 months prior. At that time she had been intubated and had a gastric lavage, after which she had a nasogastric feeding tube. A tracheotomy was necessary because of prolonged intubation (longer than 20 days). During the hospital stay her T-cannula was recurrently obstructed by crust and secretion and her symptoms seemed to be relieved after T-cannula change. On endoscopic examination, performed by an ENT resident, it was apparent that the right side of her vocal fold seemed to be paralyzed, and injection laryngoplasty was initially planned to solve her aspiration problem.\nOn detailed examination of her airway, however, a glottic scar band was found at the posterior glottis, which seemed to be the cause of the limited mobility of her right vocal fold (). Moreover, there was a TEF on the left posterior wall of the trachea, 1 cm above the level of tracheostoma (). We confirmed that it was a TEF by verifying leakage through the fistula on oral intake of water. Surgical intervention was planned for her problems.\nThrough an anterior cervical horizontal incision, the skin, subcutaneous fat, and platysma were elevated as one layer and the flap was raised to the level of the suprahyoid region. The sternohyoid muscles were divided in the midline and the thyroid isthmus was divided and ligated to expose the anterior surface of the trachea. The trachea was freed circumferentially only above and below the site of the fistula, and care was taken to maintain the dissection as close as possible to the outer tracheal surface, thereby avoiding injury to the recurrent laryngeal nerves and to preserve the lateral blood supply to the unresected trachea. The tracheal resection was done from the 2nd to the 4th tracheal rings (2.5 cm in length), and the esophageal fistula was found to be a slit-like shape, 1 cm in length (). It is of paramount importance to assure that the tracheal cut end has a normal diameter and mucosal appearance. The opening of the airway gave complete exposure to the esophageal defect. The edges of the esophageal defect were debrided and a two-layer closure was was made over a nasogastric tube.\nAfter closure of the esophageal defect, the trachea was reconstructed via interrupted 4-0 Vicryl sutures with 4 mm interval between stitches. Before completion of the anastomosis, the distal ventilation system was removed and a new endotracheal tube advanced beyond the anastomosis line. Excessive anastomotic tension was avoided by performing laryngeal and tracheal release. The wound was then filled with sterile saline solution to test the anastomosis. The cervical incision was closed by covering the anastomotic line with the thyroid isthmus and by approaching the linea alba cervicalis. Two soft multi-holed drain catheters were placed. Soon after, the larynx was evaluated with suspension laryngoscopy. Under microscopic magnification the scar band causing posterior glottic synechia was resected with micro surgical instruments. Topical 0.04% mitomycin C solution was applied with 3 mm-sized cotton balls around the interarytenoid area, to prevent synechia or scarring.\nThe patient was moved to ward via recovery room with her intubation tube in situ. Extubation was done early the following morning. There was no sign of airway obstruction or aspiration. She recovered both her voice and oral diet. On post-1 year follow-up visit, she had no dyspnea or aspiration and both vocal folds were freely mobile (). |
A 30-year-old male patient with nonsignificant medical history reported to our department with a chief complaint of pain in right mandibular region. On history taking there were episodes of intermittent pain for the past 15 days. Pain was moderate in nature, nonradiating, aggravates on taking sweets and chewing foods, and relieves on taking medication. On clinical examination a deep carious lesion was seen with respect to 46. Exaggerated response was observed during pulp testing with electric pulp tester and lingering pain was observed with cold pulp test compared to contralateral teeth. IOPAR revealed radiolucency involving enamel, dentin, and pulp with no periapical changes in relation to 46 (). It was diagnosed as acute irreversible pulpitis. Root canal treatment was decided and explained to the patient. After securing local anesthesia (2% lignocaine, inferior alveolar nerve block on the right side) rubber dam was applied and endodontic treatment was initiated. After gaining the proper access four canals were located, two in the mesial and two in the distal. It was evident under magnification that the MB and ML were placed well apart with an isthmus joining two canals. Hence, the possibility of MM canal should be anticipated in the isthmus. On exploration with DG-16 probe, we found 2 additional canals between MB and ML (). IOPAR revealed one MM joining the MB canal and another joining the ML canal in the middle third. To confirm this we advised a CBCT of the right mandibular molar. CBCT revealed four canals in the mesial root and two canals in distal root (Figures and ). Access was refined and orifices were enlarged using orifice openers. The working length was determined with radiographic technique and apex locator (). Both the mesial and distal canals were enlarged up to the size of 25/6% taper (M two, VDW) followed by an intracanal medication with calcium hydroxide and chlorhexidine was placed for 1 week. At the 3rd appointment, master cone was selected () and obturation was performed using cold lateral compaction technique and AH-plus root canal sealer. shows the IOPAR immediately after obturation. |
A 67-year-old female patient without serious intercurrences underwent surgery for grade 2 invasive endometrial uterine carcinoma. After adjuvant brachytherapy, the patient was regularly followed up. Twenty-three months after the primary surgery, she developed vertigo and temporary left-sided hemiparesis. Brain MRI showed a solitary lesion in the right temporal lobe (Fig. ). Considering its favorable location, the patient's good general condition, and the absence of extracranial illness, the patient was indicated for neurosurgery and underwent radical resection without any sign of residual tumor on the postoperative CT scan. Histology confirmed metastasis of the adenocarcinoma. Adjuvant RT was not indicated, and observation by control MRI 3 months after surgery was recommended. This MRI, performed 2.5 months after the surgery, unfortunately showed early local recurrence with an enhancing lesion localized ventral from the resection cavity and widely touching the dura with perifocal edema (Fig. ).\nConsidering the patient's continuing good general condition, confirmed absence of extracranial disease, and operability of the newly discovered recurrence, the patient was indicated for a second resection, which resulted in a subtotal resection limited mostly in areas infiltrating the dura mater. Histology verified metastasis of a partly necrotic tumor of a similar appearance to that in the previous resection.\nThe patient was indicated for postoperative RT, and planning of RT started exactly 1 month after the operation, when the patient underwent planning MRI. Unfortunately, there was further progression of the tumor on this MRI, with distinct propagation along the adjacent meninges, especially more rostrally. No third operation was planned anymore, and the patient, with rapidly progressing metastasis, was indicated for palliative RT. Considering the character of the primary disease, the absence of extracranial metastases, and the locally aggressive behavior of the known macroscopic brain metastasis (together with the absence of further intracranial lesions), the patient was indicated for local RT and not for WBRT, despite meningeal impairment. The aim was also to reduce the RT dose to radiosensitive neurons in the hippocampal regions as much as reasonably achievable.\nThe target volumes and critical organs (including both hippocampi) were contoured in the RT planning system EclipseTM version 11.03 (Varian Medical Systems, Palo Alto, CA, USA). During the construction of the clinical target volume (CTV; the region of known or suspected macroscopic and microscopic disease), the emphasis was put on a sufficient coverage of the area of contrast-enhancing adjacent meninges. An isocentric margin of 3 mm was added to the CTV, leading to the planning target volume (PTV; generally speaking, it is an additional margin to accommodate for all potential causes of uncertainty, such as interindividual variability in target volume definition, inaccuracies in image coregistration, movements of patients during RT, etc.) (Fig. ). To ensure a stabile and reproducible position of the patient, an individually prepared thermoplastic fixation mask was used, as well as daily on-board verification imaging in the irradiation treatment room (image-guided RT-IGRT) via cone beam CT equipment with the possibility of subsequent online correction of the patient's position using a table with 6 degrees of freedom. Due to the size, shape, location, and spatial orientation of the PTV, and considering the previous progression of the disease, a dosage of 10 × 3.5 Gy was prescribed to the PTV. The patient was irradiated on a Varian TrueBeam STx linear accelerator (Varian Medical Systems) utilizing the volume-modulated RT technique delivered by 2 coplanar (209°) 6-MV arcs (Fig. ). In the course of RT, the patient was given corticoids for prophylactic purposes with sequential tapering after the end of RT.\nThe first postirradiation MRI (performed 2.5 months after RT) showed a regressing tumor with a remaining contrast-enhancing area in the adjacent dura, which continued to regress on the subsequent control MRI after another 2.5 months. Currently, the patient is 2.5 years after the end of RT, and only some posttreatment changes were described in the area of the right temporal lobe, without any intracranial enhancing lesions according to the last MRI scan. |
A 14.5-year-old male patient of white Caucasian ethnicity (EP) presented to the Oral and Maxillofacial Surgery team, complaining of limited mouth opening and dental crowding. He reported functional and social difficulties associated with his limited mouth opening, and he was unable to have orthodontic treatment due to the same reason. His secondary concerns were an asymmetry of the right side of his lower jaw and constant dull headaches, which were interfering with his school attendance. He reported a noticeable reduction in his mouth opening from the age of 13 years, which coincided with his pubertal growth spurt. His mother and General Dental Practitioner also noticed this.\nEP presented with a Class II division 2 incisor relationship on a moderate Class II skeletal base with a chin point deviation to the left of his facial midline and an average lower anterior face height and Frankfort-mandibular plane angle. His maximum opening when assessed at age 15 years and 9 months was 15 mm between the maxillary and mandibular incisor teeth. Intraorally, he was in the adult dentition with all teeth erupted except his third molars. He had anterior dental crowding with dental centre line shifts and a deep impinging but atraumatic overbite. His right premolars were in scissor bite, and he had a scissor bite on the left side, associated with an anterior mandibular displacement which deviated to the left, in order to achieve maximum intercuspation. His oral hygiene was good, considering his limited mouth opening (Figs. , , , , , and ).\nA dental panoramic tomograph revealed prominent bilateral mandibular coronoid processes (Fig. ). Magnetic resonance imaging (MRI) scans revealed no obvious pathology of his temporomandibular joints. CT scans taken in a closed and open mouth position confirmed the presence of bilateral elongated coronoid processes with apparent impingement between the coronoid processes and zygomatic arches and the presence of bilateral pseudoarthrosis between the prominent coronoid process and the internal surface of the zygoma, as viewed in the parasagittal plane (Fig. , ). Both temporomandibular joint complexes were morphologically normal with slightly underdeveloped condylar processes and a noted absence of expected movement of the condyles or discs in the open mouth position.\nThe patient was consented for bilateral coronoidectomy surgery via an intraoral approach to address his limited mouth opening. This was carried out when he was 15 years and 11 months old (Figs. , , , and ).\nPost-operative rehabilitation was largely facilitated by the use of the TheraBite® (registered trademark of Atos Medical AB, Sweden). This is an easy-to-use manual physiotherapy device which the patient places within their mouth passively and then activates to stretch their muscles of mastication to increase mandibular opening and mobility. The main indication is to improve mouth opening caused by soft tissue fibrosis (scar tissue) post-surgically [].\nAt 2 months, a significant increase in interincisal distance was noted, improved to 26 and 27 mm. The importance for continued jaw exercises was emphasized, and the use of the TheraBite device was checked at every review appointment. At his 3-month post-surgical review, EP reported that his occlusion felt more comfortable and he could comfortably open his mouth. His unassisted and assisted maximum mouth opening was 32 and 33 mm, respectively (Fig. ). He had recently discontinued the use of the TheraBite device.\nFollowing the completion of his post-surgical physiotherapy, EP expressed a wish to pursue orthodontic correction of his malocclusion. Orthodontic reassessment and planning was undertaken, and his orthodontic treatment carried out. His maximum mouth opening remains unchanged.\nThe TheraBite physiotherapy device has previously been successfully used in the post-surgical rehabilitation of a patient with bilateral coronoid process hyperplasia. It consists of two opposing padded, horseshoe-shaped surfaces which distribute forces evenly across all contacting teeth when activated. This should technically minimize the risk of dental trauma and joint overloading due to force application. A physiotherapy regime which commenced between 3 and 7 days post-surgically and consisted of 10-min exercises performed three times per day and repeated over 3–6 months has been advocated by previous authors [].\nThe patient described in this case report commenced using their TheraBite appliance 1 week post-operatively and was asked to adhere to a similar regime as advocated above. The patient ceased using his appliance approximately 3 months post-surgery when he could comfortably achieve the maximum opening provided by the TheraBite appliance without the need for additional forces. He reported using the appliance for a total of 45 min per day rather than the 30 min minimum advocated.\nEP’s maximum mouth opening was regularly reviewed for 6 months post-surgery to ensure this did not relapse. |
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 52-year-old, Caucasian, 1 para, obese (body mass index (BMI) 32.46) female presented to our department for progressive increase in abdominal circumference in the previous year associated with constipation and dyspnea. A fibromatous uterus had been diagnosed previously by pelvic magnetic resonance. Her surgical history included a previous cesarean section. No relevant disturbances of the menstrual cycle were referred by the patient. Physical exam showed an abdomen entirely occupied by a pelvic mass reaching the xiphoid process, which was especially evident when the patient laid supine (Fig. ). On bimanual pelvic examination, the superior third of the vagina was making it impossible to visualize the cervix. Abdominal and vaginal ultrasound performed on hospital admission confirmed a huge fibromatous uterus. Cervicovaginal smear and endometrial sampling, to exclude potential endometrial cancer, could not be performed for the above reported anatomical reasons. The patient had normal hematological, the liver and renal function parameters. Tumor markers were within the normal range. The patient was counseled on the various surgical options and the associated risks, and she opted for a minimally invasive approach, if feasible. Then, detailed written informed consent, prepared by a forensic expert physician, was obtained for the procedure as well as for the publication of a case report and the accompanying images. The TLH was performed as described above. No intraoperative complications occurred; the operative time was approximately 200 min. Intraoperative blood loss was 300 ml due to bleeding at the time of skeletonization of the left uterine vein, which was particularly large and frail. The removed uterus weighed 5700 g. The histological examination revealed a benign fibroid uterus. The patient left the hospital on postoperative day 3 in a very good state. Seven days after discharge she was readmitted to our department because of fever with elevated C-reactive protein (CRP) level and white cell count associated with left basal thoracic pain; then, she underwent total body computed tomography (CT) that showed basal bronchopneumonitis, which resolved with antibiotics. The patient was discharged after 2 days and continued antibiotic therapy at home. One month after discharge, the patient was in excellent condition. |
A 44-year-old nulliparous woman was transferred to an Australian tertiary maternity centre with severe acute onset abdominal pain at gestation of 32 weeks and 2 days. Maternal observations on admission were within normal limits and a fetal CTG demonstrated a reactive trace. Following admission, the pain intensified and a bedside ultrasound demonstrated oligohydramnios and a fetus in breech presentation. The patient was commenced on oral antibiotics and received intramuscular corticosteroids for presumed premature prolonged prelabour rupture of membranes.\nThe patients past medical history included a laparoscopic fundal myomectomy performed eight years ago at a private health care facility. In addition to this her medical history included a laparoscopic ovarian dermoid cystectomy, gastric band insertion, and a provoked deep vein thrombosis (DVT), for which the patient no longer required anticoagulation.\nThe pain intensified during the night and a formal ultrasound was performed early the next morning. This ultrasound confirmed anhydramnios and uterine rupture with the right fetal arm seen intra-abdominally (). Fetal growth parameters were within normal limits with the estimated fetal weight plotted on the 50th centile.\nThe patient was transferred to theatre for an urgent caesarean section at gestation of 32 weeks and 3 days. A midline laparotomy was performed and the right fetal arm was seen protruding through a ruptured anterior myomectomy scar to the level of the fetal shoulder ().\nThe fetal right arm and hand were oedematous and bruised but otherwise uncompromised (). The neonate was delivered via a classical caesarean section, which extended the uterine rupture into an inverted “J” shape and allowed for delivery without additional trauma to the neonate or mother. This classical incision was then closed in two layers with mass closure of the abdominal wall (). As the site of the rupture was at the avascular uterine scar, there was minimal blood loss from the uterus. Presumably, the fetal arm also provided a degree of compression and haemostasis.\nThe patient was advised against future pregnancies due to the increased risk of uterine rupture in subsequent pregnancies. She went on to have an uncomplicated postoperative course and was discharged home three days following delivery. The neonate was transferred directly to the Special Care Nursery and had an uncomplicated neonatal course. A Doppler ultrasound of the neonate's right arm, performed on day one, did not show any arterial stenosis or venous thrombosis. |
This 2,850 g male infant was born to 34-year-old gravida 3, para 3 women at 39 weeks of pregnancy. The mother received prenatal care. There were no remarkable pregnancy complications and she had a normal ultrasound study at 26 weeks gestation. Her previous deliveries resulted in term, healthy newborns who all delivered vaginally after a short labor. Mother previously suffered from a thyroid cancer and tracheostomy was performed to her 3 years before the last pregnancy. On the day of delivery, labor began spontaneously. Due to discomfort mother was out of bed and the rupture of membranes occurred while the patient was standing at the bedside, which was immediately followed by the precipitous, vertex delivery of her infant. The neonate fell down approximately 70 cm to the floor. Apgar scores were 9 and 10 at 1 and 5 minutes after the birth respectively. There was no remarkable problem in physical examination after birth except a right temporoparietal bruise. An emergency ultrasound performed after the birth that did not show any hematoma. Twelve hours after birth the second ultrasound was performed due to remarkable subgaleal hematoma on physical examination. The second ultrasound examination revealed a subgaleal hematoma with a 17×33 mm EDH. Emergency head computed tomography (CT) scan was performed. The head CT revealed a massive parietal EDH with 20 mm thickness and a linear parietal skull fracture (). The patient was transported to operating room immediately. Skin incision was done by the 5 cm inverted U-shaped under CT scan guide. To minimize blood loss from scalp, surgical clamps were used around the skin incision each 1–2 cm. The subgaleal hematoma and connected EDH were evacuated spontaneously due to high pressure. The craniotomy was done with a mosquito scissor. The clotted part of the EDH was evacuated with normal saline infusion after bone flap removal. Tack up sutures with 5-0 silk was performed around the craniotomy site in each centimeter (). Central tack up suture was performed. The bone flap replaced and fixed with 4-0 nylon to the skull in 4 points. The skin was closed with simple running sutures. The blood loss was minimal. The patient transported to Neonatal Intensive Care Unit after the surgery. On first post-operative day we performed a control ultrasound study and there were no signs of hematoma. We repeated the ultrasound examination 3 days after surgery and the study revealed full evacuation of hematomas. He had no neurological deficits and discharged 4 days after surgery. |
A 57-year-old obese female patient who presented initially for evaluation of severe mid-back pain and an inability to stand up straight. One year prior to her presentation, she had had an instrumented anterior and posterior spine fusion from T11 to S1 for a degenerative lumbar disc disease. Neurological examination showed intact motor power with normal sensation in both upper and lower extremities. A standing anteroposterior (AP) and lateral X-rays of the dorso-lumbar spine showed segmental pedicular screw instrumentation with interbody cages done at every level from T11 to S1 (). There was an apparent sagittal spine malalignment with a complete loss of lumbar lordosis and positive sagittal vertical axis. The uppermost pedicular screws at T11 level appeared to be backed out. There was no fracture of the upper instrumented vertebra or the supra-adjacent vertebra.\nAfter thorough discussion of the treatment options with the patient, she elected to have a trial of conservative management. She was started on a physical therapy program to strengthen her back musculatures along with analgesics and anti-inflammatory medications for pain. Follow-up after 6 months showed minimal response with persistence of symptoms, mainly back pain and poor standing posture. She underwent extension of the posterior spine fusion and instrumentation up to T5 with augmentation of the pedicle screws at T5 with PMMA cement and prophylactic vertebroplasty at T4 (). Intraoperatively, care was taken not to disrupt the interspinous or the supraspinous ligament between T4 and T5 in order to avoid adjacent segment problems, particularly proximal junctional kyphosis.\nPostoperatively, the patient progressed satisfactorily. She was able to stand up straight with only tolerable back pain. However, two months after surgery, she developed sudden motor and sensory impairment of both lower extremities while getting out of bed. She said there was no history of trauma or of falling. She was taken to a nearby hospital where physical exam showed complete loss of motor power and sensation in both lower extremities. Computed tomography (CT)-myelogram done at that hospital showed signs of obstruction at T4-T5 level. She was transferred to our hospital four days later. Neurological examination confirmed the absence of motor power in all muscle groups with absent sensation in all dermatomes of both lower extremities (ASIA A). The last normal sensory level was T4 (breast level). She had positive bilateral Babinski reflexes with loss of bowel and bladder continence. X-rays of the dorsal spine showed no hardware failure or any vertebral collapse at the proximal junctional area (). Reviewing the CT-myelogram confirmed the obstruction of dye flow at T4-5 level. She was taken immediately to the operating room where posterior spine decompression through laminectomies was done from T3 to T5 with extension of the instrumentation to T3 using transverse process hooks.\nOn the second day, the patient showed progressive improvement in her neurological status. She regained normal sensation in both lower extremities and started to wiggle her toes. Repeated CT scanning showed no hardware failure or any vertebral collapse of either T4 or T5 (). MRI suggested T4-T5 acute disc herniation compressing the spinal cord ().\nThe patient then underwent T4-T5 discectomy done through a costo-transverse approach along with interbody fusion at the same level using autologous bone graft and extension of the instrumentation up to T2 using pedicular screws.\nPostoperatively, the patient's neurological status continued to improve gradually. At two weeks after operation, she had normal sensation in both her lower extremities with good bowel and bladder control. She was able to move her feet and adduct her legs with some quadriceps activities. She was started on an extensive physical therapy program and she is showing a remarkable improvement in her motor power. |
A 59-year old female was referred to our EPS center outpatient clinic because of progressive symptoms of bowel obstruction almost 33 months after KTX. The nausea, vomiting and abdominal pain predominantly occurred shortly after eating solid meals. The patient’s medical history included end stage renal disease secondary to polycystic kidney disease. She had a 26-month history of PD before her first KTX and was treated with PD for almost 4 years before undergoing her second transplantation with a kidney from a living donor. During PD treatment she had no signs of ultrafiltration failure and had experienced one uncomplicated peritonitis episode with Staphylococcus aureus.\nHer symptoms had started insidiously one year after transplantation while she received a tacrolimus-based immunosuppressive regimen. Diagnostic work-up did not show any signs of inflammation with normal radiological imaging of the abdomen. Almost 23 months after her last transplantation a diagnostic laparoscopy was performed elsewhere, but no macroscopic abnormalities were reported. However, peritoneal biopsies were taken and showed signs of fibrosis without active or chronic infiltration. As the symptoms and weight loss persisted, she was referred to our clinic for a second opinion.\nAt presentation she had lost 5 kilograms of weight over the last year (BMI 19 kg/m2) and was unable to tolerate solid foods. No abnormalities were found at physical examination, and laboratory tests showed no signs of systemic inflammation (C-reactive protein (CRP) < 1 mg/L, albumin 40 g/L) and adequate graft function (serum creatinine 91 umol/L). A recent abdominal CT scan did not reveal any abnormalities compatible with the diagnosis of EPS although a “feces sign”, consisting of intraluminal feculent material in the small bowel, was observed (Figure ). Additionally, the CT scan showed a small amount of localized ascites in the abdomen but no other diagnostic signs of EPS like bowel tethering, calcifications, or peritoneal thickening. Despite the absence of typical findings, but the severity of the progressive symptoms we considered the possibility of localized EPS, a condition in which the peritoneum shows encapsulating sclerosis predominantly at the level of the terminal ileum [,]. Surgical exploration was considered as a final diagnostic procedure. During the operation, a classical picture of EPS was found characterized by a thin cocoon-like sclerotic membrane encasing the small bowel (Figure A). A complete resection of the encapsulating sclerotic membrane and total enterolysis were performed, combined with complete removal of the thickened visceral peritoneal membrane (Figure B), which lead to restoration of peristalsis durante operationem. Histologic evaluation of the visceral peritoneal membrane was performed, supporting the diagnosis of EPS, and showed dense sclerosis with patchy mononuclear cell infiltration (Figure ). On the fifth postoperative day, an emergency ileocecal resection with protective loop ileostomy was necessary because of a perforation at the level of the ileocecal junction where a serosal injury had been made during the first operation. The patient recovered soon after surgery, and in an attempt to prevent further recurrences, was prescribed 10 mg twice-daily tamoxifen and 10 mg once daily prednisolone. After five weeks the loop ileostomy was closed and bowel continuity restored, with an uneventful postoperative course. One year after EPS surgery, the patient has gained almost 20 kilograms in body weight and is doing well with a stable graft function and without clinical signs of EPS recurrence. |
A 49-year-old female was initially referred by her GP 6 years ago with a history of intermittent abdominal pain for 2 years and iron deficiency anaemia. Abdominal pain was mild and located mainly in the centre but with some generalization throughout the abdomen. It was associated with mild nausea at times but no vomiting. She has a history of longstanding constipation, and pain would get worse during days of constipation. There was no history of weight loss. There was no other significant background history apart from some non-specific pelvic and knee joint pains for which she takes ibuprofen on and off. She does give an account of some irregular menstrual cycle but not massive bleeding. She underwent a gastroscopy, which was normal, but colonoscopy failed due to inadequate preparation. The impression was that her irregular menstrual cycle contributed to her anaemia and that she was suffering from slow-transit constipation, which resulted in poor bowel preparation. She was started on oral iron, and the plan was to monitor her haemoglobin and do a stool occult blood test; if this is positive, to repeat colonoscopy. Her stool occult blood test was negative on a couple of occasions, so she was continued per oral iron and kept under observation for anaemia. Due to ongoing issues with anaemia, she had a complete colonoscopy done in 2015, which was normal. She was re-referred by her GP in February 2019 with ongoing problems with chronic anaemia. Symptomatically, she complained of severe tiredness, and her abdominal pain had worsened with occasional episodes of severe abdominal pain, central in origin, which were related to her meals. She did give a history of nausea and episodic abdominal pains, but no vomiting and constipation had been getting worse lately. She required a couple of iron infusions with her GP to keep her iron reserves up.\nHer latest Hb was 7.5 g/dL, MCV − 62.3 fL, iron − 2.3 μmol/L, and ferritin − 1.8 ng/mL. Her systemic examination was unremarkable. At this stage, she had a repeat OGD, which showed a couple of shallow ulcers in the pylorus likely due to NSAIDs, and histology showed mild active inflammation but no metaplasia or dysplasia. Her repeat colonoscopy was unremarkable. She went onto have MRE to investigate for a cause of anaemia which was unremarkable, and of note, there was no stricture seen. She underwent capsule endoscopy in September 2020 as a part of investigations of her ongoing anaemia, which showed a large area of ulceration in the distal small bowel with an evident stricture. The capsule bounced back and forth here and then seemed to progress to an area that is blood-stained, ulcerated, and again stenosed. Prep was somewhat compromised in this area, so it was hard to be 100% confident that these are 2 distinct ulcers, but probably favoured 2 separate areas of ulcerations and strictures here.\nThe capsule seemed to not progress beyond this point. A follow-up X-ray abdomen confirmed capsule retention, and subsequent CT abdomen with contrast also showed the presence of the capsule in the distal ileum just proximal to a small bowel stricture. A retrograde review of the MRE also raised the suspicion of stricture in the distal small bowel. The patient was asymptomatic from a capsule retention point of view. She was referred for double-balloon enteroscopy to remove the retained capsule, but unfortunately, the retrograde DBE attempt failed due to poor prep. After discussing the pros and cons of the retained capsule with the patient, it was mutually decided to leave the capsule in place for now as she is asymptomatic, start her on misoprostol, and avoid NSAIDs. She was advised to immediately contact the hospital emergency department if she developed any obstructive symptoms. Otherwise, she is being followed closely in OPD. She was also briefed not to have a pregnancy and an MRI scan. To date, she is doing well on misoprostol with no obstructive symptoms, and her Hb has been stable (Fig. , , ). |
A 72-year-old male patient presented to us with complaints of dull aching pain in the left iliac fossa and constipation for 3 months. He had undergone a TEP for a left inguinal hernia 10 years ago, using a microporous polypropylene mesh and non-absorbable tackers. His comorbidities included hypertension and ischemic heart disease. On examination, he was haemodynamically stable and had a palpable diffusely tender lump in the left iliac fossa measuring around 4 cm × 3 cm. The rest of the abdomen was soft, and per rectal examination was unremarkable. Haematological and biochemical investigations were normal. A contrast-enhanced computed tomogram revealed an ill-defined hypodense collection in the left iliac fossa, abutting the left rectus abdominis and left internal oblique muscles with the loss of fat planes []. There was a suspicion of communication with distal descending colon and areas of calcification [], and air specks were seen within the collection near the site of communication. Colonoscopy revealed a piece of mesh protruding within the lumen of the sigmoid colon occupying three-fourth of its lumen []. There were isolated diverticula within the sigmoid.\nAt exploratory laparotomy, a segment of sigmoid colon was found adherent to the abdominal wall and the area of the left internal ring []. On adhesiolysis, a piece of polypropylene mesh along with metallic tacker was found exposed and penetrated into the sigmoid colon lumen from the preperitoneal space with a purulent collection of approximately 10cc around the area. The adherent segment of the sigmoid colon was resected and a Hartmann's procedure was performed. The mesh and tacks eroding into the sigmoid colon [] were removed, but no attempt was made to disturb medial part of the mesh incorporated in the extraperitoneal space. A lavage was given and a drain was placed in the area. The culture of the pus grew Escherichia coli sensitive to carbapenems, which was administered for 5 days. The patient made an uneventful recovery and was discharged on the 6th post-operative day. The histopathology of the specimen showed diverticular disease with perforation of the colon. |
During a routine mammogram, a 64-year-old female was found to have two 7-mm focal asymmetries and lymphadenopathy. Her initial cancer stage was diagnosed as cT1cN1cM0. Four weeks after her positive mammogram, she underwent a needle biopsy of an axillary lymph node that demonstrated malignancy. She was initially diagnosed with right breast cancer stage 2A which was ER+, PR+ and HER-2Neu negative. The surgical biopsy was then diagnosed as metastatic invasive lobular carcinoma. Upon pathological staging she was subsequently staged as Stage 3C. Her final stage via pathology was pT1N3M0. Her past medical history included hypertension, endometriosis and a benign thyroid nodule. Her surgical history included a hysterectomy and a hernia repair of unknown site. She was a retired social worker and a widow.\nAfter initial staging, the patient had neoadjuvant chemotherapy. She completed four out of four cycles of cyclophosphamide with doxorubicin and subsequently completed eight out of eight cycles of taxol. She responded well to chemotherapy with no significant treatment delays or major side effects. After completion of chemotherapy, she underwent a right lumpectomy with axillary lymph node dissection. Fifteen out of 18 dissected lymph nodes were positive for malignancy. Three weeks after surgery, a bone scan showed no evidence of skeletal metastases. Her lumpectomy margins were also found to be inadequate which required a re-excision of the right breast four weeks after her initial lumpectomy.\nShe received an initial episode of physical therapy (PT) for right upper extremity (UE) lymphedema for eight visits by another clinician. This retrospective chart review resulted in limited availability of data and clinical insights into the patient's initial episode of care therefore we will focus on the second episode of care. The patient had initially presented with minimal swelling of the UE and moderate swelling of the right breast and chest wall. She also demonstrated decreased right shoulder range of motion (ROM) for flexion and abduction which resulted in difficulty with raising her arm overhead as well as pushing and pulling. After the eight visits of PT, she required minimal assistance with compression wrapping and swelling had decreased by approximately 1 cm. Her right shoulder flexion had improved to 150° and abduction to 142°. Her therapy was discontinued early due to a new finding of a renal mass that required a nephrectomy.\nAs a component of her routine follow-up, she underwent a computerized tomography scan that found a right kidney mass that was suspicious of carcinoma. A biopsy revealed papillary renal cell carcinoma which required a right radical nephrectomy. Concurrently, her radiation oncologist recommended external beam radiation to her breast and axilla. She was also started on anastrozole (Arimidex). Her radiation therapy was delayed one month due to the nephrectomy. She completed 30 cycles of external beam radiation over six weeks. Throughout her radiation treatments, she received ongoing consultations and screening by a physical therapist who was stationed in the radiation oncology department.\nClinical findings\nThe case described was the patient’s second episode of care as the first episode of care was interrupted by the need for a radical nephrectomy. This second episode of care lasted for 10 visits and the patient was seen three times per week. This episode of care was initiated 50 weeks after her initial mammogram, 26 weeks after her lumpectomy and 17 weeks after discharge from her first episode of outpatient PT (Figure ). All measurements and examination procedures were completed by the same physical therapist for this episode of care.\nSubjective History\nUpon listening to the patient’s subjective remarks regarding when the swelling started and how it began post-surgically, surgical swelling was on the initial differential diagnosis list. However, as the swelling remained longer than two to three weeks and there was not a clear inflammatory process, lymphedema was considered to be more likely. In addition, the likelihood of lymphedema was increased due to her history of radiation and a BMI greater than 30. She also reported difficulty with reaching above her head as well as tightness and a pulling sensation when reaching above or behind her; this would require examination for lymphatic cording after lymph node impairment. The examination also included assessing for infection or cellulitis which may precipitate lymphedema. Prior to the initial history, the patient completed an Upper Extremity Functional Index (UEFI), in which the patient reported difficulty reaching into high cupboards, putting a shirt on over her head and lifting a bag of groceries. The patient’s overall UEFI score was 48/80 with a score of 80 being no difficulty with any tasks (Table ). The patient’s goals were to decrease her pain, size of her right breast and upper extremity and improve her shoulder ROM in order to be independent with home maintenance activities and performance of her ADLs. Based upon her prior episode of PT care for her right UE lymphedema, it was anticipated that she would be knowledgeable of her lymphedema diagnosis and management, however upon the initial subjective history, it was found that this foundational knowledge was lacking.\nTests and Measures\nPostural and palpatory assessment: Upon observation of the patient’s physical stature, she was moderately overweight, with obvious difference in size of the upper extremities and breasts. She demonstrated postural deviations including a slight forward head, rounded shoulders, and a posterior pelvic tilt. She also presented with a concave chest wall. Her right breast was observed to be larger and had a peau d’orange type texture along the inferior border of the right breast with an increase in fibrotic tissue of the right breast. She was also more sensitive to palpation of the right breast, especially along the lateral and inferior side of the breast. She demonstrated increased palpatory tenderness of the posterior aspect of the right axilla which is consistent with the symptom presentation pattern for lymphatic cording. There were no signs of cellulitis, infection or other inflammatory process.\nObjective measurements: Upper extremity and trunk girth measurements were taken utilizing a standard cloth tape measure (Tables , ). Diagnostic criteria for lymphedema is generally accepted to be a 10-15% increase in total extremity volume and may be reflected by a 2-cm increase in anthropometric measurement as assessed via tape measure []. Standard landmarks were utilized to compare repeated measures. The patient's shoulder ROM was assessed via a plastic goniometer in supine. The strength of her bilateral shoulders was quantified via manual muscle testing (MMT) in sitting as described by Kendall (Table ). Her cervical spine range of motion was unremarkable.\nPhysical Therapy Diagnosis\nThe patient was classified with Stage 2 secondary lymphedema without significant complications. Stage 2, also called spontaneously irreversible stage, is characterized as having lymphostatic fibrosis, hardening of the tissue, no pitting, positive Stemmer sign, and increased risk of frequent infections []. As this lymphedema was precipitated after a cancer diagnosis and disruption of lymphatic pathways due to surgery and radiation therapy, it was anticipated that this would become a chronic condition.\nEvaluation and Clinical Decision Making\nThe likelihood of lymphedema was increased due to the history of lymph node dissection, radiation, and surgery. This clinical suspicion was further reinforced by the objective findings of increased anthropometric measurements and skin changes of her breast and upper extremities as well as her AROM and strength deficits. Based on these findings, the patient would benefit from education for a home exercise program (HEP) including stretches, strengthening exercises and patient education on self-lymphatic massage. The most important issues were to focus on achieving the patient’s goals of improving her function by reducing swelling of the right upper extremity and breast, as well as educating her on how to manage the diagnosis independently. This would also include instructing her on a HEP to improve her posture, shoulder AROM and strength.\nBased on observational assessment of her sitting and standing posture, she would benefit from exercises to assist in achieving and maintaining optimal upright posture which included chin tucks and scapular retraction. In addition, the patient would require education on the lymphatic system and the components of comprehensive decongestive therapy (CDT). The tightness of right pectoralis muscle was believed to be contributing to her shoulder ROM limitations, therefore, instruction on postural stretches, including a pectoral doorway stretch and use of a wand to do shoulder flexion and abduction stretches, would be required. Additionally, the patient would be educated and coached on aerobic exercise via a walking program to improve cardiovascular fitness. As an adjunct to her physical therapy, she was encouraged to utilize the facility’s indoor track and instructed to do simple stretches and strengthening exercises with both elastic bands and light weights. The patient received education on the health system’s Cancer Survivorship Exercise and Wellness aftercare program where she could continue with an exercise program after she was discharged from physical therapy to continue to progress her strength and cardiovascular endurance and maintain her ROM. In order to evaluate the patient's ongoing progress, at every treatment the patient would be asked how long she wore her compression padding for her breast swelling and the compression bandaging for her right upper extremity and whether she had been compliant with her self-lymphatic massage and HEP.\nTherapeutic interventions\nThere were several goals that were pursued in physical therapy: decreasing anthropometric measurements of the right upper extremity and breast, instructing the patient on self-lymphatic massage and compression bandaging, and achieving independence in a HEP to improve her shoulder AROM, strength and posture. Physical therapy started with manual lymphatic drainage, education on her lymphatic system and the rationale for its dysfunction. To reduce the swelling of the right upper extremity and breast, compression bandaging of the right upper extremity and breast was also initiated. On treatment day three, the patient was instructed in proper performance of self-lymphatic massage and compression bandaging. In order to assure steady limb and breast reduction, she would be required to perform these tasks at home on the days she was not in PT. Every treatment session after day three, the patient and therapist engaged in a thorough review of self-lymphatic massage and compression bandaging until she was able to consistently provide return demonstration for accurate performance of these techniques. Once the patient's breast edema was reduced, she was advised to wear a compression bra to maintain this reduction.\nTo decrease the patient's stress and anxiety related to incorporating the lymphedema program into her current lifestyle, the patient received extensive education on the clinical rationale for the various treatments and the patient was provided an opportunity to ask clarifying questions throughout each treatment. Education also included instruction to remove the compression bandages in the event of sharp pain, numbness or tingling. Finally, the patient received a handout and a personalized video recording of the self-lymphatic massage and compression bandaging to assist with compliance and performance.\nThe patient received manual therapy including trigger point releases of the right upper quadrant to reduce tightness of the pectorals, subscapularis, teres minor and major, trapezius, infraspinatus, latissimus dorsi and rhomboids to help increase shoulder ROM and assist in achieving upright posture. She was also given active upper extremity exercises to perform while wearing her compression bandages. These exercises were aimed to assist in actively pumping the fluid out of the right upper extremity and included elbow flexion/extension, wrist flexion/extension and fist clenches. These active exercises would use the compression bandaging as a counterforce to pump the fluid out of the upper extremity to assist in decreasing her anthropometric measurements.\nKey postural exercises provided included chin tucks, shoulder shrugs, shoulder circles, and scapular retraction/adduction. The patient received shoulder ROM exercises, including shoulder flexion and abduction with a wand, and supine gravity-assisted shoulder flexion. As the patient progressed, she also received new stretching exercises to increase her shoulder ROM and postural stretching and strengthening exercises to help the patient sustain an upright posture. The initial shoulder stretching regimen included passive shoulder flexion on a table, shoulder abduction with a wand to improve glenohumeral and scapulothoracic motion. She also performed shoulder extension and adduction with elastic bands that provided moderate resistance. She also performed shoulder flexion and abduction exercises with light weight and high repetitions. She also received exercises in a supine position that she could perform on her bed at home. These included alternate shoulder flexion stretches and shoulder abduction to increase pectoral ROM. Finally, she was given strengthening exercises in supine including shoulder flexion with elastic bands from 90° flexion to her end range, horizontal shoulder abduction/adduction and internal/external rotation with the arm at the side of the body with elastic bands. In standing, she was instructed in strengthening exercises including shoulder extension and adduction with an elastic exercise band and shoulder flexion and abduction exercises and biceps curls and triceps extension using light weights with approximately two sets of 15 repetitions.\nOutcomes\nPhysical therapy appeared to be effective as the patient demonstrated a decrease in anthropometric measurements of the upper extremity and trunk (Tables , ). Tidhar et al. reported a minimally clinically important difference of circumferential measurements as greater than 1% for either the arm or leg []. As the standard error of measurement (SEM) for anthropometric measurements was less than 1%, the patient demonstrated a greater than 1% reduction in swelling for all measurements.\nThere was an increase in shoulder ROM for abduction of 22° (Table ). A reduction in shoulder abduction ROM of ≥20 degrees is associated with greater difficulty with household activities and hobbies []. Using the UEFI, it was observed that the patient had an improvement in her UE function and ADLs since beginning physical therapy (Table ). This change was found to be greater than the minimal detectable change of 7.9 scale points as cited by Binkley et al. [].\nAs the patient was able to achieve her initial goals of becoming independent with the self-lymphatic massage and the self-compression bandaging and decreasing her anthropometric measurements, the focus of therapy shifted toward other goals. These goals included addressing her posture, shoulder ROM and strengthening exercises. Physical therapy helped this patient take control over her physical issues by decreasing the swelling of the right UE and breast. The patient’s improvement in her shoulder ROM now allowed her to be able to reach into higher cupboards with less difficulty. The education on self-lymphatic massage and compression bandaging empowered the patient to manage this condition herself if she encountered a re-exacerbation in swelling.\nAfter discharge, the patient was advised to continue with self-lymphatic massage and compression bandaging at night for the next three months on a daily basis to maintain the decreased anthropometric measurements and wear her compression sleeve and compression bra throughout the day. At the three-month mark, she was instructed to start weaning herself off the compression bandaging and to schedule a follow-up with her physician. The therapist also recommended utilizing the unaffected arm for blood pressure measurements and blood draws/punctures to reduce the risk of exacerbation of lymphedema. She was also instructed not to submerge herself in a hot tub or sauna due to increasing her chance of exacerbating her lymphedema. She was given handouts on skin care and helpful guidelines. The patient was encouraged to increase her daily walking program to 30 minutes and continue with the stretching and strengthening home exercises. |
A 50-year-old male patient with pain in the maxillary right first molar and a blackish growth on the right side of hard palate since 12 days visited the Department of Oral Medicine and Radiology. The patient did not report taking medications for any other illnesses. Habitual history was negative. Extra-oral examination revealed enlargement of bilateral submandibular lymph nodes, which were oval in shape, mobile, and nontender. On intraoral examination, a black exophytic growth was seen on the right side of the hard palate (). The lesion extended onto the buccal aspect involving the gingiva between the maxillary right first and second molars (). It was soft in consistency and nontender. Small satellite lesions were seen on the palate surrounding the lesion. A clinical diagnosis of malignant melanoma was made. Radiographs were taken and incisional biopsy performed.\nOrthopantomogram showed carious maxillary right first and second molars with destruction of the interdental bone between them. The continuity of the floor of the maxillary sinus was disrupted in the maxillary right first molar region. The periodontal ligament space in relation to all the right maxillary molars and second premolar was widened (). CT scan showed an ill-defined enhancing soft tissue mass on right side of hard palate, extending posteriorly upto the soft palate. There was no evidence of erosion or sclerosis of bone due to the soft tissue mass (Figures and ). Bilaterally enlarged level I, II, V lymph nodes were seen.\nIncisional biopsies were taken from both the lesions. Histopathological studies revealed numerous atypical melanocytes within the epithelium and also invasion into the connective tissue. These cells were epitheloid to spindle in shape, with vesicular, hyperchromatic nuclei, and prominent nucleoli. Few mitotic figures were also seen (). Thus, the pathological examination confirmed the diagnosis of malignant melanoma. The patients were then referred to the Regional Cancer Institute for further treatment. Both patients underwent excision of the primary lesion along with radical neck dissection and postoperative radiotherapy. |
We report a rare case of IVC aneurysm in a 22-year old Afghan-Iranian male patient. The patient had a history of blunt abdominal trauma one week prior to his referral to the emergency department of our center. On his initial abdominal trauma, a complete physical examination and focused assessment with sonography for trauma (FAST) was done. The investigations were normal and the patient was discharged from the emergency department. The patient has had vague abdominal pain after his discharge.\nOn the referral of the patient to our center, we planned an abdominopelvic computed tomography (CT) scan with oral and IV contrast. The scan illustrated an IVC saccular aneurysm originating from right side of the IVC below the renal veins (). We assumed two possible etiologies. The aneurysm could incidentally and in another hand it could be related to the patient’s recent history of abdominal trauma. Magnetic resonance venography was also conducted and it also confirmed the diagnosis of a saccular type III IVC aneurysm ().\nWe planned open resection and repair of the aneurysm. A midline laparotomy was done. After thorough exploration of the abdominal and pelvic cavities, a right medial visceral rotation was conducted by mobilization of the right colon and a Kocher maneuver (The Cattel-Braasch Maneuver). The right kidney was left in situ. The entire sub-hepatic IVC was exposed. A saccular aneurysm with dimensions of 4*5 cm was found on exploration (). The aneurysm was located below the renal veins and the neck of the aneurysm was at the right side. The aneurysm was confined to the infrarenal IVC and there was not any associated venous anomaly. Thus, it was a type III saccular IVC aneurysm. A partial Satinsky clamp was applied posterior and left to the site of aneurysm origin on IVC and a longitudinal incision was done anterior to the neck of the aneurysm. Then, the entire aneurysm was resected. The neck of the aneurysm was closed with lateral venorrhaphy by running 6.0 polypropylene sutures ().\nThe patient had well recovery after the operation. Postoperative anticoagulation was administered by unfractionated heparin and warfarin. Warfarin anticoagulation was continued for three months to prevent venous thrombosis and probable pulmonary embolism. The patient’s follow-up did not reveal any morbidity. Postoperative CT scan was also conducted on seventh postoperative day. Postoperative appearance of IVC was normal (). |
A 60-year-old male patient reported with a chief complaint of painful swelling over the left side of the neck region since 2 months. The pain was dull and intermittent. The swelling was gradual n slow. There was no significant past medical, dental, and family history. He had a history of beedi smoking (smokeless tobacco) for 30 years, with a frequency of 10–12/day. He also had a history of gutkha chewing for the same period with a frequency of 3–5 packets/day.\nExtraoral clinical examination revealed palpable and tender swelling extending from behind the ear lobe to the angle of the mouth on the left neck region [].\nThe intraoral examination showed an ulceroproliferative lesion involving the left posterolateral part of the tongue extending onto the soft palate involving faucial pillars was seen. The ulcer was tender on palpation, exhibiting irregular margins with ill-defined borders surrounded by erythematous area. Oral hygiene was poor with generalized stains and calculus. Generalized attrition was present. No limitation of mouth opening was seen. Tongue movements were within normal limits. Left submandibular lymph nodes were palpable, hard, tender, and were fixed to the underlying structures [].\nBased on the clinical features, a provisional clinical diagnosis of carcinoma of the base of the tongue was given. After obtaining written consent from the patient, an incisional biopsy from the lateral border of tongue was performed under local anesthesia and sent for histopathologic examination. The patient was advised to get a magnetic resonance imaging (MRI) done.\nMRI showed the lesion extended into the posterior wall of the pharynx and to the base of the skull along with evidence of nodal metastasis and since invasive carcinoma could not be ruled out from the incisional specimen, treatment was planned accordingly [].\nAll the accessible areas of the oral cavity were excised and debulking surgery over the pharyngeal mass was done. Radical neck dissection was done to removed the neck mass. Surgery was done under general anesthesia. Moreover, patient was referred for radiotherapy and chemotherapy.\nThe specimens were routinely fixed, processed, and stained with hematoxylin and eosin. The stained sections revealed dysplastic stratified epithelium is seen invading the connective tissue in the form of nests, islands, and lobules []. A few areas showed epithelial cells proliferating in the form of chords interconnecting with each other []. Islands of epithelium were made up of basaloid appearing cells with peripheral palisaded arrangement, showing large vesiculated nuclei with an increased nuclear-to-cytoplasmic ratio and scant amphophilic cytoplasm. Surface epithelium showed features of dyplasia.\nIslands also displayed areas of comedo-necrosis and focal keratinization []. Mitotic figures were also abundant. Stroma around the tumor was composed of fibrous connective tissue infiltrate along with chronic inflammatory cells chiefly composed of lymphocytes. Lymph nodes also showed metastasized tumor cells proliferating in lymphoid tissue.\nBased on the histopathological features, a diagnosis of BSCC of oropharynx was given. |
A 77-year-old male patient presented with gradually progressive swelling of the scalp of 6 years duration. There was no history of headache or any discomfort pertaining to the lesion. The swelling gradually increased in size, and the patient tried to hide the swelling by wearing a turban. However, for the past 1-month patient had on and off headache with difficulty to sleep and neck pain due to the giant size of the tumor. Furthermore, he could not hide the tumor using a turban as the size of the tumor was huge.\nA swelling of size 19 cm × 12 cm × 7 cm extending fully over the bifrontal scalp noted. The lesion was extending posteriorly up to the middle of parietal convexity, and laterally, the lesion was seen overhanging the temple []. The skin over the swelling appeared smooth, and there was loss of hair over the swelling. No visible engorged veins or visible pulsations present. The swelling was soft in consistency, and the skin over the swelling was pinchable. Mobility and fixity could not be assessed due to the large size of the swelling. The swelling was nonpulsatile, and there was no impulse on coughing. The patient was further evaluated with routine blood investigations, which were within the normal limits. The X-ray of the skull showed midline erosion of the calvarium of the frontal and parietal bones []. Magnetic resonance (MR) imaging showed a large expansile lytic lesion of size 18 cm × 9 cm × 6 cm arising from the intradiploeic region of the frontal bone causing destruction of both tables of the frontal bone, the lesion was limited by the dura causing mass effect on the frontal lobes and effacement of the frontal horns. There is no contrast enhancement and MR venogram showed decreased filling of the superior sagittal sinus in the anterior one-third [].\nThe lesion was excised completely. Pale yellow capsule was dissected free from the scalp layers. The capsule was adherent to the bone with destruction of the bone. The capsule was opened, and yellow-colored pultaceous material was removed. The capsule was excised completely. The area of the bone where the capsule was adherent was nibbled. There was no intradural extension or dense attachment to the superior sagittal sinus. Cranioplasty was done with a titanium mesh implant []. Histopathology was consistent with epidermal cyst. |
A 43 year old male patient came to the department of Oral medicine and Radiology with the chief complaint of pain in the upper lip for the past 15 days. The patient experienced a mild, intermittent, dull aching type in the same region. His Past medical history was non-contributory and in the past dental history the patient revealed the history of trauma from road traffic accident 15 years ago, during which the patient had suffered from lip laceration and fracture of anterior teeth. Laceration in the lip was sutured immediately and later root canal treatment and crown placement was done. He further added that, 2 years after the trauma, he had developed pain and swelling in the upper lip in relation to 11, 12. A minor surgical procedure was done and a tooth spicule was removed. Constitutional signs and review of all systems appears to be normal on general examination. On local examination, inspection revealed no abnormality in the upper lip, labial mucosa and the entire oral cavity. On palpation a painful tiny hard mass measuring about 5 mm approx was palpable in the upper lip 0.5 cm lateral to the midline in relation to 11 and 12. On hard tissue examination prosthetic crown was present in relation to 11, 12. Considering the chief complaint, history and correlating with the clinical findings the mass in the upper lip was provisionally diagnosed as a foreign body in the upper lip.\nAn intra oral Periapical radiograph of the upper lip revealed a single radiopaque mass measuring about 3 X 2 mm in size (Fig .1).\nBlood investigation was performed which revealed to be within normal limits. Then an excisional biopsy was done by placing a single incision under local anesthesia (Fig.2).\nAll procedures were performed under aseptic condition (Fig.3).\nA review was done after 7thday, first month, third month and after 6 month. All necessary check radiographs were taken. The wound healing was satisfactory.\nHistopathological examination shows the connective tissue mass with interspersing trabeculae of mature bone and osteocytes in lacunae surrounded by loose to densely arranged collagen fibers (Fig.4 (a,b)). Hence the final diagnosis was suggestive of osseous Choristoma. |
A 56-year-old female presented to OPD with complaints of right sided supraclavicular neck swelling for last 2 years and associated pain and tingling in the right arm for past 1 year. There was no history of fever, trauma, systemic illness. On examination, a 5X4 cm spherical swelling was palpable in the right supraclavicular area which was non tender, not fixed to the overlying skin and it was more mobile in the horizontal direction than in the vertical direction. On neurological examination, muscle power in all muscles of the upper limb was found to be 5/5 with no signs of wasting and sensations were intact. Tinel sign was negative. Decision to take a FNAC of the swelling was taken which revealed spindle shaped cells and schwann cells which was suggestive of schwannoma. Furthermore, CECT neck was done which showed a heterogeneously enhancing solid cystic lesion in the right supraclavicular region medially extending into and causing widening of right C6-C7 neural foramen ().\nMRI neck and chest were also ordered which showed a well-defined solid cystic lesion in right supraclavicular region which was isointense on T1WI and heterogenous enhancement was seen on post contrast scan which confirmed our diagnosis of Schwannoma most probably arising from the brachial plexus ().\nAfter a thorough evaluation of the case, and taking proper consent from the patient after explaining all possible complications, the decision of undertaking excision of the tumour under general anaesthesia was made. A horizontal incision was given over the swelling and tumour was exposed. Trunks of the brachial plexus were seen passing around the tumour ().\nThe tumour was carefully excised without causing any damage to the trunk and sent for histopathological examination.\nThe histopathology of the tumour specimen showed a characteristic cellular pattern of alternating regions containing compact spindle cells called Antoni type A areas and more loosely arranged, hypocellular zones called Antoni type B areas which was consistent with the diagnosis of Schwannoma ().\nHence, a final diagnosis of schwannoma of the Brachial plexus was made. In the postoperative period, numbness and tingling in the right arm along with stiffness at the elbow joint was noticed. Patient is being regularly followed up in the last 6 months and has shown improvement in stiffness, tingling and numbness with regular physiotherapy. |
This 18-year-old male patient presented at the Oral and Craniomaxillofacial Surgery Clinic to consider surgical treatment options for reducing an enlarged tumor of the back. The patient had more than six café au lait spots on the trunk and extremities, axial and inguinal freckling and several cutaneous tumors that were slightly raised above the level of the skin. The patient had no physical discomfort, no motor or sensitive deficits. The patient stated that he had been operated 2 years earlier on a tumor of the back in another hospital. More detailed information was not available. Despite this previous treatment of the tumor, the remaining tumor mass disturbed him both physically and in his self-perception. The patient stated that the tumor had been growing again since the first operation.\nOn the back there was a tumorous protrusion of the intact skin with a maximum above the spine, which extended from the lower thoracic region close to the edge of the pelvis (Figure 1 A ). The tumor was clearly prominent under tight-fitting clothing. The skin in this area was darker pigmented throughout the lumbar region and showed hirsutism. The tumor was insensitive to touch and pressure, showed no fluctuation on palpation, and the covering skin moved with the tumor.\nB-scan ultrasound revealed an inhomogeneous mass with focal, partly string-like reflections inside the space occupying lesion. Borders were poorly defined and the tumor mass reached to the spinous processes of the spine. The tumor appeared as solid mass and contained no cavities suggestive of necrosis. The tumor was resected in general anesthesia. When the lesion was exposed, a black pigmentation became apparent, which was partially arranged in a stripe-like pattern and frayed at the edges (Figure 2 ). The tumor was resected and the contour of the back reshaped. Despite dense suturing of the wound margins a hematoma developed, which was emptied. Secondary wound healing took 21 days and led to a stable healed wound (Figure 1 B ). There was no movement restriction of the patient after the wound had healed.\nUpon neuropathological investigation a spindle-shaped, 22x9x2 cm3 large skin sample with centrally located 6 cm long scar was seen. Cutting the skin exposed white and slightly greasy tissue on both sides of the scar with spotty brown-black pigmentation.\nHistological examination revealed a diffusely grown neoplasia of medium to high cellular density in the subepidermal connective tissue, consisting of roundish and oblong cells with delicate cytoplasmic extensions and slightly pleomorphic, small, round-oval, sometimes comma-shaped nuclei. The cells showed different degrees of pigmentation. Repeatedly, pseudo-Meissner corpuscles were observed. There was no evidence of mitoses and no Turnbull-positive hemosiderin pigment was detected. Immunohistochemistry demonstrated labeling of the tumor cells with antibodies against S100-protein and melan-A and to a lesser extent also with antibodies against HMB45. The Ki-67-proliferation index was less than 3%.\nA subepidermal diffusely grown pigmented (melanotic) neurofibroma WHO grade I was diagnosed (Figure 3 ). |
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 69-year-old lady presented with the retention of urine with a residual volume of 2 L and renal impairment. She had in the past undergone partial cystectomy and received radiotherapy for muscle invasive bladder cancer. Investigations revealed left hydronephrosis and hydroureter. Left nephrostomy was inserted and nephrostogram revealed stricture in the lower end of the left ureter [].\nLeft antegrade JJ stent insertion was thus carried out. She discharged with the advice of clean intermittent self catheterization as the creatinine stabilized at 274 mmol/L. Left JJ stent was removed after 6 weeks with flexible cystoscopy. Follow-up IVU demonstrated the persistence of the stricture. She, therefore, had re-insertion of the JJ stent in the antegrade manner on the left side. There was difficulty in managing to pass the guide wire across the strictured segment. However, it passed across the stricture and the lower end of the stent appeared to be in the bladder [].\nPostoperatively, she developed leakage of urine from the vagina. Cystoscopy did not reveal obvious fistulous tract, but the lower end of the left ureter or the ureteric orifice could not be identified. Fluoroscopy revealed extra-anatomic location of the stent []. With a probable diagnosis of ureterovaginal fistula, a nephrostogram was performed that showed the JJ stent to have passed across the stricture but the exact location of the lower end could not be definitely identified [].\nAlthough the dye was seen entering the bladder, the course of the lower end of the stent was not in the line of the ureter. The escape of dye into the vagina was also seen demonstrating the presence of vaginourinary fistula []. To improve the patient's quality of life, with informed decision, ileal conduit urinary diversion was carried out. The lower end of the left JJ stent was found to be in the perivesical tissue with a lot of necrotic debris surrounding it. Postoperative period was uneventful and she has been symptom free with no further deterioration of renal function on follow-up. |
A 63-year-old female patient was admitted to our hospital with intermittent epigastric abdominal pain for the past three months. Results of the physical examination on admission indicated no icteric sclera. The abdomen was soft with no palpable abdominal mass. The patient had experienced a weight loss of about five kg in the past two months and had no history of hepatitis B or C. She had been exposed to dogs and sheep and denied any history of exposure to infected cases from the epidemic area. After admission, CA19-9 was measured and was 796.20 U/mL. No serological examination for echinococcosis was performed because of the limited conditions of our hospital. Test results from pelvic ultrasound indicated menopausal uterus and uterine fibroids. Test results from gastroscopy showed chronic non atrophic gastritis. Colonoscopy revealed multiple polyps in the large intestine (basically removed); intestinal histopathology (cecum, biopsy) showed severe chronic inflammation of the mucosa and adenomatous hyperplasia of the individual glands. Contrast-enhanced computed tomography of the upper abdomen (Fig. A) revealed a more homogeneous thickening of the gastric wall in the antrum. Round unenhanced low-density foci with a diameter of 4.6 cm was seen in the S7 segment of the liver. Nodular calcifications were also observed. No significant dilatation was noted in the intrahepatic and extrahepatic bile ducts. The size and shape of the gallbladder were normal, the wall was not thick, and no significant abnormal density was observed in the cavity. The pancreas, spleen, and adrenal glands showed no significant abnormalities. Test results from computed tomography indicated liver cyst and intrahepatic calcifications. Contrast-enhanced magnetic resonance imaging of the liver and gallbladder (Fig. B, ) revealed a normal size and shape of the liver and proportion of each lobe, and the intrahepatic and extrahepatic bile ducts and flow vessels ran naturally. A long T1 and long T2 cystic signal with a diameter of about 4.7 cm was observed in the right lobe of the liver, with liquid level, short T1 high signal intensity in the lower layer, high signal intensity on diffusion-weighted imaging sequence, and enhancement of the cyst wall on the enhanced scan. Test results from magnetic resonance imaging showed that the space-occupying lesion of the right lobe of the liver had been considered to be more likely a hepatic hydatid cyst. Preoperatively, three-dimensional reconstruction demonstrated the location of the tumor and its relationship with the surrounding vessels (Fig. A).\nThe patient underwent laparoscopic S7 segmentectomy. Intraoperative findings showed that the tumor was located at the S7 segment of the liver and was about 5 × 4 cm in size and partially protruding from the surface of the liver, with an intact capsule and clear boundary with normal liver tissue. The tumor compressed the right hepatic vein and its tributaries and densely adhered to the right hepatic vein (Fig. B). On postoperative pathology, a mass was observed immediately adjacent to the liver capsule, with a volume of 5 × 5 × 4.5 cm. The section surface showed a brown turbid fluid, a smooth inner wall, and greyish red, greyish yellow, and soft section surfaces of other liver tissues. The pathological section showed a low-grade mucinous cystic neoplasm (volume 5 × 5 × 4.5 cm) in the S7 segment of the liver, with steatosis in the surrounding hepatic tissue area, chronic inflammatory cell infiltration in the portal area, and no tumor cell involvement in the margin of the liver resection.\nImmunohistochemistry demonstrated tumour cells CK7 (+), CK19 (+), and CEA (−); stromal cells ER (+), PR (+), α-inhibin (a small amount +), vimentin (+), desmin (+), and actin (+) (Fig. A–C). This study was approved by the Ethics Committee of Yantai Affiliated Hospital of Binzhou Medical University. |
A 67-year-old woman was referred to Department of General, Visceral and Transplantation Surgery of University Hospital Essen with a palpable mass in the upper abdomen. An abdominal CT revealed a large mass in the tail of the pancreas (10 × 14 cm) (Figure \n) without evidence of other peritoneal disease during staging investigation for a suspected carcinoma of the left breast. Two weeks previously, lumpectomy of a 3.5 cm tumor of the left breast had been performed by gynecologists. Sentinel lymph node examination was negative. Histology showed a primary poorly differentiated neuroendocrine carcinoma of the mammary gland. The patient’s medical history was significant for mediastinal sarcoidosis and a 0.7 × 0.9 cm MCC removed from her left forearm 2.5 years previous, which was Merkel cell polyomavirus (MCV) DNA positive after quantitative PCR. No viral DNA was found in peripheral blood. Postoperative adjuvant external beam radiation therapy of 52 Gy was given on the left forearm. Clinically, the patient reported abdominal discomfort and weight loss of 8 kg over the previous 4 months. Although the pancreatic mass was large, there was no evidence of vascular involvement or peritoneal disease and by all criteria was resectable. A somatostatin receptor scintigraphy showed enhanced uptake in the pancreatic tail region and excluded other involved areas. An extended distal pancreatectomy and splenectomy along with resection of the splenic flexure of the colon were performed and the tumor was removed intact. Pathological examination revealed a 14 × 10 × 8 cm solid mass of small cells in the pancreatic tail. Grossly, the mass displayed a glassy cut surface, containing areas of necrosis and hemorrhage. The spleen and four identified lymph nodes were negative for tumor as well as negative for the presence of MCV. Histological evaluation revealed a mitotic, highly active tumor (mitotic count 35 per high power field) with endocrine architecture of solid formations (regular, round nuclei with little cytoplasm). The tumor had immunohistochemically strong staining for synaptophysin, CD56, and in some areas, chromogranin. The tumor cells were strongly positive for cytokeratin 18 with a typically perinuclear granular (dot-like) reaction and also for cytokeratin 20 and the PAN-cytokeratin-specific antibody CK-MNF-116 with a paranuclear “dot-like” pattern (Figure \nA). There was no expression of gastrin, glucagon, insulin, serotonin, somatostatin, TTF-1, or CD117. The proliferative activity (Ki-67) reached approximately 80% (Figure \nB). Evaluating the presence of MCV due to the positivity of the primary tumor, the metastatic tumor was also MCV positive. Based on the clinical, histological, and viral status of the tumor, the diagnosis of a metastatic-MCC in the tail of the pancreas was made. Further histological investigation of the prior removed neuroendocrine breast tumor and the MCC of the left forearm confirmed neuroendocrine origin and identical histology to the previously resected MCC of the left forearm (similar viral profile as well). The patient was referred to oncologists for further evaluation and therapeutic treatment. At 2-year follow-up, the patient was still disease-free, without any complications related to disease progression or recurrence. |
The patient was a 63-year-old female with a past medical history of hypertension and ulcerative colitis who presented to the emergency department with worsening epigastric pain. The pain started four days prior with one episode of non-bloody emesis, nausea, and one episode of dark stool. She denied previous history of abdominal surgery or trauma. She was not on any anticoagulant. Vital signs were within normal limits. On examination, the patient was diffusely tender to palpation, especially in the epigastrium. Initial lab work was unremarkable except for a mild leukocytosis of 12.3 k/uL and hemoglobin of 11 g/dL. A CT scan of abdomen/pelvis with intravenous contrast showed a large amount of blood in the upper abdomen (Figure ) with high attenuation material adjacent to the greater curvature of the stomach (Figure ) and around the liver consistent with hemoperitoneum, although a mass could not be excluded.\nGiven the presence of hemoperitoneum and diffuse abdominal pain, the decision was made to undergo urgent diagnostic laparoscopy. Upon entering the abdomen, a large amount of blood was encountered around the upper abdominal viscera. The gastrocolic ligament was taken down to reveal an additional 800 mL of blood within the lesser sac as noted on preoperative imaging (Figure ). An adherent clot was discovered on the posterior aspect of the stomach with a small amount of active extravasation. At this point, the procedure was converted to an open approach via an upper midline incision to adequately expose and control the source of bleeding. The stomach was retracted cephalad to expose the posterior body where a necrotic, friable mass was found along the superior aspect of the greater curvature. A partial gastrectomy was performed with a linear cutting stapler to wedge out the mass with grossly negative margins; the mass was found to be 7 x 6 x 3 cm with areas of necrosis and hemorrhage. An intraoperative upper endoscopy was performed to inspect the gastric and duodenal mucosa that appeared grossly normal. Intraoperative frozen section was positive for a stromal tumor with spindle cells. Final pathology of the mass demonstrated a high-grade gastrointestinal stromal cell tumor with spindle cells with positive KIT and Discovered on GIST-1 (DOG1) mutations. Postoperatively, she was admitted for observation and discharged without incident on postoperative day 3. The patient was referred to oncology and started on imatinib with planned duration of therapy of at least three years given tumor rupture at presentation. |
A 36-year-old Iranian man was admitted to our emergency department on 31 August 2006, presenting with epigastric and retrosternal pain of two and a half hours duration. His detailed medical history revealed that he had no risk factors for coronary artery disease, however, BD had been diagnosed 10 years earlier and he was on colchicine 1 mg/day. Oral aphthous ulcers were exacerbated during coronary artery events. Eye examination was normal. He had an episode of thrombophlebitis of his left leg in 2004 and had been taking warfarin but had discontinued the medication.\nMedical examination revealed blood pressure of 130/70 mmHg and heart rate of 85 beats/minute and the patient was pale and perspiring. Chest auscultation revealed no abnormalities. His electrocardiogram (ECG) revealed normal sinus rhythm with ST segment elevation on II, III and aVF and reciprocal ST segment depression on V1-V6. Laboratory tests showed elevation of plasma total creatine phosphokinase (CPK) and CPK-MB activities. There were no findings consistent with coagulation and fibrinolysis disorders. He was diagnosed as having an acute inferior wall myocardial infarction, therefore nitroglycerin, heparin, aspirin and beta blocker therapies were started immediately followed by thrombolytic therapy with streptokinase within 1 hour. After 40 minutes, his chest pain was relieved and there was a significant reduction of ST segment elevation along with increased cardiac enzyme levels. A transthoracic echocardiogram showed mild apical hypokinesia and a left ventricular ejection fraction of 50%.\nOn the third day of hospital admission, he underwent coronary angiography. Coronary angiography revealed an 8 mm giant aneurysm of the proximal left anterior descending artery, an 8 mm aneurysm of the proximal left circumflex coronary artery (Figure ) and a 9 mm aneurysm of the proximal right coronary artery (Figure ). Based on clinical evidence, electrocardiogram and coronary angiography, we considered that the acute myocardial infarction in our patient was due to a coronary aneurysm. Therefore, we did not attempt any coronary intervention and decided to continue with medical therapy including azathioprine, colchicine, prednisolone, aspirin, beta blocker, nitroglycerin and enalapril. On 25 November 2006, the patient experienced another episode of chest retrosternal pain which lasted for 7 hours. His ECG revealed significant ST segment depression on V1-V6. Cardiac enzymes did not rise so he was diagnosed with unstable angina. No changes in ECG were noticed after 5 days. The patient was not adhering to drug therapy and when his coronary events occurred drug therapy was restarted. The next episode of retrosternal pain occurred on 28 February 2007 and lasted for 5 hours. His ECG showed tall T waves on precordial leads. Laboratory tests showed elevation of plasma total CK and CK-MB activities. He was diagnosed with an acute anterior wall myocardial infarction. Medical treatment was started but since he had received thrombolytic therapy 5 months earlier, streptokinase was not administered. The echocardiogram showed septal, apical and anterior wall hypokinesia with an estimated left ventricular ejection fraction of about 25-30%. He was discharged 10 days later with his previous medication plus digoxin, warfarin, frusemide, and spironolactone. On 2 August 2007, he experienced another bout of retrosternal pain that lasted for 7 hours. ECG showed ST segment elevation on precordial leads. Laboratory tests showed elevation of plasma total CK and CK-MB activities. This time, a new anterior myocardial infarction was diagnosed, medical treatment was started and azathioprine was switched for pulse cyclophosphamide 10 mg/kg, but the patient then discharged himself. At the time of writing, the patient is well with pulse cyclophosphamide every 2 months and prednisolone 7.5 mg/day, but unfortunately, he is non-compliant to drug therapy and so it was not possible to switch him to oral medication. |
A 560 gm male baby was born at 23+6 weeks of gestational age by spontaneous vaginal delivery to a 41-year-old mother with prolonged rupture of membranes for 48 hrs. Mother was treated with clindamycin and received two doses of betamethasone prior to delivery. The baby was hypotonic at birth and was noted to have poor respiratory effort. He was intubated and received the first dose of surfactant and was placed on synchronized intermittent mandatory ventilation (SIMV) with FiO2 0.4 and transported to the neonatal intensive care unit. Initial chest roentgenogram (CXR) showed diffuse ground glass opacity suggestive of respiratory distress syndrome. He received the second dose of surfactant on first day of life. He was hypotensive and dopamine drip was started. He was treated with intravenous ampicillin and gentamicin for 48 hrs. Initial blood cultures were negative. He received a course of ibuprofen to facilitate PDA closure.\nOn the third day of life, he developed pneumothorax on right side of the chest, which resolved spontaneously in 48 hrs. On the fifth day of life, he had recurrent oxygen desaturations and repeat CXR showed pulmonary interstitial emphysema (PIE) in both lungs (). On eleventh day of life, his respiratory status worsened requiring increased inspired oxygen concentration. CXR showed right side pneumothorax and cystic lesion in the left lower lobe, 8 mm in diameter. A chest tube was inserted on the right side and the pneumothorax resolved in 72 hrs. The cystic lesion in the left lower lobe gradually increased in size to 33 mm in diameter in the next two weeks (). His oxygen requirements increased gradually to FiO2 0.9–1.0 on SIMV with high inspiratory pressures.\nOn nineteenth day of life, he was switched to high frequency oscillatory ventilation with inhaled nitric oxide 20 ppm to improve oxygenation and prevent further air leak. He was started on intravenous dexamethasone. Three hours after administration of dexamethasone, he suddenly became apneic and bradycardic with oxygen desaturation to 20% on HFOV with FiO2 0.8, mean airway pressure (MAP) 11 cm H2O, delta P 24, and frequency 14.5 Hz with inhaled nitric oxide 19 ppm. He had cardiopulmonary resuscitation (CPR) with chest compression. His blood gases showed significant respiratory acidosis. He developed tension pneumothorax on left side with pulmonary interstitial emphysema and pneumoperitoneum (Figures and ). His abdomen was distended but remained soft with bowel sounds. He had emergent chest tube placement. A Penrose drain was inserted into abdomen which drained minimal peritoneal fluid.\nDuring the next few days, he improved and HFOV was switched to synchronized intermittent mandatory ventilation (SIMV) with FiO2 0.4. He was started on enteral feeds and he tolerated them well. Next day, he had acute deterioration with oxygen desaturations, bradycardia, and hypotension. He had significant respiratory and metabolic acidosis on blood gases. CXR showed right upper lobe atelectasis. His SIMV was switched back to HFOV. He was noted to be anemic and was transfused with 15 mls/kg of packed red blood cells. He remained hypotensive with poor perfusion on dopamine and epinephrine infusions. He was treated with intravenous meropenem and linezolid to treat presumed sepsis. He had distended abdomen and abdominal X-ray showed dilated loop of transverse colon with no evidence of intra-abdominal free air. Blood cultures were negative at 5 days. He died from cardiorespiratory failure. Autopsy confirmed premature lungs appropriate for gestational age, pulmonary interstitial emphysema in both lungs, 4 mm cystic lesion lined by fibrous tissue in left lower lobe which may represent localized pulmonary interstitial emphysema (Figures and ), and congested and dilated loop of transverse colon with no macroscopic or microscopic evidence of perforation or pneumatosis intestinalis. Diaphragm was intact. Both bacterial and viral cultures of tissues and fluids at autopsy were negative. |
A 7-year-old boy presented with behavioral problems since infancy. Detailed evaluation of the patient's early developmental history revealed that he was first in birth order, born of a wanted but unplanned pregnancy. During antenatal period, at 36 weeks of pregnancy, mother was found to have oligohydramnios and possible congenital cardiac defects were reported for the fetus. The child was born of a preterm delivery (36 completed weeks) by emergency cesarean section due to fetal bradycardia. The birth weight of the child was 1.7 kg, he had delayed cry and was cyanosed at birth. Cardiac evaluation at birth confirmed cardiac anomalies (patent ductus arteriosus, ventricular septal defect, tricuspid regurgitation, and left atrium to right atrium shunt), and he was started on tablet digitoxin. Thereafter, as he grew, it was observed that he had a global developmental delay and was detected to have bilateral profound sensorineural hearing loss at 6 months of age. Over the years he continued to manifest delayed milestone and developed autistic features in the form of poor eye contact, poor social skills, poor communication skills, engaging in repetitive head rocking (shaking head side to side) and hand flapping (moving fingers and hand like that of a bird, quick, bending from the wrist) movements, and fixed routine (did not like change in place, while visiting relative's place or if any guest came to their house was seen to become irritable). In addition, since the age of 3 years, he was found to have symptoms of attention deficit hyperkinetic disorder (ADHD) (could not sit at one place for more than 2–3 min, difficult to engage him in any activity). Over the years, he became very adamant about the fixed routine and hyperactivity kept on increasing, also started hitting and biting mother, especially if he did not get what he wanted, which led to severe distress and burden on the mother and resultant psychiatry consultation and admission to child psychiatry inpatient unit. There was no history suggestive of head injury, seizures, frequent diarrhea and vomiting, birth marks, failure to thrive. Physical examination of the child revealed abnormalities in the form of small head (head circumference 49 cm) and bilateral flat feet. On the mental status examination, there was lack of eye to eye contact, he was found to be hyperactive, had irritable mood, along with frequent side to side movement of head and flapping of hands. On evaluation, his intelligence quotient was found to be 25. Magnetic resonance imaging showed multifocal symmetrical T2/fluid attenuated inversion recovery hyperintensities in B/L cerebral hemisphere suggestive of sequelae of congenital rubella infection. All other blood investigations were within normal limits except for Vitamin D levels, which were low (<3 ng/ml). Ophthalmological examination showed evidence of pigmentary retinopathy. He was advised to use hearing aids for profound sensorineural hearing loss by the otorhinolaryngologist. Cardiac evaluation confirmed the presence of cardiac defects; however, there was no decompensation.\nOn the basis of available evidence, he was diagnosed as having with mental retardation, atypical autism, and attention deficit hyperkinetic conduct disorder. All these symptoms possibly represented a clinical sequelae of CRS.\nIn the inpatient setting, he was managed with behavior therapy (positive reinforcement, ignoring, modeling, and prompting), parental counseling along with tablet atomoxetine 20 mg/day, tablet risperidone 1 mg HS, tablet phenargan 25 mg/day, and Vitamin D supplementation. Over the period of 8 weeks, patient showed significant reduction in hyperactivity, adamant behavior, and interaction with mother improved. This led to significant reduction in burden on the mother. He has been maintaining well with significant improvement in hyperactivity and various adaptive functions. |
A 24-year-old male patient presented to our emergency department with severe left elbow pain and limited range of motion after falling from height on an outstretched hand 1 hour prior to his presentation. To note, the patient has no history of prior elbow dislocation or trauma during his childhood. On clinical examination, the patient was found to have posterolateral dislocation of his left elbow joint with severe tenderness over the medial aspect. There was minimal numbness over his left 4th and 5th fingers, but no other vascular involvement was noted. Anteroposterior and lateral radiographs of the left elbow were done that showed posterolateral dislocation of the left elbow joint with concomitant medial epicondyle avulsion fracture with intra-articular entrapment of that fragment ().\nClosed reduction was done under sedation, and after multiple failed attempts due to the entrapped medial epicondyle fragment, subsequent reduction of the medial epicondyle fragment was achieved ().\nAfter the reduction, and for proper postreduction evaluation, varus and valgus stress tests under fluoroscopy were done that showed grand instability of the elbow joint. A computed tomography scan with 3D reconstruction was then ordered to rule out any associated missed fracture on radiograph and for adequate preoperative planning. The CT scan showed a displaced medial epicondyle avulsion fracture but no other associated bony injuries ().\nThe next day, the patient was transferred to the operating theater for open reduction and internal fixation. In the operating room, with the patient placed in the supine position, general anesthesia and prophylactic antibiotics were administered. With his left upper limb on a hand table, a medial approach to the left elbow joint was done with a longitudinal 5 cm incision over the medial epicondyle. After appropriate dissection, the medial epicondyle fragment was identified, still partially entrapped in the ulnohumeral joint line, with its unruptured intact medial collateral ligamentous complex. The fragment was reduced with 1 K wire and fixed with 1 cannulated half-threaded 40 mm × 4.5 mm screw and a washer ().\nA washer was used in order to optimize compression and not taking the risk of unintentional intrusion of the screw head through the cortical bone or fracturing the fragment. Careful inspection was done, leaving no entrapped soft tissue inside the fracture site during reduction. Postoperatively an above-the-elbow posterior splint was applied to the elbow joint in 90° of flexion with neutral forearm rotation. After 1 week, making sure that the swelling decreased and the 4th and 5th finger paresthesia has resolved, a full-circular above-the-elbow cast was applied in the same previous anatomic position. Control X-rays were done at 3 weeks postop that showed proper integrity of the reduction ().\nSo the decision was taken to remove the cast and keep the right arm in an arm sling for 1 more week with minimal careful range of motion. After that, physiotherapy was started consisting only of passive progressive flexion/extension range of motion with no varus or valgus stress for the following 3 weeks. At 12 weeks postop, the patient had full range of motion of his elbow joint and adequate varus and valgus stability, and control X-rays done showed union of the avulsed medial epicondyle fragment (). At this point, the patient was allowed to get back to normal daily activities and will be allowed to resume sports activities at 6 months postoperatively. The future plan was removal of the screw at 6 months after the surgery. |
A 31-year-old female presented to the emergency department in King Fahad University hospital in Saudi Arabia with dyspnea. She was found to have an elevated D-dimer in her laboratory studies. A lung perfusion scan was ordered to exclude pulmonary embolism. The scan demonstrated a normal homogeneous pattern of tracer uptake in both lung fields with no obvious areas of peripheral segmental perfusion defects noted in either of lung fields. Also, the CXR was performed and showed a bilateral small atelectatic band as well as a small left pleural effusion in addition to evidence of alveolar hemorrhage. The patient was admitted to the ICU and received 500 mg tablet of TXA orally, antibiotics, 6 units fresh frozen blood, and 1-unit RBCs; after 9 days, she was given 500 mg of TXA intravenously. The patient was diagnosed with SLE and pulmonary hemorrhage and lupus nephritis. The CXR was repeated and it showed improvement. The platelets are improved. The procalcitonin was < 2, which indicated a less likely source of infection and more likely of an inflammatory process likely of her disease. Cultures from her BAL also showed no growth. After 1 week, the patient began to have hemoptysis again. A CXR was done which showed bilateral pleural effusions with bilateral lung bases developing atelectatic changes. Additionally, there were bilateral confluent ill-defined patchy opacities in the mid and lower lung zones with a prominent bilateral central pulmonary vasculature; the computed tomography with contrast shows the pulmonary trunk and main branches with segmental and subsegmental branches appeared well-opacified without evidence of filling defect or aneurysm formation. Lung parenchyma demonstrated multiple bilateral patchy ground-glass opacities and consolidation noted throughout the lung parenchyma predominantly within the lower lobe which was not sparing the pleural surface. It was associated with a tree-in-bud appearance. The patient was started on 500 mg of nebulized TXA every 8 h for 1 day. Five days later, the patient showed improvement as evidenced by stable hemoglobin, no longer requiring more blood products, and was discharged. |
A 26 year old male, A.P. presented to the chest clinic with a painless nodular swelling over the left lower chest in the midclavicular region. This nodular swelling was present for 3 months prior to the presentation and it gradually increased over a period of 2 months, and then it became soft and burst open one day with thick serosanguinous pus. Over a period of next one month, the discharge from this open ulcer continued and it became bigger and also extended deep into the skin involving the subcutaneous tissue. This ulcer was painless and had produced a big defect in the chest wall. He was being treated with local applications of antibiotics and oral antibiotics without much relief. There was history of intermittent fever initially for about 15 days. There were no respiratory complaints and no history of anorexia or weight loss. There was no history of tuberculosis either in childhood or adulthood. He was a nondiabetic and nonalcoholic.\nExamination showed averagely built male with BMI of 23.5, no clubbing and lymph adenopathy. Respiratory system examination was normal. Local examination revealed a large solitary oval ulcer over left lower chest in 6th intercoastal space in the midclavicular region of 6.5cms X 4.5 cm in dimensions, with undermined edges, having yellowish slough with scanty serous discharge (). The ulcer was extending deep into the skin almost to an extent of 2.5cms involving subcutaneous tissue with raised edges and had vegetations and crusts; it was slightly tender, and surrounding skin was indurated. There was no involvement of the regional lymph nodes. Tuberculosis was kept in mind in investigating this ulcer as it was progressing over a period of 3 months. His hemogram was normal, HIV and VDRL were negative. Chest radiograph was normal with no evidence of hilar adenopathy (). CT Scan of the thorax was also performed, which revealed no parenchymal infiltrations or cavity, and also there was no evidence of any mediastinal lymphadenopathy (). PPD test was 16 mm. Biopsy from the edge of the ulcer was done which showed granulomas consisting of epitheloid cells, Langhans' type of giant cells, lymphocytes and macrophages (). Fungal elements were negative. The findings were suggestive of tuberculous ulcer. As the diagnosis of tuberculosis of the chest wall was made, and there were no primary involvement of the lungs, every effort was made to find out any primary lesions anywhere in the body. This included examination of the oral cavity, ears, skin, conjunctiva, abdomen, kidneys and the bones. Abdominal ultrasonography did not revealed any mass or cystic lesions in the intestines or in the kidneys. But no primary lesion anywhere in the body could be identified.\nThus, the diagnosis of primary chest wall tuberculous ulcer was made and he was started on autituberculosis regimen -Category III regimen with Isoniazid, Rifampicin and Pyrazinamide thrice weekly under RNTCP. After one month of therapy, the ulcer started regressing in size, slough disappeared and serous discharged stopped. After the end of 6 months of therapy, the ulcer healed completely and the opening in the chest wall closed completely (). He was given extended therapy of Isoniazid and Rifampicin for another 2 months to prevent the recurrence. He is doing well during the follow up period. |
A 63-year-old female presented to the emergency department with throat pain following ingestion of a fish bone. Unbeknownst to any of the hospital staff, the patient was assuming the identity of another 57-year-old female. There was no suspicious behaviour at the time to suggest that the patient was committing identity fraud. She spoke an uncommon Chinese dialect and was accompanied by her niece who was able to assist minimally with English translation. The patient described odynophagia, which started immediately after accidental ingestion of a fishbone. She had a CT chest arranged by her GP prior to coming to hospital, which showed a 25 mm opaque foreign body in the upper oesophagus at the T2/3 level associated with a small, contained perforation.\nExamination revealed a hemodynamically well patient with a midline laparotomy scar and mild epigastric tenderness. The patient was unable to provide a surgical history consistent with her midline laparotomy. This was assumed to be due to language barrier preventing accurate translation from the patient’s niece to the attending doctor. The patient’s electronic medical record was extensively reviewed and did not reveal any previous surgeries. It was noted however that she had a documented history of chronic hepatitis B and had been attending the hospital’s gastroenterology clinic with regular abdominal ultrasounds to assess her liver. Besides this, the patient did not have any other significant history recorded.\nThe patient underwent a gastroscopy where a foreign body resembling a fishbone was removed endoscopically by a surgeon (). She tolerated the procedure well and remained clinically stable post-procedurally. She was kept fasted for three days before a progress CT chest confirmed that the oesophageal perforation had healed. The CT chest incorporated the upper abdomen down to the L4 vertebra. The spleen was notably absent on the CT scan (), raising the possibility that the patient may have had an emergency splenectomy in the past, which would explain her midline laparotomy scar. However, her previous abdominal ultrasounds including one performed as recently as three weeks prior to her admission demonstrated that she still had her spleen (). This imaging discrepancy raised suspicion of possible medical identity fraud.\nThe patient was directly informed of the discrepancy seen in her imaging. She confessed to committing medical identity fraud, stating that she was an international visitor hoping to avoid the out-of-pocket cost associated with hospital admission. The seriousness of her actions was emphasized to her and she agreed to pay the full cost of her hospital stay. Following consultation with the hospital’s medicolegal department in conjunction with the victim of identity fraud, a decision was made not to press any charges. A telehealth follow-up appointment at four weeks demonstrated that the patient was at her baseline health. She was tolerating solid foods and denied having any chest pain. The patient expressed sincere regret at having committed identity fraud and provided a verbal apology to the hospital. |
This case report describes the fracture of a temporary femoral hemodialysis catheter during placement in an old man with gastric carcinoma and extensive abdominal and retroperitoneal metastasis, in an attempt to draw lessons from and nurture experience among practitioners.\nA 76-year-old man was admitted with acute kidney injury and anuria. He underwent a subtotal gastrectomy for gastric carcinoma 7 years ago. Three months prior, he had a similar admission with anuria which required temporary hemodialysis. At that time, a computed tomography and magnetic resonance imaging of his abdomen revealed an atrophic right kidney, extensive intra-abdominal metastasis, and retroperitoneal involvement causing bilateral hydronephrosis. A temporary double lumen dialysis catheter was inserted in the right femoral vein for acute hemodialysis. A double J stent was placed in the left ureter. His urine volume gradually returned. The dialysis catheter was removed after 7 days. During his second admission with acute oliguric kidney injury, ultrasonography of his bilateral femoral and iliac veins revealed no stenosis or thrombus in femoral and distal iliac veins. A 19.5 cm/13.5 Fr acute dual lumen dialysis catheter [Mahurkar, Covidien, Minneapolis, MN] was placed into right femoral venous using universal Seldinger technique. The procedure was relatively straightforward although the patient experienced some moderate, transient pain during the advancement of the catheter. At the end of the procedure, there was no flow in one of the two lumens.\nSubsequent radiography showed that the end of the catheter had doubled back and the first 4 cm of the catheter had fractured (Fig. ). Venography showed a stenosis in the middle of his right iliac vein (Fig. ). The stenosis was thought to have veered the curve end of the guide wire back toward the direction of advancement, and “misguided” the catheter which subsequently broke off. A second dialysis catheter was inserted successfully in the right internal jugular vein under screening. The fractured catheter tip was removed surgically under direct vision. The blood vessel wall was incised over the lodged fragment, the fractured tip was removed, and the incision closed. The narrowing of the right iliac vein was thought to be due to previous femoral catheter placement and associated thrombus formation, or possibly metastatic tumor invasion of the blood vessel wall. More attention and vigilance are required in future similar cases. |
A 66-year-old male patient complained severe back pain and radiating pain to both leg for several days. Spinal MRI demonstrated a huge intradural mass compressing conus medullaris and cauda equina at the L1-2 level, with slight ring enhancement on the surroundings (). He was very healthy previously and did not have any risk factor for stroke.\nA laminotomy on the appropriate level was done and dura was opened vertically. On the ventral side, there was a large dural opening and through the defect a large intradural disc material was extruded. The ruptured disc was removed totally with microsurgical piecmeal technique. In order to minimize post operative CSF leakage ventral defect and dorsal dural opening was closed watertightly. Fibrin sealant was covered on the sutured area and lamina was replaced with miniplate fixation. On postoperative MRI, it was removed successfully ().\nOn the day after surgery, blood mixed with CSF came through the drainage bag, and the patient was instructed to take a rest in lying position. After operation his back pain was minimized and radicular pain was disappeared and the patient frequently took a sitting position against medical advice and about 300 cc of CSF was drained just within 4 hours.\nTwo days after the surgery, the patient complained unexpected headache, dizziness, nausea and vomiting, while neurological condition was stable, pupillary reflex on both eyes were normal as well as limb motor power, but horizontal nystagmus was detected on both eyes. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage with size of 3×3 cm on the right cerebellum and 1.5×1 cm on the left cerebellum. While brain stem was not compressed, fourth ventricle was distorted and headache was aggravated, leaving the decision to surgery (). Suboccipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed (). After craniotomy, the patient showed clinical improvement. He was able to leave the hospital after two weeks of initial operation without any neurological deficit. |
A total of 75-year-old obese female with body mass index (BMI) of 36.5 (obese Class II; according to WHO classification), came with complaint of pain in both knees (left >> right) with difficulty in walking for last 10 years with swelling on left leg for last 1 week. She had severe pain in the left knee which badly affected her activities of daily living. She was a known case of hypertension for last 8 years and hypothyroidism for last 20 years. She was recently diagnosed with diabetes mellitus. X-rays of the left knee () showed advanced osteoarthritis, and she was advised for left TKA. On physical examination, the patient had swelling and mild tenderness over the left leg without apparent signs of venous thrombosis. Distal pulses of the left leg were feeble and Homan’s Sign was negative. Doppler ultrasound of the lower extremity was done which showed acute thrombosis involving femoral and popliteal vein in the left leg ().\nThe patient was subsequently evaluated by a senior vascular surgeon. She was advised treatment for DVT and to wait for at least 3 months before TKA. However, the patient was so disabled by the knee pain that she insisted on scheduling the surgery as early as possible. Published literature did not show any case report in which TKA was done in a diagnosed case of DVT. Although a number of surgical procedures had been done in last in patients with DVT [, , ]. In all such patients, inferior vena cava (IVC) filter was implanted to prevent serious complications of DVT due to thromboembolism, during and after surgery. The goal of IVC filter was to prevent fatal PTE. Therefore informed consent was taken, explaining to the patient, all the pros and cons of the surgery. Retrievable IVC filter (OPTEASE® Retrievable Vena Cava Filter, Cordis Corporation) was implanted through right femoral vein under fluoroscopy guidance one day before the surgery (). The patient was given enoxaparin sodium injection 40 mg (Clexane, Sanofi) 12 h before surgery.\nTKA using PS 150 (Depuy Orthopaedics, Inc. USA) on the left side was done ( and ) under general anesthesia. The patient was not given regional anesthesia in the form of spinal or epidural anesthesia to prevent from intradural bleeding which may cause subdural hematoma leading to neurological deficit. Tourniquet was applied only at the time of cementing of implants. Wound was closed in multiple layers and suction drain was not used.\nPostoperatively the patient was put on therapeutic dose of DVT management. Injection enoxaparin 30 mg twice a day, subcutaneously was given for 6 days and then she was put on tablet rivaroxaban (Xarelto, Bayers) [] 15 mg twice a day for 3 weeks [] and then on 20 mg once a day for 3 months. DVT Foot Pump was applied immediately after surgery in the recovery room. DVT Stockings were applied on 2nd post-operative day after change of dressings. Physiotherapy and walker aided mobilization was started on 1st post-operative day. Patient developed swelling over the knee with multiple ecchymotic patches. The surgical wound heals well at 2 week time. The pain and swelling over the lower limb had subsided over the period of 3-month. The patient is now 1 year post-operative follow-up and is doing well. |
An 83-year-old man underwent surgical excision of a malignant peripheral nerve sheath tumor (MPNST) at the right knee at another hospital and was then referred to our hospital for further chemotherapy. Three months after the start of chemotherapy, the patient complained of severe pelvic and low back pain. A PET CT was performed which showed multiple bony lesions with a variable (moderate to high) degree of metabolic activity raising suspicion that these were metastases. The lesions, however, had a very unusual appearance and evolution as seen on CT.\nInitially, the lesions presented as small rounded lytic lesions with a well-defined sclerotic margin (Figure ). They exhibited a rapid growth but the initial appearance of central lysis and surrounding sclerotic margin was preserved. Follow up PET CT scan was performed after seven weeks to evaluate the response to chemotherapy. It revealed a second concentric band (halo) around some of the lesions. This band (halo) had a ground-glass appearance and was surrounded by a second sclerotic rim. This rim was thinner and less sharply demarcated than the more central rim (Figure ). The multiple lesions were in different phases of evolution and as such had a different appearance at any given time.\nPresence of multiple lesions, a known primary tumor and moderate to high uptake of FDG tracer on PET scan (Figure ) suggested metastatic disease, despite the unusual appearance of the lesions.\nOther bony metastases were also evident on CT. Some were entirely sclerotic and a few had an ill-defined lytic appearance. Collapse of a vertebral body and fracture of the upper endplate of another vertebra due to metastases were also present.\nBone biopsy of a lesion with the above described doughnut appearance located in the left pubic bone was performed. A biopsy was obtained in the central lytic area and another biopsy in the peripheral halo (Figure ). Histological evaluation of both the samples showed infiltration of bone marrow by malignant spindle-shaped cells arranged neatly in bundles. Histological and immunohistochemical studies were compatible with metastases from a spindle cell tumor (in this case MPNST). |
A 50-year-old man of 65 kg weight, 172 cm and height underwent emergent craniectomy for traumatic subdural hemorrhage of the brain. The patient was a stupor and in an intubated state. In the operating room, the initial vital signs were blood pressure of 118/83 mmHg, heart rate of 115 beats/min, and peripheral oxygen saturation of 99% by the infusion of norepinephrine. General anesthesia was induced and maintained by sevoflurane and remifentanil infusion under volume-controlled ventilation. The arterial catheterization on the right radial artery was performed. The central lines on the right subclavian vein and two more peripheral lines on both the saphenous vein of medial malleolus were placed.\nDuring operation, after the dura mater of the brain was dissected, massive bleeding developed by sinus bleeding. The arterial blood pressure dropped to 50/35 mmHg and the heart rate increased to 130 beats/min. The bolus administration of phenylephrine revealed no impact on vital signs. Epinephrine infusion was initiated with norepinephrine. Concurrently, the packed red blood cells (pRBCs) rapidly transfused through central and peripheral lines. Rapid transfusion device, level one infusion system (Model H1025), was used to augment the flow. In addition, transfusion simultaneously was done by applying manual pressurized pumping through peripheral lines. Despite the administration of vasopressors and massive transfusion, the blood pressure remained lethally low.\nApproximately 30 minutes after massive transfusion, we found a hardened right low leg like a stone. We had transfused blood into the peripheral line of the right saphenous vein by applying manual pressure but it was unrecognized because the extravasation of blood was obscured by a surgical drape. Immediately, fasciotomy was performed to release all four compartments by orthopedic physicians. The operative findings included a large hematoma and the muscle appeared dark red on the opening site of fasciotomy. The muscles were rapidly returned to normal color appearance after the removal and irrigation of the hematoma. The incisions were left open with sterile dressings []. The origin of the hematoma was the transfused dark red blood.\nThe blood pressure was gradually stabilized to 100/60 mmHg after bleeding control. The estimated blood loss was 8,000 mL and the amount of transfused blood was 3,800 mL. After surgery, there was no additional tissue damage due to ACS in the low leg but there was continuous oozing and leaking blood from the operative site of craniectomy. The postoperative hemoglobin level decreased steadily to 6.9 g/dL on the fourth day, even after continuous blood transfusion. The patient's brain revealed a severe edematous condition. His vital signs also were unstable continually even though dopamine, norepinephrine, and epinephrine were infused. On postoperative fifth day, he expired due to cardiac arrest. |
A 69-year-old woman presented to the Rheumatology Clinic in January 2010 for evaluation of generalized morphea/localized scleroderma diagnosed 7 months after receiving local radiation to right breast for treatment of breast cancer. In September 2008, breast cancer was diagnosed by needle biopsy when an abnormal cluster of calcifications was identified by a screening mammography in September 2008. After consultation with her surgeon, oncologist, and radiation therapist, she underwent lumpectomy and sentinel lymph node biopsy. The cancer was estrogen receptor negative, and the sampled lymph nodes were negative. The tumor was estrogen and progesterone receptor positive. She opted not to take tamoxifen or other antiestrogen therapy. To prevent cancer recurrence, external beam radiation to right breast was completed (October 2008). She experienced local radiation side effects of erythema and superficial blister formation that resolved with local wound care.\nApproximately 7 months after completing radiation therapy, she developed two painful blisters in the inframammary fold of the right breast. On examination she was found to have generalized induration of the right breast and right axilla attributed to postradiation fibrosis. The breast and axilla were warm to touch and painful to palpation. That was with sparing of the areola. Additional lesions distant from the radiation field were also noted. These included hyperpigmentation of the skin at the waistline, induration of the skin in the left upper inner thigh and left groin, and a shiny patch of thickened skin on the anterior left shin. The lesions not involving the breast and axilla were not painful.\nIn May 2009, a punch biopsy of the left groin lesion diagnosed localized scleroderma (morphea). On microscopy, the skin surface was thin with a slightly keratotic epidermis. The papillary dermis was edematous and homogenous. The reticular dermis had dense collagen in bundles with intervening mild lymphoid and plasma cellular inflammation present around the adnexal structures. Mild chronic inflammation in the subcutaneous fat was noted at the base of the biopsy. For treatment of the right breast and axillary lesions, topical calcipotriol and topical betamethasone dipropionate were prescribed without benefit. Painful ulcers developed in the area of application in the right axilla which healed slowly when the topical medications were discontinued. The area under the right breast remained painful with chronic superficial ulceration. Application of topical silver impregnated dressings was of no benefit.\nIn addition to the skin lesions, she described fatigue and generalized arthralgias. She denied more specific symptoms of systemic connective tissue disease, that is, no history of Raynaud's, esophageal reflux, shortness of breath, cough, joint swelling, morning stiffness, sicca symptoms, pleuritis, or serositis. Prior to diagnosis of breast cancer, she had no significant past medical or psychiatric history and was on no prescribed medications. Family history was negative for connective tissue disease. Physical examination confirmed circumferential induration of the right breast with sparing of the areola. Induration extended into the right axilla. Superficial erosion of the epidermis was noted in the inframammary fold of the right breast. A band of hyperpigmented, thickened skin was noted along the anterior waistline. A hypopigmented indurated patch was noted in the left groin with a healed punch biopsy site. Thinning of the skin with hypopigmentation and superficial telangiectasias was noted in the upper left medial thigh. A 3 cm patch with central hypopigmentation was present on the left anterior mid tibia. She had no sclerodactyly. Nail fold examination for capillary changes was normal. Examination of the heart, lungs, and abdomen was normal. Laboratory testing was normal, including complete blood count, chemistry panel, thyroid function tests, and urine analysis. Sedimentation rate and C-reactive protein were normal. Lyme titer was negative. Thyroid autoantibody testing was negative. ANA was interpreted as borderline positive, with titer of 1 : 160 in a speckled pattern. Further testing for ANA subtypes was negative for anti-topoisomerase, anti-RNP, anti-Smith, anti-ds DNA, anti-SSA, and anti-SSB.\nShe was prescribed minocycline 100 mg twice a day, and, after three days of therapy, she reported dramatic improvement in generalized pain and fatigue. The superficial erosions in the inframammary fold healed. However, despite the initial perceived benefit, the right breast remained warm and tender to palpation. New lesions occurred on the right lower extremity. In August 2010, methotrexate 7.5 mg weekly and titrated to 12.5 mg was prescribed. Folic acid 1 mg per day was prescribed to prevent methotrexate side effects. After the addition of methotrexate, no new lesions occurred. Signs of inflammation in the irradiated right breast resolved though skin thickening remained unchanged. The lesions on bilateral lower extremities softened. Minocycline was discontinued in March 2011 when abnormal pigmentation developed as a side effect. She remained without signs or symptoms of a systemic connective tissue disease. |
A 59-year-old African-Caribbean man presented with a two-month history of neck pain, hoarse voice, dysphagia and breathing difficulties. He had an anterior neck swelling that increased rapidly in size. Clinical examination revealed an enlarged, hard and fixed goitre that was very tender on palpation. The trachea was deviated to the left side and there was no cervical lymphadenopathy. Fibre-optic laryngeal examination showed reduced mobility of the right vocal cord. Blood test showed a normal blood cell count and calcium and thyroid function tests, negative thyroid peroxidase autoantibodies and an erythrocyte sedimentation rate (ESR) of 95 mm/hr. A computed tomographic (CT) scan of the neck and thoracic outlet showed a large enhancing thyroid mass predominantly affecting the right lobe causing deviation of the trachea to the left with no cervical lymphadenopathy (Figure ).\nDuring surgery this thyroid mass was found invading all the surrounding structures, including the carotid arteries, internal jugular vein and the right recurrent laryngeal nerve. The trachea was significantly deviated to the left side by this mass and no tissue planes could be identified for dissection. Anaplastic carcinoma of the thyroid was suspected, though unlikely due to the age of the patient. As surgical resection was impossible, a wedge biopsy was taken to establish histological diagnosis. Histopathology showed an admixture of fibrous tissue with focal collagen hyalinization and inflammatory infiltrate rich in lymphocytes and plasma cells. Occasional giant cells were present with atrophic thyroid follicles. At this stage, the diagnosis was confirmed as Riedel's thyroiditis, based on the histology results. The patient was subsequently started on 80 mg/day of prednisolone. After four weeks, there was marked improvement in the voice and swallowing of the patient with reduction in the size of the goitre. Within two weeks of starting steroids, the ESR was noted to have fallen to 10 mm/hr. Prednisolone was gradually tapered over 10 months to a dose of 5 mg on alternate days. Repeat CT scan confirmed reduction in the size of the goitre with minimal shift in the trachea (Figure ). |
A 32-year-old male was admitted with history of upper abdominal discomfort and pain which had progressed over 2 months. A large firm mass was palpated in the right hypochondrium and lumbar region. Triple phase computed tomography (CT) of the abdomen was performed, showed a large heterogeneous infiltrating mass in the right upper retroperitoneum. The mass measured 23 cm × 17 cm × 17.5 cm in dimensions. The lesion extended from the undersurface of right lobe of liver (which is infiltrated by the mass) to the level of the right renal hilum. Antero-posteriorly the mass extended from the right paravertebral region to the anterior abdominal wall. The hepatic flexure and ascending colon were displaced anteriorly by the mass. The anteromedial relations of the mass were antropylorus, splenoportal axis, the displaced and invaded inferior vena cava and the pancreatic head. The abdominal aorta was medial to the lesion. The right adrenal gland was not visualized separately. The upper pole of right kidney was infiltrated by the mass with posterior displacement of hilar vessels. The mass showed areas of hemorrhage, necrosis and solid enhancing nodular tissue within it.\nThe tumor thrombus in inferior vena cava extended into the hepatic part of inferior vena cava and right atrium. The azygous system was dilated as a result of the inferior vena cava obstruction. Moderate ascites was also seen [].\nThe possibility of renal tumor was excluded by the fact that the epicenter of the mass was outside the kidney with secondary involvement of the renal parenchyma. The imaging differentials were primary retroperitoneal tumor, adrenal tumor, and tumor arising from the inferior vena cava.\nAn ultrasound guided biopsy was performed and samples were sent for histopathological evaluation. Histopathological sections showed a tumor composed of spindle to oval pleomorphic cells with eosinophilic cytoplasm, indistinct cell borders, and oval to elongated moderately pleomorphic nuclei. Few bizarre cells and an occasional mitosis were also noted. On immunohistochemistry, the tumor cells were positive for smooth muscle actin, epithelial membrane antigen, focally positive for desmin and negative for cytokeratin, S-100 protein, CD117, and CD10 [].\nThe histopathological impression was high grade leiyomyosarcoma. Clinico-radiological correlation led to the diagnosis of leiomyosarcoma arising from inferior vena cava, adrenal, or primary retroperitoneum.\nOnly treatment for retroperitoneal leiomyosarcoma is surgical resection with clear margins followed by radiotherapy and/chemotherapy. Before histopathological diagnosis was made, patient received supportive management including analgesics. Due to the poor general health status, the patient expired without any further intervention. |
A 30-year-old male patient presented with pulsation of the skull and dizziness during bending down. Neurological examination revealed a dysdiadochokinesia on both sides, no further neurological deficits. The scalp was soft. A bone resistance was not palpable. Cranial magnetic resonance imaging (MRI) showed an extensive growing, contrast enhancing lesion expanding at the supra- and infratentorial convexity, infiltrating and destroying large parts of the skull, and infiltrating the skin (). CT scanning and 3D-reconstruction images stress out the massive destruction of the calvarian bone (Figures and ).\nA surgical procedure with the aim of complete tumor resection in a curative manner was not possible, so that a digital subtraction angiography (DSA) was done to identify the arterial blood supply of the tumor. The tumor was fed by branches of both internal and external carotid arteries and additionally by the right vertebral artery. The feeding branches were embolised to induce decrease of tumor size and growth. The patient was discharged and was followed closely in our out-patient department.\nTwo months later, the patient presented with progressive ataxia and dysarthria. On examination, we discovered circumscribed skin necrosis of the skull in consequence of embolization of the feeding arteries and the skin infiltration of the tumor. Despite previous embolization, MRI showed marked increase of the infratentorially localized tumor with cystic components with compression of the fourth ventricle and the brainstem. In consideration of the new findings, we resected parts of the tumor located in the posterior fossa and at the occipital convexity via an extended sub-occipital approach. During surgery, the tumor was located in the epidural space with diffuse infiltration of the bone and the skin. Histopathological work-up revealed an anaplastic meningioma WHO grade 3 with high cell density, tall polymorph nuclei and high mitotic rate with a high proliferation index of 60% (). Molecular genetic examination of the tumor tissue showed no chromosomal aberrations. The patient recovered well from surgery and was discharged without neurological deterioration.\nSix months after the first operation in a followup MRI scan, a clear tumor progression was found. We performed a new operation with the most extensive tumor resection. In the further course, the patient developed a subcutaneous CSF accumulation in the region of surgical approach. A cranial MRI scan showed CSF circulatory disturbance (). For further clarification of new-onset findings, a MRI scan of the spinal axis was initiated. The MRI scan showed metastasis of the cervical spine with a pathological fracture of the 4th and 5th vertebral bodies. Foremost, a corporectomy of the cervical vertebral bodies 4 and 5 accompanied with anterior fusion with plate and screws was conducted (). A ventriculoperitoneal shunt was afterwards implanted. The cervical spine was then irradiated. The patient died 17 months after diagnosis of tumor. |
Case 1: A 56-year-old female presented to our institution with progressive vision loss. Her medical history was non-contributory. An ophthalmological evaluation showed a right central scotoma. Cranial MRI showed a mass suggestive of a carotid artery aneurysm. DSA revealed a 25.3 × 18.5 mm aneurysm with a 4.5 mm neck arising from the medial wall of the right ophthalmic segment (Figure ), and the BOT of the ICA and Allcock’s test were performed to understand the condition of cerebral blood flow compensation. To clip the aneurysm and reconstruct the right ICA, she was offered both surgical and endovascular treatment, considering the risks and benefits. The management plan was formulated to proceed with the hybrid operation as an elective procedure. During the operation, we placed the balloon in the C2-C3 segment of the ICA due to a relatively narrow-necked aneurysm (D/N ratio of 5.6). Then, we performed craniotomy via a pterional approach using the IAC technique to remove the ACP. We found that the right optic nerve was compressed by the giant aneurysm and that the optic nerve was crossed by the aneurysm neck; removal of the ACP and dissociation of the optic nerve from the aneurysm neck sufficiently revealed the aneurysm neck (Figure and ). After the placement of the first clip, first intraoperative DSA showed that the aneurysm had been clipped and that there were small amounts of residue of the aneurysm neck (Figure and ). A supplementary miniature clip was placed during the operation. Second intraoperative DSA showed that the aneurysm had been completely clipped. However, stenosis occurred in the ICA with poor visualization of the optic artery and poor visualization of the distal branch vessel of the ICA (Figure and ). A miniature clip with angular tips was used to replace the original clip. Third intraoperative DSA showed that the aneurysm was completely clipped. The ICA with stenosis was relieved, and visualization of the optic artery and distal branch vessel of the MCA was improved (Figure and ). |
A 48-year-old man presented with a two-month history of weight loss and obstipation. He did not complain of diarrhea, hematochezia, or abdominal pain. There was no history of inflammatory bowel disease, skin disease, thyroid cancer, or genital cancer. He had no family history of inflammatory bowel disease or colon cancer. The results of his physical examination and laboratory tests were normal, and he did not show any verrucous lesions or pigmentation of the skin, alopecia, or onchyodystrophy. The patient subsequently underwent a colonoscopy, which revealed five sessile polyps, ranging from 1-2.5 cm in size in the descending and transverse colon. In addition, an obstructing mass was found in the proximal descending colon (). The initial endoscopic impression was that this mass represented a malignant lesion and multiple biopsies were performed. The multiple polyps in the descending and transverse colon were suspected to be colonic tumors. Biopsy analysis showed that the colonic polyps and the obstructing mass were sites of chronic inflammation, and they showed no signs of malignancy. CT scans showed no evidence of malignant disease in other organs. The patient underwent a total colectomy with ileorectal anastomosis, since the mass was causing luminal obstruction that resulted in obstipation and because multiple synchronous colon cancers were suspected. The gross specimen consisted of 135 cm of colon tissue. Six polypoid lesions were present in the transverse colon and descending colon. The largest polypoid lesion encircled the entire circumference of the transverse colon (). Microscopic examination showed that the polyps contained ramifying smooth muscle bands that arose from the muscularis mucosa. The smooth muscle bands were thick in the center of the polyp and thinner on the periphery, contributing to the polypoid appearance of the lesion. The surface epithelium was composed almost entirely of goblet and absorptive cells that appeared to be normal (). These features were consistent with a hamartomatous polyp. Postoperatively, the patient was examined using a duodenofiberscope and underwent a small bowel series. The results of these procedures showed no evidence of polypoid lesions. |
An 18-year-old male patient presented with a painful snap over the lateral aspect of his knee whenever he flexed his knee and low grade ache over the lateral side of the knee following sitting down/squatting. He worked as a manual labourer and was a club level basketball player. He could consistently reproduce a clearly audible snap by contracting his biceps femoris muscle with the knee in between 80° and 100° of flexion. The symptoms had started spontaneously around 12 months back without any specific trauma, and had been getting worse over the past 6 months. It was preventing him from playing a sport and doing his job that involved squatting. He was initially treated conservatively by avoidance of activities that precipitate the symptoms; however, he was not responsive to physical therapy for 6 months and then symptoms got worse. He was not able to play basketball for 6 months, and had not been working for the last 3 months. His knee examination was normal except for a palpable movement of the biceps femoris tendon over the fibular head when the knee was taken through 80°–120° of flexion. The biceps tendon could be easily palpated and passively moved anteriorly and posteriorly over the fibular head, reproducing mechanical irritation in the distal tendon. Radiography and magnetic resonance imaging scans did not demonstrate any abnormality.\nThe patient was given a general anaesthetic and was positioned supine with the knee at 60° of flexion against a foot and thigh bolster. A 5 cm incision was made in line with the biceps tendon over the fibular head, ending at Gerdy’s tubercle. Superficial and deep dissection exposed the common peroneal nerve at the level of the neck of the fibula, and a neurolysis was performed from the fibula neck back under the biceps tendon and into the posterior compartment of the thigh. The terminal insertions of the biceps tendon were then carefully exposed and examined. In Terry and LaPrade descriptions, the main tendon of the long head divides just proximal to the fibular head and gives an insertion to the posterolateral edge of the fibular head just posterior to the LCL insertion (the “direct arm” of the long head) before continuing on as a thinner anterior arm that ends by blending with aponeurosis of the anterior compartment of the leg as well as giving some deep fibres of its own to the lateral edge of the fibula, thus making a sling with the direct arm encompassing the LCL insertion (). In our case, it was the direct arm that was thin and relatively deficient, and the anterior arm was hypertrophic, cordlike, and inserted into the anterolateral fascia on the tibia that blended with the Gerdy’s tubercle over the ITB insertion ( and ). It was this thickened cord that moved from superior to the fibular head to inferior to the fibula as the knee was flexed, causing a loud “snap” as it flicked over the prominence of the fibular head at that ROM. There was also a hypertrophic lateral prominence of the fibular head.\nThe insertion of this hypertrophic anterior arm was carefully detached () from the tibia and a No. 5 Ethibond (Ethicon, Somerville, NJ, USA) suture was whip stitched on its distal 20 mm. The whipstitching involved taking five throws on either side of the detached tendon with 10 cm of two free suture ends at the distal most aspect of the tendon from where it was detached much like whipstitching hamstring tendons in an anterior cruciate ligament reconstruction. The prominent posterior-lateral border of the fibular styloid was identified and removed using a small osteotome () and a rongeur was used to obtain a smooth edge. Using a guide wire and a 7 mm reamer, a socket was drilled through the fibular head. The detached portion of the biceps tendon was then shuttled through this tunnel using the free ends of the suture whipstitched on its terminal portion and tied to a metallic button () to dock it in the socket created. The knee was brought back into extension and as the biceps tendon was quite tight coming into full extension, it was lengthened slightly using a pie crusting technique. The knee could then be easily brought into normal hyperextension. The wound was closed with monocryl (Ethicon).\nPostoperatively, the knee was put in a ROM brace blocking terminal 30° of extension and was mobilised non-weight bearing using crutches for 2 weeks. He was then rehabilitated to get full extension by prescribing active and active assisted exercises using a rolled towel under the heel with the knee in extension and asking the patient to extend the knee further. He was prevented from doing active hamstring contractions for 6 weeks: this was done by locking the knee in extension for 2 weeks while walking and releasing it at rest for passive flexion. At the 6 week mark, the ROM was normal, including slight hyperextension, and the patient was allowed to commence active hamstring contractions and gentle running. He returned to full sporting activities by 3 months after surgery and had a ROM of 0°–130°. At the one-year follow-up, the patient had a visual analog scale score of 0 and no recurrence of symptoms, and he was fully functional in day to day activities as well as playing club level basketball. |
A 49-year old man presented with a right abdominal pain, peaks of fever and significant weight loss. His medical history was marked by a right WT at the age of 6 weeks, treated by right nephrectomy followed by adjuvant regional radiotherapy. The precise details on the administered radiotherapy could not be found but most of the schemes applied at this time consisted of relatively large fields to intermediate doses. The complete work-up included an abdominal CT scan and a magnetic resonance imaging showing a 100-mm mass in the right flank, invading the hepatic flexure of the right colon, the segment VI of the liver and the right psoas muscle (Fig. –). The tumor appeared hypervascularized on the arterial phase, displaying a wash-out on the portal phase. Colonoscopy showed a tumor invading the right colon lumen, described as from extrinsic origin. Multiple biopsies were performed during colonoscopy, showing a poorly differentiated tumor of unknown origin. Tumor markers, including CEA, CA19.9 and alpha-fetoprotein, were negative. Of note, the patients had no history of liver disease, nor of alcohol consumption, serology for hepatitis A, B and C was negative and liver imaging did not show any sign of cirrhosis. Moreover, previous abdominal CT scan performed 5 years before in the context of abdominal occlusion did not reveal any liver lesion. On this basis and in the absence of any other secondary location, an exploratory laparotomy has been planned.\nAt surgery, an invasive tumor at the right flank was found, involving the segment VI of the liver and the hepatic colonic flexure. No plane of dissection could be observed between the tumor and the psoas muscle. Accordingly, en bloc resection including right hemicolectomy, resection of liver segments V and VI and resection of the anterior sheet of psoas muscle has been performed (Fig. –). Postoperative course was uneventful and patient was discharged on postoperative day 12. Pathologic examination demonstrated a poorly differentiated HCC (Fig. ) and a margin-free (R0) resection. Arginine-positive staining confirmed the diagnosis of HCC (Fig. ). Of note, the liver at distance of the tumor appeared of normal structure, without any signs of cirrhosis or other liver damage. Twenty weeks after surgery, the control CT scanner showed a multifocal recurrence. At this time, the patient was proposed for whole-liver 90Yttrium intra-arterial radioembolization. |
A 60-year-old African American female was following up for her chronically elevated alkaline phosphatase levels. She had a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, allergic rhinitis, and chronic lower back pain. Patient has a family history of arthritis, cardiovascular disease, and diabetes mellitus; she denies ever using alcohol or tobacco.\nWith the onset of elevated alkaline phosphatase level and vague abdominal pain in 2013, an abdominal ultrasound performed in December showed hepatic steatosis. Viral serologies for hepatitis during 2013 were negative, as a gastrointestinal consult was required to determine the need for a liver biopsy. A liver biopsy was subsequently performed, which showed focal mixed micro and macrovesicular steatosis. Portal tracts showed minimal focal chronic inflammation, no significant fibrosis, and no iron deposition.\nThe vague abdominal pain that she was experiencing waxed and waned for two years. Additionally, the patient experienced some vague chest pain and dyspnea that prompted an echocardiogram in February of 2015, which demonstrated a left ventricle ejection fraction of 44%. Consequently, a left heart catheterization in the following month showed no significant coronary disease with a dilated left ventricle with an ejection fraction of 50%. A 2-year follow-up in July of 2015 showed suspicious cirrhosis by Computed Tomography (CT) scan (), possibly due to granulomatous changes and chronic inflammation. A CT scan was determined to be necessary for our patient because of rising alkaline phosphatase without other explainable etiologies, in addition to the patient's appetite suppression and vague abdominal pains. Patient's weight during this time was 207 lbs (93.89 kg) and was advised to diet and exercise. After 4 months of continuous symptoms, especially with abdominal pain, a laparoscopic cholecystectomy was performed with a liver biopsy that showed subsequent granulomatous changes in September of 2015. The liver biopsy showed coalescing periportal nonnecrotizing epithelioid granulomas with associated multinucleated giant cells and chronic inflammation. The chronic and patchy inflammation is representative of the granulomatous hepatitis, despite not having elevated transaminases. The granulomatous changes suggested possible sarcoidosis (). The liver biopsy was not histologically suggestive of nonalcoholic steatohepatitis, with no steatosis noted. Chest X-ray at that time showed no significant findings.\nInflammatory bowel disease (IBD) was not explored in the patient because she never had clinical signs on past or present examinations, denying any symptoms of IBD including alternating bowel habits, predominant constipation, or diarrhea. Laboratory studies 2 years and 6 months since the onset, at the end of 2015 showed negative antinuclear antibodies (ANA), negative rheumatoid arthritis factor, negative cyclic citrullinated peptide (CCP) antibodies (IgG/IgA), elevated C-reactive protein of 8.9 mg/L, normal complement C3/C4, elevated B-type natriuretic peptide 688.6 pg/mL, and negative mitochondrial (M2) antibody. Subsequent office visits and additional laboratory results are shown in .\nAdditionally, patient experienced peak weight loss with a weight of 154 lbs. (69.85 kg) in 2016. During this time period, an echocardiogram showed a decreased ejection fraction of 26%. This result and a history of having ventricular tachycardia resulted in the patient having an automated implantable cardioverter-defibrillator (ICD) placed.\nUrinalysis in June 2017 showed RBC 0-5/hpf, WBC 0-5/hpf, bacteria 2+, and moderate calcium oxalate crystals. Additionally, patient's weight increased in 2017 to 190 lbs. (86.18 kg). |
A 44 year-old female with a history of breast cancer, which was removed by modified radical mastectomy three years previously, was referred to us by her surgeon for evaluation of a mass in the right atrium (RA) that was discovered incidentally during follow-up computed tomography (CT). On enhanced CT imaging, a slightly enhancing homogenous round low-density mass was observed in the RA (). The patient had remained asymptomatic following her breast cancer resection, specifically denying dyspnea, lightheadedness, syncope, or lower extremity edema.\nOn examination, the patient appeared well nourished and in no acute distress. Vital signs included a blood pressure of 118/78 mmHg and heart rate of 75 beats per minute. Baseline biochemical and hematological tests were within normal limits. A chest X-ray revealed a normal-sized heart and no evidence of metastatic nodules in the lung fields. On auscultation, there was a regular rate and rhythm without murmur and clear breath sounds in both lung fields. The patient had normal peripheral pulses and no peripheral edema.\nTransthoracic echocardiography (TTE) revealed a cystic tumor in the RA with homogenous echogenicity, adjacent to the interatrial septum but not obstructing the right ventricular inflow. The mass was difficult to visualize by TTE because of its low echogenicity and its thin fibrous capsule. There was no pericardial effusion or epicardial mass suspected as metastasis from the breast cancer. Transesophageal echocardiography (TEE) demonstrated a mobile mass in the RA with homogenous low echogenicity that measured 28 × 29 mm. A bicaval view at a 119° angle of rotation revealed that the mass did not develop from the mid portion of the fossa ovalis and that it nearly filled the lower portion of the RA cavity in this image plane (). We advanced the TEE probe and rotated the angle to 87° to obtain a longitudinal image plane that included the orifice of the inferior vena cava (IVC) and the lower interatrial septum. The mass protruded into the RA and was attached to the interatrial septum near the orifice of the IVC (). Contrast echocardiography using an intravenous injection of agitated saline provided a clearer delineation and spatial resolution of the mass, revealing a lobulated surface ( and ).\nA right atriotomy was performed under total cardiopulmonary bypass. The right atrial mass was found to arise from the lower limbus of the fossa ovalis, and it had a well-developed capsule. Successful resection of the mass resulted in a 1 cm sized defect of the interatrial septum, which was closed with a pericardial patch. The remainder of the operative course was uneventful.\nHistopathologically, the lesion was cystic and contained transparent fluid. The cyst was lined with a single layer of endothelial cells with fibrous septa and lymphoid infiltrates (). Immunohistochemically, the endothelial cells demonstrated a positive reaction for CD34 (). The final diagnosis was a cardiac lymphangioma. |
A 53-year-old woman with no significant past medical history presented initially to an outside hospital with a two-day history of a mild headache followed by acute worsening of the headache, nausea, vomiting, and loss of consciousness immediately prior to presentation. A CT scan of the head demonstrated diffuse, thick subarachnoid hemorrhage, a small amount of intraventricular hemorrhage, and an intraparenchymal hemorrhage within the inferior left frontal lobe (Fisher grade 4). The patient was then transferred to our hospital for definitive management. Upon arrival at our hospital, she was intubated, stuporous, localizing to noxious stimuli in her left arm, and withdrawing to noxious stimuli in her right arm and legs (Hunt Hess 4). A CTA demonstrated a dorsal variant aneurysm of the left internal carotid artery (Figure ). The patient was taken to the operating room that day for a left frontotemporal craniotomy for clip reconstruction of the aneurysm with a single fenestrated clip. It was felt during surgery that the vessel could be successfully reconstructed using clip reconstruction without clip wrapping.\nPostoperatively, her neurologic examination findings remained depressed but consistent with her examination at presentation. On hospital day 3, a surveillance DSA demonstrated reconstruction of the vessel without evidence of residual aneurysm filling or significant vasospasm (Figure ). The patient’s clinical examination slowly improved over the next several days. On hospital day 21, an intravenous heparin infusion was started for several persisting deep venous popliteal clots. On hospital day 22, the patient became acutely somnolent. A CT scan of the head demonstrated new subarachnoid hemorrhage around the clip site and a new, thin subdural hematoma along the left convexity concerning for aneurysm rerupture. An emergent DSA showed a new dorsal variant aneurysm just distal to the previous clip site (Figure ). The new aneurysm was multilobulated and measured approximately 7 mm in its maximal dimensions. There was also evidence of active pulsations within the aneurysm during angiography. The collective decision of the patient’s family, and the treating neurosurgeon was to proceed with treatment by flow diversion. The patient was given 10 mg of intravenous abciximab, and a 4.5×25 mm Pipeline Flex device (ev3/Covidien/Medtronic) was placed across the aneurysm. The patient was then given a second dose of 10 mg of abciximab. To provide as much protection as possible, the decision was made to cover the aneurysm with a second flow diverter. Another 4.5×20 mm Pipeline Flex device was then placed within the first device in a duplicative fashion. An immediate follow-up angiogram demonstrated good contrast stasis within the aneurysm (Figure ).\nImmediately after the procedure, the patient was taken for a repeat CT scan, which demonstrated new, diffuse subarachnoid hemorrhage and intraventricular hemorrhage, which was expected due to her prior decline in her neurological status. On examination, her pupils were nonreactive bilaterally and she was not responding to noxious stimuli. She also required a vasopressor infusion to maintain her hemodynamic function. The patient’s family decided to withdraw care, and the patient died. |
A 69-year-old man with no prior history of medication or anticoagulant therapy first noticed a painless swelling in his left flank in 2005. This swelling gradually increased over 6 years, resulting in the formation of a mass in the left flank region. In June 2011, the patient presented to a local hospital after mild pain developed. The patient did not have any definite history of trauma or surgery that could have caused the left abdominal/back lesion. Computed tomography (CT) indicated the presence of a left retroperitoneal mass with left hydronephrosis because of external compression by the mass and a right atrophic kidney. A double J-stent was placed in the left ureter. The serum creatinine level changed from 0.72 mg/dL before double J-stent insertion to 0.53 mg/dL after the treatment.\nOn physical examination at the Gunma University Hospital, a firm area of swelling with an approximate size of 20 cm × 15 cm was detected. Blood tests results indicated that the patient had mild anemia and a hemoglobin level of 10.7 g/dL. The patient’s coagulation profile and platelet count were normal. However, CT indicated the presence of a huge mass (20 cm × 15 cm × 13 cm) compressing the left kidney in the upward direction in the retroperitoneal space. Contrast-enhanced CT revealed that the mass was not uniform but included scattered calcification and a partly enhanced rim (Figure ). On T-1 and T-2 weighted magnetic resonance imaging (MRI), high signal intensity and several partition walls were observed in a major portion of the mass (Figures and ). No bone metastases were noted on bone scintigraphy.\nBased on these results and the patient’s clinical history, we suspected the presence of CEH, in addition to soft tissue malignancy and hemangiomas. Open abdominal surgery via the intraperitoneal approach was then performed. The mass was located in the retroperitoneal space, was completely encapsulated, and did not exhibit any evidence of invasion to the neighboring tissue; however, it was found to be partly adhering to the left ureter and psoas muscle. On exploration, we observed that there was no vascular malformation in the surrounding tissue. Although a slight adhesion was present between the mass and the left ureter, dissection was performed relatively easily because of a ureteral stent that was placed prior to the operation. However, the mass was partially adhering to the aorta, and therefore, we decided to perform dissection at a site close to the mass. Despite this careful dissection, the traction exerted on the thin capsule of the mass resulted in its rupture. We noted that the mass was filled with a dark brown substance including blood cells, necrotic tissue, and fibrin (Figures and ). Histopathological examination of the mass capsule revealed dense fibrous connective and fatty tissue containing numerous old clots (Figure ). No evidence of neoplasia was found. The postsurgical diagnosis was a CEH in the retroperitoneal space. During the postoperative period, the patient developed high fever and a subcutaneous emphysema that spread out from the left thoracic wall to the left abdominal wall. As a result of consulting a dermatologist, a subcutaneous emphysema seemed to be caused by the operative stress than a bacterial infection. He received compression therapy by a compression garment. The laboratory data revealed leukocytosis and elevated levels of β-D-glucan. Antibiotic therapy with cefazolin was replaced with doripenem and clindamycin. In addition, treatment with fosfluconazole was initiated. We could not locate the site of inflammation or infection after examination by CT, urine culture, sputum culture, and blood culture. Thereafter, the fever and subcutaneous emphysema resolved, and the β-D-glucan levels gradually declined until normalization. No sign of CEH recurrence was observed 2 years after surgery. |
Patient #1
A 78-year-old female first presented to our department in 2014 with BRAF mutation-positive melanoma metastatic to the brain, left adrenal gland, and spleen. Prior to this, she was in excellent health managing her household pets until she noticed an enlarging mass in the right neck behind her ear. After she hit her head on the bus she was driving, she was incidentally found to have scalp lesions as well. Both the mass and lesions were biopsied and the patient was found to have metastatic melanoma. During workup for a clinical trial, she underwent a positron emission tomography-computed tomography (PET-CT) scan in November 2013, which revealed hypermetabolic areas in the adrenal gland and spleen, in addition to bilateral scalp and neck. A magnetic resonance imaging (MRI) of the brain the same month revealed two small enhancing metastatic lesions. On the day of treatment initiation, she was found to have eight lesions and was thus treated with Gamma Knife (GK) in 2013 by the outside institution, in addition to three cycles of ipilimumab.
On interim scanning in 2014, she was found to have at least five new lesions. She was motivated to pursue further treatment with GK. On the day of her GK procedure in April 2014, imaging and evaluation by our service showed 16 lesions in the brain (Figure ). Since she lived four hours away from our center and WBRT would be logistically difficult for the patient, the decision was made to proceed with GK. All 16 lesions were contoured and prescribed a highly conformal treatment plan receiving 18 Gy to various isodose lines in one to three shots. The patient tolerated the treatment well, but subsequent imaging in 2015 showed a right frontal lobe lesion concerning for disease progression. The patient therefore underwent a right frontal craniotomy and received postoperative GK to the lesion two months later. Since then, the patient has been on pembrolizumab maintenance treatment.
At the last follow |
In June 2018, a 55-year-old Thai woman living for the last 25 years in Switzerland presented with a history of two subcutaneous, painless, nonitching nodules to a dermatologist in Switzerland. The nodules had been present for 4 years, and the patient reported neither growth nor change of morphology over time. On palpation, two firm subcutaneous nodules of coarse consistency, both measuring approximately 4 cm in diameter, located on the right upper thigh in close proximity to each other, were identified. Neither signs of inflammation nor local lymphadenopathy was present, and the physical examination was otherwise unremarkable. Basic laboratory investigations (including differential blood count, C-reactive protein, and liver function tests) were all within normal limits. Because the clinical presentation suggested a benign soft tissue process, imaging was dispensed under the assumption that definite diagnosis would be established by surgical excision and histological examination. Hence, the patient was referred to a plastic surgeon. On incision of the first nodule, a whitish, thin, flattened, worm-like object (∼0.3 × 15 cm) was pulled out. On incision of the second nodule, a morphologically similar structure was removed (). (Note: Because of the unexpected findings at incision of the first nodule, the second nodule was operated on 10 days later, after our laboratory had been consulted and a provisional diagnosis had been established.)\nBecause the findings were suspicious of a helminth, two samples (one from the first resected worm fixed in formalin and the other one from the second resected worm stored in normal saline solution) were sent to the National Reference Center for Human Parasitic Diseases at the Swiss Tropical and Public Health Institute in Basel. Macroscopic and microscopic investigation of the sample stored in normal saline solution showed an amorphous structure exhibiting slow, undulating movements. An anterior end was identified by finding an oral opening of a helminth, whereas the posterior end was disrupted. A part of the sample was embedded in paraffin and used for histological investigation, which revealed typical characteristics of spargana: a folded cuticula with microvilli and calcareous corpuscles (). For species determination, DNA was isolated from another part and a sequence of the mitochondrial cytochrome oxidase (COX1) gene was amplified and sequenced as described elsewhere. A 398–base pair-long sequence of the COX1 was determined (GenBank accession number MK910864) showing 100%, 99.25%, and 90.20% sequence homology to Spirometra erinaceieuropaei (no single nucleotide polymorphisms [SNPs]), Spirometra decipiens (3 SNPs), and Sparganum proliferum (> 35 SNPs), respectively (). Thus, the helminth was identified as S. erinaceieuropaei. The healing of the wounds proceeded without complications. No oral anthelminthic treatment was administered, and no subsequent lesions occurred since. |
A 21-year-old male construction worker was brought to the emergency department in an ambulance after falling from an eight-meter high platform. He was on a spine board and a cervical collar was applied. He was conscious and cooperative but was in great pain. He was not able to define what had happened and how he fell but probably he attempted to grip the scaffolding during his fall. He was holding his left arm above his head in a hyperabducted position and was unable to change his posture. Attempts to bring his arm down towards his trunk were failed due to mechanical resistance and significant pain. Also, his elbow was deformed and he was keeping it in flexed position. His left radial pulse was barely palpable. A quick neurologic examination was performed but unfortunately the axillary nerve was not assessed at that time. There were open skin wounds on the right foot, right calf and left hand. A written informed consent was obtained from the patient.\nRadiological evaluation revealed the diagnosis of inferior shoulder dislocation and posterior elbow dislocation (Figure 1). There were also fractures of clavicle, scaphoid, base of the first metacarpal extending into the carpometacarpal joint (Bennett fracture) all in the same side (left) and calcaneus fracture at the contralateral side. The emergency physicians ordered a whole body computed tomography (CT) as it is considered a routine work- up for multi-trauma patients to detect possible soft tissue injuries of the chest and abdomen. Considering the situation, the senior surgeon (first author) decided to reduce elbow and convert the inferior shoulder dislocation into an anterior dislocation straightaway while patient was still on the X-ray table without administering any medication as it would have had caused delay. Standing at the head of the table, he distracted the patient’s flexed elbow to yield translation and felt the reduction and tested it by elbow passive range of motion. The surgeon flexed his own left elbow to 90 degrees and adducted his arm firmly, then, grasped patient’s left elbow and wrapped it by his fingers so that the patient’s elbow was kept in slightly flexed position. He placed his right hand’s palm on the patient’s chest to provide counter traction so that volar side of surgeon’s wrist was lightly touching and leveraging the dislocated humeral head (Figure 2a). Then, he twisted his torso in counterclockwise direction to generate upward and outward traction (Figure 2b) and gradually adducted the patient’s arm by taking small side steps, changing his position but maintaining the traction generated by his dynamic trunk posture (Figure 2c, d). Finally, patient’s arm was adducted against the body.\nSurprisingly, the patient responded with a complete relief of pain. Radial pulse was checked and found normal. X-rays obtained subsequently showed that both dislocations were reduced. Then, a long arm plaster splint and a Velpeau bandage were applied. Afterwards, further evaluation and treatment of the patient proceeded.\nShoulder and elbow joints were also included in the total body CT scan. Both joints were reduced but there was a minimally displaced humerus greater tubercle fracture (Figure 3). Fortunately, no additional serious injury that necessitated emergent surgical intervention was detected and cleaning and suturing of wounds were accomplished under local anesthesia. A posterior short leg plaster splint was applied to right side. Next day, scaphoid fracture was fixed with headless compression screw and Bennett fracture with K-wires percutaneously under regional anesthesia. The elbow was reexamined and found stable. The clavicle and calcaneus fractures were managed conservatively. After completion of review diagnostic studies and multidisciplinary care, the patient was discharged at sixth day.\nThe patient was followed-up regularly and appropriately. The Velpeau bandage immobilization was discontinued and K-wires were removed at fifth week. Pendulum exercises for shoulder and passive range of motion exercises for elbow were initiated. At sixth week, a rotator cuff strengthening program was initiated. At third month, the range of motion at left shoulder was not satisfactory and magnetic resonance imaging was performed which revealed complete rupture of the supraspinatus tendon (Figure 4).\nLoss of deltoid muscle mass was also noticeable. Then, rotator cuff repair with mini open exposure was performed. Six months after the injury, there was obvious wasting of the deltoid muscle and left brachial plexus electromyography revealed isolated axillary nerve lesion. However, the patient was elevating the left arm approximately 160 degrees without any pain apparently with compensatory action of accessory muscles and external rotation of shoulder as well as by increased rotation of the scapula (Figure 5). The patient was referred to a hand surgeon and no additional intervention was recommended for axillary nerve lesion. All fractures healed clinically and radiographically and the patient returned to his work as a construction worker with considerable recovery of motion and strength at ninth month. Four years after the injury, he was still employed as a worker. |
This patient, a 38-year-old male, is the Case 1 patient's younger brother who also suffered from congenital insensivity to pain with anhydrosis from birth. He suffered from Charcot spine, and spinal fusion was performed many times due to the collapse of the spinal joints. During this treatment, hip X-rays showed the collapse of left femoral head getting worse, and we followed up this patient carefully, using conservative treatment, as long as it was possible for him to walk on one crutch. However, he was admitted to our hospital suddenly because he felt a swelling in his right hip joint and then could no longer stand.\nClinical examination revealed swelling and a shorting of the right hip joint, but the joint was completely pain free. A hip X-ray revealed the disappearance of the right femoral head and destructive changes in the right acetabulum; nevertheless, the right femoral head was not collapsed before two months (). If this patient had not received THA, he would surely have spent the rest of his life in a wheelchair due to the collapse of the bilateral hip joints.\nWe used a posterolateral approach, performed in the lateral decubitus position with the same operation protocol of Case 1. In this case, the cementless acetabular cup was press fit in accordance with the preoperative plan. In addition, we inserted dome screws into the cementless acetabular cup in order to achieve initial fixation. On the femoral side, we inserted the cementless femoral implant into the femoral canal with the same operation protocol of Case 1. After inserting the implant, we performed an impingement test to prevent bone-to-implant or bone-to-bone impingement. Finally, the short external rotator muscles separated from the proximal femoral bone were completely repaired to their original position. The postoperative rehabilitation schedule was full weight bearing after the operation; a hard abduction brace was used to prevent postoperative dislocation.\nFour weeks after surgery, despite being put in a hard abduction brace, postoperative posterior dislocation occurred, as in Case 1. Similarly, posterior dislocation occurred 3 times in the six months after surgery. Afterwards, through continuous use of the hard abduction brace, the posterior dislocation did not recur, and it was possible for him to walk on one crutch. However, five years after surgery, a late dislocation occurred when he arose from a chair. After closed reduction, we closely supervised the posture of dislocation and put him in a hard abduction brace continuously. There were no clinical signs of implant loosening in the hip X-ray taken, compared with the postoperative X-rays (). |
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 23-year-old woman presented with a palpable mass in her right lateral thigh, which was first diagnosed a year before, became noticeably larger over the last 2 to 3 months. The mass was non-tender and felt a little warm to the touch. The mass lesion was not soft at first; however, it became softer as it grew in size. The woman had no prior history of injury and a clinical examination revealed that the mass lesion was not tender and did not display any discharge or drainage sinus.\nThe initial sonography revealed a well-circumscribed large cystic mass located in the subcutaneous tissue. It consisted of two cysts; one large main cyst and another daughter cyst. The main cyst was predominantly composed of hypoechoic fluid and debris in the dependent portion within it. Inside the cyst, a hyperechoic nodular lesion was observed. The daughter cyst adjacent to the main cyst also contained debris-like materials (). A Doppler sonographic examination showed no evidence of a vascular signal, and MRI obtained two months later showed a high signal intensity cystic lesion with a wall of low signal intensity on both the T1- and T2-weighted images. The size of the mass was measured to be about 5.5×4.8×2.4 cm. The daughter cyst had a fluid content at slightly lower signal intensity than the main cyst on a T2-weighted image. A nodular lesion within the main cyst was also observed as low signal intensity on a T2-weighted image, which was similar to the sonographic finding. The solid portion of the mass was directly adjacent to the cysts, and was contiguous with the peripheral wall of the smaller cysts (). With gadolinium enhancement, the solid portion and cystic wall diffusely enhanced in a similar fashion (). The preoperative differential diagnoses, based on the imaging findings (US and MRI), were a complicated epidermoid cyst, cystic change of a neurogenic tumor, and a parasitic cyst such as a hydatid cyst.\nA surgical excision of the mass was performed, and the mass was revealed as a brownish, smooth and myxoid nature. Furthermore, the mass showed extensive cystic change and a focal solid nodule in the cystic wall. A microscopic examination revealed that the mass was composed of a mixture of abundant giant cells and mononuclear cells with diffuse interstitial hemorrhaging and cystic degeneration (). The immunohistochemical results revealed that the mass had a diffuse positive stain for CD68 () and a focal positive stain for S-100; however, it was negative for desmin, which is consistent with a giant cell tumor. |
A male neonate was born at 25 + 6 weeks of gestation to 35 years old gravida 2, parity1 (G2P1) mother with antiphospholipid antibody syndrome. This was an in vitro fertilization (IVF) pregnancy. She was Rubella immune and negative for Hepatitis B surface antigen, Venereal disease research laboratory test (VDRL), Human immunodeficiency virus, Gonococci and Chlamydia. Her urine culture and vaginal swab for Group B Streptococci was also negative. Her anatomy scan at 18 weeks of gestation showed normal fetal anatomy and a short cervix for which she underwent cervical cerclage placement at 20 + 5 weeks gestation. There was no history of chorioamnionitis or prolonged rupture of membranes. She presented at 25 + 5 weeks with preterm labor and had a spontaneous vaginal delivery the next day. She had received two doses of Betamethasone and Magnesium sulphate prior to delivery. He initially required positive pressure ventilation followed by intubation and surfactant administration with an acceptable response. Umbilical arterial and venous catheters were placed and the neonate was transferred to neonatal intensive care unit (NICU) in a stable condition.\nA blood culture was drawn at birth and empiric treatment with Ampicillin and Gentamicin was intiated. The antibiotics were discontinued after 36 hours as the blood culture showed no growth and he remained clinically stable. In addition, as per unit protocol, an endotracheal aspirate was sent for a Ureaplasma culture on admission. This grew a Mycoplasma species for which 3 days of intravenous Azithromycin was given.\nA head ultrasound on day 4 of life showed bilateral intraventricular hemorrhage (grade 3) with mild ventriculomegaly and a hemorrhagic venous infarct in the right frontoparietal region. Umbilical arterial catheter was removed on day 4 of life whereas umbilical venous catheter was removed on day 6 of life. He remained stable till day 7 of life when he presented with an acute clinical deterioration presenting as lethargy and tachycardia; a septic work up including blood and cerebrospinal fluid (CSF) cultures was completed and Vancomycin and Cefotaxime were started as empiric antibiotics. His CSF analysis showed red blood cells (RBC) count of 4887 × 10E6/l, pleocytosis of white blood cells (WBC) 9620 × 10E6/l with neutrophilic predominance, hyperproteorachia - protein 8300 mg/l and hypoglycorachia - glucose 0.1 mmoles/liter. Gram staining in CSF was negative. Within hours he developed generalized clinical seizures which was treated with Lorazepam and Phenobarbital followed by a Levetiracetam load and maintenance dose. He had further episodes of clinical and subclinical seizures which resolved after further adjustment of levetiracetam doses.\nHis first CSF culture was suspected to grow Mycoplasma Hominis and was sent to the regional national diagnostic laboratory for confirmation. The CSF culture was repeated along with a sample for 16s ribosomal RNA PCR analyses. The 16s ribosomal RNA PCR analysis confirmed Mycoplasma hominis in both CSF samples. Antibiotics were then changed to Moxifloxacin and Doxycycline. The repeat CSF culture after 48 hours of Moxifloxacin and Doxycycline showed no growth. CSF analysis done seven days after starting this treatment showed RBC 5650 × 10E6/l, WBC 449 × 10E6/l, protein 3763 mg/l and glucose 0.2 mmoles/liter. Subsequent CSF findings repeated after another three days showed further improvement, RBC 7187 × 10E6/l, WBC 93 × 10E6/l, protein 3691 mg/l and glucose 0.5 mmoles/liter. No growth was seen on any of these CSF cultures. Serial head ultrasound scans were done which showed progressive ventriculomegaly, post hemorrhagic ventricular dilatation and cystic evolution of hemorrhagic/venous infarct in the right frontoparietal region. Although these findings could be attributed to extreme prematurity; there is a likelihood that infection with Mycoplasma Hominis may have played a role in its progression. There have been documented cases of Mycoplasma Hominis meningitis resulting in CNS complications including intraventricular and periventricular hemorrhage, hydrocephalus, and infarction []. Lumbar taps were repeated as therapeutic measure to reduce ventriculomegaly, but optimal volumes of CSF were not obtained. Because of the ventriculomegaly, he was evaluated for a possible shunt on day 31; this was deferred because of the stable ventriculomegaly.\nAntibiotics were given for a total duration of six weeks after which he was discharged home with a normal neurological examination. He was referred to Neurodevelopmental clinic for follow-up. |
A 45-year-old man, without significant personal or familial medical history, was admitted with a history of abdominal distention and intermittent abdominal pain for a month. Abdominal MRI was conducted to identify a solid mass with an irregular lobulated configuration located in the right upper quadrant with a diameter of 20 cm. (Figure ). Biopsy and pathology examinations came to no conclusion. The patient had no hematemesis or melena and no elevated lesions on the skin. Physical examination indicated that a huge mass could be palpated with tenderness in the upper quadrant. With only symptomatic treatment, the patient still complained of an exacerbation of abdominal distention and reduction of urine. Bloody fluid was observed in catheter drainage. Cystometry was then conducted to conform a diagnosis of abdominal compartment syndrome. Evidence indicated that the patient could be suffering from a tumor rupture and hemorrhage. Surgery was performed to relieve the symptoms and resect the tumor.\nLaparotomy indicated that the enterocelia was filled with ascites with a drainage of 5000 ml. The major part of the tumor was located in the right upper quadrant, invading the transverse colon, omentum and gastroduodenum. The peritoneum and the surface of the mesenterium were both implanted with numerous nodules with a diameter that varied from 0.5 to 3 cm. (Figure ) In the paracolic ditch of both sides, the right phrenic top and pelvic area were all affected by tumors. A cytoreductive surgery was then performed to remove as much of the visible tumor as possible. The surgeries performed included total peritoneal resection, partial hepatectomy, subtotal colectomy, partial small bowel resection, partial right diaphragm resection and terminal ileostomy. (Figure ) The surgery went smoothly with 1200 ml blood loss. A CT scan on September 21 showed the tumors had been totally resected and left no obvious metastatic lesions (Fig. ).\nThe pathological test revealed that the tumor was composed of both epithelioid and spindle cells with intermediate grade nuclear atypia and a mitotic count of 11/50 HPF. An IHC assay revealed that both spindle and epithelioid cells displayed positive cytoplasmic staining of ALK, SMA and desmin. Florescence in situ hybridization was also conducted to test for ALK rearrangement. This primary pathology finding provided a convincing diagnosis of inflammatory myofibroblastic tumor. Considering the tumor was spreading all over the abdominal cavity and that ALK staining of the tumor was positive, crizotinib was suggested as adjuvant therapy. However, the patient was unable to tolerate treatment with crizotinib because he was suffering from severe vomiting. The elevation of ALT and AST of serum also indicated liver damage. We had to stop treatment temporarily.\nA month after the operation, the patient began to complain of abdominal pain and uncontrollable vomiting. The vomitus was an acid liquid with a volume of 500 ml daily. No excreta could be seen in the pouch. A solid mass with a diameter of 5 cm could also be palpated around the ileostomy. The patient was diagnosed with incomplete intestinal obstruction. A CT scan was conducted and revealed tumors recurring with extensive metastasis involving the liver, spleen, small intestine and right pleural cavity (Fig. ). Bilateral pleural and abdominal effusions could also be observed.\nCrizotinib remained to be the only option to save the patient’s life. However, following the rapid progression of intestinal obstruction, the administration of crizotinib seemed impossible because of the unstoppable vomiting. Administration through the nasogastric tube was also performed, but turned out to be ineffective because the drug was thrown up for severe vomiting. Finally, we came up with a possible solution for administration of crizotinib—giving the drug by nasogastric tube through the terminal ileal stoma created during the operation. After getting consent from the Ethical Committee of Zhongshan Hospital and the patient, we started treatment by giving crizotinib 100 mg bid. The dose was gradually increased to 200 mg bid based on the monitoring blood tests. The capsule was opened and the powder was mixed with pure water. The mixture was then injected into the nasogastric tube which had been placed backward into the end ileum with a length of 50 cm from the stoma. After one week’s administration, the patient presented with less vomiting and reflux and was even able to consume solid food. Excreta could be seen in the pouch. The evaluation of prealbumin also indicated an improvement of nutritional level. Compared with the previous treatment, the patient was suffering less from vomiting but elevation of ALT was still observed. However, after two weeks’ treatment with the drug, oliguria suddenly appeared. Further blood and urine tests indicated hyperuricemia (1071 μmol/L) and an abnormal creatinine level (440 μmol/L), indicating the patient’s kidneys had shut down. Based on the patient’s symptoms and auxiliary examinations, the diagnosis of tumor lysis syndrome (TLS) was confirmed. We immediately gave dialysis and other auxiliary treatment. However, the disease progressed so fast that the patient suffered cardiac arrest and was not able to be revived. |
A 40-year-old woman (body mass index 44.6) and a history of open SG 2 years earlier was submitted to a revisional open SG due to inadequate weight loss and concomitant incisional hernia repair. The post-operative course was prolonged due to fever and the patient was discharged on the 12th post-operative day. Shortly after discharge, the patient developed fever and abdominal pain, the clinical condition deteriorated and 7 days postoperatively she was admitted to a regional centre. An abdominal computed tomography (CT) scan with intravenous contrast medium revealed a collection measuring 127 mm × 95 mm × 90 mm with a fluid gas level. The patient was referred to our institution.\nOn admission, the patient had clinical signs of sepsis necessitating supportive conservative management. A percutaneous CT-guided drainage of the collection with an 18G needle with the placement of a 10F was performed. An upper gastrointestinal (UGI) gastrografin swallow study[] depicted a leak near the gastroesophageal junction []. Seven days later, a new CT scan showed significant reduction of the collection (74 mm × 37 mm), whereas a left-sided pleural effusion developed. A UGI endoscopy revealed the presence of a 4–6 mm in diameter fistula located 30 mm below the gastroesophageal junction. Due to the fact that the leak persisted, as it was confirmed by a UGI study, a decision was made to apply the OTSC device. A 16.5 mm OTSC was then deployed with successful closure of the fistula orifice. Five days after the OTSC placement, a revisional CT scan revealed complete resolution of the encapsulated collection and elimination of the pleural effusion. Subsequently, additional imaging work up with revisional UGI and UGI endoscopy [] confirmed the proper placement of the clip, the closure of the leak and the absence of a sleeve stricture. The patient returned to oral diet and the clinical condition ameliorated.\nThe total hospitalisation stay was 65 days. During the follow-up, the patient continued to tolerate oral intake and remained asymptomatic. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.