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We report the case of a 71-year-old woman who initially underwent outpatient MRI of the lumbar spine for an abnormal gait and sciatica when she was found to have an incidental, large pelvic mass (). Her past medical history included an appendectomy and ovarian cystectomy, osteoarthritis, and peripheral neuropathy. Following MRI, she was referred for an emergency outpatient gynecological opinion, at which time a transabdominal ultrasound scan confirmed the presence of a 9 × 5.6 × 10-cm complex cystic mass posterior to the bladder and superior to the fundus of the uterus (). The ovaries could not be identified, and blood tests, including tests to determine full blood count, kidney function, liver function, and CA125 and carcinoembryonic antigen levels, were all normal. Despite a large palpable abdominal mass, she remained relatively asymptomatic, complaining of some lower abdominal discomfort and urinary incontinence controlled with a pessary. In light of the normal CA125 and large pelvic mass, she was booked for an urgent diagnostic laparoscopy, bilateral salpingo-oophorectomy, and excision of the large pelvic mass. Laparoscopy revealed the mass to be arising from the small bowel mesentery, and the only procedure performed was peritoneal washing, which did not show any significant abnormality microscopically. A follow-up computed tomography (CT) scan of her chest, abdomen, and pelvis was done, and her condition was discussed at the colorectal multidisciplinary team (MDT) meeting.\nThe CT scan revealed a well-encapsulated enhancing mass with multiple septations and locules measuring 8.6 cm × 9 cm × 7.5 cm (). Neither invasion into adjacent structures nor any associated lymphadenopathy was observed. Two indeterminate low attenuation lesions without any ascites or peritoneal deposits were found within the liver. She went on to have a lower midline laparotomy and excision of her mass. At the time of operation, dissection of the mass from the mesentery was unsuccessful, and complete excision required the removal of approximately 50 cm of the small bowel, followed by a hand sewn anastomosis with interrupted 3-0 polydioxanone sutures. Her recovery was uneventful, and she was discharged.\nMacroscopically, the mass, which measured 105 mm × 90 mm × 75 mm, was within the mesentery of the small bowel and had a brown, lobulated external surface and a multiloculated, cystic cut surface. The small bowel itself was unremarkable. Microscopic examination showed a well-circumscribed neoplasm composed of nests and trabeculae of polygonal cells with moderate amounts of eosinophilic cytoplasm (). Immunohistochemical staining showed strong diffuse staining with chromogranin (), synaptophysin (), CD 56, and vimentin, with patchy positivity for S100 protein and BcL2. AE1/3, CD34, CD117, desmin, MNF116, and podoplanin were negative. MIB-1 showed less than 1% positivity. These findings are consistent with a diagnosis of a paraganglioma.\nDuring her postoperative follow-up, liver MRI with primovist revealed a 24-mm hypovascular lesion that could not be further characterized. Her case was discussed at the regional neuroendocrine tumor MDT, and a Gallium 68 Dotanoc positron emission tomography (PET) CT scan was recommended; the scan showed no evidence of uptake in the liver and no evidence of disease elsewhere. She continues to remain well one year postoperatively and is under yearly surveillance with CT.\nWritten informed consent was obtained from the patient.
A 60-year-old man who was working in a squatting position at a construction site was struck by a 600 lb H-beam falling from 2 m over his lower back and buttocks area. When he arrived at our hospital 3 hours after the injury, he already had been diagnosed with a bilateral anterior dislocation of the hip () and a spine fracture. He was transferred to our hospital from a private clinic with the right hip reduced, but the left hip remained unreduced. On arrival at our hospital, the patient had severe lower back pain and bilateral hip pain, but the vital signs were stable and there were no neurologic deficits. Roentgenographic studies were obtained in the department of emergency medicine and the plain pelvis film showed that the right hip was reduced, but the left femoral head was displaced over the obturator foramen; a right superior and inferior ramus fracture, and a right acetabulum fracture were noted (). The lumbar spine film showed disruption of the axial alignment and decreased vertebral body height of L5 (). A pelvic computed tomography (CT) demonstrated an extra-articular fracture of the right acetabulum, sacral alar, and the anterior portion of the sacroiliac joint on the left. On lumbar spine CT, there was canal encroachment by the fractured body of L5 (), a greenstick laminar fracture, bilateral inferior articular process fractures of L4, and a left sacral alar fracture (). Closed reduction was achieved under general anesthesia by longitudinal traction on the left leg while an assistant applied lateral traction on the upper thigh while simultaneously pushing the femoral head toward the acetabulum. After reduction, posterior segmental fixation was done from L3 to S1 on the unstable lumbar burst fracture (). Bilateral Buck's traction was applied for 6 weeks, followed by non-weight bearing for 6 weeks. Three months after the injury, he gained full range of motion on both hip joints and there were no complications at the 2 year follow-up.
A 65-year-old female Caucasian patient, suffering from intraoral purulent discharge in her left mandibular angle and the front of her left upper jaw, was referred to our hospital by her dentist. Her medical history revealed that she had suffered from postmenopausal osteoporosis, which was initially treated with two months of alendronate (70 mg once weekly) administered orally, followed by three annual infusions of zoledronic acid (5 mg intravenously). In addition, our patient was allergic to penicillin and was treated for diabetes mellitus type II with metformin.\nIntraoral examination revealed the presence of a fistula formation in her left mandibular angle in region 38 (Figure ) communicating with a retained left third molar. There was also a fistula formation in her upper jaw (region 22/23) communicating with her upper left lateral incisor and canine (teeth 22 and 23), which showed signs of chronic endodontic infections and had received endodontic and surgical treatment (root resection) in the past (Figure ). Both sites were marked by a purulent discharge on compression which was accompanied by mild to moderate pain on palpation. A panoramic radiograph and cone beam computed tomography identified radiolucent areas at the resected apices of teeth 22 and 23 as well as the region surrounding her left lower wisdom tooth (Figure and ).\nA fluorescence-guided removal of necrotic bone parts in her left mandibular angle was performed as previously described [] and her left third molar was removed (Figure ). In addition, the upper jaw necrotic bone was resected under fluorescence-guidance and a root-resection of her lateral incisor and canine was carried out under general anesthesia (Figure ). Furthermore, her right third molar was removed. After the procedure, our patient received an intravenous antibiotic treatment (clindamycin 600 mg, three times daily) and was discharged five days later. The antibiotic was continued for 10 days at the same dose. During the follow-up there was no sign of infection and complete mucosal closure was achieved at all sites (Figure and ).\nHistological evaluation revealed the typical hallmarks of an early ONJ lesion, including areas of necrotic bone coinciding with signs of infections as well as areas with increased bone turnover (Figure ).
An 85-year-old man was presented by his general practitioner complaining of the presence of an erythematous round lesion that was protruding from the surgical scar of his previous sternotomy. He mentioned that the lesion has been growing slowly over time and that lately was also associated with pain in the area. The patient has undergone aortic valve and aortic root replacement with the use of a prosthetic tube graft 7 years ago. The general practitioner referred him to the cardiothoracic unit of our hospital; physical examination confirmed the presence of a non-pulsatile, erythematous round lesion in the cranial third of the previous sternotomy scar with a surrounding bruise (Fig. \nand .\nContrast-enhanced computed tomography (CECT) scan was performed and revealed a 7-cm pseudoaneurysm arising from a 5-mm fenestration of the distal suture line of the Dacron graft with significant amount of thrombus. The pseudoaneurysm was pushing the sutured sternum forward causing diastasis of the sternotomy and was extending anteriorly to the sternum in the subcutaneous tissue (Fig. \nand .\nThe patient was discussed in the aortic multidisciplinary meeting and was considered as of high risk for surgical revision; an endovascular approach was suggested as an alternative option and was referred to interventional radiology.\nThe procedure was performed under local anesthesia. Written informed consent was obtained explaining the risks and benefits of the procedure, including the risk of potential pseudoaneurysm rupture during manipulation and potential embolic material migration in the cerebral circulation. A retrograde left femoral artery access was obtained and a 5F sheath was inserted. Through a pigtail catheter, angiographic evaluation of the ascending aorta in anteroposterior and oblique views was followed in order to delineate the neck of the pseudoaneurysm. A second arterial access through the left axillary artery followed by another 5F sheath was inserted. Using this access, the neck of the pseudoaneurysm was catheterized and a 0.035 in. standard hydrophilic guidewire was advanced into the pseudosac. The wire was then changed to a 0.035 in. Amplatz extra stiff guidewire (Cook Medical, Bloomington, IN, USA) and a 9F delivery sheath was introduced in the sac. An Amplatzer muscular ventricular septal defect occluder (St. Jude Medical, St. Paul, MN, USA) plug measuring 15 × 7 × 10 mm was advanced in the pseudoaneurysm neck and was successfully deployed. The final ascending aortogram confirmed the device position with the blockage of the to-and-fro flow into the pseudoaneurysm sac and with contrast stasis within the pseudoaneurysm cavity. The next day, the subcutaneous swelling was significantly reduced in size and a month later the skin wound was corrected surgically (Fig. ). CECT was further performed at 72 h after the procedure, at 1 and 6 months, and at 1 year after the procedure, and documented complete exclusion and reduction of the size of the pseudoaneurysm sac (Fig. ).
A 4-year-old girl who had been complaining of intermittent abdominal pain since 2 years prior presented with a right lower abdominal mass that had been palpable since 6 months prior. At the time of her visit to Seoul National University Children's Hospital, the patient had no abdominal or leg pain. On examination, she had no fever but a 5-cm pulsatile mass-like lesion was palpable on her right lower abdomen. The patient was born, weighing 3.3 kg, by vaginal delivery after 38 weeks and 1 day of gestation. No other abnormalities were found in the screening test. The patient, who had been healthy with no special medical history after birth, had a medical history of hand-foot-and-mouth disease 1 year earlier. She had also been hospitalized to receive pneumonia treatment 12 months after birth and 1 month before visiting our hospital. She had no medical history of abdominal injury. No evidence of inflammation or collagen vascular disease was found in the blood test, and all test results were within their normal ranges.\nAbdominal ultrasonography revealed a 4.6 × 5.0-cm well-defined mass in the right lower quadrant, with large internal vascularity (). Abdominal CT revealed a 5.2 cm × 4.5 cm × 5.1 cm, right-sided, partially thrombosed, saccular, iliac artery aneurysm. The aneurysm could be observed at the aortic bifurcation level. The left iliac artery of the patient was normal. However, in the right iliac artery, a communication with the aneurysm, which was located at the level where the common iliac artery bifurcates into the internal and external iliac arteries, was confirmed with contrast enhancement during the CT (). The aneurysm was pushing the internal iliac artery to the medial side, and the external iliac artery could not be traced (). The right common femoral artery was found at the inguinal ligament level by joining of the deep circumflex iliac artery and inferior hypogastric artery, which were more prominent than those of the left side. The size of the right common femoral artery was equal compared to the left side femoral artery, and were located in the same anatomic position. Both iliac veins were normal.\nThe surgery started with a transverse incision in the right lower abdomen. We reached near the iliac artery by retroperitoneal approach. An encapsulated pulsatile mass measuring 5 cm × 5 cm × 5 cm was found strongly adhered to the right common iliac artery and the surrounding tissues, particularly with the ureter. It was pushing the ureter to the anterolateral side. As it was difficult to separate the mass from the surrounding tissues, we placed vascular clamps on the proximal right common iliac artery and the distal right internal iliac artery. Then, we made an incision in the middle of the mass in the direction of the blood circulation. Large blood clot was found inside of the mass. The inside of the mass was covered with intima. As the mass had a pinpoint fistula with the right internal iliac artery on its medial side, primary closure of the fistula was performed by using a Prolene 6-0 suture (). No leakage was observed when the vascular clamps were removed, and normal distal flow was confirmed by checking the dorsalis pedis pulse. All of the aneurysm, except the parts that were strongly adhered to the surrounding tissues, was removed.\nA pathological examination confirmed that it was a true aneurysm, considering that all layers of the vascular wall were stretched with no deficit (). An intimal fibroplasia was confirmed (), and an organizing thrombus was accompanied by chronic inflammation (). Although myxoid degeneration was observed, we found no evidence of vasculitis. In addition, no bacteria were identified from the bacterial culture of the blood clot found from the aneurysm.\nThe patient was discharged 3 days after the surgery without any complication. Five months passed since the surgery, and the patient is doing well without any abdominal or leg pain.
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up.
A 39 year old woman was referred to the Department of Oral and Maxillofacial Surgery with acute pain and swelling in the left mandible. Nonsurgical endodontic treatment on tooth #35 and incision and drainage in the left mandible had been performed at a private clinic 1 week before. She experienced severe pain, left facial swelling, and restricted mouth opening after the treatment. She was admitted and treatment with intravenous antibiotics (Combicin Inj., 3 g, Samsung Pharm., Seoul, Korea) was scheduled. Her medical history was non-contributory.\nAfter 10 days, the patient was referred to the Department of Conservative Dentistry for root canal treatment of teeth #27 and 35. The patient exhibited a decrease in spontaneous pain in tooth #35 after administration of medication. A clinical examination revealed decreased left facial swelling and limited mouth opening. However, tenderness to palpation on gingival tissue around tooth #35 remained. A periapical radiolucent lesion on tooth #35 was observed and initiation of previous root canal treatment on tooth #27 was confirmed in the periapical radiograph (). Previously initiated therapy with acute apical abscess on tooth #35, and previously initiated therapy with normal apical tissue on tooth #27 was diagnosed. Root canal treatments were scheduled for teeth #27 and 35. When temporary filling material was removed, it was observed that Depulpin had been used on tooth #27. Since root canal treatment of tooth #35 was initiated around the same time in the same local clinic, the use of Depulpin in tooth #35 was strongly suspected. After 1 month, teeth #33 and 34 demonstrated negative responses to an electric pulp test. Consequently, root canal treatments of teeth #33 and 34 were performed. After completion of root canal treatment of teeth #33 - 35, alveolar bone exposure persisted and the initial incision line of gingival tissue around #33 - 34 did not show signs of healing (). The patient was referred to the Department of Oral and Maxillofacial Surgery for further evaluation. Additional radiographic examination was performed and a bone scan showed increased inflammation of the left mandible. Final diagnosis was determined as focal osteomyelitis of the mandible in the region around teeth #33 - 35. Teeth #33 and 34 were extracted, and decortication and saucerization of the left mandible were performed in the Department of Oral and Maxillofacial Surgery (). After surgery, the patient did not present with any specific symptoms ().
On April 23rd 2015, a 47-year-old female patient with a surgical history of cesarean section in 1992 was admitted to our department complaining about postprandial pain and distention of the right lower abdomen for 17 years after the resection of most part of the transverse colon. She suffered from constipation since 1988, with the average defecation frequency once 3-4 d, and the lowest once a week, and received no special treatment then. However, she did not experience any abdominal symptoms during the first 20 years of her life.\nOn 10th February 1998, she was hospitalized in Department of Emergency Surgery in our hospital because of bellyache and constipation, and was discharged after conservative treatment. However, she was re-hospitalized due to intestinal obstruction and was suspected as “adhesive ileus” based on her operation history only 6 d later. The transverse colon resection was planned. The pre-surgical blood and urine tests were normal. The endoscopic pathological examination and the routine fecal examination were not conducted. The surgery was conducted on 12th March. During surgery, it was observed that the middle of the transverse colon was significantly distended to approximately 10 cm in diameter. Around 25 cm of the dilated colon was removed, and the splenic flexure was rectified. The post-operational pathological examination showed infiltration of acute and chronic inflammation cells and focal hemorrhage (the immunohistochemistry and specific staining tests were not performed, possibly due to the fact that HD was not considered, or to the unavailability of such a test then). However, after the first surgery, she still experienced constipation, and postprandial bloating and bellyache, and soon felt obvious aggravation of the symptoms. She was then prescribed with laxatives. She was hospitalized to our hospital again in 2000 due to ileus, and refused the suggested reoperation. She was discharged when feeling better after conservative management, and depended on laxatives thereafter. From 2000 to 2015, the patient was admitted to hospital for several times due to intestinal obstruction, and the symptoms were relieved after symptomatic treatment like gastrointestinal decompression, enema, and anti-inflammation. Unfortunately, during this period, she had not been proposed the diagnosis of HD.\nThe patient had hypertension since 2002, and the blood pressure (BP) could be initially well-controlled by oral nitrendipine treatment. However, later on the BP gradually elevated, and had to be antagonized by the addition of captopril. In recent 2 years, the patient experienced aggravated anorexia and post-meal symptoms, obvious weight loss (about 20 kg), progressive continuous cough, and significantly elevated BP (146/100 mmHg at admission, and 180/110 mmHg as the highest level during drug administration), which could be poorly controlled by oral symptomatic treatment drugs. On April 21st 2015, the colon contrast pneumobarium conducted in the Fourth Affiliated Hospital of Anhui Medical University indicated giant right hemi-colon, and she came to our department seeking for medical management. The patient weighed 44 kg at admission. The physical examination showed a bulging abdomen with an about 15 cm-long old surgical scar on the right upper abdomen. The drum sound was obvious during percussion, and the frequency of the bowel sound was 5 times per min. All the other physical examinations were normal.\nFor the hospitalization in our department, the routine blood and fecal tests were normal, and the urine test showed the presence of bacteria (429/μL). Imaging examinations offered informative clues for diagnosis (Figure ). The chest radiography showed right pleural effusion and thickening, and potential colon interposition. The abdominopelvic computed tomography (CT) and the colon double contract pneumobarium radiography revealed significant expansion of the cecum, the ascending colon, the hepatic flexure of colon, and the remnant transverse colon, with the most dilated area 13.6 cm wide. Abundant residual stool, gas, and liquid existed. An annular stenotic transitional segment (only 3.8 cm wide) could be perceived, and the original transverse-descending colon anastomosis was slightly narrow with limited distension capability. All the other intestines were normal. The neighboring organs and tissues underwent marked displacement and deformation under pressure.\nRight colectomy was conducted for the patient to remove the aganglionic and the dilated fragments based on the initial consideration of HD followed by ileum-colon anastomosis, and the resected intestine included the non-dilated bowel 6 cm beyond the anastomosis of the initial surgery. The intraoperative frozen section pathological examination convinced us of the completeness and definitiveness of the eradication of all the remnant aganglionic bowel segment. An intestine segment with normal ganglion cells could be seen in the resected specimen pathologically. During surgery, we observed mild adhesion of the abdominal cavity, the obviously outstretched colon, and the deformed liver due to extrusion (Figure ). The right lobe of the liver markedly shifted upwards, and the left lobe underwent compensatory enlargement. The left colon and rectum were all fine in morphology and motility with satisfactory tension perceived and without abnormal dilation or constriction, and the intraoperative pathology further supported that they were normal in structure with sufficient ganglion cells and should not be removed, which seems different from the common understanding that they are usually affected in HD[]. The postsurgical pathological report supported the HD diagnosis, showed the remnant aganglionic section left behind by the first surgery, and importantly, confirmed the definitiveness of the reoperation based on the presence of normal bowel segment with normal ganglion cells in the resected specimen (Figure ).\nInterestingly, after reoperation, the BP dropped to 138/69 mmHg at discharge without the assistance of any drug, and cough was also cured. Symptomatic treatment has thus been ceased since then. Up till now, the patient has been followed up once every month. No adverse event was observed. She reported satisfactory diet, without distention and ache of the abdomen, cough, or hypertension. The defecation frequency is 3-4 times per day without the assistance of laxative, the bowel movement is active and smooth, and she gains weight of about 6 kg with satisfactory fecal control. She feels much better concerning quality of life (QoL), especially in the digestive aspect. Contrary to the initial surgery, the patient did not feel recurrence/worsening of any HD-related symptoms. The abdominal CT scan and X-ray examination conducted in May 2016 did not reveal abnormality. Her condition was still closely and carefully watched on, and she expressed great willingness to share her case.
In 2015, a 56-year-old female with a few week’s history of severe, acute onset of progressive pain of her left thigh was referred to radiology for further musculoskeletal imaging. The symptomatic patient informed that she was frequently climbing steep stairs.\nThe first radiograph demonstrated very subtle periosteal reaction and cortical elevation in the anterior, mid to upper portion of a left femoral shaft [ and ].\nSubsequent MRI revealed intra-cortical linear hyperintense signal abnormality in association with periosteal elevation, periosteal fluid, and associated muscle edema at the femoral insertion of vastus intermedius [-]. The imaging pattern was almost identical to the previously reported cases of adductor magnus avulsion insertion syndrome.[ The only minimal difference was the anterior location as per vastus intermedius muscle insertion site.\nGiven, the clinical scenario and acute symptoms following frequent climbing of stairs and clinical examination, a vastus intermedius avulsion insertion injury was suspected. However, due to the rarity of such isolated injuries and limited literature review, a possibility of osteoid osteoma, osteomyelitis, or even neoplastic process was also included in the spectrum differential diagnoses. In addition, a follow- up radiograph and microscopic verification were advised to eliminate the differential diagnoses.\nThe symptomatic patient requested conservative management with analgesics and did not agree for any interventional procedures such as biopsy at that time. The associated pain resolved in few months.\nAfter a year, the patient was completely asymptomatic, however, decided to represent for a follow-up plain film of the left thigh. This was performed, and the radiograph revealed cortical thickening involving the femoral shaft in the setting of reactive changes and associated healing process [ and and ]. The visualized extensive bone thickening was similar to the typical reactive focal cortical changes seen in osteoid osteoma.\nA complementary biopsy to rule out osteoid osteoma or osteomyelitis and establish a definite diagnosis was again advised and requested as the site of avulsion was unusually higher than the common insertion site involving the mid- tendon area rather than tendon-bone junction. Following discussions and review of the images, the patient agreed to undergo the procedure. The histological examination finally confirmed the suspected benign reactive periosteal reaction [].\nIdentical imaging features with associated cortical thickening on follow-up radiographs in the setting of “thigh splints” were previously reported. However, the cortical thickening observed in the current literature was less conspicuous, likely as per much shorter follow-up period.[\nIn subsequent clinical reviews over the 3 years, the same patient reassured that the previously noted symptoms never came back and she was comfortable during her average, daily physical activities without any disability.
A 51-year-old male presented with progressive hearing loss of last 4 years and dizziness of few months duration. He did not have a history of a head trauma or of any brain surgery. On admission, neurological and physical examination revealed left side deafness, no facial weakness, or no other low cranial nerve deficit like loss of gag reflex, uvular deviation, tongue deviation. His facial sensory and mastication function were normal. The patient did not have any known systemic disease of bone and family history or physical characteristics of neurofibromatosis. His blood profile, including his serum calcium, phosphorus, and alkaline phosphates, was normal. CT scan showed that the tumor mass had destructed IAC completely and temporal bone to petrous apex, grown around the cochlea, reached the carotid artery in its petrous portion, extended to jugular foramen (). We noticed pneumatized area of opposite temporal bone corresponded to eroded area by tumor (). On brain MRI, the tumor was a 4×3.8×3 cm sized, heterogeneous lobulated, well-defined mass with destruction of IAC and extended to CPA cistern. The tumor was confined to posterior fossa and not extended to Meckel's cave (). The combined translabyrinthine with retrosigmoid suboccipital approach was used for the resection of the tumor. At the first time of surgery, we removed the tumor piece by piece within temporal area with translabyrinthine approach, but we could not find facial nerve with this approach. So we performed additional retrosigmoid suboccipiral approach, and it allowed the exposure the lateral recess area easily and origin site of facial nerve from brain stem. After detection of facial nerve with intraoperative facial nerve monitoring, we dissected facial nerve from proximal to distal area. The dissection of the facial nerve within the temporal bone was very difficult, because the facial nerve was severely adhered to the tumor mass () and the complexity of eroded temporal bone. The tumor was extended to jugular foramen by destruction of superior wall of jugular foramen. The consistency of temporal bone was felt to be normal and the colors and the consistency of the tumor were typical of VS. We successfully achieved total removal of tumor and preserved facial nerve in continuity. Histological examination confirmed a typical schwannoma. There were no abnormal vascularity and malignant features (). The postoperative course was uneventful with normal facial nerve function and the vertigo was resolved.\nThe patient was good condition after 18 months of follow-up without cranial nerve dysfunction. He also did not show any evidence of the recurrence or residual tumor in postoperative MRI performed at 15 months of follow up.
A 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.\nHis vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L.\nPatient was seen by the urology on-call in the ED and his bedside ultrasound done by the urologist revealed a 10 cms cystic lesion anterior to the lower pole of the right kidney with irregular internal echogenicity. Patient was admitted to urology department for further evaluation and management.\nInpatient CT Intravenous Pyelography (IVP) was done and the left kidney showed relative hypoenhancement and reduced excretion of contrast, associated with diffuse ureteric thickening and periureteric fat stranding which could be related to a passed left renal calculus or a differential diagnosis of ureteropyelonephritis which was less likely due to diffuse involvement of left kidney. There was a tubular cystic structure in the right flank with inferior tip at the same site of previously inflamed appendix stump base which could represent mucocele of the appendix stump ().\nPatient was then transferred under the care of the general surgery department, where he underwent a colonoscopy which demonstrated an extrinsic compression at the caecum and appendiceal orifice and a smooth pedunculated polyp measuring 10 mm in the sigmoid colon (). Exploratory laparotomy was done, the mucocele was resected, and patient recovered well. Histopathology revealed a benign mucinous cystadenoma. The patient was discharged well with an outpatient surgical follow-up.
A 40-year-old man was brought to the ED by emergency medical services after he was found outdoors displaying an altered mental status, right-sided facial droop, headache, and unsteady gait. On initial evaluation, the patient was drowsy, following commands poorly, and could not answer questions appropriately. His initial Glasgow Coma Scale score was 13 (eye - 3, motor - 4, verbal - 6). Provocative testing revealed inconsistent right-sided ptosis with an otherwise non-focal neurologic exam.\nGiven this presentation, there was a concern for stroke. The patient underwent computed tomography and computed tomography angiography of the head and neck; both were negative for any evidence of ischemic or hemorrhagic stroke or other abnormalities. During his continued evaluation, he reported a headache, which he described as left temporal pressure with associated dental pain. He reported exacerbation of the headache with light and sound but reported not having had any nausea or vomiting. He conveyed that his headache was consistent with previous migraines, just more severe. He did not report any neck stiffness, fever, or sweats. Medical records showed that the patient had been in the ED five other times in the past 30 days with either headache or dental pain. On one visit the patient reported dental pain, was noted to have poor dentition, and pain was improved after dental block. On another visit the patient reported chronic headaches that were relieved by anti-inflammatory medications. Each of these previous assessments did not reveal any fever, neck stiffness, or altered mental status and thus did not trigger concern for intracranial pathology or meningitis requiring further workup. Each time, after symptomatic improvement with medications given in the ED, the patient was discharged and instructed to follow up with his family medical doctor.\nLater in the patient’s ED course, a family member arrived and reported that the patient had been mentally decompensating over the previous two weeks. The family member stated that the patient had been acting abnormally, including urinating, and defecating in his bedroom and walking around the house naked. The family member was not aware of the patient having had any recent illness, recent travel, exposure to birds, or having pets at home. The family member reported that the patient worked as a sandblaster and had a sporadic history of marijuana and alcohol use. Given the patient’s behavioral change, a lumbar puncture was performed for further investigation.\nThe procedure was performed in the standard fashion, positioned in the left lateral decubitus position. The initial opening pressure was 42 centimeters of water (cmH2O) (reference range: 5–25 cmH2O). Analysis of cerebrospinal fluid (CSF) from tube four revealed a red blood cell count of 5 millimeters cubed (mm3) (reference value: 0 mm3), white blood cell count of 178 mm3 (reference range: 0–5 mm3), neutrophils 40% (reference value: 0%), lymphocytes 35% (reference range: 60%–70%), eosinophils 4% (reference value: 0%), protein 100 milligrams per deciliter (mg/dL) (reference range: 15–55 mg/dL), glucose 20 mg/dL (reference range: 40–80 mg/dL) and lactic acid 5.4 millimoles per liter (mmol/L) (reference range: 1.2–2.4 mmol/L). Given the concern for meningitis, the treatment team started the patient on empiric antibiotics (vancomycin 2 grams, ceftriaxone 2 grams, and acyclovir 710mg given parenterally) while the patient was in the ED.\nThe patient was admitted to the hospital where he was followed by infectious disease specialists and given continued empiric medications as described above. Two days after the initial lumbar puncture, the cryptococcal CSF antigen test returned positive. The patient was then started on amphotericin 450mg parenterally and flucytosine 1750mg orally. Cerebrospinal fluid and blood cultures tested positive for C. neoformans on day three. The patient received six therapeutic lumbar punctures during his admission for increased intracranial pressure, as well as eventual placement of a ventriculoperitoneal shunt for persistently elevated intracranial pressure after two months of therapy. A fourth-generation antigen/antibody HIV enzyme-linked immunosorbent assay (ELISA) test during admission was negative. Investigation and workup for other disease processes causing immunosuppression (including cirrhosis, autoimmune disorders, hematologic malignancy, sarcoidosis, previous steroid use, immunosuppressive therapy) were all negative. Further exploration into his alcohol use noted that it was “sporadic” and was thought to be non-contributory. Magnetic resonance imaging done during his hospitalization revealed increased T2/weighted-fluid-attenuated inversion recovery signal representing ventriculitis consistent with cryptococcal meningitis (). Hallucinations and odd behaviors were continually noted during the patient’s admission, although these symptoms improved gradually. Upon discharge from the hospital, the patient was placed on 1600mg of oral fluconazole daily for three months and then continued maintenance therapy of fluconazole 400mg for 12 months. One year from the patient’s initial diagnosis of cryptococcal meningitis, he had some improvement in his cognition and was able to live independently, though he continued to struggle with symptoms of headache despite having a ventriculoperitoneal shunt and was unable to work. He continues to follow with infectious disease to ensure continued remission from cryptococcal meningitis.
A 77-year-old male with a past medical history of coronary artery disease status post coronary artery bypass grafting, hypertension, chronic obstructive pulmonary disease, diabetes mellitus type 2, and cerebrovascular accident presented to a local hospital with acute abdominal pain and bloating. A computed tomography (CT) scan of the patient's abdomen and pelvis was performed and showed intraabdominal bleed and multifocal liver lesions. Initial complete blood count (CBC) revealed a hemoglobin of 7 g/dL and he was transfused one unit of packed red blood cells prior to transfer to our institution. On arrival, CT angiogram of the abdomen and pelvis showed multiple dense, heterogeneous masses throughout the liver with associated perihepatic and intraperitoneal hemorrhage and areas of tumor blush were noted but no extravasation was seen to suggest active hemorrhage. There was also multiple enlarged periportal and upper mesenteric lymph nodes, likely representing metastatic adenopathy. There were no lesions present on the pancreas. CT chest was obtained and showed no evidence of intrathoracic metastatic disease. Initial blood work revealed normal liver function tests, appropriate response in hemoglobin to transfusion and negative viral hepatitis panel. Tumor markers revealed AFP elevation to 8705 ng/mL, normal Carcinoembryonic Antigen and Cancer Antigen 19-9. Magnetic Resonance Imaging (MRI) of the abdomen and pelvis showed multiple lesions throughout the liver with targetoid appearance. There was no evidence of cirrhosis and these lesions did not have imaging characteristics of typical HCC (Figure ). It was suspected the multifocal liver lesions were HCC given the elevated AFP. However, the MRI was not consistent with HCC and a liver biopsy was obtained. Pathology results were consistent with poorly differentiated, large cell-type neuroendocrine carcinoma with metastatic disease to the liver (Figure ). The patient had an unremarkable colonoscopy and esophagogastroduodenoscopy six months prior to presentation therefore, it was suspected the primary origin of NET was in the small bowel. Regarding the intraabdominal bleed noted on initial CT scan, this remained stable on repeat scans and surgery recommended conservative management. The planned chemotherapy regimen will be Carboplatin and Etoposide.
Patient is a 45-year-old female with past medical history significant for paroxysmal atrial fibrillation and diabetes mellitus. She was admitted to the hospital for generalized malaise. She was found to be bacteremic and a CAT scan showed findings consistent with an abscess and resultant osteomyelitis of the left sternoclavicular junction. She underwent multiple debridement by the cardiothoracic team. She had a residual defect at the sternoclavicular joint and a small sized skin defect. She was discharged home with a negative pressure wound therapy device. Patient was readmitted to the hospital with a non-healing wound with active drainage (Fig. ). These findings were consistent with osteomyelitis and a cutaneous fistula. We recommended further debridement of the wound and bony elements and muscle coverage. Patient was taken to the operating room and Under general anesthesia, the wound was evaluated and marked (Fig. . The skin surrounding the cutaneous wound was excised to healthy tissue. The cardiac surgeon assisted in the excision of the non-viable part of the clavicle. At the end of the debridement, the defect included part of the manubrium, most of the medial part of the clavicle and the first rib, the skin overlying the pectoralis in the midline was incised and carried down to the subcutaneous tissue. The ipsilateral pectoralis muscle was dissected and lifted off the chest wall from medial to lateral. The pectoralis was also released inferiorly from it’s attachment to the serratus. The pectoral artery pedicle was identified and preserved. After completely undermining the flap we could not obtain adequate muscle bulk and length to provide adequate coverage. A decision was made to further release the pectoralis from its humeral attachment. The attachment of the pectoralis to the humerus was identified and released (Fig. ). The result was a completely detached pectoralis except for its attachment at the vascular pedicle (Fig. ). The muscle was mobilized medially and superiorly to cover the defect. There was adequate coverage for the sternoclavicular defect. Two Jackson Pratt drains, one subcutaneous and the other sub-muscular were placed and secured. The muscle was tacked down with multiple interrupted absorbable sutures. The incision was closed in a layered fashion. Patient tolerated the procedure well. She was discharged home a few days after surgery. The drains were removed in the clinic. Patient was seen for a follow up about 3 months after surgery. The incisions were well healed. She was discharged from the plastic surgery clinic (Fig. ).
A 70-year old woman was admitted from a dermatologist to the Department of Plastic and Breast Surgery, Roskilde, Denmark. A biopsy verified well-differentiated full-thickness squamous cell cancer was found at the right side of the lower lip. The tumour had been present for three years. The patient had a history of ischemic heart disease with a percutanous coronary intervention and implantation of a stent in 2002. She was a heavy smoker. No alcohol overconsumption was reported. By clinical examination, a 15 × 15 mm sore, firm, central ulcerating tumour was seen located at the vermillion border (). At the mucosal side of the lip, leukoplakia was observed.\nNo enlarged lymph nodes in the cervical region was found at the clinical examination.\nSurgical intervention would remove approximately 50% of the lower lip. The patient was offered radiotherapy as an alternative to surgery and chose the former. She underwent a series of radiotherapy for a period of two months.\nFive weeks after the initial clinical examination at our clinic, the patient was readmitted to our department from the Department of Oncology at Copenhagen University Hospital due to recurrence of the squamous cell cancer located to the lower lip. At this point, the patient presented a monstrous, ulcerating tumour, involving most of the lower lip (). No clinical signs of systemic spread to lymph nodes in area was found by thorough clinical examination and palpation of the head and neck. Furthermore, a 18FDG-PET-CT was performed and ruled out further local or systemic spread.\nFirst, a total excision of the lower lip including the commisures during which free resection borders of 1 cm were confirmed by intraoperative frozen section diagnosis. 8 days after primary excision, histopathology confirmed free resection borders, and reconstruction of the lower lip by bilateral Fujimori technique was performed (, , ). Due to paucity of mucosal tissue between the orifice of the parotid duct and commisures of the mouth besides a relatively narrow labial sulcus, the remaining lack of mucosal lining was reconstructed by use of split skin harvested from the right thigh.\nAt a clinical follow-up three months after surgery, palpable enlarged, firm lymph node was found located to the lower jaw. Biopsy confirmed the histological diagnosis of metastasis from squamous cell carcinoma. Position Emission Tomography Scan (PET) confirmed the localisation of metastasis from a squamous cell carcinoma on the left side of the jaw, but as well on the right side. No distant metastases were found. Clinical presentation 5 months after surgery is seen in .\n5 ½ months after the initial admission to our department, bilateral neck dissection was performed. Several metastases with extensive perinodular growth was found on the right side, and infiltrating underlying musculature on the left side. The patient was referred to the Department of Oncology, Herlev Hospital, Denmark, where radiotherapy was given.\nOne months after completed radiotherapy, the patient presented in our clinic a very sore, ulcerated tumour at the jaw line on the left side. The tumour was adherent and dripping with what appeared to be saliva. Punch biopsies were not representative. A computer tomography (CT) scan confirmed local recurrence of aggressive squamous cell cancer. The patient was referred for more extensive surgery and further treatment, which is why eventual defatting of the lip was postponed.
A 63-year-old man was referred to Chonbuk National University Hospital emergency center because of a coil migration during endovascular coil embolization. He had received treatment for a left MCA bifurcation unruptured aneurysm at a local medical center. A neurovascular surgeon was not present at this particular medical center and the nearest hospital with one who could perform surgical management and endovascular management for such a patient with a coil migration complication was Chonbuk National University Hospital, which was located approximately two hours away from the local medical center.\nAt admission, he had stuporous mental status and right hemiparesis grade III. Initial brain computed tomography taken at the emergency center showed no intracranial hemorrhage, but showed a metallic object which appeared to be a migrated coil around the left insula (). Cerebral angiography performed at the local medical center showed a saccular aneurysmal sac, which measured 9.41 mm × 6.54 mm in size with a relatively broad neck of 4.38 mm at the left MCA bifurcation (). The coil part of coil embolization had detached from the aneurysmal sac and migrated to the left M2 inferior branch (). An emergency left pterional craniectomy was performed. After a left fronto-temporal opening, the left sylvian fissure was split and the MCA bifurcation was exposed. Following dissection of the sylvian fissure, the aneurysmal sac and M2 inferior branch were found, and the aneurysmal sac was in an unruptured state. After placement of temporary clips at the proximal and distal M2 inferior branch, the artery was incised, and the migrated coil and thrombus were visualized (). The migrated coil and thrombus were removed gently and safely, and the arteriotomy vessel was repaired with 10-0 nylon (). An intraoperative trans-cranial Doppler ultrasound confirmed the presence of distal flow in both M2 branches. The aneurysmal sac was clipped using a Sugita titanium #18 clip and a prophylactic decompressive craniectomy was performed (). The patient recovered from general anesthesia with mild dysarthria and right hemiparesis grade IV. Postoperative magnetic resonance diffusion-weighted imaging showed the acute cerebral infarction in the left M2 inferior division territory () and magnetic resonance angiography showed decreased blood flow in the left M1 distal portion, maybe due to a clip artifact (). After 14 days, he was in stable condition with no aggravating signs of neurologic symptoms, therefore, he was discharged. At the six-month follow-up, the patient was neurologically intact.
A 70-year-old Caucasian man with a past medical history of hypertension, significant smoking history, and atrial fibrillation presented to the emergency department with complaints of chest pain and dizziness. The chest pain began 5 h prior to presentation; it was described as dull, retrosternal, non-radiating, and associated with a sensation of dizziness. Of note, the patient had initially been prescribed apixaban, however, during an outpatient visit with his primary care physician, a decrease in haemoglobin was noted and due to concerns for gastrointestinal bleed, apixaban was held 4 months prior to presentation. An electrocardiogram showed atrial fibrillation with a rapid ventricular response. Vitals upon arrival showed a blood pressure of 136/84, heart rate of 128 p.m., respiratory rate of 16 breath/min, and oxygen saturation of 97% with nasal cannula flow of 5 L/min. Physical exam was remarkable for an irregular heart rate and rhythm, and decreased breath sounds at the right lower lung base. Troponin levels were normal. Chest X-ray demonstrated mild cardiomegaly and a right pleural effusion. Left venous lower extremity duplex was positive for deep vein thrombosis of the popliteal and gastrocnemius veins. A transthoracic echocardiogram (TTE) was performed which showed a normal sized right ventricle with normal function. Most notable was the presence of a large mobile echogenic mass swirling around in the right atrium, consistent with a thrombus in transit, elevated pulmonary artery systolic pressures, and severely reduced left ventricular function (). Computed tomography pulmonary angiography demonstrated vermiform filling defects in the right atrium extending to the inferior vena cava and right ventricle, dilation of the right ventricle and right atrium with increased right cardiac pressures, segmental acute pulmonary embolism in the left lower lobe, and chronic pulmonary embolism in the right main pulmonary artery extending to the proximal right middle lobe pulmonary artery (). Rate control management for atrial fibrillation and weight-based protocol for venous thromboembolism with intravenous unfractioned heparin infusion was initiated. Subsequently, the patient was admitted to the cardiac care unit, with repeat TTE after 8 h, showing resolution of thrombus.
A 6-year-old Hindu girl child, belonging to a small town, was brought in by her parents to the psychiatry OPD with the complaints of a bald patch on the vertex of her head due to her pulling out her own hair. She was a full-term normal vaginal delivery with no antenatal or postnatal complications. She was immediately breast fed and it was continued exclusively till 8–9 months. Her mother was 28 years old at the child's birth. The motor milestones were achieved at an appropriate age, but her speech and social milestones were delayed. She could only make cooing sounds by 3 years of age, communicated with her parents by sign language, and never making eye contact. They also saw repetitive movement in the form of running around in circles, and she was extremely sensitive to certain kinds of touches and textures. This is when her parents first took her to a doctor, and she was diagnosed with autism spectrum disorder with moderate severity of symptoms. They tried putting her in a school at the age of 4 years, but she could not adjust there and has been home since then. Parents unfortunately could not afford any occupational therapy or sensory stimulation therapy for the child. She needs assistance in all daily activities but is toilet trained by day, for which she communicates with her mother. After almost 2 years, they again attempted to reintegrate the kid into a school, and this is when she started having symptoms of irritability and pulling out her own hair from her scalp for the last 2–3 months, leading to a bald patch on the vertex of her scalp []. She pulled out the hair and threw it on the floor and was seen doing it repeatedly even after her parents asked her not to. Other than that, she had no crying spells and her sleep and appetite were well maintained. On examination, the child was fidgety, uncooperative, and only comfortable on her mother's lap. She did not initiate any eye contact and constantly tried to go out of the examination room as she was probably uncomfortable with the new setting. Her IQ/DQ testing was planned, started on syrup fluoxetine, and referred for occupational and sensory stimulation therapies. An assessment to quantify the severity of autism spectrum symptoms was also planned. Unfortunately, as the patient due to logistical reasons, the patient could not come to the same hospital for follow-ups and the improvement could not be assessed.
A 19-year-old female presented to fracture clinic 1 day after sustaining a twisting injury to her right knee. At presentation the knee was mildly swollen without effusion. There was significant tenderness on the medial patella. A longitudinal medial para patellar scar and longitudinal medial scar over the MCL were noted. Range of motion was 0–40° actively.\nThe patient had undergone an MPFL reconstruction 5 years previously. At presentation there was no ligament laxity. The patient was given a supportive splint and advised to mobilize as tolerated.\nThe patient failed to fully improve with these measures, continuing to experience severe pain on the medial knee, as well as symptoms of locking and giving way. Her extensor mechanism was found to be intact, but range of motion in flexion was limited to 95° due to pain overlying the quadriceps tendon and medial aspect of the knee. A reproducible click was both heard and palpated between 0° and 20° of flexion, a finding which had not been noted previously.\nCT (Fig. ) and MR imaging showed an endobutton and endocord sitting superior to the patella, with both impinging upon the articular surface of the medial patella facet. A metal susceptibility artefact was seen at the medial femoral condyle, which was identified as an interference screw.\nImaging enabled assessment of the graft tunnels (Figs and ). It appeared that an oblique tunnel had been drilled from the medial epicondyle to the anterior cortex of the femur at the level of the suprapatellar fat pad.\nBased on tunnel positions, we conclude that the original surgeon had perforated the anterior femoral cortex when drilling from the medial femoral condyle. Due to this an anterior cortex endobutton fixation was used to supplement the medial condylar interference screw fixation. A degree of likely soft tissue interposition in the suprapatellar region led to migration of the endobutton, and subsequent rupture from its scar tissue bed following minimal trauma.\nAt athroscopy, the endobutton was found embedded in the synovium of the suprapatellar pouch. The trailing endocord was located under the medial facet of the patella, and was seen to be impinging on the medial patellar facet and femoral trochlea. Both the offending endobutton and endocord were removed. An osteochondral defect had also formed within the medial patella facet and a chondroplasty was performed. At the time of operation patella tracking was normal with no sign of instability, suggesting that the MPFL reconstruction had its intended therapeutic effect.\nPostoperatively the patient gradually built up her activity levels and restored range of motion. At 2 months follow-up, she had no effusion and her pain and locking symptoms had entirely resolved.
A 47-year-old female patient came to the outpatient clinic of FAHZU with a complaint of an asymptomatic right axillary mass for 3 months. Physical examination revealed a soft mass 4 cm in diameter in the right axilla without any other positive findings in the right breast. An axillary lymph node biopsy was conducted in a previous local hospital, and the histopathological results were suggestive of some metastatic carcinomas with an unknown primary lesion, while suspicion of lobular carcinoma of breast could not be ruled out.\nIn order to locate the primary lesion and other metastatic lesions, a PET-CT scan was performed in FAHZU, which reported multiple lesions with significantly increased FDG (18F-fluorodeoxyglucose) intensity presenting in the right side axilla. Meanwhile, the FDG (18F-fluorodeoxyglucose) was slightly elevated at the right elbow, considered as an inflammation or trauma (Fig. ). Therefore, a surgical resection of the right axillary lymph nodes and right supraclavicular lymph nodes was conducted in FAHZU. The histopathology report showed that 31/32 lymph nodes in the right axilla and 10/10 lymph nodes in the right supraclavicula were positive for metastatic carcinoma. For the time being, suspicion of metastatic epithelial sarcoma and metastatic breast cancer could not be ruled out.\nWith more detailed medical history review and physical examination, a mass on the right forearm was found (Fig. ). After a car accident 20 years ago, the mass had been growing slowly over the last decade without causing any pain or ulceration. There was also no abnormality of the right forearm X-ray in routine examination. An MRI scan was applied to the right forearm tumor and the report indicated that metastatic tumor could not be excluded. Therefore, a core needle biopsy (CNB) of the mass in the right forearm was conducted and the histopathology report suggested evidence of ES. So far, breast cancer was excluded and a surgery was performed to remove the right forearm tumor. After that, the patient received 6 cycles of chemotherapy with modified mesna, doxorubicin, ifosfamide and dacarbazine (MAID). Radiotherapy was denied to her after a multidisciplinary treatment (MDT).\nTen months after operation, the patient came back with complaints of pain and redness in the right breast (Fig. ). This time, there were still no positive findings in ultrasonography and PET-CT scan, while the blind CNB of the right breast showed whole breast metastasis of ES. In order to seek a useful therapeutic target, the patient was given a genetic testing. Regrettably, there was no positive result of the metastatic breast sample, sequenced by a 381-cancer-gene panel in a lab. She went through another 6 cycles of chemotherapy with Gemcitabine and Docetaxel, and took Apatinib for maintenance treatment. During the last follow-up (26 months after diagnosis), the disease was under control.\nIn our case, pathology was the most important basis for excluding metastatic breast cancer. The axillary lymph nodes were poorly differentiated under microscope, which was why occult or metastatic breast cancer could not be ruled out in the first place. Histopathological examination showed that the neoplasm was identifiable by tumor nodules with central necrosis surrounded by medium-sized fairly uniform, plump epithelioid cells, and short spindle cells merging in the periphery with relatively abundant eosinophilic cytoplasm (Fig. ). IHC showed CK (pan) (+), EMA (+), CK7 (−), CK8 (+), CK19(+), Vimentin (+), CD34 (++), CD31 (−), F8-R-Ag (−), CD68 (−), S-100 (−), MelanA (−), HMB45 (−), CK5/6 (−), P63 (−), ER (−), GATA-3 (−), E-adherin (−), P120 (+/−), TFE3 (−), MyoD1 (−), CD45 (LCA) (−).\nAfter the right forearm mass was found, further IHC and Molecular Genetics of the lymph nodes were performed. The results suggested that all the neoplastic cells exhibited loss of INI1 protein and were negative for ERG gene rearrangement yet positive for EMA, CK8, CK19, Vimentin and CD34 (Fig. ). Besides, the neoplastic cells were completely negative for high molecular weight cytokeratin CK5/6, P63. Proliferation index ki-67 was approximately 30%. After the forearm operation, visual inspection of the resected specimen showed that it was located beneath the dermis without cutaneous and ulcerous presentation and could not be separated from the bone (Fig. ). Finally, we considered that the patient was with a conventional distal-type ES and the primary lesion was in the right forearm, excluding breast cancer.
This report focuses on a 41-year-old Caucasian male with a background of severe inflammatory bowel disease (IBD). The patient received a small bowel, proximal colon, and abdominal wall transplantation at our unit in March 2014 after developing intestinal failure associated liver disease after a prolonged period of total parenteral nutrition.\nThe ITx functioned well for over a year with the patient regaining nutritional independence from the parenteral feed. His immunosuppressive regime was altered in April 2015 due to renal dysfunction with a switch from tacrolimus to sirolimus based immunosuppression. In September 2015, he presented to our centre with fevers, night sweats, and general malaise. A histopathological report of allograft biopsies taken upon initial admission demonstrated severely active acute ileitis and colitis, most in keeping with an infectious cause of his symptoms. However, immunostaining for EBV, EBER, CMV, HSV, and adenovirus and special stains for fungi were all negative. Other pertinent negatives from these initial studies included no excess of crypt apoptotic bodies, no blood vessel thrombi, and no evidence of dysplasia or malignancy. C4d staining and HLA-B37 Class I but not Class II antibodies were detected at a low level. A PET-FDG scan revealed pericolic inflammatory changes along the course of the transplanted large bowel with diffuse FDG uptake. These investigative findings provided contradictory accounts of the pathoaetiology of the patient's presentation. Favoured differentials at this stage included an infectious cause, a recurrence of IBD, or sirolimus induced ulceration.\nStoma output progressively increased and he became increasingly clinically malnourished as the degree of intestinal failure progressed. In November 2015, histopathological studies demonstrated patchy, ulcerated epithelium with some regenerative changes. Still no changes were seen in the superficial blood vessels visualised in these biopsy samples, decreasing the likelihood of a rejection episode and favouring the notion of a recurrence of IBD.\nThe extensive investigations employed up until this point had not successfully generated a single clear hypothesis as to the aetiology of this gentleman's presentation and were inconsistent with his response to empirical therapies. Despite receiving increasing steroid doses, the patient continued to deteriorate with intermittent septic episodes.\nIn early December 2015, the patient developed an erythematous rash localised to his abdominal wall allograft. Histological analysis of an abdominal wall sample revealed Grade 3 rejection (Banff classification) with apoptotic keratinocytes in the basal cell layer. Subsequent ITx biopsies revealed increased numbers of apoptotic bodies in the crypts in association with severe mucosal ulceration and granulation tissue, now suggestive of combined acute rejection of both abdominal wall and intestinal graft (Figures and ). Plasma citrulline levels demonstrated a progressive downward trend with levels consistently below 10 micromol/L from this period in December 2015 onwards. Over the same time course, faecal calprotectin levels also progressively increased. However, despite continued steroid and antithymocyte globulin therapy, he suffered ongoing intestinal inflammation and based on the macroscopic appearances of his transplanted bowel (), a right transplant hemicolectomy was performed in February 2016.\nBased on previous positive experience [], we used mesenchymal stromal cells (MSC) as a last resort treatment to salvage graft function. Two empiric cycles of intravenously administered autologous mesenchymal stromal cell therapy (two doses of 2 million cells/kg one week apart) were commenced in March 2016. However, no clinical improvement was observed. The decision was therefore taken to proceed with total explantation of the remaining bowel and abdominal wall transplant in April 2016. Histological studies of the explanted allograft revealed features of mucosal infarction and necrosis along with perivascular inflammatory changes suggestive of chronic rejection. He has since been discharged home on total parenteral nutrition and awaits a second intestinal transplant.
A 30-year-old, unmarried Caucasian male presented with a history of having been sexually assaulted five days earlier in a nearby city by a group of unknown males. Reportedly they kicked and stamped on him and during the assault a glass bottle was forcibly inserted into his rectum and the bottle neck broke.\nThe patient appeared very agitated and requested that only females be involved in his care. The residents on call for surgery were both female. When the male on call surgical consultant arrived the patient became very agitated and uncooperative.\nOn examination, there was no evidence of external injury to him. His abdomen was soft and showed a well-healed lower midline incision. He attributed this scar to a laparotomy done for abdominal pain in his childhood. Plain X-Ray of his abdomen showed the broken off upper part of a glass bottle (Figure )\nThe patient refused a rectal examination on the ward. On examination under anaesthesia, in the lithotomy position, no evidence of perianal trauma was found. A flexible endoscope was inserted and the broken glass bottle was confirmed to be in the sigmoid colon. An endoscopic snare was passed and the broken glass bottle retrieved (Figure ). Repeat endoscopy did not show any damage to the mucosa. The neck of the glass bottle was found to have a roll of paper inserted within it (Figure ).\nThe following morning the patient complained of pain in his abdomen. His abdomen was tender though there was no guarding or rigidity. Due to the possibility of rectal perforation, a CT scan of his abdomen and pelvis was arranged.\nDue to the unusual circumstances, the case was discussed with a second surgical consultant within the same department. Surprisingly, he recognised the patient from a previous post at a nearby hospital. The same man had presented under a similar sounding name with an almost identical history. On that previous occasion he had also claimed to have been sexually and physically assault in a car park, during which time a bottle top was reportedly inserted into his rectum. This was removed under general anaesthesia shortly after which he self-discharged, with no follow-up being possible as he had no General Practitioner.\nDuring the current admission, an attempt was made to telephone the person the patient had nominated as his next of kin. However, the number proved to be of someone in a foreign country who denied knowing the patient and informed us that he had received a similar enquiry, about a month ago from another hospital in the UK.\nA psychiatric consultation was requested upon which the patient became angry and refused further treatment. However, with the encouragement of a nurse, he later agreed to see the psychiatrists. The psychiatry team did not find any evidence of a formal psychiatric disorder, other than the possibility of Munchausen's syndrome. When asked about the possible earlier presentation at another hospital the patient became very angry and took his own discharge against medical advice.\nHe had told us that he was not registered with a GP and later it was discovered that the home address he had given at registration was a fictitious one. During his stay he had no visitors and it was not possible to contact any true next of kin, as the names and addresses given were also false.
An 8-year-old girl was admitted to our general ward because of left lower extremity pain and ulceration. In outpatient visits she received analgesics as it was assumed that the pain was musculoskeletal. The chief complaint had begun 80 days prior to presentation. Left leg pain gradually increased from a simple sore foot only after playing or walking to a severe continuous pain that became aggravated during the night. At first, the skin over the shin became scaly, then erythema and ulcer appeared. The girl's parents denied any recent trauma.\nThe patient was born at 28 weeks' gestational age with 570 g weight and 29 cm height. There was no history of exchange or umbilical catheterization in the neonatal period. Expect for a delay in speaking, the rest of her developmental milestones were normal. The postnatal hearing screening test was normal. Growth parameters were always undesirable. At the age of 2 years, she experienced a prolonged seizure and right hemiplegia due to a cerebrovascular accident. Thrombophilia was not diagnosed when the accident happened, but aspirin and enoxaparin were started. After that, phenobarbital was started because of convulsions, but since drug tapering was associated with stuttering and prolonged aphasia, the drug was continued. She was the third child of non-related parents. The other children were normal.\nOn physical examination, she was a sweet girl interested in socializing. Her general condition was good but she seemed tired and sad, because of difficulty in falling asleep for a long time. Her head circumference, weight and height measurements were 35 cm, 7 kg and 77 cm, respectively. Her bird-like face was remarkable. Her hair was sparse and thin. Her skin was highly pigmented. There was no pallor or jaundice ( and ). Body temperature was within the normal range. Other vital signs, including blood pressure and level of consciousness, were normal.\nThe left foot was cool and bluish compared to the other side. The dorsalis pedis pulses of both extremities were not detectable. The popliteal artery pulse was not detectable on the left side but the right side was normal. Femoral pulses were normally palpable. No edema or varicose veins were apparent. The skin of the left extremity was shiny and a 5 by 3 cm corrosive ulcer with well-demarcated and gangrenous margins was evident on the shin. The ulcer bed was white and dark red without any obvious secretion (). There were also two smaller wounds on the fourth toe and anterior aspect of the knee on the same side. The ankle brachial index was 0.2 and the resting ankle pressure was 40 mmHg. Oxygen saturation was 35% and 95% in the left and right toes, respectively.\nSensory system examinations of both legs were normal at the level of patient cooperation. However, the patient complained about a burning sensation in the left extremity. The muscle strength of the right upper and lower limbs was slightly lower than that of the left, because of the previous cerebral cardiovascular event. Her heart, lungs and abdomen were normal.\nSince we were suspicious of a vascular problem according to the history and physical examination, we urgently asked for a consultation with a vascular surgeon and ordered Doppler ultrasound and limb angiography. Doppler ultrasound revealed a monophasic spectral wave and low peak systolic velocity in the left limb. In parallel, CT angiography confirmed long segmental narrowing and significant stenosis in the left superficial femoral artery ().\nThe potential complications of endovascular surgery in such a patient with small vasculature were described to the parents and they did not consent to surgical intervention. On the other hand, there is not sufficient evidence on the safety and efficacy of several medical treatments in pediatrics. Therefore, conservative wound care, organ placement at the level of heart, aspirin and better nutrition were recommended.\nOn the follow-up visit, the condition of the wound had improved. The patient's mood, appetite and sleep were not acceptable, so a psychological consultation was requested.
A 73-year-old woman with a previous history of hypertension and myocardial infarction was admitted to the neurosurgery department via the emergency room because she could not open her eyes and had altered consciousness. She was diagnosed as acute infarction on the bilateral paramedian midbrain including bilateral cerebral peduncle by magnetic resonance imaging ().\nAfter conservative management, her conscious level improved but she was still unable to open her eyes. Examination revealed pronounced bilateral ptosis, with left and right pupil diameter of 6 mm and 3 mm, respectively. The left pupil was not reactive to light. There was marked limitation of adduction, moderate limitation of depression and elevation in the movement of both eyeballs. Abduction was normal. There were no other findings of central nervous system disease that could cause ptosis from brain imaging, and no evidence of other orbital disease causing ptosis in an ophthalmologic examination. Muscle strength rated using the Medical Research Council Scale was grade 3/5 in both upper limbs and 4/5 in both lower limbs. She was transferred to the department of rehabilitation medicine for intensive rehabilitation management. Participation in the rehabilitation programs was difficult due to continuing inability to open her eyes.\nWe tried taping her lids with Micropore tape and used lubricants to prevent exposure keratopathy. However, this method was less efficient due to blinking. Eye-putti eyelash glue-mediated fixation of the upper eyelid to the supraorbital structures was ineffective. The patient became frustrated and depressed, and refused to participate in the rehabilitation programs.\nAfter about 6 months from the stroke attack, bilateral ptosis was not improved at all. Consultations were held with the department of plastic surgery with the aim of considering surgical treatment, with the thinking that it would be hard to anticipate spontaneous recovery. Plastic surgeons planned the surgical correction of bilateral ptosis and the Muller's muscle procedure was done, considering the benefits and losses.\nAfter surgical correction, the upper lid height was improved from 7.0 to 4.0 mm on the right side and from 7.0 to 4.5 mm on the left side. The palpebral fissure height was 3.5 mm on the right side and 3.0 mm on the left side (). The patient was quite contented with the effect of the operation and actively participated in the rehabilitation programs. She was able to perform activities of daily living and mobility with minimal assistance. The effect of surgical correction has persisted for at least 6 months.
Ms. X, a 45-year-old elementary school music teacher, reported that she had a traumatic neck and dorsal spine injury 2 years ago. It was diagnosed as cervicalgia and dorsalgia. She got up from a squatting position and hit her head under a steel box fixed on a wall 3 feet from the ground. She felt immediate bilateral neck, dorsal and lumbar pain and stiffness, and also reported blurred vision and nausea. The next day, she visited her physician where cervical, dorsal and lumbar X-rays were taken. No particular lesion could be identified by X-rays. Six months later, she was scheduled for CT and bone scans of the cervico-thoracic spine that once again did not lead to any specific diagnosis with the exception of moderate degenerative disc disease at T8 and T9. Her cervico-thoracic spine pain had persisted since then, accompanied by pain radiating to the right shoulder. The patient also reported moderate restriction of her cervical range of motion and intermittent occipital headache, particularly when neck pain was exacerbated. Her symptoms were increased by sustained neck positions, computer work for several minutes and sitting in a car for prolonged periods as driver or passenger. She also reported insomnia as a result of neck pain. She was off work for 15 months after the injury and returned to work progressively in the last 18 months, on a part-time basis. The patient received physical therapy during the first 18 months after her injury. Before consulting for exercise therapy, she received chiropractic treatments (mainly spinal manipulative therapy), twice a week for 3 months, to restore mobility of the cervical and dorsal spine. At that time, and based on the absence of any neurological signs, the patient was diagnosed as having "mechanical neck pain". Chiropractic treatments temporarily relieved her symptoms, but the pain and stiffness kept returning 48–72 h after spinal manipulative therapy. At the time of the first consultation in kinesiology (exercise therapy), moderate limitation in cervical range of motion was observed, with stiffness and tightness of the right upper trapezius muscle and bilateral trigger points in the medial scapular region. The patient reported baseline neck pain of 6/10 on the visual analogue scale (VAS) at the beginning of the intervention. She took non-steroidal anti-inflammatory drugs 2–3 times a week. She had no past history of neck pain and unsteadiness prior to the traumatic incident.\nSensorimotor control was assessed by posturography analysis a few days before and after the 8-week intervention program. Postural steadiness was measured on a force plate (OR6-2000, AMTI, Watertown, MA, USA). The patient was asked to stand barefoot on the force plate, with her feet in a narrow stance (feet side-by-side position), arms hanging at her sides and her head in a normal, forward-looking position. Outlines of her feet were traced to ensure that foot placement was constant across trials. Each trial lasted 30 s. A modified version of the Clinical Test of Sensory Interaction on Balance (mCTSIB) was used [] to assess the relative contributions of 3 sensory inputs of the postural control system. In this case study, the mCTSIB involved 10 quiet standing trials (see Table ), with a varying surface (firm and soft support) and visual input (eyes-open (EO) and eyes-closed (EC)). To reduce the contribution of the vestibular system or to exacerbate the mismatch between vestibular and neck proprioceptive inputs, 3 additional head positions were tested. The 3 neck positions were: maximum neck/head extension backward (EXT) and maximum lateral flexion of the neck to the right (RLF) and left sides (LLF). No trunk movement was allowed during the neck displacements. At the beginning of each trial, the patient was asked to perform neck movements within a comfortable limit and to maintain the position during the 30-s trial.\nGround reaction forces and moments were recorded from the force platform. Analog signals were sampled at a frequency of 100 Hz and filtered with a zero-lag sixth-order Butterworth low-pass filter at 6 Hz of cut-off frequency. Details of data processing are reported elsewhere []. Mean centre of pressure (COP) speed (mm/s) and sway area (mm2) were calculated to characterize postural steadiness. COP speed was defined as total COP displacement divided by the total period. Minimal metrically-detectable changes (MMDC) for COP speed in both the antero-lateral (A/L) and medio-lateral (M/L) directions and COP sway area were calculated by the intra-class coefficient and standard deviation (SD) reported earlier []. For a 30-s trial in the EO and firm surface condition, the MMDC of COP speed were ± 1.73 mm/s and ± 0.71 mm/s in the A/L and M/L directions, respectively, and ± 80.1 mm2 for COP sway area. These values served to detect clinically-significant changes in postural steadiness after the intervention. To the authors' knowledge, intra- and inter-session reliability and MMDC in COP measurements have never been tested in neck pain subjects.\nAfter the initial evaluation (18 months post-injury), the subject performed exercise training twice a week for 8 weeks. Each session, lasting 60 min, was supervised by an experienced kinesiologist. The exercise therapy program was aimed at improving neck muscle fitness and sensorimotor control of the cervical spine. It included:\n▪ Strengthening exercises: with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. Typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhomboids) are illustrated in Figure . These exercises were designed to increase sustained isometric effort tolerance of the neck muscles. Progression included unstable surface and escalating resistance.\n▪ Oculomotor and head/eye exercises: in the upright, sitting and supine positions. Eye tracking involved moving target exercises (Figure ) and eye/head coordination exercises (Figure ). Progression included increasing neck rotation amplitude, instability on a Swiss ball and augmenting neck muscle activity with the head in a weight-dependent position (Figure ).\n▪ Balancing exercises: standing with a narrow stance, tandem stance and single leg stance. Progression included the use of foam under each foot to augment postural instability (Figure ). Visual inputs were manipulated by focusing on a point 2 m away on the wall at eye level and under EO plus EC conditions. These exercises typically lasted 30 s.\n▪ Stretching exercises: to sometimes reduce neck/shoulder stiffness and enhance neck range of motion.\nAfter ruling out all risk factors for major adverse events (vertebral artery dissection or the presence of major vertebral pathologies), the chiropractor initiated a series of treatments. Twice a week during the 8-week program, spinal manipulative therapy was applied to the patient's spine. The mobilization techniques and manipulated joints were chosen according to chiropractor clinical assessment that included the patient's history, physical examination as well as joint and muscle palpation. Treatment consisted of short-amplitude, high-velocity spinal manipulative thrust (chiropractic-diversified technique) on vertebral segments determined by manual palpation of joint restrictions and tenderness. Since pain on palpation was identified at the C2–C3 level on both sides, chiropractic adjustments were performed at this level either left or right, depending on the patient's pain tolerance.\nPain was the only clinical outcome formally monitored before and after the rehabilitation program. Prior to the program the patient reported significant pain and scored 6/10 on the VAS. Following the 8 week rehabilitation program, the patient scored 2/10 on the VAS. Associated neck disabilities were not assessed during the treatment period but the patient returned to work fulltime after a 24-month sick leave related to neck pain and disabilities. It was decided that the patient was able to return to usual working activities following what was described by the patient as a significant improvement in neck pain and related disabilities.\nPre- and post-intervention COP measures are shown in Figures and . After 16 exercise sessions, the COP sway area decreased between 74.7% (EO, foam surface, LLF) and 95.4% (EC, foam surface, RLF). However, in condition 1 (EO, firm surface), the COP sway area increased from 86 mm2 to 100.3 mm2 (14.7%). This increment is well under the MMDC of ± 80.1 mm2 and does not represent a clinically-significant change in postural steadiness. As depicted in Figure , COP speed values were reduced during all conditions after the exercise intervention in both the antero-posterior (A/P) and M/L directions. In the A/P direction, the decrease in COP speed ranged from 44.1% (EO, firm surface) to 79.1% (EO, foam surface, LLF). In the M/L direction, the diminution in COP speed ranged from 50.5% (EO, firm surface) to 72.0% (EO, foam surface, LLF). During condition 1 (EO, firm surface), the decline in COP speed represented a clinically-significant change in postural steadiness with -4.1 mm/s and -3.7 mm/s in the A/P and M/L directions, respectively.
A 75-year-old man was referred to Chungbuk National University Hospital owing to urinary frequency. He had a history of transurethral resection of the bladder for invasive urothelial carcinoma 8 years previously. The tumor was of a low grade and invaded the subepithelial connective tissue. However, proper muscle involvement was not evaluable because the specimen had no proper muscle component. The patient had been treated with Bacillus Calmette-Guerin (BCG) and had lived without recurrence. The patient underwent a transurethral biopsy under the clinical impression of recurrent urothelial cancer. There was widespread urothelial carcinoma in situ; therefore, radical cystoprostatectomy with orthotopic bladder substitution (Ghoneim) was carried out. Grossly, the mucosal surface of the urinary bladder showed multifocal flat erythematous lesions, and there were no remarkable lesions in the remainder. The microscopic findings showed multiple urothelial carcinoma in situ lesions throughout the mucosa of the urinary bladder and both ureters (). The left seminal vesicle was covered by large polygonal tumor cells, which were confined to the mucosa in single to several layers (). The tumor cells had large and hyperchromatic nuclei with distinct nuclear membranes and relatively abundant eosinophilic cytoplasm. In addition, bizarre-shaped tumor cells showing irregular hyperchromatic or smudged nuclei were occasionally identified. The tumor cells mostly involved the mucosa between the epithelial cells and the basal lamina of the seminal vesicle, a feature that is referred to as pagetoid spread. In some areas, the entire thickness of the mucosa was replaced by tumor cells. The mucosa of the ejaculatory duct and adjacent prostatic acini and duct were also scattered with tumor cells (). On the basis of the overall findings, we considered that the urothelial carcinoma in situ of the urinary bladder revealed mucosal spread to the seminal vesicle along the ejaculatory duct. In addition, there was an incidental prostatic adenocarcinoma, which was a small, solitary lesion with a Gleason score of 6. At the time of the surgery, the patient's serum prostate-specific antigen level was 0.87 ng/ml. The patient had no evidence of disease for 5 months after surgery.
A 45-year-old South Asian woman presented with a progressively worsening of proximal muscle weakness. Initially there was a mild pain in her thighs and arms which was followed by a difficulty getting up from the seated position and inability of raising her arms. There was no dysphagia, regurgitation or difficulty in breathing. During this particular presentation there was no dermatological manifestations suggestive of dermatomyositis or mechanic’s hands. There was no history suggestive of Raynaud’s phenomenon or any joint pains. There was a mild nonproductive cough which developed a few weeks after the onset of the muscle symptoms without any notable shortness of breath of exertion or wheezing. There was no other evidence of any connective tissue diseases.\nThere was no ptosis, double vision or fatiguability to suggestive myasthenia. Patient appeared to be clinically euthyroid without any overt features of hypothyroidism. There was no history of statin use at the time of the presentation or prior to that. Patient denied any similar history previously nor was there a history of a similar disease among her family members.\nExamination revealed bilateral symmetrical proximal muscle weakness with a muscle power of 4/5 in all four limbs. Reflexes were intact without any muscle wasting. There were no overt features of dermatomyositis. Auscultation of the lungs revealed a few bilateral basal fine end inspiratory crepitations suggestive an interstitial lung disease. Second heart sound was of normal intensity. A diagnosis of inflammatory myositis was considered with a concurrent interstitial lung disease. With this clinical text she was thoroughly investigated.\nCreatinine phosphokinase levels were elevated with a value of 1435 u/l. Inflammatory markers were elevated with a ESR of 54 though the CRP was only slightly elevated. ANA was negative. Findings on electromyography was consistent with an inflammatory myositis. Muscle biopsy which was carried out revealed inflammatory cells in between the muscle fibers causing complete necrosis of some of the muscle fibers. Anti Jo-1 antibody was positive. HRCT revealed bilateral homogenous sub pleural basal ground glass opacification suggestive of non-specific interstitial pneumonitis (Fig. ). She was started on oral prednisolone 1 mg/kg/day with azathioprine 50 mg per day which was later increased to 100 mg per day. Subsequently her muscle power improved, CPK levels normalized and the cough which was present improved.\nShe attended her follow up clinic visits and was compliant with her medication. She was in remission for 2 years with low dose prednisolone and azathioprine. She was asymptomatic with no muscle pains, proximal muscle weakness and CPK levels were within normal range. She continued to be free from any cough or shortness of breath. ESR was persistently normal with values in the mid 20’s.\nFollowing a period of unsatisfactory compliance of 4 weeks, she presented with fissuring and cracking of the fingers suggestive of mechanic’s hands (Fig. ) without any muscle pain or weakness. She denied any recurrence of the cough which she had during the initial disease presentation and did not have any shortness of breath. Her CPK was within normal limits at that time. Though there was no evidence of a systemic relapse, the steroid dose was up titrated while continuing azathioprine. However, the mechanic’s hands did not improve and subsequently in the following month she started to complain of a pain in her thighs and arms with a subtle weakness. Her CPK had risen to 1427 u/L and ESR risen to 47. Given the overall clinical picture it was decided that she required escalation of her immunosuppressive therapy. She was started on IV cyclophosphamide 500 mg every 2 weekly and after 3 doses the skin manifestations started to resolve and CPK had normalized (Fig. ). Hydroxychloroquine 200 mg daily was added as patient had prominent dermatological manifestations with photosensitivity (Table ).\nRepeat HRCT revealed stable nonspecific interstitial pneumoniae without any radiological progression. Lung function tests revealed a restrictive lung disease with a FVC of 78% of predicted, FEV1 of 94% of predicted with FEV1/FVC of 124%. DLCO was 49%.
A 50-year-old female reported to the department of oral medicine with the complaint of pain in the left side of the upper jaw since seven months, which was spontaneous, dull and reduced on taking analgesics. She visited a general dentist five months ago and maxillary left second molar was extracted as it was considered as the causative tooth for pain, however, the patient did not get relief and the pain continued. She noticed swelling of left side of the face, which gradually increased in size and there was a concomitant decrease in size of her left eye opening and the eyeball was pushing superiorly since two months. Her medical and family history was noncontributory and upon general physical examination, all her vital signs were within normal limits. On extraoral examination, a diffuse swelling was seen on the left maxillary area extending from infraorbital margin to mid of the cheek supero-inferiorly and ala of nose to outer canthus of eye antero-posteriorly, which was soft in consistency and tender on palpation []. Intraorally, swelling was evident on palpation extending from maxillary tuberosity to the vestibule causing vestibular obliteration till the posterior aspect, which was tender and soft in consistency on palpation [].\nOn the basis of history and clinical examination, a provisional diagnosis of malignant neoplasm of maxillary sinus was considered. Routine hematological investigations revealed the values to be normal. Panoramic and paranasal sinus view showed haziness in left maxillary sinus. The coronal CT revealed a large mass originating in left maxillary sinus with destruction of its medial, superior and postero-lateral wall. Medially, this mass was extending into left nasal fossa leading to marked luminal compromise on the left side and superiorly extension into left orbit was noticed. Posteriorly it was extending into infra-temporal fossa, left masseteric space and left pterygomaxillary fissure. Partial erosion of anterior maxillary wall, hard palate and lateral pterygoid plate on left side and extension of this mass from lateral maxillary wall into left cheek was also noticed [Figure and ].\nIncisional biopsy was performed and on histopathological examination, hematoxylin and eosin stain showed basophilic cells arranged in large lobar sheets with intertwining connective tissue septa. Cells had large round nucleus with minimal pleomorphism and a thin rim of cytoplasm. Pronounced vascularity and formation of pseudorosettes (Homer-Wright type) were seen in some areas, suggestive of esthesioneuroblastoma [Figure and ]. Immunohistochemistry revealed strongly positive neuron-specific enolase among the tumor cells and S-100 showed weak association [Figure and ]. So based on clinical examination and the investigations performed, a final diagnosis of esthesioneuroblastoma was given. The case was referred to the oncology institute for the management and the patient was started with chemotherapy, cisplatin 50 mg (per day) and 5 fluorouracil 1 mg (per day), and recalled after 15 days; there was improvement in the symptoms after which the patient was lost to follow up.
A 35-year-old Caucasian female patient who presented for surgical fixation of left femur fracture sustained six months previously from a ground level fall with known primary hypothyroidism (for 12 years, on thyroxine replacement) with history of hypokalemia for last 13 years (on regular oral potassium supplements). Upon workup the patient was diagnosed with left-sided neck of femur fracture and was admitted in hospital for surgical management. There was no history of fracture in past. Her menstrual cycle was regular. There was no history of renal stones. There was positive history of hypokalemic periodic paralysis twice in past (12 and 13 years back). Her family history was unremarkable. There was no history of recurrent oral or ocular ulcers. On examination there was no uveitis, oral ulcers, lacrimal or parotid gland enlargement. Her workup was done which is shown in Table below. It showed hyperchloremic non anion gap metabolic acidosis and hypokalemia. DEXA scan revealed osteoporosis at right femoral neck (both T and Z scores were <-2.5) and at right hip (both T and Z scores were <-2.5).\nShe underwent left-sided dynamic hip screw fixation under general anesthesia which she tolerated well. On the fourth postoperative day she was allowed full weight bearing with walker. After surgery she was started on oral Ibandronate 150 mg once monthly (for osteoporosis) and tablet calcium carbonate (600 mg elemental calcium) twice daily and vitamin D 2000 IU twice daily. Due to low vitamin D levels she was given one intramuscular injection of vitamin D (200,000 IU). Oral potassium supplement three tablets thrice daily were continued. Potassium citrate was added in her regimen to correct renal tubular acidosis. Thyroxine 100 mcg was continued five days a week and 150 mcg was advised two days a week (the dose was adjusted according to recent thyroid stimulating hormone (TSH) value of 9.97 which is suboptimal). So the possible clinical diagnosis in this case is renal tubular acidosis with osteoporosis and hypokalemia. Nephrology recommended anti-SSA and anti-SSB despite negative antinuclear antibody (ANA) screen as these may be positive in RTA. In this patient anti-SSA came positive while anti-SSB came negative. During follow up her potassium level got normalized to 4.6, bicarbonate improved to 20.2 and TSH normalized to 1.45. We will get her repeat DEXA scan next month (to see any improvement in her bone mineral density after correction of vitamin D deficiency). Our clinical diagnosis in this patient is possible or incomplete Sjogren's syndrome (as she lacks few clinical features on examination) causing type-1 RTA (distal RTA) with osteoporosis.
A 56-year-old woman, a mother of 3 children, presented to the surgical department with a history of multiple neck lumps of 4 months duration. She also had generalised vague abdominal pain, loss of appetite and lower back pain. She had no significant medical, family or psychosocial history. Clinical examination revealed multiple, bilateral enlarged cervical lymph nodes which were firm to hard in consistency. Thyroid examination revealed a 2 × 2 cm firm lump on the lower pole of the left thyroid lobe. Examination of other lymph node groups revealed enlarged right inguinal lymph nodes. Abdominal examination and rectal examination were normal. Vaginal examination revealed a hard, unhealthy uterine cervix. Breast and axillary examination were unremarkable. She had spinal tenderness, but the neurological examination of the lower limbs was normal.\nHer basic blood investigations, liver profile and renal functions were within the normal limits. Ultrasound scan of the abdomen revealed no abnormalities. Ultrasound scan of the neck revealed multiple nodules in the thyroid, with increased vascularity, and multiple enlarged cervical lymph nodes with obliterated fatty hila suggestive of malignant deposits. Contrast enhanced computed tomography of the neck, chest, abdomen and pelvis showed a mass in the uterine cervix (Fig. ) with multiple enlarged lymph nodes in the inguinal, iliac, para-aortic, anterior mediastinal and bilateral deep cervical groups (Fig. ). There were multiple low-density nodules in the thyroid gland (Fig. ). A mixed density mass lesion was also noted in the lower pole of the left thyroid lobe (Fig. ). Furthermore, an anterior wedge fracture of the L2 vertebra was seen, probably secondary to bone metastases.\nBiopsies from the uterine cervix and endometrial curettage revealed moderately differentiated squamous cell carcinoma, signifying local extension of the cervical carcinoma into the endometrium (Fig. ). Excision biopsy of a left cervical lymph node revealed metastatic deposits of moderately differentiated squamous cell carcinoma similar to that of the uterine cervix (Fig. ). Ultrasound-guided fine needle aspiration cytology of intra-thyroid nodules revealed malignant squamous cells (Fig. ). This was followed by a panendoscopy of the upper aerodigestive tract which yielded negative results.\nA multidisciplinary meeting with the oncologists, surgeon, gynaecologists, pathologists and radiologists was conducted. Considering the histopathological and imaging findings with negative panendoscopy, a diagnosis of squamous cell carcinoma of the uterine cervix metastasising to the cervical lymph nodes and thyroid gland was made. A decision was made to commence palliative chemoradiotherapy. After 6 months, the patient developed generalised body oedema. She was transferred to a specialised cancer treatment centre for further palliative management, where she passed away a short while later, due to acute renal failure secondary to ureteric obstruction.
A 62-year-old gentleman who is known to suffer from hypertension, dyslipidemia, and hypothyroidism for the past 15 years, presented to the emergency room with complaints of high-grade intermittent fever with chills but no associated rigors for the past 2 days. He also complained of minimal abdominal discomfort in the right upper quadrant and rated the pain at 2 on a pain scale of 10. There was no radiation, no known aggravating or relieving factors associated with the pain. There was no history of any nausea, vomiting, diarrhea, other symptoms suggestive of urinary tract or respiratory tract infection. He was a chronic user of tobacco with a history smoking cigarettes amounting to 40 pack years over the last 40 years. He also consumes alcohol socially and gives no history of any intravenous (IV) drug abuse. His current medication history includes amlodipine 10 mg and lisinopril 40 mg once daily for his hypertension, levothyroxine 50 µg once daily for hypothyroidism and atorvastatin 20 mg once daily at night for dyslipidemia.\nOn general physical examination, the patient had no pallor, icterus, lymphadenopathy or edema. He was running a temperature of 102 °F (38.9 °C) and was tachycardic with a heart rate of 110 beats per minute. His blood pressure on the right upper arm was measured at lying down posture as 90/60 mm Hg. Upon abdominal examination, there was mild tenderness in the right upper quadrant with no guarding or rebound tenderness. Cardiac examination revealed no murmurs and respiratory system examination was unremarkable.\nA working diagnosis of cholecystitis was made at this juncture, and further investigations were proposed to confirm the diagnosis. The blood testing results are summarized in . There was leukocytosis with 70% neutrophils, but liver function tests were normal. The patient underwent a CT abdomen with contrast. This identified an abscess in the right lobe of liver about 15 mm in diameter () with no evidence of any gallstones or other abnormalities. An ultrasound scan of the right upper abdomen also reported the same findings and ruled out cholecystitis as there was no pericholecystic fluid found. Two sets of blood cultures were sent, and he was started on empiric antibiotic treatment with IV vancomycin, metronidazole, and piperacillin-tazobactam. Meanwhile, all blood cultures grew Streptococcus anginosus, and the antibiotic treatment was de-escalated to ceftriaxone 2 g once daily IV based on the sensitivity pattern. At this juncture, an opinion was sought from the interventional radiologist who opined that the abscess need not be drained as it was small and loculated, rather treat conservatively with IV antibiotics. Repeat blood cultures sent 2 days after starting antibiotic treatment turned out to be negative.\nThe patient was questioned further to investigate the possible source of infection except for a history of significant unexplained weight loss of about 15 pounds in the last 3 months. The patient then underwent a two-dimensional echocardiogram which ruled out any vegetation or valvular abnormalities. Trans-esophageal echocardiography was also normal. Meanwhile, the patient was discharged with a peripherally inserted central line to continue IV ceftriaxone for a total period of 4 weeks and to follow-up in the outpatient department (OPD) with colonoscopy. Subsequently, the following week, the patient had a colonoscopy done on OPD basis and was diagnosed to have colon carcinoma at the splenic flexure (). Biopsy of the colonic mass confirmed it as adenocarcinoma.
A 56-year-old woman, a mother of 3 children, presented to the surgical department with a history of multiple neck lumps of 4 months duration. She also had generalised vague abdominal pain, loss of appetite and lower back pain. She had no significant medical, family or psychosocial history. Clinical examination revealed multiple, bilateral enlarged cervical lymph nodes which were firm to hard in consistency. Thyroid examination revealed a 2 × 2 cm firm lump on the lower pole of the left thyroid lobe. Examination of other lymph node groups revealed enlarged right inguinal lymph nodes. Abdominal examination and rectal examination were normal. Vaginal examination revealed a hard, unhealthy uterine cervix. Breast and axillary examination were unremarkable. She had spinal tenderness, but the neurological examination of the lower limbs was normal.\nHer basic blood investigations, liver profile and renal functions were within the normal limits. Ultrasound scan of the abdomen revealed no abnormalities. Ultrasound scan of the neck revealed multiple nodules in the thyroid, with increased vascularity, and multiple enlarged cervical lymph nodes with obliterated fatty hila suggestive of malignant deposits. Contrast enhanced computed tomography of the neck, chest, abdomen and pelvis showed a mass in the uterine cervix (Fig. ) with multiple enlarged lymph nodes in the inguinal, iliac, para-aortic, anterior mediastinal and bilateral deep cervical groups (Fig. ). There were multiple low-density nodules in the thyroid gland (Fig. ). A mixed density mass lesion was also noted in the lower pole of the left thyroid lobe (Fig. ). Furthermore, an anterior wedge fracture of the L2 vertebra was seen, probably secondary to bone metastases.\nBiopsies from the uterine cervix and endometrial curettage revealed moderately differentiated squamous cell carcinoma, signifying local extension of the cervical carcinoma into the endometrium (Fig. ). Excision biopsy of a left cervical lymph node revealed metastatic deposits of moderately differentiated squamous cell carcinoma similar to that of the uterine cervix (Fig. ). Ultrasound-guided fine needle aspiration cytology of intra-thyroid nodules revealed malignant squamous cells (Fig. ). This was followed by a panendoscopy of the upper aerodigestive tract which yielded negative results.\nA multidisciplinary meeting with the oncologists, surgeon, gynaecologists, pathologists and radiologists was conducted. Considering the histopathological and imaging findings with negative panendoscopy, a diagnosis of squamous cell carcinoma of the uterine cervix metastasising to the cervical lymph nodes and thyroid gland was made. A decision was made to commence palliative chemoradiotherapy. After 6 months, the patient developed generalised body oedema. She was transferred to a specialised cancer treatment centre for further palliative management, where she passed away a short while later, due to acute renal failure secondary to ureteric obstruction.
A 56-year-old female with a history of uncontrolled biopsy-proven bullous pemphigoid began treatment with cyclosporine 100 mg three times a day for a total daily dose of 300 mg. After five weeks of therapy, the patient complained of nervousness and shakiness, and the cyclosporine dose was decreased to 100 mg twice daily for a total daily dose of 200 mg. After an additional five weeks of cyclosporine therapy at 200 mg daily, the patient returned with complaints of the gradual onset of redness, swelling, and pain of her left hand over the past six weeks (Figure ). On examination, erythema and violaceous swelling were present on the patient’s left hand, most predominant over the dorsal and palmar aspects of the left second and third metacarpals, and left proximal and mid phalanges. There was tenderness to palpation and pain with movement of the left hand and phalanges. The patient described the associated pain as a burning sensation. Although erythromelalgia was considered, this was believed to be a local reaction, and the cyclosporine was continued as treatment for the patient’s bullous pemphigoid.\nSeven weeks later, the patient returned complaining of significantly worsened redness, swelling, and pain of the left hand with progression of involvement of the right hand. On examination, the erythema and edema involved the dorsal and palmar aspects of the left hand and phalanges, most severely affecting the left proximal phalanges. The right hand was also visibly erythematous with edema most prominently involving the right second proximal phalanx. The patient complained of worsened pain, described as “burning similar to a sunburn” that significantly worsened upon exposure to the sun or heat. The pain also worsened with passive and active movement of the hand or digits, as well as palpation of the affected areas. The patient endorsed improvement with exposure of the hands to cold temperatures, particularly describing relief of the pain while running the hands under cold water. At this time, the cyclosporine dose was decreased to 100 mg once daily with a diagnosis of erythromelalgia secondary to cyclosporine. It was hoped that a lower dose of cyclosporine could be used to treat the bullous pemphigoid, with resolution of the symptoms of erythromelalgia.\nSix weeks later, the patient returned for a follow-up to evaluate the erythromelalgia. The erythema and edema had significantly improved, with only minor swelling of the second and third phalanges of the left hand and the second phalanx of the right hand. The patient's symptoms improved following the transition to low-dose cyclosporine therapy (100 mg once daily). At an additional follow-up eight weeks later, the patient’s symptoms of erythromelalgia had completely resolved.
A 31-year-old woman was admitted to our hospital with a 3-year history of progressive memory loss and headache. The patient mainly complained of difficulties doing her usual daily routine activity job for about 1 year and misplacing personal objects, she was having difficulties doing simple calculations and drawing simple paper patterns, resulting in erroneous calculations and wrong measurements along with decreasing ability to perform complex tasks such as arranging a meeting with her old friend, pay bills, and marketing. Childhood and prior developments were apparently normal. No neuropsychiatric disorders could be assessed in the family. She did not take drugs, including alcohol. Her past medical history was uneventful and was negative for stroke, transient ischemic attack, chronic infection, or other chronic illness. Except for incontinence and a slight slurring of speech, the physical examination revealed no further neurological deficits, especially no speech impairment, seizures or myoclonia were observed. The Mini Mental State Examination score was suggestive of dementia (21 of 30) and very low on the cognitive efficiency profile. There were also deficits on tests of visuospatial ability. Nevertheless, she experienced no changes in personality, appetite, or sleeping pattern noted, nor was she observed to be a snorer or have spells of apnoea, and there was no history of auditory or visual hallucinations. Blood count, biochemical profile, sedimentation rate, coagulation profile, and the results of radiography of the chest were normal. Cerebrospinal fluid analysis showed normal results. Results of Venereal Disease Research Laboratories testing were negative, and no malignant cells were identified by cytological examination. Serum vitamin B12, folic acid, and thyroid-stimulating hormone levels were within normal limits. Computerised tomography of the brain revealed mild left hemispheric mass effects. MR imaging and proton MR spectroscopy were performed on a clinical whole body 1.5-T imaging unit. T2-weighted and fluid attenuated inversion recovery FLAIR images revealed an ill defined area of signal intensity alteration in the left frontal region with involvement of rostrum of corpus callosum with minimal postcontrast enhancement. The lesion was causing effacement of cortical sulci []. The magnetic resonance spectroscopic imaging results showed an increased choline peak, a decreased N-acetyl aspartate (NAA) peak with an increased Ch/Cr ratio at the site of lesion. The patient was given supportive care for a period of 15 days following that she improved a little bit and the patient was given supportive care for a period of 15days following that she improved a little bit and discharged, and at discharge, her MMSE was 22/30 and she was also referred to higher centre.
A 71-year-old woman with a history of dialysis-dependent CKD, treated with PD for 6 years, hypertension, obesity, and status post-weight loss bariatric surgery (unknown type), presented to the hospital complaining of rectal bleeding. At time of dialysis initiation, 6 years prior, a presternal-type PD catheter was placed due to morbid obesity at the time (BMI of 50 kg/m2 with a weight of 128 kg). The catheter consisted of 2 flexible silicon rubber tubes joined together with a titanium connector. The distal portion included the coiled fenestrated segment and was placed in the deep pelvis, while the external portion included a swan neck shape and 2 Dacron cuffs and was tunneled to the surface of the abdomen. The catheter was anchored with a purse-string suture in the posterior rectus sheath and tunneled to an exit site over the abdomen. The patient was treated with automated PD: 5 exchanges over 9 h with 2 L fill volume and no day dwell.\nOn admission, the patient was afebrile, with a blood pressure of 101/66 mm Hg, heart rate of 85/min, and oxygen saturation of 98% while breathing ambient air. She appeared well and was in no distress. Lung examination revealed normal respiratory effort. On palpation, the abdomen was soft and not tender. The patient had normally active bowel sounds. There was no drainage, induration, or erythema at the PD catheter exit site. The superficial cuff of the catheter was found incidentally to be external to the exit site. The external cuff was sufficiently distant from the exit site so as not to be causing any trauma to the tissue. The patient underwent workup for gastrointestinal (GI) bleeding and was found to have an ascending colonic arteriovenous malformation, which was treated successfully with argon plasma coagulation. On hospital day 5, she was found to have abdominal tenderness associated with erythema and yellow nonpurulent drainage at her exit site concerning for an ESI. She was started on empiric antibiotics with ciprofloxacin. Wound cultures grew methicillin-resistant Staphylococcus aureus and Actinomyces species. The peritoneal fluid cell count was unremarkable (7 white blood cells/mm3), and peritoneal cultures showed no growth. Antibiotics were adjusted based on organism sensitivities, and a 14-day course of oral doxycycline was prescribed.\nOn hospital day 13, during routine daily care for her peritoneal catheter site, it was noted that her deep cuff had extruded from the exit site (Fig. ). At first, there was concern that because the inner cuff of the catheter, which should have been located in the rectus sheath, had migrated out, the patient would be left with no clear anchor for the catheter in the tract. The patient had undergone 2 computed tomography scans during the course of her hospitalization as part of her gastrointestinal bleeding workup. A review of the scans (Fig. , ) revealed the PD catheter distal end within the pelvis and the titanium connector within the subcutaneous tissue. At the time of discharge (hospital day 16), her PD catheter remained functional, and no surgical intervention was needed. The patient did not undergo shaving of the extruded deep cuff since it had migrated a sufficient distance out of the exit site to prevent further trauma to the area (Fig. ).
A 53-year-old female presented with gradually progressive diminution of vision in her left eye for 2 months. She had a history of diabetes mellitus for 20 years for which she is taking insulin. Her most recent HbA1C was 7.5%. She had no history of hypertension or renal problems. She had no past ocular history. Examination revealed a corrected distance visual acuity (CDVA) of 20/40 in her right eye and 20/100 in the left. Anterior segment examination showed nuclear sclerosis in both eyes. Posterior segment examination revealed intraretinal hemorrhages in all 4 quadrants indicating severe nonproliferative diabetic retinopathy in both eyes with clinically significant macular edema in the left eye confirmed by fluorescein angiography (). Spectral domain optical coherence tomography (OCT) of the macula was done and revealed multiple cystic spaces, mild subfoveal neurosensory detachment, and diffuse retinal thickening with a central subfield macular thickness of 332 μm in the left eye (). The right eye showed only few cystic spaces with minimal thickening. OCTA (Optovue, Inc., Fremont, CA, USA) was done in both eyes and showed areas of capillary nonperfusion in the superficial capillary plexus (SCP) of the maculae of both eyes (Figures and ). Three monthly intravitreal bevacizumab injections were done to treat the macular edema in the left eye. One month following the last intravitreal injection, CDVA improved to 20/60 in the left eye and was stable in the right eye. OCT showed improvement of the macular edema in the left eye (). OCTA was performed in both eyes and showed decreased vascular density of the SCP of the left eye compared to pretreatment OCTA while a mild increase was noted in the vascular density of the SCP of the untreated right eye (Figures and ). The patient was then followed up without requiring further intravitreal injections and 4 months following the last intravitreal injection OCTA was repeated in both eyes and showed improvement of the vascular density of the SCP of the left eye with unchanged SCP in the right eye (Figures and ). CDVA was 20/60 in the right eye and 20/100 in the left. Clinical examination revealed retinal neovascularization in the right eye with clinically significant macular edema in both eyes. OCT showed increased center-involving macular edema in both eyes with recurrent neurosensory detachment in the left eye (). Three monthly intravitreal bevacizumab injections were then done for treatment of proliferative diabetic retinopathy in the right eye and the macular edema in both eyes. One month following the last intravitreal injection, CDVA was 20/40 in the right eye and 20/60 in the left, OCT showed decreased macular thickness in both eyes (), and OCTA revealed decreased vascular density of the SCP of both eyes (Figures and ). Changes in the deep capillary plexus closely followed those in the SCP at all stages.
A 17-year-old female presented with painful nonhealing ulcer over a large scar on the left leg since 1 year. The ulcer did not improve on treatment with various topical and oral medications. The lesions started with formation of red blister, which doubled in size within 2 days and ruptured to form an ulcer within 1 week period. It took about a year to heal forming a large hypertrophic scar. After around 1 year, she developed another ulcer over the scar, which progressed to the present size over 1 month. There was no history of any prior trauma, abnormal bowel habit, joint pain, or frequent bleeding from the ulcer. On examination, there was a well-defined ulcer of size 11.5 cm × 6.7 cm over a hypertrophic scar (20 cm × 8 cm) over the left lower leg []. The base of ulcer had red granulation tissue. The margin was pigmented with undermining at some portions and punched out edge. The healed scar had resulted in flexion deformity at the ankle joint []. The examination of other parts of skin was normal. The site of Bacille Calmette Guerin injection had healed without hypertrophic scar. Provisional diagnosis of PG, Marjolin ulcer and posttraumatic eczema was made. Biopsy from edge of ulcer was done for histopathological examination. All routine investigations, such as complete blood count, peripheral smear comments, were within normal limits. Pus on Gram stain and culture sensitivity did not show any organism. Biopsy showed subcorneal neutrophilic pustules with dermis showing neutrophilic infiltration [Figures -]. The upper and mid dermis showed fibrillar collagen in orderly arrangement [Figures and ]. Based on history, clinical morphology and histopathology a final diagnosis of PG over a healed hypertrophic scar was made. The patient was treated with dexamethasone pulse (100 mg dexamethasone in 300 mL 5% dextrose infused over 2 hours) on 3 consecutive days with 30 mg oral prednisolone and 100 mg dapsone daily. There were signs of improvement in the form of decrease size and re-epithelization of the ulcer characterized by decreased depth of ulcer over 2 weeks with slopping of the edge. After seven doses of monthly dexamethasone pulse and oral prednisolone in tapering doses and dapsone 100 mg, the ulcer healed completely [Figure and ]. The patient is on regular follow-up.
A 90-year-old woman was referred for management of CIED pocket infection. She had a history of complete heart block with pacemaker implantation in 2000 and cardiac resynchronization therapy defibrillator upgrade in 2014, end stage renal disease, hypertension, cerebrovascular accident, rheumatoid arthritis, diabetes mellitus, and remote lymphoma. She presented with 1 year of progressive left chest wall device pocket swelling, tenderness, and erythema. On examination the device site was swollen and tender to touch (). She had no systemic signs or symptoms of infection. Her lab work did not reveal any hematologic abnormalities. An echocardiogram was performed with no evidence of endocarditis or lead vegetation. Management strategies were discussed with the patient and her family. Owing to her advanced age and multiple comorbidities, a lead extraction was not done and she underwent a CIED pulse generator removal, debridement, and complete capsulectomy. A new cardiac resynchronization therapy pacemaker device was placed in subpectoral fashion on the left side. At the time of the procedure an intense inflammatory reaction as well as necrosis was noted, but no purulence was seen. Swabs from the pocket as well as tissue from the capsule were sent for culture. The pocket was irrigated with hydrogen peroxide as well as antibiotic solutions and a negative-pressure wound therapy device was placed to assist with pocket closure. She recovered well and was discharged on a 3-week course of oral doxycycline. All cultures remained negative. An area of induration and discoloration persisted and increased in size, breaking through the epidermis and exposing vascularized tissue (). Eleven weeks after her original surgery, she was brought back to the operating room for a pocket exploration, debridement, and primary wound closure. Tissue sent for pathology revealed large B-cell lymphoma. Given the patient’s remote history of B-cell lymphoma, this was felt to likely be a reoccurrence.\nAn 84-year-old man was referred for management of a CIED pocket infection. He had a history of complete heart block with pacemaker in 1995, right ventricle lead revision in 2003, and a generator replacement in 2011. Past medical history was otherwise significant for permanent atrial fibrillation, diabetes mellitus, hypertension, and previous squamous cell carcinoma of his right forearm. He initially presented to an outside hospital with a “cyst” located in the left infraclavicular region. The “cyst” was excised and the wound left open to drain because of concern for infection. The wound culture was positive for Staphylococcus aureus. His wound was cared for by a dermatologist with topical ointments and systemic antibiotics for 4 months without wound healing. He was treated with vancomycin and piperacillin/tazobactam. He was referred for further management and lead extraction. Upon admission, he was afebrile and hemodynamically stable. His examination was significant for an open left upper chest wound measuring 5 × 2 cm, which was warm and tender to palpation and draining purulent fluid (). The area was slightly superior to his pacemaker pocket, with concern for lead erosion. A left upper arm nodule was also noted. Wound cultures were positive for Enterococcus faecalis and Pseudomonas aeruginosa. Blood cultures were negative. An echocardiogram was negative for endocarditis or lead vegetation. Infectious disease was consulted, and they recommended continuation of piperacillin/tazobactam and device extraction because of its proximity to the infected wound and concern for involvement. Plastic surgery was consulted for wound evaluation prior to the device extraction. He underwent pulse generator removal and extraction of 3 permanent transvenous pacemaker leads without complication. His pocket contained a small amount of serous fluid, which was cultured, but otherwise there was no evidence of infection. A temporary-permanent pacemaker was placed via his right internal jugular vein. The plastic surgery team excised and debrided his clavicular wound and placed a split-thickness skin graft from his left thigh to the wound. After 72 hours of negative blood cultures, the patient underwent placement of a leadless pacemaker (Medtronic Micra™; Medtronic, Inc, Minneapolis, MN). He was discharged home to complete 2 weeks of intravenous antibiotic therapy with piperacillin/tazobactam. Pathology results from the wound debridement revealed moderately differentiated squamous cell carcinoma (SCC) extending into the deep margin and focally into the peripheral margins. He was referred to Oncology to discuss further management of the SCC. Prior to decision, a biopsy of the left upper arm nodule was performed to evaluate for disease in transit. The pathology results from an incisional biopsy were significant for B-cell lymphoma. He has undergone infusions to treat the lymphoma and continues to be followed by an oncologist for both his lymphoma and SCC.
A 66-year-old woman was admitted to our hospital due to infection of the pacemaker pocket for one month.\nThe patient was diagnosed with sick sinus syndrome for which she received a dual-chamber pacemaker 10 years ago. One month prior to admission, after carrying a heavy burden, she found redness and swelling at the pocket site, which gradually ulcerated. The local hospital gave her an antiinfection treatment of cephalosporin for a week, but the outcome was not positive. Therefore, she was transferred to our hospital for further treatment.\nThe patient had a history of hypertension, type 2 diabetes mellitus, and chronic gastric ulcer. She underwent a meningioma resection 7 years earlier and cataract surgery in both eyes 8 years earlier. The patient had no history of hepatitis or tuberculosis.\nThe patient had no significant past history or family history.\nThe patient's blood pressure and blood glucose were well controlled by medication. Her body temperature was normal three days before the operation.\nExcept for swelling and ulceration at the pocket site, other physical examination results were normal. There were no abnormalities in the laboratory examination, electrocardiogram, chest X-ray, or preoperative echocardiogram. Multiple blood cultures were negative before the preventative use of vancomycin 0.5 g/q8h.\nAfter excluding the contraindication of operation, the left leads were extracted successfully, and a temporary pacemaker was implanted on the other side. Intraoperative angiography revealed patency of the bilateral subclavian veins (Figure ). The results of the pacemaker pocket tissue and lead culture showed the presence of Staphylococcus epidermidis, which is sensitive to vancomycin. Vancomycin was used continuously after the operation. The next day after the operation, the patient complained of pain radiating from the left chest to the mandible, with a pain score of 6. She began to present intermittent fever accompanied by sweating. Therefore, blood cultures were performed at that time; however, the results were negative. The serum concentration of vancomycin was up to standard. Three days after the operation, the patient felt that the pain in the left chest was alleviated, but increased pain in the left neck and throat accompanied by an irregular cough (dry cough, no sputum) appeared. Physical examination showed neck tenderness, normal tonsils, and a normal uvula. A few days later, the patient still had an intermittent low fever with sweating. Laboratory examination showed that routine blood and procalcitonin levels were normal, the erythrocyte sedimentation rate (ESR) was 44 mm/h, and the hypersensitive C-reactive protein (CRP) level was 45.6 mg/L. The operation incision and temporary pacemaker placement site were observed to be dry and clean without redness, burning, effusion, or pus. Seven days after the extraction, the patient felt relieved of pain in the left chest and neck and said that the pain was confined to the mandible. A submandibular mass was found through palpation. Routine blood tests, blood biochemical indexes, and procalcitonin levels were normal. Her ESR was 65 mm/h, hypersensitive CRP was 57.4 mg/L, plasma D-dimers was 9.58 mg/L, and fibrinogen was 5.6 g/L.\nColor Doppler ultrasound showed left internal jugular vein thrombosis. Occlusion of the left common jugular vein, internal and external jugular veins, and subclavian vein was further demonstrated by computed tomography venography (CTV) (Figure ). The patient refused the intravenous or subcutaneous use of anticoagulants; therefore, rivaroxaban was given.
A 56-year-old woman, a mother of 3 children, presented to the surgical department with a history of multiple neck lumps of 4 months duration. She also had generalised vague abdominal pain, loss of appetite and lower back pain. She had no significant medical, family or psychosocial history. Clinical examination revealed multiple, bilateral enlarged cervical lymph nodes which were firm to hard in consistency. Thyroid examination revealed a 2 × 2 cm firm lump on the lower pole of the left thyroid lobe. Examination of other lymph node groups revealed enlarged right inguinal lymph nodes. Abdominal examination and rectal examination were normal. Vaginal examination revealed a hard, unhealthy uterine cervix. Breast and axillary examination were unremarkable. She had spinal tenderness, but the neurological examination of the lower limbs was normal.\nHer basic blood investigations, liver profile and renal functions were within the normal limits. Ultrasound scan of the abdomen revealed no abnormalities. Ultrasound scan of the neck revealed multiple nodules in the thyroid, with increased vascularity, and multiple enlarged cervical lymph nodes with obliterated fatty hila suggestive of malignant deposits. Contrast enhanced computed tomography of the neck, chest, abdomen and pelvis showed a mass in the uterine cervix (Fig. ) with multiple enlarged lymph nodes in the inguinal, iliac, para-aortic, anterior mediastinal and bilateral deep cervical groups (Fig. ). There were multiple low-density nodules in the thyroid gland (Fig. ). A mixed density mass lesion was also noted in the lower pole of the left thyroid lobe (Fig. ). Furthermore, an anterior wedge fracture of the L2 vertebra was seen, probably secondary to bone metastases.\nBiopsies from the uterine cervix and endometrial curettage revealed moderately differentiated squamous cell carcinoma, signifying local extension of the cervical carcinoma into the endometrium (Fig. ). Excision biopsy of a left cervical lymph node revealed metastatic deposits of moderately differentiated squamous cell carcinoma similar to that of the uterine cervix (Fig. ). Ultrasound-guided fine needle aspiration cytology of intra-thyroid nodules revealed malignant squamous cells (Fig. ). This was followed by a panendoscopy of the upper aerodigestive tract which yielded negative results.\nA multidisciplinary meeting with the oncologists, surgeon, gynaecologists, pathologists and radiologists was conducted. Considering the histopathological and imaging findings with negative panendoscopy, a diagnosis of squamous cell carcinoma of the uterine cervix metastasising to the cervical lymph nodes and thyroid gland was made. A decision was made to commence palliative chemoradiotherapy. After 6 months, the patient developed generalised body oedema. She was transferred to a specialised cancer treatment centre for further palliative management, where she passed away a short while later, due to acute renal failure secondary to ureteric obstruction.
A 15-year-old male with a prior diagnosis of VACTERL association presented with respiratory symptoms for several years including recurrent pneumonia, episodes of chest pain, and moderate persistent asthma. At a young age, several anomalies associated with VACTERL were identified and surgically repaired. The patient’s cardiac anomalies included transposition of great vessels, single coronary artery, ventricular septal defect (VSD), and patent ductus arteriosus (PDA). The patient's other anomalies included vertebral body deformity with scoliosis, bilateral cleft hands, and right radial dysplasia. The patient experienced failure to thrive as an infant requiring gastrostomy tube feeding. His medical history also included gastroesophageal reflux disease (GERD) and Nissen fundoplication. The patient had a mild cognitive delay and denied any dysphagia with solids or liquids. The patient reported the ability to belch up large amounts of fluid and food.\nA CT scan from another institution showed communication between the trachea and esophagus approximately 2 cm superior to the manubrium along with a dilated esophagus (Figure ). The TEF was not seen on a previous CT scan. Prior to surgical intervention, a cardiology consult was completed along with an echocardiogram to confirm vessel anatomy. Bronchoscopy and esophagoscopy were performed preoperatively to confirm H-type fistula location and to exclude the presence of a proximal fistula tract. The fistula was noted to be 6 cm distal to the vocal cords and then was cannulated with a Fogarty catheter to aid in localizing the tract intraoperatively. The tissue surrounding the fistula was fibrotic and the tracheal side of the tract measured approximately 1.5 cm in diameter and was larger than the esophageal segment of the tract. Surgical repair was performed via a left cervical approach, and a sternohyoid muscle flap was placed over the repair between the trachea and the esophagus.\nThe patient was transported to the intensive care unit (ICU) in stable condition and remained intubated overnight with care to avoid excessive suctioning of the endotracheal tube and positive pressure to prevent failure of the repair. The patient was closely followed postoperatively with monitoring for possible expanding hematoma, fever, and respiratory distress. Laryngoscopy was performed upon extubation, which confirmed normal laryngeal vocal cord motion. A contrast swallow study and fluoroscopic esophagogram were performed two days postoperatively demonstrating no leak from the repair site or residual patency of the repaired fistula (Figures and 2B). The patient tolerated a soft mechanical diet and denied hoarseness, change in voice, and difficulty breathing. The postoperative course was without complication and he was discharged on hospital day four. The patient will continue to be monitored in an outpatient clinic.
A 79-year-old male with longstanding history of advanced prostate cancer on androgen deprivation therapy presented to his urologist after noticing a mass on the tip of his urethral meatus. A subsequent biopsy of the mass was positive for SCC, and the patient underwent partial penectomy and lymph node dissection that revealed positive right inguinal lymph nodes (three out of seven) revealing pathologic T2N2M0 disease. He received adjuvant chemotherapy by extrapolating data of its benefit when given in the neoadjuvant setting. The standard TIP regimen was not pursued given patient's concern for side effects. The patient proceeded with alternative plan of chemoradiation with 5 weeks of weekly low dose carboplatin and paclitaxel. In addition, he received radiation with a total dose of 5000 cGy over 25 fractions to the right inguinal region. However, the patient developed disease recurrence with nodal involvement nine months later. On restaging CT imaging, the patient was found to have new involvement of the left pelvis. A nodal conglomerate measuring 31×58 mm with central necrotic change was identified in the left inguinal region.\nGiven the patient's age, performance status, and local recurrence of disease, he was started on therapy with chemoradiation with curative intent one month later. Treatment with an additional round of chemoradiation with low dose carboplatin and paclitaxel was given for 5 weeks. He had radiation with a total dose of 5000 cGy over 25 fractions to the left pelvic region. He had stable disease with chemoradiation, but he eventually developed disease progression within a year from the end of chemotherapy. At that point, he was considered for second-line therapy with the PD-L1 inhibitor atezolizumab. After being on atezolizumab for approximately 2 years, he developed biopsy-proven bullous pemphigoid, an immune-mediated toxicity of the skin that has been described with those agents. A restaging scan at approximately 2 years showed near complete response, so patient has been placed on treatment holiday at the time of this report. He was started on prednisone 1 mg/kg per immune-mediated management guidelines and had quick resolution of his blistering symptoms [].
The affected individual was a female, 26 years old at the time of analysis. She was born at term (birth weight 2455 g, length 47 cm) after an uncomplicated delivery. The proband had unstable blood sugar levels with episodes of hypoglycemia in the neonatal period.\nIn the first year of life, the patient had a high level of blood platelets and signs of hyperactive bone marrow on bone marrow biopsy, without suspicion of malignancy. She also had cholestasis and prolonged jaundice up to six months of age. A sweat test was normal.\nThe patient’s parents were of European origin, healthy and not known to be closely related. The grandparents were born in two small villages (within 16 km distance) in Northern Sweden, hence the parents were suspected to be cryptically related. The proband had an unaffected sister, who was born eight years later.\nThe proband had no facial dysmorphic features. At three to four months of age, she presented with nystagmus and profound hearing impairment, which was suspected to be congenital. At age four months, she was hospitalized because of poor weight gain. She was tube fed for an extended period of time due to poor weight gain. In the first year of life, she experienced episodes of hypoglycemia and a liver biopsy was performed. The biopsy revealed fatty liver; however, the liver function as evaluated by biochemical parameters underwent subsequent stabilization and she showed no clinical insufficiency later in life. Liver biopsy was repeated at six years and showed only minor fibrotic changes. She was treated with hearing aids, but at 21 years of age she communicated using sign language. Cochlear implantation was refused.\nFull field electroretinography (ffERG) was recorded during general anesthesia mainly according to the standardized protocol for clinical electroretinography (ISCEV) using a Nicolet analysis system (Nicolet Biomedical Instruments, Madison, Wisconsin) at the age of eight years. These recordings confirmed a rod-cone degeneration with no residual rod responses but still remaining cone function. Delayed cone response also confirmed progressive rod-cone degeneration (). Fundus examination revealed pigmentation, degeneration, and atrophy in the macular area, but not with the typical pattern observed in Usher syndrome. The proband is considered deaf with severe visual handicaps including no night vision, problems with glare, reduced visual field, and low central vision.\nPsychomotor development was normal. The proband did not display intellectual disability and walked without support at age 13 months, but had poor balance. A computed tomography (CT) scan, performed at age six months, showed agenesis of corpus callosum. At two to three years of age she had episodes of generalized seizures. The patient displayed primary amenorrhea. During the first year of life, hypotonia was pronounced, electromyogram showed low amplitudes, and was suspected of indicating myopathy. Therefore, muscle biopsy was performed, revealing disputable minor abnormalities. However, there were no clear signs of either mitochondrial or myopathic abnormalities, and subsequent electron microscopy returned normal results. Plasma lactate was elevated.
The first patient was a 49-year-old man involved in a helmeted mountain bike accident and self-presented to the ED with a complaint of right flank pain. He was initially stable in the ED and underwent a CT scan of the abdomen and pelvis for flank pain that revealed an American Association for the Surgery of Trauma (AAST) grade 5 renal laceration with active extravasation of contrast coincident with profound hemorrhagic shock (). Initial resuscitation, allowing for permissive hypotension, included 3 units each of packed red blood cells (pRBC) and fresh frozen plasma (FFP) targeting a systolic blood pressure of 90 mm Hg. The patient had a history of Crohn’s disease with multiple abdominal operations and bowel resections, as well as a ventral hernia repair with mesh. Given the expected difficulty of operative repair, a right common femoral artery (CFA) 7 French arterial sheath was placed under ultrasound guidance and plans made to emergently proceed to surgery for nephrectomy with REBOA use for Zone 1 RAO if needed. However, once arterial access was established with the 7 French sheath, invasive arterial line revealed a higher blood pressure (systolic pressure of 110) than what was noted with noninvasive measurement techniques. The response to resuscitation with the access for immediate REBOA placement and RAO if needed, gave the clinicians confidence and the time to rapidly explore other treatment options in a difficult surgical patient. Urology and Interventional Radiology (IR) were consulted, and in discussions at the bedside, the decision was made to initially pursue angioembolization given the hostile abdomen and successful experience with renal artery embolization, both in renal cell carcinoma and in traumatic hemorrhage. IR was able to perform the procedure through the Prytime Medical REBOA system’s 7 French sheath which further expedited time to definitive therapy. After embolization, the 7 French sheath was maintained overnight with the REBOA catheter immediately available in the intensive care unit (ICU); neither were needed as the angioembolization proved successful and durable, and the sheath was removed the following morning and the REBOA returned to the REBOA cart. The patient required 3 days in the ICU and was discharged on hospital day 14. Overall, this case illustrated some unappreciated benefits of REBOA technology: (1) Improved monitoring and patient data for triage and medical decision making provided by early arterial access; (2) Emergency medicine and surgeon confidence that RAO could be done in seconds if needed allowing exploration of other management avenues; and (3) IR interventions, including angioembolization, were performed via the already placed 7 French sheath facilitating more rapid therapy in the IR suite. Overall, REBOA catheter insertion for RAO was not ultimately required for the patient to have benefited from the step-up REBOA technology bundle.
A 68-year-old woman with primary biliary cholangitis and decompensated cirrhosis is admitted to the intensive care unit with gram-negative septic shock related to spontaneous bacterial peritonitis. She is intubated and on mechanical ventilation and delirious. She has rapidly progressive acute kidney injury and was recently placed on continuous renal replacement therapy. The right internal jugular dialysis line has been steadily oozing and soaking through the dressings with blood. She also has a large subcutaneous hematoma in the left lower quadrant at the site of a paracentesis performed 48 h ago. Her hemoglobin levels have been steadily dropping each day and she has needed several blood transfusions over the past week. Her platelet count is 36 000/µl, fibrinogen 77 mg/dl, PT 28 s, and INR 3.2. The bleeding has not responded to platelet or cryoprecipitate transfusion administered by the critical care team prior to our consultation. The critical care team is requesting advice on the potential source of her continuous low level bleeding and any therapies that might offer benefit.\nThe transition from an acutely decompensated state to ACLF requiring organ support, is accompanied by a further decline in platelet count and fibrinogen levels, and a further increase in the PT/INR. Whilst global hemostasis assays demonstrate rebalanced hemostasis with hypercoagulable features in patients with acute decompensation, in ACLF there is broad individual variation with evidence of both hypo- and hypercoagulable characteristics and variable fibrinolytic activity., Sepsis, acute kidney injury and procedural intervention predispose to bleeding and are common in patients with cirrhosis., , Importantly, over a third of admissions to critical care units are precipitated by sepsis. AKI is present in up to 20% of those hospitalized with decompensation and 75% in those requiring critical care support., The incidence of major bleeding in ACLF was reported as 17% in a single center cohort (n = 211). Comprehensive laboratory evaluation of 80 patients with decompensated liver disease with/without AKI (predominantly ward based care) demonstrated both hypo and hypercoagulable features, with greater platelet dysfunction, lower factor XIII and increased fibrinolysis, along with further hypercoagulable features and hypofibrinolytic features., These factors likely contribute to instability of an already delicately rebalanced coagulation status in this patient. Renal replacement therapy may contribute to rebalancing hemostasis by optimization of fluid balance and improving platelet function, although there are no studies investigating this.\nFurther derangement of routine coagulation parameters seen in ACLF resembles that of disseminated intravascular coagulation (DIC). However, the defining characteristics of DIC are of systemic coagulation activation with intravascular fibrin formation leading to small/medium vessel thrombosis and organ dysfunction rather than hepatic synthetic failure and endothelial activation of ACLF. The diagnosis of DIC relies on the use of a scoring system in the presence of a recognized associated condition. This is problematic in liver disease as all components of the DIC score are frequently abnormal in ACLF (Table ). In the aforementioned critically ill cohort of patients with cirrhosis (n = 211), 63% of patients met the laboratory diagnostic criteria for DIC. Whilst the DIC score was significantly associated with an increased risk of major bleeding, marked thrombocytopenia (platelets < 30 000/µl) and hypofibrinogenemia (<60 mg/dl) were stronger predictors of bleeding (along with aPTT > 100 s). Hypofibrinogenemia is the least common feature of DIC, but is prevalent in critically ill patients with advanced liver disease. The need and/or benefit of correcting it is not well established. Hyperfibrinolysis is a further diagnosis to consider; this is extensively described during liver transplantation secondary to endothelial release of tissue plasminogen activator (t-PA). Whether it is a defined feature of ACLF remains uncertain; recent studies utilizing plasma-based clot lysis assays have demonstrated shortened clot lysis times with increasing disease severity, but with wide inter-individual variation. In this cohort, sepsis appeared to be associated with hypofibrinolysis, and bleeding events were not associated with shortened clot lysis times.\nThe overlapping features of these diagnoses are highlighted in (Table ). There are no specific established therapies for bleeding in ACLF and the cornerstone of treatment is to address the underlying cause, in this case sepsis and associated AKI. The role of continued hemostatic support is uncertain, conventional supportive targets for bleeding patients with DIC are unlikely to be appropriate in this patient group given the specified thresholds for platelet count (<50 000/µl), PT (<1.5× normal) and fibrinogen (<1.5 g/L) may be ‘supranormal’ compared to the individual's baseline coagulation parameters. Alternate replacement therapy such as PCC and fibrinogen concentrates should be reserved for those with volume overload where FFP/cryoprecipitate transfusion is not possible (although there is no evidence to support their use in this setting). Outside GI bleeding (HALT-IT), there are no specific studies of antifibrinolytics in ACLF and bleeding. However, antifibrinolytics are suggested as a rescue therapy for controlling bleeding post procedurally.,\nFor this patient, the mainstay of therapy is management of sepsis and AKI. Whilst there is no evidence, a trial of antifibrinolytics is warranted (with prompt cessation when bleeding stops). If this fails, low dose fibrinogen concentrate (for example 1 g as a single dose) may be appropriate, particularly if fluid balance is challenging. This should not be continued to achieve a specific fibrinogen target but emphasis should be on bleeding control. Given the low yield and questionable efficacy of platelet concentrates in this setting, platelet concentrates are not recommended. Similarly, as large volumes of FFP are required for a meaningful reduction of the PT/INR, its questionable efficacy, and the risk of volume overload resulting in a paradoxical increased bleeding risk, FFP is not recommended.
A 27-year-old male patient was referred to Department of Periodontics with the complaint of developing hollowness in the left cheek region which was causing esthetic concern to the patient. The patient also suggested to check intraorally and revealed that he has been observing this change since 2 months. There was no significant past medical history or dental history related to it.\nExtraoral findings revealed a hollow oval-shaped depression of about 1 inch × 0.8 inch in dimension in the left cheek region, adjacent to nasolabial fold below the malar region []. On palpation, the buccal mucosa appeared normal. Intraoral clinical examination revealed marked concavity between 24 and 25 region. Roots appeared more prominent and tissue biotype was thin []. Intraoral periapical radiograph was advised which revealed marked reduction in radio-opacity between 24 and 25 in comparison with adjacent teeth region []. The teeth appeared vital on testing. Treatment was planned that consisted of exploring the defect with open flap surgery. The bone sounding was another option to be considered to evaluate the defect, but since the bone height appeared to be normal, clinically and radiographically, the surgical approach appeared to be more accurate for the direct visualization of the defect. After the blood investigations were found to be within normal limits, that is, a complete blood count was carried out to rule out the general health status, a full-thickness mucoperiosteal flap was elevated, which included a crevicular incision clubbed with two vertical incisions to delineate the area of interest []. Flap reflection revealed exposure of extremely thin bone on 24 and two fenestration defects on the root of 25. Roots appeared more prominent with marked concavity between them []. However adequate bone was found adjacent to 23 and 26 on either side. Two corticotomy sites of 0.5-mm diameter were prepared adjacent to the root prominence in the bone for vascularization. In the concavity and over the defect, bone allograft consisting of demineralized freezed dried bone allograft of particle size ranging from 500 to 1000 μ (DFDBA) (Tissue Bank of Tata Memorial Hospital, Mumbai) was placed [] and covered with PRF membrane []. The flap was sutured using 4-0 black braided silk. Periodontal dressing was placed over the flap (Coe-Pack, GC America). The patient was discharged with prescription of antibiotics and anti-inflammatory medication (amoxicillin 500 mg thrice a day for 5 days and diclofenac sodium twice a day for 3 days), for better predictability of results and less postoperative infection. The patient was instructed to use 0.2% chlorhexidine mouthwash (Hexidine, ICPA Health products) for 2 weeks. The patient was recalled after 8 days and sutures were removed. The healing was uneventful. The patient was followed up for 3, 6, and 9 months []. At the end of 9 months, a postoperative radiograph was advised which revealed marked radio-opacity between 24 and 25 []. The patient was satisfied with the outcome of the treatment. Extraoral view of depression near left modiolus treated by correction of fenestration in relation to 24 and 25 [].
We report the case of a 31-year-old Caucasian woman, gravida 3, para 1, who was referred after a second trimester fetal anatomy screening at 20 weeks gestational for a suspicion of a complex fetal cardiac malformation, for which several specialized opinions tried to reach consensus.\nThe obstetrical history of the patient includes a previous Caesarian section with a normal course of parturition and a spontaneous miscarriage. The current pregnancy presented a low risk for aneuploidy according to the performed cell-free fetal DNA test. The classical karyotype performed after the abortion did not reveal any chromosomal abnormalities.\nPrevious ultrasound evaluations were incongruent and reported the following findings:an isolated aortic arch anomaly (supposedly aneurysmal dilation from which the left common carotid artery emerges) and coarctation of the aorta with the anterograde flow; ventricular septal defect, coarctation of the aorta, and a vascular formation located superior from the aortic arch with the appearance of an arteriovenous fistula; aneurysmal dilation located above the pulmonary trunk bifurcation and a dilated left common carotid artery with a retrograde flow; minor ventricular septal defect with a normal ductus venosus triphasic flow.\nWe performed fetal echocardiography, which demonstrated a mild cardiomegaly with a left deviated 72-degree heart axis, normal aspect of the four-chamber view, a small membranous ventricular septal defect, and ductal aortic coarctation; the ductus venosus flow was normal (, and ). In addition, we identified an aneurysmal structure measuring 1.63/1.25/1.16 cm with turbulent Doppler flow, situated above the emergence of the pulmonary trunk and continued by a dilated vascular structure that bifurcates in the cervical region; the aneurysm seemed connected to the left pulmonary artery as well. A dilated left subclavian artery was also suspected (, and ).\nIn the context of complex cardio-vascular malformations, the patient requested the termination of the pregnancy by drug-induced abortion.\nThe hands-on dissection of the fetus revealed a set of abnormalities that could stand as an anatomical basis for what has been found during the ultrasound examination.\nThe first and the most pronounced aspect was the distention of the whole venous system of the neck and mediastinum. The specimen presented a linguo-facial vein that described a rather sinuous pathway alongside the inferior margin of the mandible (). Both the linguo-facial vein and the external jugular vein appeared with a markedly increased caliber, around 4–5 times larger than expected for this gestational age. Both left and right jugular veins and the right subclavian vein were assessed as three times larger than usual, respecting the normal relations to the neighboring structures ( and ).\nThe confluence between the left jugular and subclavian vein into the left brachiocephalic vein was observed to be very dilated to superior and inferior, extending above the superior margin of the omohyoid muscle as well as below the inferior concavity of the aortic arch. Moreover, on the inferior side of the enlarged brachiocephalic vein, a vessel could be observed descending lateral to the left vagus nerve and communicating with the left pulmonary artery. The left pulmonary artery was observed to be dilated as well, around twice as normal ().\nRegarding the great vessels of the heart, there are some anomalies to be discussed. A narrowing of the aortic arch was identified distally to the emergence of the left subclavian artery ( and ). A large, patent ductus arteriosus was found, ending right at the narrowing level observed in the aortic arch (ending right at the coarctation level) (). The left subclavian artery was dilated as well, sizing as much as the ascending aorta and the aortic arch, creating the illusion of a terminal branch rather than a lateral one ( and ).\nHeart analysis concluded no distinct changes in heart architectural formation for this gestational age. Atrioventricular and ventriculoarterial concordance was noted. Atria and ventricles were increased in relation to the mediastinum. Surprisingly for an aortic coarctation, the right atrium was not found to be enlarged.
The 19-month-old female case was born at term, 49 cm in height and 2765 gr weight, by normal delivery. That was the first gestation and first delivery of the mother. The gestational age was 28. The mother in question had no serious disease throughout her pregnancy. There is no kinship between the mother and the father. There is nobody else within the family who has this anomaly. The case was diagnosed with JS when she was 4,5 months old. Her mother applied to an ophthalmologist due to the fact that her forty-day baby failed to follow the objects around. On account of the fact that the ophthalmologist told the mother that her baby was yet too little and she would be able to make an eye contact in a few months, the mother waited until the baby was 4 months old. However, seeing that there was no change at all in the baby's condition, she had to apply to a neurologist. In the cranial CT examination of the baby, the cerebral trunk seemed to be in its usual shape, whereas there were findings of deformation in the 4th ventricle, and there was the sight of a molar tooth in the mesencephalon and superior cerebellar peduncle. The superior cerebellar peduncle was found to be thicker than expected. A cleft in the cerebellar vermis drew attention. During the ophthalmologic examination, no nystagmus was found. The mother defined her baby as a “floppy one,” stating that she could not even establish an eye contact with her, that her tongue was always protruded, and that she had no problem with her respiration or her ability to understand. The case started to speak only after reaching the age of 1, and her first sensible word was “mom.” When the case was 12 months old, she was made to start a private educational institution upon the doctor's advice since her motor development had fallen behind that of her peers. As the mother could see the improvement in her child as time went by, she decided to continue physiotherapy and rehabilitation sessions. When the case was 19 months old, she was included in the physiotherapy and rehabilitation program in a private medical center. The case had motor movements such as head control, assisted sitting, and turning right and left before the physiotherapy and rehabilitation program started on. However, there were no such movements as crawling, turning from the supine position back to the sitting position, and staying on forearms in a facedown position. In order to determine the motor functioning level as well as the skill level of the case, the Gross Motor Function Measurement Test (GMFM) was used. This test consists of a total of 88 items along with 5 functional dimensions, which involve lying and rolling (17 items); sitting (20 items); crawling and kneeling (14 items); standing (13 items); and walking, running, and jumping (24 items) that are followed by one another consecutively in neurological development order. The test in question was standardized in the way that it would indicate the developments in time. The scoring of each item is performed according to the likert scale. If the activity cannot be started on, then “0” point is given, whereas if it is started independently, then “1” point is given; on the other hand, if the activity is partially completed, then “2” points are given, and if it is completed independently, then “3” points are given. The maximum scores to be obtained from the sections are as follows: lying and rolling: 51; sitting: 60; crawling and kneeling: 42; standing: 39; and walking, running and jumping: 72. The total score obtained in each section is divided by the overall score of that section and is then multiplied by 100, as a result of which the total score for that section (%) is calculated. The calculation for the total score is obtained by dividing the sum of these 5 sections by 5 [, ].\nOur case got 20 points from the lying and rolling section of the test (). While in this section, she got the overall score from the items involving the full joint range of motion and flexion of right and left hips and knee in the supine position; she failed to get any score from the items involving stretching the right and left arms forwards on forearms in a prone position. She got 5 points from the sitting section in which there was no function she was able to do independently (). She got 3 points in total from the crawling and kneeling sections, and just as in the sitting section, there was no activity in these sections that she could do independently (). On the other hand, our case got 1 point from the last two items of the scale which involved standing up; yet, she could not get any point from the walking, running, and jumping section ().\nThe functional independence level of the case was determined by using the Pediatric Functional Independence Measure (WeeFIM). The WeeFIM evaluation gauge was formed by taking the Functional Independence Measure (FIM) as the model, which was used as the evaluation method for adult rehabilitation. This gauge is used to determine the functional independence levels of the children with cerebral paralysis and other developmental disorders as well as the changes occurring in time-dependent functions []. The Turkish validity and reliability study on WeeFIM was conducted by Erkin and Aybay in 2001 []. WeeFIM is a measurement method consisting of 18 items and 6 sections referred to as self-care, sphincter control, mobility-transfer, locomotion, communication, and cognitive function. In these sections, while the function in each item is being performed, the scoring is done from 1 to 7 according to whether or not any aid is received, the number of aids, whether or not the activity is done on time, or whether an assistive device is required or not. When the task assigned is performed by totally receiving help, then it is evaluated as 1 point, whereas when it is performed totally independently, in proper time and in a secure way, then it is evaluated as 7 points [].\nOur case got 9 points from the self-care field, which is one of the substeps of WeeFIM, whereas, she got 2 points from the sphincter control field, 4 points from the transfers field, 3 points from the movement field, 13 points from the communication field, and 15 points from the social status field ().\nThe case was included in the physiotherapy and rehabilitation program by the physiotherapist for one hour for 5 days a week throughout the period of 13 months. In order to support the normal motor development during the treatment program, Bobath's neurodevelopmental treatment approach was applied. While the neurodevelopmental steps were being followed, the near-term and far-term targets were determined by starting from what the case was able to do. In physiotherapy practices, particular attention was paid to normalizing sensorial and motor experiences as well as forming the good posture, facilitating the balance and righting reactions, optimizing the muscular tonus, and maintaining motor control. Within the scope of neurodevelopmental treatment, again, particular attention was paid to keeping the distal and proximal segments in harmony. It was targeted that stability in the proximal segment and a proper movement in the distal segment be exposed. Within the scope of this treatment, the use of audio-visual stimulants was taken care of in the course of the activities, since motor learning was of great importance. By taking into consideration the motivation of the case, particular attention was paid to the repeating numbers of activities, their variability, and teaching the activities within the functioning process. The activities that were focused on involved turning from the supine position back to the sitting position, crawling, transferring weight, unassisted sitting, climbing up, taking steps, walking, and climbing up and down the stairs. When the case was 32 months old (), the second examination was made by another physiotherapist. As a result of the examination, it was determined that our case was able to turn around independently from the supine position to prone position and vice versa, that she was able to lift her herself up on her forearms in the prone position, that she was able to sit on her own, and that she was also able to crawl and walk independently. During the second examination of GMFM test, our case got a full score from lying and rolling and sitting sections, all the activities of which she was able to perform independently. In the meantime, she got 38 points from the crawling and kneeling sections, 30 points from the standing section, and 31 points from the walking, running, and jumping sections (). On the other hand, as for the substeps of WeeFIM, she got 12 points from the self-care field, 2 points from the sphincter control field, 11 points from the transfers and movement fields, 13 points from the communication field, which was the same as the initial value, and 16 points from the item, social status (). The written informed consent form was received from her mother for the publication of this case report and any accompanying images.
A 53-year-old female presented with gradually progressive diminution of vision in her left eye for 2 months. She had a history of diabetes mellitus for 20 years for which she is taking insulin. Her most recent HbA1C was 7.5%. She had no history of hypertension or renal problems. She had no past ocular history. Examination revealed a corrected distance visual acuity (CDVA) of 20/40 in her right eye and 20/100 in the left. Anterior segment examination showed nuclear sclerosis in both eyes. Posterior segment examination revealed intraretinal hemorrhages in all 4 quadrants indicating severe nonproliferative diabetic retinopathy in both eyes with clinically significant macular edema in the left eye confirmed by fluorescein angiography (). Spectral domain optical coherence tomography (OCT) of the macula was done and revealed multiple cystic spaces, mild subfoveal neurosensory detachment, and diffuse retinal thickening with a central subfield macular thickness of 332 μm in the left eye (). The right eye showed only few cystic spaces with minimal thickening. OCTA (Optovue, Inc., Fremont, CA, USA) was done in both eyes and showed areas of capillary nonperfusion in the superficial capillary plexus (SCP) of the maculae of both eyes (Figures and ). Three monthly intravitreal bevacizumab injections were done to treat the macular edema in the left eye. One month following the last intravitreal injection, CDVA improved to 20/60 in the left eye and was stable in the right eye. OCT showed improvement of the macular edema in the left eye (). OCTA was performed in both eyes and showed decreased vascular density of the SCP of the left eye compared to pretreatment OCTA while a mild increase was noted in the vascular density of the SCP of the untreated right eye (Figures and ). The patient was then followed up without requiring further intravitreal injections and 4 months following the last intravitreal injection OCTA was repeated in both eyes and showed improvement of the vascular density of the SCP of the left eye with unchanged SCP in the right eye (Figures and ). CDVA was 20/60 in the right eye and 20/100 in the left. Clinical examination revealed retinal neovascularization in the right eye with clinically significant macular edema in both eyes. OCT showed increased center-involving macular edema in both eyes with recurrent neurosensory detachment in the left eye (). Three monthly intravitreal bevacizumab injections were then done for treatment of proliferative diabetic retinopathy in the right eye and the macular edema in both eyes. One month following the last intravitreal injection, CDVA was 20/40 in the right eye and 20/60 in the left, OCT showed decreased macular thickness in both eyes (), and OCTA revealed decreased vascular density of the SCP of both eyes (Figures and ). Changes in the deep capillary plexus closely followed those in the SCP at all stages.
The patient was a 79-year-old female who presented to the emergency department with an eight-hour history of abdominal pain associated with nausea and vomiting. She also complained of obstipation for the past day as well as right hip pain. Her past medical and surgical history includes right upper lobectomy for adenocarcinoma of the lung in 2008, left nephrectomy for renal cell carcinoma, prior pulmonary embolism, hypertrophic cardiomyopathy and Stage IV chronic kidney disease. Her vital signs on admission showed tachycardia and hypotension. On examination, decreased bowel sounds and mild distended was observed. A computer tomography (CT) scan of the abdomen and pelvis was performed and showed small bowel obstruction with air-fluid levels as well as a right-sided obturator hernia with a loop of small bowel which appeared incarcerated inside (Figures , ). Initial laboratory studies showed mild leukocytosis with a WBC of 10.7, hemoglobin of 15 and hematocrit of 44.3. Creatinine was at a baseline level of 1.8. The patient had a nasogastric (NG) tube placed in the ER with an output of 500 cc of bilious output and was resuscitated with crystalloid and brought to the operating room.\nThe patient was deemed unstable to undergo a laparoscopic approach and she underwent an infraumbilical midline laparotomy through which the right-sided obturator hernia was gently reduced. The bowel was inspected and was deemed to be healthy and viable. The obturator hernia was then repaired using a polypropylene mesh plug. She had an uneventful recovery. The nasogastric tube was removed on POD 2 and the patient was started on clear liquids diet. She regained full bowel function on post-operative day 3. The patient subsequently had her diet advanced to a regular diet which she tolerated until discharge.\nThe patient returned to the emergency room six months later with the sudden onset of left hip pain associated with lower abdominal pain while walking. Soon thereafter, the patient began belching but did not develop nausea or vomiting. She underwent a CT scan of the abdomen and pelvis in the ED that demonstrated a left-sided obturator hernia as well as small bowel obstruction (Figures , ). The patient was otherwise hemodynamically stable, and her laboratory studies were within normal limits. The patient was taken for an urgent midline laparotomy through her prior incision and the left obturator hernia was reduced. Intraoperatively, the bowel appeared viable and did not require any resection. The obturator hernia was repaired in a similar manner as the initial surgery with a polypropylene mesh plug. She was extubated the morning after her surgery. Recovery proceeded in a timely fashion as in her previous hospitalization. Her NG tube was removed on post-operative day 2 and she was started on a clear liquid diet. Her diet was advanced, and she remained asymptomatic until discharge.
A 59-year-old woman with a history of non-ischemic dilated cardiomyopathy was referred to our facility for further investigation of an unprovoked PE beginning 2 years prior. A small filling defect diagnosed as PE was reported within the RLL pulmonary artery on CTA imaging 2 years before presentation at our institution []. Her only symptom at the time of diagnosis was dyspnea. Outside testing for thrombophilia was unrevealing. She was treated with anticoagulation for 6 months following the diagnosis of PE on CTA. She denied smoking, hemoptysis, headache, gastrointestinal bleeding, history of stroke or cancer, chest trauma, recent surgery, chronic lung infections, or long-distance travel. Vital signs, physical examination, and laboratory results were unremarkable. The patient presented at our institution 2 years following original diagnosis of PE. CTA at our facility was less convincing in demonstrating RLL pulmonary artery filling defect; however, hypertrophied arteries in the right lung base [] and upper abdomen [] were identified. The hypertrophied arterial structure in the right lung base was present on the CTA from 2 years prior. Our current CTA interpretation described no evidence for PE but suggested the possibility of a pulmonary arteriovenous malformation. In fact, careful retrospective evaluation of the CTA from our facility reveals the fact that hypertrophied arteries are present in both the thorax and the abdomen. This combination is highly suggestive of SA-PAF instead of a simple pulmonary arteriovenous malformation limited to the thorax. Regardless, conventional angiography is indicated and definitive for either diagnosis on CTA.\nThe patient underwent conventional angiography for further investigation. Abdominal aortogram demonstrated a hypertrophied artery originating from the right renal artery communicating with RLL pulmonary artery. The right renal angiography confirmed a hypertrophied right inferior phrenic artery []. Selective arteriogram of the right inferior phrenic artery confirmed flow to the inferior RLL pulmonary artery [].\nPulmonary angiography did not demonstrate a PE or pulmonary arteriovenous malformation; however, competitive inflow was seen within the inferior RLL pulmonary artery due to SA-PAF. The right pulmonary arterial pressures were mildly elevated. Given the absence of pulmonary arteriovenous malformation, PE, or significant pulmonary hypertension, a conservative approach was elected with the intent to have the patient return for embolization of SA-PAF if symptoms developed.
A seven-year-old boy was referred to our clinic because of swelling over his sternum and the right side of the frontal bone. On physical examination, there was a firm, large mass measuring 3 cm × 4 cm lying over the manubrium of the sternum and another bony mass measuring 4 cm × 5 cm over the right frontal area. The patient had a history of right renal mass three years earlier, for which radical nephrectomy had been performed. The histopathologic evaluation of the renal mass had been reported as mesoblastic nephroma. Thus, no further investigation and therapy had been applied for the patient at that time.\nFollowing his referral to our clinic, the patient underwent a thorough examination including brain, chest, and abdominopelvic computed tomography (CT), which were normal except for two bony mass lesions. A brain CT scan showed an expansile bone lesion in the right frontal bone, invading the surrounding soft tissues (, ). Similarly, a chest CT scan showed a heterogeneous mass in the manubrium of the sternum composed of soft tissue and bone components, in favour of metastasis (). Whole-body scintigraphy with 99mTc-MDP showed an increased uptake of radiotracer in the frontal bone and the manubrium of the sternum. The patient was scheduled for excisional biopsy of the sternum mass. Histopathological examination revealed fibromuscular tissue infiltrated with round tumour cells with small to moderate amounts of cytoplasm and high mitotic activity accompanied by vascular invasion, which was consistent with a small round cell tumour with sarcomatous pattern (, ). Re-evaluation of pathological specimens at the time of nephrectomy was carried out which was in favour of CCSK and revealed a misdiagnosis of mesoblastic nephroma in the earlier report. Immunohistochemistry on the specimen of the sternal mass was performed, revealing negative results for WT-1 and positive results for CD-99 in favour of CCSK (, ).\nThe patient was diagnosed with relapsed, metastatic CCSK accounting for stage IV. Chemotherapy with Ifosfamide, Carboplatin, and Etoposide (ICE protocol) was started, and due to the lack of favourable response after three courses, doxotubicin and cyclophosphamide were added. Six months later, he had additional active bone lesions in the left humerus and ischium. He was scheduled to receive radiotherapy over his involved bones and also considered as a candidate for autologous stem cell transplantation.
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up.
A 38-year-old Chinese female presented with pain at the right upper side of the chest and adjacent soft tissue swelling for 3 months. A week before admission to our hospital, she was suffering from a gradually severe pain at the chest and fever. As a result, the patient was referred to our hospital for examination and treatment. Physical examination showed the patient had a mild soft tissues edema at her right upper lateral chest wall and severe pain was elicited upon chest pressure. The patient had a low grade fever of 37.4°C. There was no weight loss and no palpable lymphadenopathy or organomegaly. The laboratory results, including blood count, differential, liver and renal function, were within the normal range. A computed tomography (CT) scan of the chest revealed a single osteolytic lesion in the right second rib with associated soft tissue mass, measuring 6.0 × 5.0 × 5.0 cm in size. The most of rib was observed to be destroyed and the involvement of adjacent pleura and right upper lobe of lung were also noted (Figure ). The lesion showed moderate enhancement after gadolinium injection. There was no enlarged lymph node found in mediastinum and thoracic cavity. A CT scan of neck and abdomen showed no pathologic findings, particularly no lymphadenopathy could be observed. A CT guided needle biopsy was performed initially, but histopathological examination showed pieces of fibrosis with infiltration of inflammatory cells. Therefore, a surgical biopsy followed by a microscopic examination was performed. After diagnosis, the patient underwent polychemotherapy according to a modified COPP protocol (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, oncovin, procarbazine, prednisone) for five cycles before initiation of involved field radiotherapy. The lesion was regressed, and the patient was on regular follow-up for 24 months after radiotherapy. The bone marrow examination was performed at 6 months after radiotherapy, there was no abnormality found. During the period of following-up, there was no sign of recurrence of tumor and lymph node enlargement.
A 34-year-old man presented with a 6-month history of pain and swelling in his left knee. His medical history included prior presentation with a similar complaint for 5 years, involving left knee pain and difficulty walking. A mass had been detected in the center of his left distal femur, with a soft tissue component. The mass had increased in size and had become painful. There was no history of trauma.\nPhysical examination revealed a fixed, hard, painless, and palpable mass measuring 7-8 cm in diameter and locating on the patient's left distal femur. The patient had no neurovascular problems and no palpable lymphadenopathy. Standard laboratory test results were within normal limits. A roentgenographic study showed destruction of the distal femur and a corresponding dense soft tissue mass (). An MRI examination revealed a mass with focal cortical bone destruction in the distal metadiaphyseal region of the femur. On MRI, this lesion was mainly located in the subcutaneous tissue but extended through the fascia and into the muscle and bone. Osseous involvement was detected on radiographs as subtle bone erosion of the distal femur anterior cortex. The associated soft tissue was isointense to muscle on the T1-weighted image and was intermediately hyperintense to muscle on the T2-weighted image and showed intense enhancement after contrast medium administration (). No evidence of regional or distant metastasis was found in the patient. Biopsies of the neoplastic lesion contained elevated numbers of inflammatory cells.\nIn February 2011, the patient underwent distal femoral tumor resection and reconstruction with a modular prosthesis. During surgery, the tumor appeared encapsulated and consisted of multiple poorly circumscribed nodules, and the cortex appeared excavated from the outside. The excised lesion was 16 cm × 12 cm × 8.5 cm in size, with a capsule-like structure, and demonstrated a beige cut surface. The tumor had infiltrated the bone tissue as well as the soft tissue.\nHistopathologically, the lesion demonstrated numerous poly-morphonuclear leukocytes, each with a large vesicular nucleus. The tumor tissue was composed of atypical cells with boundaries that could not be clearly defined (). Immunohistochemical examination of tumor cells revealed that they were negative for myoglobin, desmin, CD30, smooth muscle actin (SMA), epithelial membrane antigen, and HHF-35 (anti-muscle actin antibody) but positive for CD68-phosphoglucomutase 1 (PGM1). The patient was readmitted in his third year of clinical follow-up, with no evidence of disease.
A 30-year-old man presented with low back pain and pain in the right lower extremity for 1 month, which aggravated for 3 days. After being admitted to our hospital, the patient could not walk upright due to severe pain. He was previously healthy and denied the history of hypertension and diabetes.\nOn physical examination, patient had pain upon pressure on L4/5 interspinous tissue and right paraspinous region, range of motion of the hip joint was normal, straight-leg raising test and augmentation test were 30 degree on the right (positive) and 70 degree on the left (negative), right knee and right ankle reflexes were weakened. Strength in extensor hallucis longus of the right foot was grade 4, and no abnormalities were found in other muscles of the lower extremities. The bilateral femoral nerve stretch test was negative. There was no obvious abnormal skin sensation in the perineal and sellar regions. Bilateral Babinski's signs were negative, Visual Analogue Scale (VAS) score was 9 points. Preoperative CT and MRI of the patients showed central to right sided disc herniation at the L4/5 level (Fig. ). There were no absolute contraindications for PELD. The patient underwent PELD for L4/5 disc herniation under local anesthesia, and the nucleus pulposus tissue removed during the surgery is shown in Figure . The low back pain and pain in the right lower extremity of the patient disappeared immediately after surgery with a VAS score of 1. Patient was given routine medications after surgery. After 24 hours of surgery, the patient got out of bed and walked under the protection of lumbar support belt. One week after the surgery, the condition of patient was obviously improved and he was discharged. The patient was asked to continue the functional exercise properly and not to perform heavy labor.\nThirty-seven days after the surgery, the patient complained of recurrent low back pain on the right side, and pain on the outer side of his lower leg, which aggravated when walking and seriously influenced the activities of daily life. The patient was then admitted to our hospital again. On physical examination, patient had slight tenderness upon pressure on L4/S1 interspinous tissue and right paraspinous region, hip joint range of motion was normal, straight-leg raising test and augmentation test were 50 degree on the right (positive) and 70 degree on the left (negative). Right knee and right ankle reflexes were normal. There was no obvious abnormality in the strength of muscles from lower extremities. The bilateral femoral nerve stretch test was negative. There was no obvious abnormal skin sensation in the perineal and sellar regions. Bilateral Babinski's signs were negative, VAS score was 8 points. MR imaging showed cystic mass with low signal on T1-weighted images (T1WI), and high signal on T2-weighted images (T2WI) (Fig. ). Blood routine test upon admission showed white blood cells of 6.88 × 109/L, neutrophil percentage of 54.5%; erythrocyte sedimentation rate of 7 mm/hour, and C-reactive protein of 0.2 mg/dL. After reviewing the literature, and considering the above clinical characteristics and imaging findings of the patient, the patient was diagnosed with symptomatic PDP after PELD.\nThe patient was initially treated with conservative treatment, including administration of aescin and mannitol by intravenous infusion, physical therapy, sacral canal injection. After nearly 1 week of systemic treatment, patient's symptoms were not relieved. Then discography at L4/5 and ozone ablation was performed under local anesthesia. Results of intra-operative discography are shown in Figure . The low back pain and pain in the lower extremity disappeared immediately after the surgery, with a VAS score of 1 point. Patient was given routine medications after surgery, and after 24 hours of surgery, the patient got out of bed and walked under the protection of lumbar support belt. The patient's condition improved significantly after 1 week of surgery and discharged. The patient was asked to continue their functional exercise properly and not to perform heavy labor.\nThe patient had no complaints of low back pain and leg pain (VAS score was 0 points) at 3 months of follow-up. MR imaging showed that cystic mass that was found originally at L4/5 level on the right side had disappeared; the cystic long T2 signal at the posterior part of the L4–5 disc had disappeared, and L4/5 disc herniation had also disappeared (Fig. ). The patient had no complaints of low back pain and leg pain (VAS score was 0 points) at 1-year follow-up (MRI examination was not performed).
A 38-year-old male presented to the surgery outpatient department with complaints of odynophagia and chest pain for two weeks. The symptoms had started after a meal when the patient felt the sensation of a foreign body in the throat, which he reportedly swallowed with a bolus of food. As the initial evaluation with neck and chest X-rays was reported as normal, he did not receive any specific intervention. However, in the third week after ingestion, he developed chest pain and fever. On evaluation with a contrast-enhanced thorax, chest, and abdomen scan, he was diagnosed with a right-sided pleural effusion and a suspected foreign body in the periesophageal region of the lower thoracic esophagus close to the inferior vena cava (Figures , ).\nFrom the hiatus region, the foreign body was located at approximately 5 cm cephalad. An intercostal drain was placed under image guidance and approximately 750 mL of serosanguinous pleural effusion was drained. An upper gastrointestinal contrast study did not show any contrast extravasation from the esophageal lumen. Upper gastrointestinal endoscopy also did not show any signs of recent perforation or a foreign body in the esophagus. An after adequate chest optimization, he underwent laparoscopic foreign body removal.\nThe procedure was done under general anesthesia in the supine split leg position. After initial access and the creation of a pneumoperitoneum through the left paramedian 12 mm port using an open method, five additional 5 mm ports were placed, including two midclavicular line ports on either side, a left subcostal port for assistance, and an epigastric port for liver retraction. The gastrohepatic ligament was divided to reach the right crus. The phrenoesophageal membrane was then opened to enter the mediastinum. The esophagus was then looped with an umbilical tape at the level of the hiatus and used for subsequent retraction. The right side of the esophagus was dissected meticulously, preserving the vagus nerves. At about 6 cm from the gastro esophageal junction, there was a fibrotic tract along the lateral aspect, which was then cut with scissors exposing the 2.7 cm long metallic foreign body (Figure ).\nRight pleura were thickened and were not opened. The foreign body was then extracted and removed under vision (Figure ).\nThe tract, which was seen extending to the esophagus, was clipped on the esophageal side using a hemolock. A thorough mediastinal lavage was given and a 16 Fr suction drain was placed in the paraesophageal region. An upper gastrointestinal oral contrast study that was done on the second postoperative day did not reveal any contrast leak, and the patient was started on an oral diet. He had an uneventful postoperative course and was discharged on the fifth postoperative day.
A 70-year-old man was admitted to the emergency department with a 1-month history of coughing and dyspnea. He developed a productive cough with purulent sputum, left chest wall pain, and 3 days prior to arrival ecchymosis developed on the left upper quadrant of the abdomen. He did not have a recent history of thoracic or abdominal trauma, and it was unknown if he had a history of thoracic surgery. The initial chest x-ray showed a hyperdensity in the left lower lung, an obliterated diaphragmatic border with an atelectasis, and a decreased lung volume. A computed tomography (CT) scan with contrast of the chest was obtained. The scan film showed a protrusion of the lung through the left 7th intercostal space (). Therefore, he was diagnosed with a lung herniation, and a medical conservative treatment was performed.\nOn hospital day 10, after experiencing uncontrolled coughing, the patient complained of aggravated dyspnea and left chest wall pain. The subsequent chest x-ray showed increased hyperdensity with a gas-filled area above the left dome of the diaphragm. He also showed dullness to percussion and chest wall tenderness. On hospital day 12, a CT scan with contrast of the chest revealed herniation of the bowl and omental fat in the anterior portion of the left hemithorax ().\nOn hospital day 13, the patient was transferred to the department of thoracic surgery and underwent an emergency operation due to the incarceration of the bowl and a parapneumonic effusion due to passive atelectasis. The operation revealed a partial agenesis of intercostal muscle, costal cartilage around the 7th anterolateral intercostal space due to the lack of developed intercostal muscle (), an 8 cm defect of the diaphragm, and a herniation of the small bowel located in the anterior portion of the left thoracic cavity (). The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. The patient was discharged 12 days postoperatively.
JC is a 12-year-old male who was involved in a T-bone motor vehicle collision one day prior to presentation at our Level 1 Pediatric Trauma Center. He was initially treated at an outside hospital for a closed left humeral shaft fracture, and a coaptation splint was placed with no reduction; radial nerve function was reported intact. The patient had continued pain in the arm and was brought to our emergency department (ED) by his father for further evaluation. Upon evaluation in the ED, this was an isolated closed injury, and the patient was fully neurovascular intact in sensation with full motor strength in all peripheral nerves. Initial radiographs () showed a displaced midshaft humerus fracture of 35° varus angulation. After discussion with the patient's father, given his continued pain and significant angulation, a closed reduction under conscious sedation was performed, and a coaptation splint was placed. Postreduction radiographs () showed some mild distraction but with overall acceptable alignment in 15° varus angulation. After the patient was fully awake from sedation, a thorough neurovascular exam was obtained (see\n) which revealed intact sensation and full strength in the median, radial, ulnar, posterior interosseous, and anterior interosseous nerves with a strong 2+ radial pulse. There was no pain with passive range of motion, and his compartments were soft and compressible. The patient and family were counseled on signs and symptoms of compartment syndrome as well as on signs of the radial nerve palsy to return to the ED with any concern. They planned to follow up with a pediatric orthopaedist within 1 week.\nFour days post reduction, the patient returned to our office for clinical evaluation. On exam, he had a dense motor and sensory radial nerve palsy () with 0/5 strength in the extensors of his thumb, fingers, or wrist. He had complete anesthesia in radial nerve distribution. Compartments remained soft with intact radial pulse and no signs of other trauma. His radiographs showed no change in position. Discussion was had with the patient and father regarding observation versus exploration of the nerve and surgical fixation. They elected for exploration, and he was scheduled for surgery. Repeat evaluation on day of surgery, 11 days post injury, showed continued dense radial nerve palsy. The patient underwent open reduction internal fixation via an anterolateral approach using a 9-hole LC-DC plate (). The radial nerve was explored and was found to be draped and stretched over a sharp fracture fragment. There was significant edema and ecchymosis around the perineural tissue; however, the radial nerve was noted to be contused but in continuity. The patient was made non-weight-bearing with range of motion as tolerated and was admitted overnight for observation and pain control but showed no change in nerve function immediately post-op.\nThe patient continued to follow up at routine intervals. His radial nerve palsy showed no improvement at 2 weeks post-op. At his next clinic visit at 6 weeks post-op, the patient had full recovery of his motor and sensory radial nerve function (). He was seen again at 3 months post-op with full shoulder/elbow/wrist/finger range of motion and 5/5 strength in all muscle groups. His fracture was fully healed on imaging, and he progressed with no residual functional deficits.
We report the case of a 31-year-old Caucasian woman, gravida 3, para 1, who was referred after a second trimester fetal anatomy screening at 20 weeks gestational for a suspicion of a complex fetal cardiac malformation, for which several specialized opinions tried to reach consensus.\nThe obstetrical history of the patient includes a previous Caesarian section with a normal course of parturition and a spontaneous miscarriage. The current pregnancy presented a low risk for aneuploidy according to the performed cell-free fetal DNA test. The classical karyotype performed after the abortion did not reveal any chromosomal abnormalities.\nPrevious ultrasound evaluations were incongruent and reported the following findings:an isolated aortic arch anomaly (supposedly aneurysmal dilation from which the left common carotid artery emerges) and coarctation of the aorta with the anterograde flow; ventricular septal defect, coarctation of the aorta, and a vascular formation located superior from the aortic arch with the appearance of an arteriovenous fistula; aneurysmal dilation located above the pulmonary trunk bifurcation and a dilated left common carotid artery with a retrograde flow; minor ventricular septal defect with a normal ductus venosus triphasic flow.\nWe performed fetal echocardiography, which demonstrated a mild cardiomegaly with a left deviated 72-degree heart axis, normal aspect of the four-chamber view, a small membranous ventricular septal defect, and ductal aortic coarctation; the ductus venosus flow was normal (, and ). In addition, we identified an aneurysmal structure measuring 1.63/1.25/1.16 cm with turbulent Doppler flow, situated above the emergence of the pulmonary trunk and continued by a dilated vascular structure that bifurcates in the cervical region; the aneurysm seemed connected to the left pulmonary artery as well. A dilated left subclavian artery was also suspected (, and ).\nIn the context of complex cardio-vascular malformations, the patient requested the termination of the pregnancy by drug-induced abortion.\nThe hands-on dissection of the fetus revealed a set of abnormalities that could stand as an anatomical basis for what has been found during the ultrasound examination.\nThe first and the most pronounced aspect was the distention of the whole venous system of the neck and mediastinum. The specimen presented a linguo-facial vein that described a rather sinuous pathway alongside the inferior margin of the mandible (). Both the linguo-facial vein and the external jugular vein appeared with a markedly increased caliber, around 4–5 times larger than expected for this gestational age. Both left and right jugular veins and the right subclavian vein were assessed as three times larger than usual, respecting the normal relations to the neighboring structures ( and ).\nThe confluence between the left jugular and subclavian vein into the left brachiocephalic vein was observed to be very dilated to superior and inferior, extending above the superior margin of the omohyoid muscle as well as below the inferior concavity of the aortic arch. Moreover, on the inferior side of the enlarged brachiocephalic vein, a vessel could be observed descending lateral to the left vagus nerve and communicating with the left pulmonary artery. The left pulmonary artery was observed to be dilated as well, around twice as normal ().\nRegarding the great vessels of the heart, there are some anomalies to be discussed. A narrowing of the aortic arch was identified distally to the emergence of the left subclavian artery ( and ). A large, patent ductus arteriosus was found, ending right at the narrowing level observed in the aortic arch (ending right at the coarctation level) (). The left subclavian artery was dilated as well, sizing as much as the ascending aorta and the aortic arch, creating the illusion of a terminal branch rather than a lateral one ( and ).\nHeart analysis concluded no distinct changes in heart architectural formation for this gestational age. Atrioventricular and ventriculoarterial concordance was noted. Atria and ventricles were increased in relation to the mediastinum. Surprisingly for an aortic coarctation, the right atrium was not found to be enlarged.
This is a case of a 63-year-old male who presented to the ED with a two-day history of painless penile shaft swelling. He had a past medical history of liver cirrhosis, hepatitis C, and alcohol abuse. The patient stated that the swelling began one day prior to presentation and that it was not improved or worsened by any specific factors, was painless, and was not associated with other symptoms such as difficulty urinating, dysuria, testicular pain or swelling, or nausea. He also denied penile or groin trauma, or being sexually active.\nOn physical exam, the patient was well appearing and in no apparent distress. His abdomen was slightly distended with pronounced abdominal veins but soft and without tenderness to palpation. His right inguinal area had a piece of gauze taped to his skin, and upon removal, we noticed a puncture wound which was clean and dry and was noted to be a few centimeters medial to the patient’s right anterior inferior iliac spine in the inguinal region and appeared to be below the inguinal ligament (Figure ).\nThe site was clean and dry and did not exhibit any swelling, tenderness, erythema, or warmth. His genital exam showed a circumcised penis with significant soft tissue swelling that involved the entire penile shaft sparing the glans and scrotum (Figure ). There was no penile tenderness on palpation or penile discharge. The testicles and scrotum revealed no signs of edema or tenderness, hernias, or abnormal lie.\nDuring our interview, we discovered that three days prior to the presentation, the patient visited the same ED for evaluation of an episode of upper gastrointestinal bleeding (UGIB) in a setting of decompensated cirrhosis for which he was evaluated and subsequently admitted to the hospital. During his ED evaluation, he underwent a diagnostic paracentesis that ruled out spontaneous bacterial peritonitis. Documentation about the procedure did not specify if ultrasound guidance was used. He was admitted for the management of decompensated cirrhosis and UGIB. Of note, the patient reports that he went to the ED with a less severe episode of penile swelling, which occurred approximately one year ago after a paracentesis, which resolved spontaneously without extra care.\nThe features (i.e., site of paracentesis) and timing of this presentation, added to the patient’s previous episode over a year ago, pointed to this being a sequela of the paracentesis he had undergone during his last hospital stay rather than an acute infectious process such as cellulitis or spontaneous bacterial peritonitis.\nWhile in the ED, the patient was evaluated by the urology service. After their evaluation, we agreed that the swelling was likely a complication due to the paracentesis and they only recommended that the patient wear tight underwear for scrotal support. Urine analysis performed in the ED was negative for urinary tract infection and was sent out for culture which did not show bacterial growth. The patient was discharged home with return parameters and reassurance that the swelling would resolve over the next couple of days. During a subsequent telephone encounter, the patient reported that the swelling fully resolved about one week after our evaluation.
The patient is a 70-year-old man with a medical history of hypertension, gout, and rectal cancer with liver metastases who presented with 4 days of nausea, vomiting, and gait instability. On physical examination, he was found to have right ptosis, left arm tremor, and right arm dysmetria. CT head showed cerebellar infarction with surrounding cerebral edema in the territory of the right posterior inferior cerebellar artery (PICA). CT angiography of the head and neck showed right vertebral thrombus with distal reconstitution from retrograde flow along with moderate-to-severe stenosis in his bilateral posterior cerebral arteries. He was not a candidate for thrombolysis with tissue plasminogen activator or endovascular intervention being outside of the thrombectomy treatment window.\nStroke workup was completed, with a normal transthoracic echocardiogram, elevated hemoglobin A1c, and elevated LDL. He received an aspirin 325 mg load and then was started on aspirin 81 mg and a statin for secondary stroke prophylaxis. His blood pressure was slowly decreased from permissive hypertension with his home antihypertensives. MRI brain confirmed a subacute stroke of the right PICA territory with secondary right tonsillar herniation and no hemorrhagic transformation (Fig. ). Mass effect was also seen with compression of the fourth ventricle without hydrocephalus. He further underwent MR angiography of his head and neck, which was significant for occlusion of his right vertebral artery from V1 to the distal V2 segment, with distal reconstitution. That is, trickle flow at the V3 segment level and normal caliber at V4 reflecting clot burden and likely retrograde flow from the basilar artery.\nIntravenous heparin infusion without bolus was started for the right vertebral thrombus with therapeutic partial thromboplastin time reached on the second day of admission. The patient began complaining of abdominal pain on the third day, with recurrence of nausea and vomiting. He became hypotensive and had tachycardia. Hemoglobin dropped from 9.4 to 5.9 mmol/L. Abdominal X-ray showed possible ileus, with bowel diameter >10 cm. CT abdomen showed left retroperitoneal hematoma from a ruptured 1.2 cm renal angiomyolipoma (mildly complex and posterior). Aspirin and heparin were stopped. He was given 3 units of packed red blood cells (PRBCs) and emergently taken for mesenteric/visceral angiography with embolization by interventional radiology (IR) (Fig. ).\nPost-procedurally, he was initially hemodynamically stable but had new-onset atrial fibrillation with rapid ventricular response to the 160s on telemetry and his systolic blood pressure dropped to 70 mm Hg. Repeat angiography of the embolized site was reviewed with IR. There was no active extravasation. He was given 1 L of fluids, 2 units of PRBCs along with amiodarone bolus and then started on an amiodarone infusion which was stopped the next day. Repeat electrocardiograms showed sinus rhythms. His hemoglobin was repeated every 8–12 h, then daily. Due to a high CHADSVASC score of 5, it was felt strongly that he needed to be on antithrombotic therapy. Repeat CT abdomens showed a stable hematoma; thus, he was restarted on aspirin 81 mg, 4 days after his embolization.\nThe case was further discussed with IR, oncology, hematology, surgery, gastrointestinal, and urology. The decision was that the benefits of anticoagulation outweighed the risks of rebleeding after embolization. His hemoglobin remained stable. On day 7 after embolization, he was started on an aspirin to warfarin bridge. Device implantation or atrial ablation for atrial fibrillation management was not selected due to patient preference. At this point, he was discharged from the hospital with home health and close multispecialty follow-up. At 6 months follow-up, he was on anticoagulation and functioning close to his baseline at home.
A 25-year-old man presented with severe neck pain without neurologic deficit after a traffic accident. The mental status of the patient was intact after admission. Physical examination showed tenderness and pain on the posterior aspect of the cervical spine. Neurologic examination revealed no deficit of motor power and sensation on all 4 of his extremities. Plain radiographs of the cervical spine revealed the C4 vertebral body slightly displaced anteriorly and increased interspinous space at the level of C4–5, magnetic resonance imaging (MRI) displayed a disruption of the anterior longitudinal ligament on the level of C4–5 and severe injury to the soft tissues of the cervical spine (Fig. ). The patient underwent a posterior cervical reduction and fusion of C4–5 using pedicle screw fixation and allograft after admission. All pedicle screws were inserted by free-hand technique, that is, the pedicle was inserted according to the anatomical landmarks of cervical spine and self-medical experience without navigation. After creating a pilot hole and confirming no arterial bleeding or cerebrospinal fluid leakage, an appropriate pedicle screw was inserted (Fig. ), C-arm machine was used to confirm the pedicle screw had no obvious deviation. The patient was neurologically intact after wake-up. However, the patient felt weakness and numbness for both of upper and lower extremities (motor power Grade II–III) in the next morning. Computed tomography (CT) scans of C4–5 and MRI of the brain were performed orderly and immediately. The CT scans revealed bilateral occupation of the pedicle screws of the foramen of C4 and C5 (Fig. ) and the MRI displayed several areas of infarction of the brainstem and cerebellum (Fig. ). Given that the symptoms of cerebral infarction may directly be caused by the occupation of bilateral VA, a second surgery was immediately decided to remove all of the pedicle screws and place lateral mass screws instead (Fig. ). The patient felt better on his all of 4 extremities following revision surgery. Fortunately, he was neurologically close to normal at a 3-month follow-up.\nThe ethical committee was waived for this retrospective study. Informed consent was obtained by patient himself.
A 17-year-old female patient was presented to our institute on April 2016 complaining of occasional back pain and spinal deformity. On examination, the patient had no limitation of physical activity, occasional pain, no neurological deficits with mild thoracic scoliosis. Reassurance of the patient and her family was done with conservative treatment. Six months later, the patient presented back with worse pain, numbness of both lower limbs, progressive deformity, and shortness of breath. MRI was ordered for her, and revealed a giant extra pulmonary mass shifting the mediastinum to the opposite side, extending opposite T6 to the lower border of T10 with intra spinal extension through the left neural foramina compressing the spinal cord. Full-length spinal PA and lateral X-rays showed left thoracic scoliotic curve extending from T5 to T9 with apex at T7 and measuring about 50° with Cobb method with thoracic kyphosis of 65° (–).\nPercutaneous US-guided needle biopsy was done, and the histopathological report confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass through posterior approach was planned for the patient after a multidisciplinary team approval in our institute comprising spine surgeon, anesthesiologist, and cardiothoracic surgeon.\nThe patient was operated under general anesthesia in prone position over a radiolucent table. Standard posterior approach to the thoracic spine was done exposing the posterior elements subperiosteally. Then pedicle screws were inserted using the free hand technique from T3 to T11 and their position was checked by intra operative radiograph. A rod was connected to the screws on the right side and then wide microscopic decompression of the spinal canal was done exposing the mass and the spinal cord. Careful dissection of the mass from the spinal cord was done and the nerve root connecting the mass to the cord was identified and ligated. Ponte osteotomy was done at the apex and then correction was done by rod derotation technique. The second rod was inserted, then Wake-up test was done, and after confirming neural integrity, posterior spinal fusion was done using local bone graft.\nAfter completion of the correction of scoliosis and excision of the intra-spinal extension on the tumor, thoracic surgeons approached the intrathoracic part of the tumor through the same incision by retraction of the back muscles medially and entering the left hemithorax through the 6th intercostal space posteriorly. Exploration of the chest showed no infiltration to the adjacent lung or mediastinal structure. Using an energy sealing device (Liga-Sure Impact™ sealer/divider, Medtronic, USA), the feeding branches from the descending aorta to the tumor were sealed and divided and then the tumor was removed en-bloc. Chest tube was inserted from a different stab in the anterior axillary line for drainage and ribs were approximated in the standard fashion; then back muscles were approximated and wound closed in layers ().\nPatient was successfully extubated on table and transferred to ICU where she was monitored for vital signs, chest tube output, and neurological manifestation and she was on IV opioids for the first 48 h. Mobilization was possible from the second day postoperative and chest tube was removed on the 4th day. Postoperative radiograph showed the correction of the scoliotic curve to 30° and the thoracic kyphosis to 32°. Patient was discharged home on the 6th day postoperative uneventfully ().\nThe tumor was a firm white mass measuring about 20 × 15 × 8 cm with smooth outer surface. Serial cut sections showed homogenous soft to firm white cut surfaces. Microscopic examination revealed sweeping long and short fascicles with wavy spindle cells and numerous mature ganglion cells in-between surrounded with hyaline and myxoid stroms. The histopathological diagnosis was consistent with ganglioneuroma. The patient was followed up at 2 weeks, 2 months, 1 year, and 2 years postoperatively. Chest CT scan was done 2 years after surgery and excluded any local recurrence.
A 68-year-old female was referred to our breast clinic by her primary care physician after undergoing screening mammography. Upon mammography, a breast mass was visualized in the left upper quadrant, measuring 13 mm × 8 mm. Ultrasonography of the left axilla revealed two suspicious lymph nodes with cortical thickening. The breast mass and a suspicious lymph node were biopsied. Pathology revealed a hormone positive ductal breast carcinoma and a lymph node metastasis in the left axilla. Patient was planned for wide local excision and axillary clearance under general anaesthesia. Routine pathology examination revealed a 1.1 cm grade 1 ductal carcinoma with clear resection margins and 18 lymph nodes, one containing a macro metastasis (pT1cN1 (1/18)). Patient was discussed postoperatively in the multidisciplinary breast cancer meeting and adjuvant Tamoxifen and breast radiotherapy were instituted (16 fractions in a total dose of 42.56 Gy).\nOne month after surgery patient presented to our breast clinic with a fever and swelling and redness of the skin in the left axilla. Under suspicion of an infected seroma, seroma aspiration was performed and sent for culture. Antibiotic treatment was instituted for one week and she remained free of symptoms for a couple of months.\nOne year after surgery and radiotherapy, our patient was seen in the breast clinic for follow up. Mammography was unremarkable. Upon physical examination there was an apparent fibrotic seroma pocket that had persisted (Fig. ). The overlying skin was sensitive to touch and displayed radiation dermatitis. Her arm and shoulder function were impaired. Range of motion was limited to 110° when abducting her arm.\nThis case was discussed with our reconstructive breast team and after informed consent was obtained a surgical excision of the fibrous seroma pocket and the overlying skin was performed. The dead space was closed with a latissimus dorsi skin and muscle flap. Low suction drains were left in place. The drains were removed on the second day post-surgery.\nSix weeks after surgery patient was evaluated in the outpatient clinic. The pain had subsided and there was no clinical seroma. Movement of her shoulder had improved greatly and abduction of the right arm was now possible up to 160° (Fig. ).
A 26-year-old Caucasian woman gravid at the 28th week of gestation was admitted to the hospital because of premature uterine contraction. She had a successful in vitro fertilization and embryo transfer, and the course of the pregnancy was uneventful apart from anemia and one incidence of one-sided renal colic. The oral glucose tolerance test made at the 24th week of gestation was negative. At admission, the vital signs were in normal range. She experienced an intense pain in the lower abdomen. She was feeling the fetal movements well. The uterus was enlarged to a size corresponding to 34 weeks of gestation. By speculum examination, there was no evidence of premature rupture of membranes or vaginal bleeding. By vaginal examination, the cervix was shortened and closed. Ultrasound examination revealed normal fetal growth regarding gestational age. Neither structural abnormalities nor hydrop of the fetus were confirmed. The amniotic fluid index (AFI) was 45 cm. The placenta was located in the anterior uterine wall. A 5.23×4.45 cm ovoid well-defined heterogenic mass in the placenta was shown ( and ). The Doppler scan showed substantial vascularity of the mass. The length of the cervix was 15 mm and internal cervical os was closed. The ultrasound middle cerebral artery peak systolic velocity was 40 cm/s, which was 1.1 multiple of the median. The patient received intravenous tocolytic drugs (fenoterol and verapamil) and one course of a total dose of 24 mg dexamethasone within 24 hours. The level of the maternal serum AFP was elevated to 304 IU/mL. The intensity of the uterine contractions was increased and an ultrasound-guided amnioreduction in aseptic technique was done, successfully aspirating 1,000 mL of clear amniotic fluid, which resulted in decreasing the intensity of the premature uterine contractions. Serial ultrasound examination at the 30th week of gestation showed a gradual increase of volume of the amniotic fluid and AFI was 43 cm. The ultrasound middle cerebral artery peak systolic velocity was 40.8 cm/s, which was 0.99 multiple of the median for the gestational age. The cervical length was not changed and the internal cervical os was still closed. Neither change of the placental tumor nor fetal abnormalities were confirmed. There was an associated gradual increase of intensity and frequency of the premature uterine contractions. A second ultrasound-guided amnioreduction procedure aspirating 800 mL of clear fluid was performed 9 days after the first ultrasound-guided amnioreduction procedure, resulting in clinical improvement. Within 2 weeks there was gradual increase of the uterine contractions. The serial ultrasound examinations at the 32nd week of gestation again showed a gradual increase of the amniotic fluid volume and the AFI reached 43 cm. The middle cerebral artery peak systolic flow was 49.9 cm/s, which was 1.1 multiple of the median for the gestational age. The cervical length was reduced to 9 mm and the internal cervical os was closed. No change of the size or character of the placental tumor or fetal abnormalities were confirmed. Twelve days after the second amnioreduction, the third one was done, aspirating 1,200 mL of clear amniotic fluid and resulting in clinical improvement. Within 1 month, a spontaneous gradual decrease of the AFI was noticed reaching a normal level for the gestational age at the 36th week of gestation along with gradual cessation of the premature uterine contractions. The size of the placental tumor remained unchanged, with an increasing relative ratio of the placental surface to the placental mass. No fetal abnormalities were confirmed in the ultrasound examinations.\nAfter uncomplicated vaginal delivery at the 38th week of gestation, the placenta was delivered completely. A healthy female 3,010 g baby was born with an Apgar score of 10. In macroscopic assessment of the placenta, a single well-circumscribed 5 cm diameter mass was found on the fetal surface of the placenta, with pale yellowish color and with a firm consistency near the edge of the placenta ( and ). The overall placental mass was 600 g. Microscopic examination showed histological features of angiomatous type of chorioangioma. Six weeks after delivery, serum level of AFP was decreased to the normal level of 2.07 IU/mL.
Six-year-old girl presented to clinic in June with troublesome hay fever symptoms. She had significant nasal obstruction and pruritus, sneezing and watery nasal discharge. The symptoms had started in early April and were progressively worsening. In previous years, she had had similar symptoms from April to July, but was asymptomatic during the rest of the year. Her doctor had prescribed oral cetirizine and intranasal mometasone furoate about 4 weeks after the symptoms started, but this treatment did not result in significant improvement. She stopped using the intranasal corticosteroid two weeks later because she was having frequent nose bleeds and had developed nasal crusting that she associated with the use of the nasal spray.\nSkin prick testing was positive to grass pollens and negative to other common airborne allergens. After checking the patient’s nasal spray technique, the allergy clinic team realised that she was not using it properly and spent some time providing appropriate training.\nThe patient was prescribed a very short course of rescue decongestant to open up her congested nasal airway and intranasal isotonic saline to minimise the formation of nasal crusting. She was advised to use daily intranasal mometasone furoate and cetirizine until the end of the pollen season, whilst attempting to minimise direct exposure to grass pollen. Her family was educated to start cetirizine and intranasal corticosteroids about 2 weeks before the beginning of the grass pollen season in the following years.\nCase 1 highlights the importance of adherence to treatment and of a correct application technique of the nasal spray for maximum effect and for minimising side effects. Nasal drops and nasal sprays require different techniques (Figure ) []. Poor technique is a common cause of treatment failure, so it is important to spend time in clinic explaining the appropriate use of these devices and providing hands-on training []. It is also important to explain the nature of the treatment, its safety profile and possible side effects. Patients should be given realistic expectations about the results of the treatment and should be informed that complete resolution does not usually occur in the treatment of chronic conditions such as allergic rhinitis. For example, in the case of intranasal corticosteroids, patients should be informed that they take a few days before any effects can be noticed. Appropriate information helps in ensuring concordance with therapy, which is critical for a good control of the nasal inflammation and for the improvement of the symptoms.\nMinimising allergen exposure is also an important part of the management of this condition. Given her grass pollen allergy, she was advised to minimize early morning and evening activities outdoors, to avoid going out after thunderstorms or on windy days during the pollen season, to wear sunglasses when outside, to avoid mowing the grass or being near it when it is being mowed, to keep windows closed as much as possible and use air-conditioning and to wash her hair at the end of the day when she arrives home as well as to bathe her eyes and douche her nose frequently during the grass pollen season.\nFinally, pollen levels rise slowly at the start of the pollen season with symptoms only presenting at a threshold level. Prior to this, exposure to small amounts of allergen will attract inflammatory cells into the nasal airway exacerbating symptoms when pollen levels rise further. Commencing hayfever treatment a few weeks prior to the expected start of the seasons, can be very helpful in delaying symptom onset and in achieving symptom control.
A 13-year-old female athlete presented to the office with left foot pain of 2 weeks duration. The pain had started gradually as she transitioned directly into basketball following her soccer season, moving from soccer cleats to basketball shoes. She participated at a high level for both sports for her age. She had no history of similar pain, but had sprained her ankle 1 month ago. She had no recent dietary changes, and there were not any concerns about her diet from her parents. The pain was located in the arch and described as tingling, worse at night, and after practice, but improved in the morning. She tried putting inserts in her shoes without relief. On exam, she was well nourished and in no acute distress. She had no visible swelling, and the alignment of her ankle, knees, and hips appeared normal. She had good arches of her feet that were symmetric bilaterally, and her gait revealed no abnormalities. Range of motion of the foot and ankle were normal. She had tenderness over the proximal second and third metatarsals on both the dorsal and plantar surfaces. She also had tenderness over the dorsal and plantar surfaces of the cuneiforms, including the arch of the foot. X-rays were obtained in the office and were negative. Due to concern for a stress injury, a magnetic resonance imaging (MRI) was obtained. The MRI showed a stress fracture involving the distal and plantar aspect of the middle cuneiform, with a stress phenomenon noted at the base of the second and third metatarsals. and show this finding.\nShe was placed in a boot for all weight-bearing activities. At 4 weeks, she was only having occasional pain. The decision was made to continue the boot for 2 more weeks. At follow-up, 2 weeks later (6 weeks total), the patient was still having pain. She admitted to participating in impact activity outside the boot at the gym since her last appointment. After discussion with the patient and her father, she was made partial weight-bearing in the boot with crutches with instructions to wean off the crutches once pain free. At a recheck 2 weeks later (8 weeks total), she was pain free walking in the boot without the crutches. She was weaned out of the boot over the next 2 weeks (10 weeks total) and then began a gradual return to impact activity without set back.
A 52-year-old female presented to the plastic surgery clinic with a chronic open wound in the left temporal lesion. Five months prior to this, the patient had undergone craniectomy for an acute subdural bleeding. The patient gradually recovered and underwent reconstructive cranioplasty two months prior to the presentation to the clinic.\nOn exam, a pressure sore measuring 6×4 cm was located in the left temporal region (). There were severe scarring near the lesion caused by previous operations. The location and size of the defect precluded many local flap options, and the patient consented to a free flap reconstruction of the soft tissue defect. The patency of superficial temporal artery was confirmed using a hand-held Doppler, and the superficial temporal vein was assumed to follow the course of this artery.\nUnder general anesthesia, the wound was debrided, after which the defect measured 8×6 cm. The wound was carefully explored, and the superficial temporal artery was followed from a proximal to distal course until we were able to find an appropriate recipient vessel about 3 cm away from the inferolateral margin of the defect.\nA 8.5×6.5 cm fasciocutaneous flap was elevated in a spindle shape from the left lateral arm. The flap included a 1-mm diameter artery and two veins. The donor site was closed primarily, and the harvested flap was attached to the defect using a 4-0 nylon stay suture. Under a microscope, the flap artery was anastomosed to the frontal branch of the superficial temporal artery, but no recipient vein could be identified. Because of this, we decided to use one of the veins as a drainage channel. This adventitia of the venous end was fixed to the skin using 9-0 nylon. The remaining border of the wound was closed with temporary drains in place.\nPostoperatively, the patient was initially managed in the intensive care unit. Postoperative hemoglobin and hematocrit were 9.5 and 27.6, respectively, and these values were kept within 8-10 and 25-30 range with daily blood counts and transfusions as needed. The exposed venous end was kept moist under heparin soaked-gauze dressing. Every 2 hours, the vein end was also mechanically dilated and irrigated using 400 IU/mL heparin-Na solution. The heparin gauze was replaced. This was continued for five days ().\nIn order to estimate the blood loss during the operation, we measured the weight of blood-soaked gauze. The amount within the gauze was 40-90 g ().\nPostoperative care included aggressive fluid therapy (Dextran®), an infusion of heparin and Eglandin®, and a blood transfusion (9 units of packed red blood cells for 5 days after operation). The hemoglobin was maintained within the targeted hemoglobin range (range, 8.4-9.5; except 7.4 on postoperative day 3) (). After five days, the vein was no longer dilated and irrigated. The flap continued to be perfused without any signs of congestion. We considered clamping the vein end, but this was considered unnecessary as the vein appeared to have closed spontaneously. The subcutaneous drains were removed on postoperative day 9. The flap survived well without any complications ().
A 47-year-old female patient visited the Endodontic Department of the University of Guadalajara, Mexico, for a checkup of the tooth #43 (right mandibular canine). She was referred by a general dentist, being asymptomatic, with caries located in the buccocervical region of the crown, which had reached the pulp chamber. The general dentist performed an initial cleaning of the caries two weeks prior, but given its depth and extent, the patient was referred for a specialized assessment. She had no history of systemic or allergy problems. In the clinical examination, a dental giroversion, with a maladjusted temporary restoration surrounded by recurrent cavities, was observed. Under magnification, it was confirmed that the caries was in clear communication with the pulp chamber. Response to the sensitivity test was intense and transitory. Radiographic examination revealed a sudden loss in the continuity of the canal () and the presence of a groove in the outer part of the root, findings that suggest the presence of a mandibular canine with two independent, narrow, and curved canals. Radiographic images of the counterpart canine showed normal characteristics (). On the basis of the clinical and radiographic findings, a diagnosis of asymptomatic irreversible pulpitis and normal periapical tissues was established, and root canal treatment was planned.\nAfter the patient provided signed informed consent, local anesthesia was administered and a dental dam was placed; the temporary restoration and decayed tissue were removed. As the dental giroversion impeded the lingual conventional opening, cameral access was created from the buccal side (). With the aid of magnification throughout the treatment, the pulp chamber roof and the lingual cervical ridge were eliminated to obtain access to the second canal. As the initial clinical and radiographic findings indicated the presence of a second root canal, the radicular pulp space was carefully screened with the DG-16 endodontic explorer (American Eagle, CA, USA), and the entrances of two root canals were found, one buccal and one lingual. On the basis of this information, the treatment protocol was focused on avoiding removal of excessive tooth structure or perforation of the roots. Under abundant irrigation with 1% sodium hypochlorite (NaOCl), the canals were explored with a size #15 K-file, and cervical flaring was carefully performed with #2 Gates Glidden bur. The working length was determined with a radiograph and corroborated with an electronic apex locator. Cleaning and shaping of the apical thirds were performed with rotatory NiTi files (S1, S2, and F1 Universal ProTaper, Dentsply, Tulsa, OK), followed by manual instrumentation with a size #35 Flexo-file in both root canals, irrigating with 1% NaOCl between the use of each instrument. Due to time constraints, intracanal dressing with calcium hydroxide was placed and the access was sealed with a temporary cement.\nAfter 7 days, the intracanal medication was removed with 17% ethylenediaminetetraacetic acid (EDTA) irrigation and ultrasonic activation. Once both canals were dried, the lingual canal was first filled, to prevent visibility obstruction, followed by the buccal root canal. They were filled with a mix of gutta-percha and resin-based sealer (AH-Plus), using lateral cold compaction. The access opening was sealed with temporary cement, and a final radiograph was taken (). The 12-month follow-up showed the access cavity restored with a composite-based sealing material, with no pain or tenderness and normal periapical tissues upon clinical and radiographic examinations ().
A 54-year-old man complained of aggravating abdominal pain 15 h after endoscopic resection of a colonic LST.\nThe patient was referred to our hospital for endoscopic resection of an LST measuring 30 mm that was diagnosed as an adenoma on pathology in the medial side of the colonic hepatic curvature. The patient was placed on a low-fiber diet on the day prior to endoscopic surgery. Adequate bowel preparation (BBPS: 3 points) was achieved using a spilt regimen of 4 L of polyethylene glycol solution and simethicone. During the procedure, our experienced team performed ESD for this lesion at first. When damage to the muscular layer caused by poor scope operability was observed, we changed into EPMR to quickly finish the operation. Prophylactic closure with clips was performed at the damage site. The tumor was removed without residue, and the wound was treated quite well without obvious perforation or hemorrhage. There was no abdominal pain after resection, and the patient was in a good condition. Routine antibiotics and intravenous nutrition were used in consideration of the large mucosal defect. Fifteen hours after endoscopic resection, the patient passed gas and then suddenly experienced severe abdominal pain that aggravated progressively over time without any alleviation.\nThe patient had a history of diabetes for 10 years without a regular oral hypoglycemic treatment. He had no history of other chronic diseases like cardiovascular disease and hypertension, and no history of trauma, surgery, or blood transfusion. He had no history of food and drug allergy.\nThe patient occasionally drank alcohol and denied a history of smoking. He had no family history of intestinal tumors.\nPhysical examination showed intolerable compression pain and rebound pain localized in the right abdomen, suggesting the presence of peritonitis.\nEmergency blood analysis showed that neutrophil proportion increased slightly (79.9%) with normal white blood cell count, hemoglobin, and red blood cell count.\nEmergency computed tomography (CT) revealed a small amount of pneumoperitoneum and substantial exudate (Figure ).
We report a case of a 62-year-old male who developed DRESS syndrome after seven weeks of antibiotic treatment with vancomycin. He initially underwent instrumented thoracic spinal fusion (T1–7) due to cord compression from a metastatic T4 lesion from renal cell carcinoma and developed a postoperative deep spinal infection. He underwent multiple washouts and vacuum-assisted closure over a period of twelve weeks, with various antimicrobial regimes, initially receiving seven weeks of vancomycin as well as a shorter duration of ciprofloxacin. He developed a maculopapular morbilliform rash, () initially on the right arm and scalp, before spreading to cover the entire head, trunk, and upper legs () which progressed to become exfoliative and was intensely pruritic and painful (). This was accompanied by a fever and eosinophil count of 9.77 × 10−9/L at the highest, occurring simultaneously with the development of the rash, and which remained elevated over the course of a month of regular blood tests. Other haematological abnormalities were also present, with a rise in both lymphocytes and neutrophils. Vancomycin was discontinued immediately, and other causes for these results were excluded, with negative blood cultures, CMV, EBV, ANA, and hepatitis B, hepatitis C, and HIV titres. There was no clinically apparent lymphadenopathy; however, a CT scan performed after the onset of symptoms showed new prominent right hilar lymph nodes, although this may have been due to metastatic cancer and not DRESS syndrome. Skin biopsy showed superficial perivascular lymphocytic infiltrate and rare eosinophils, consistent with a morbilliform drug rash. Ciprofloxacin was felt to be unlikely to be the cause of his DRESS, as he had been prescribed the drug several times in the past, as well as having a shorter duration of treatment which would not fit with the typical timeframe for DRESS, so this was continued to treat his infection.\nThe patient initially received a single dose of intravenous high-dose hydrocortisone, but due to the severity of infection and the risk of immunosuppression, he was subsequently treated exclusively with topical steroids, emollients, and antihistamines (). No liver or renal function abnormalities were noted during this time; however his eosinophils remained raised as described. He developed acute chest pain and shortness of breath four weeks after the initial rash, with new onset fast atrial fibrillation and negative troponin and creatinine kinase. A CT scan demonstrated bilateral pleural effusions, as well as progression of lung and rib metastases. An echocardiogram showed mild left ventricular and right ventricular impairment and a rim of pericardial fluid. Unfortunately, within three months of initial surgery, the metastatic spinal load increased causing further cord injury and paraplegia. Further surgical intervention was deemed inappropriate at this point, and the patient was discharged to the community palliative care team.
The patient was a 38-year-old single man from Kerman city who was admitted in Shahid Beheshti Hospital of Kerman four years ago because of aggression and behavioral change for the first time. According to the patient, he has been using oral Ritalin for the past 6 months and in the recent months, he has diluted tablets in water and injected intravenously and after injection, the shape and meaning of objects have changed for him. He had sometimes injected even up to 4 Ritalin tablets. According to the patient, he feels that he has parasitic infection and he sees cockroaches with blue color crewel on his body and because of that he has burned different parts of his body by cigarettes to destroy them. Also, he sees these bugs on the floor and around objects and because of that he fired house items many times and even fired his bed, TV and personal computer (PC). Even once, his entire house was burned in fire. Sometimes he washed objects with water to destroy bugs. He would stand under the shower for hours to send away these bugs. People around him have always seen him playing with water or fire. Along with these symptoms, he was suspicious to others and believed that they have prepared amulet for him and followed him sometimes. He complained of sleeplessness and restlessness. In physical examination, multiple skin abscesses and acute cellulitis caused by injections were visible on different areas of his body and there was bilateral pitting edema on his legs. He had also tachycardia and there was no problem in the brain CT scan and heart echocardiography.\nIn psychological condition examination, he was restless and to some extent irritable. He also had flight of ideas and noted vision and touch fantasies as well as delirium of harm and damage and being under control. Attention was reduced but immediate, near and far memories were natural. Also, knowledge of time, place and person was normal. Impairment in judgment and vision was evident. The patient was hospitalized for the diagnosis of psychotic disorder due to Ritalin injection and after preventing Ritalin consumption and recovery from infection symptoms, fornication signs were resolved. In later interviews with the patient, schizophrenic symptoms such as deliriums of pessimism and being under control were detected and the patient was treated for schizophrenia diagnosis. After discharge, in spite of regular medication, he was hospitalized for two times and both times it was after Ritalin tablet injections and he was discharged after disease symptoms were controlled and there was no obstacle for medication. By preventing Ritalin consumption after discharge, he has not experienced psychotic symptoms yet and his background disease is under control with anti-psychotic drugs.
We report a case of a 33-year-old woman who presented to our outpatient department complaining of abdominal pain. The patient had suffered from pain in the right lower quadrant for approximately 2 years, and it occurred once or twice a month without precipitating factors. The abdominal pain lasted for approximately 30 minutes and was relieved without special treatment every time. She presented to our outpatient department because the abdominal pain had worsened and occurred weekly for 1 month. Her symptoms were not related to meals, bowel movements, or her menstrual cycle, which was normal. No oral contraceptives or other medical history, recent pregnancy, or abdominal surgical history was noted, and she had a normal vaginal delivery 9 years previously. She had no identifiable pelvic inflammatory disease risk factors and no personal or family history of coagulation system related diseases. Her vital signs were stable. A physical examination showed mild tenderness on palpation of the right lower quadrant. No obvious mass was found and bowel sounds were present. A gynecological examination was unremarkable.\nLaboratory tests, including liver, kidney, and pancreatic function, were normal. The urine β-human chorionic gonadotropin level was negative. An electrocardiogram, and chest and abdominal X-ray showed no considerable changes. A routine blood test showed moderate anemia (hemoglobin: 89 g/L), and white blood cell and platelet counts were normal. The fibrin degradation product level was 12 mg/L and the D-dimer level was 4.4 mg/L in a coagulation test. Abdominal computed tomography (CT) was performed, which suggested a right ovarian vein mass and pulmonary embolism ( and ). Contrast-enhanced ultrasound showed a mass in the right ovarian vein, without blood flow into the right renal vein. Serum tumor markers were detected to exclude malignant lesion, including carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 125, and alpha-fetoprotein. The results of these markers were all negative. Other laboratory tests were performed to exclude coagulation disorders, including protein C, protein S, lupus anticoagulant, factor V Leiden mutations, and antithrombin III, and these were also negative.\nLaparotomy was performed with an initial diagnosis of an ovarian vein mass and possible intravenous leiomyomatosis of the right ovarian vein. During the operation, we observed a right varicose ovarian vein without obvious dilation (). Therefore, the varicose ovarian vein was totally removed, and thrombus was found in the ovarian vein. The thrombus started from the distal end of the right ovarian vein, and spread to two thirds of the total length of the right ovarian vein. A frozen pathological examination showed smooth muscle hyperplasia in the vessel wall, small focal degeneration, and necrosis with calcium deposition. No malignant sign was found. At this point, the diagnosis of this patient was clear. Paraffin pathology showed vascular tissue with internal thrombus formation, focal hyperplasia of smooth muscle tissue with focal mucus degeneration, and no tumorous lesions. No abdominal pain occurred after the operation, and she was discharged 1 week later on therapeutic anticoagulation with rivaroxaban for 3 months. She was followed up regularly for 1 year with no symptom of abdominal pain.
A 42-year-old man presented to the emergency department with symptoms including choking, drooling from the mouth, holding his neck with his hand, and aphonia. His family revealed that the patient had psychological abnormalities and depression and he had attempted suicide with swallowing a metallic object. The patient was hemodynamically stable. The arterial blood pressure was 130/80 mmHg and the pulse rate was 88 beats per minute. He was sent for chest, anterior-posterior, and lateral view radiographs that showed an abnormal radiopaque FB inside the esophagus and a shadow in the middle of the chest radiograph with a part of it obliterated by the heart and the vertebral shadow (). The FB had a shape similar to a spanner. Before the endoscopic intervention, the patient could not talk. His family gave an unclear history of the nature of his psychological problem. The patient was prepared for emergency surgery. He was admitted to the operation theater under general anesthesia and endotracheal intubation and rigid esophagoscopy was performed. The mouth was opened using a laryngoscope and blood and saliva were aspirated from the oropharynx. After passing a rigid esophagoscope through the orifice of the esophagus, we observed the open end of a spanner (wrench) that appeared stuck in the esophagus. After aspiration of blood and saliva around this part of the spanner, it was held with forceps and drawn out forcefully with the esophagoscope. After it reached the mouth, it was pulled out with Magill forceps (, ). The esophagus was checked again using esophagoscopy for signs of injury. The esophagus was intact with no signs of perforation. After discontinuation of anesthesia, the patient was extubated and kept under observation. Subsequently, he was discharged without any complications. After surgery, he denied having any psychological problems, but was unable to sleep and showed irritability and restlessness. He also denied having any auditory or visual hallucinations. We advised him to visit the psychology department for a consultation, but he refused and was discharged from the hospital with his relatives.
A 9-month-old girl presented to the physiotherapy department due to developmental motor delay. At 37 gestational weeks, prenatal ultrasonography showed dilated brain ventricles. She was delivered at 40 gestational weeks through C-section after 16 hours of labor and fetal distress. At 9 days of age, she underwent brain magnetic resonance imaging (MRI), which showed dilation of bilateral lateral ventricles, most prominently at the atrium, temporal horn, and occipital horn, as well as the thinning of the corpus callosum. At 8 months of age, the neurologist referred her to physiotherapy due to concerns related to developmental motor delay caused by CCA and colpocephaly. At 9 months of age, she underwent a physiotherapy assessment based on anamnesis, physical examination, and a complimentary assessment using the CME motor scale and the Alberta Infant Motor Scale (AIMS).\nThe CME motor scale is composed of 41 items for assessing motor development through automatic motor reactions. The response to each item is assessed using a 4-point scale; a score of 0, 1, 2, and 3 indicates no response, an initiated reaction, an incomplete reaction, and a complete reaction, respectively. The sum of the scores of all items is divided by a constant value to reach the maximum CME motor scale age of 16 months. Assessed motor skills and CME motor scale age are used to create a personalized treatment plan and to measure the effectiveness of intervention.\nThe AIMS is a gross motor observational tool for evaluating the activity of antigravitational muscles in 58 postures. One point is scored for each posture observed. A maximum score of 58 points indicates complete motor development. The AIMS is a validated scale used in clinical practice and research. It can detect developmental delays or abnormalities, identify mild changes in motor development, and measure the effectiveness of intervention.\nThe assessments were conducted before and after each treatment phase by two experienced physiotherapists. One of the physiotherapists was responsible for the treatment. The other one was not involved in the treatment and assessed the child using pre-recorded videos. The scores assigned by both the physiotherapists were compared, and the lowest score was considered in case of a discrepancy.\nThe intervention was based on the concepts of CME., Exercises aimed at achieving missed developmental milestones, and they were practiced actively. Although exercises targeting developmental milestones at the expected ages were started in order to build a biomechanical foundation, more complex functions were also addressed to improve basic motor skills., Therefore, when trunk control was expected, standing and walking exercises were started. When standing was expected, walking exercises were practiced. Our primary aim was to promote motor development of an advanced level in order to achieve developmental milestones quickly. Each exercise was repeated up to eight times; the difficulty level of each exercise was increased in each session. Handling was gradually reduced while moving the hands from the proximal to distal part of the child's body, which increased independent reactions. Static stretching is not included in the concept of CME although stretching is embedded within functional movement.,\nThe intervention was divided into three phases: intensive protocol, home-program protocol, and standard protocol.\nDuring the intensive protocol, the child underwent four weeks of physiotherapy intervention; 45-minute sessions were conducted twice daily five days per week for the first two weeks. The frequency was reduced to once per day during the third week in order to lessen the intensity of exercise and to avoid fatigue. Then, in the fourth and final week, the frequency was again increased to twice per day. Exercises focusing on sitting, transferring from prone and supine to sitting, crawling, transferring from sitting and crawling to standing, standing, and walking were started. Her parents were taught the exercises to ensure daily stimuli at home. The intensive protocol was conducted between the ages of 9 and 10 months, and she was reassessed at the end of this period.\nAfter the first phase of treatment, she was diagnosed with CHD. According to the cardiac ultrasonography report, she presented with moderate to severe mitral stenosis due to supravalvar mitral membrane, mild left atrial enlargement, and elevated right ventricular and pulmonary artery pressure. At 14 months of age, she underwent cardiac surgery to remove supravalvar mitral membrane. There were no complications during the surgery and recovery period.\nSeven months elapsed between the diagnosis of CHD and complete recovery allowing her to continue physiotherapy intervention at the clinic. Therefore, a home-program protocol was initiated immediately following the intensive protocol. Exercises targeting creeping, crawling, transferring from kneeling to standing, and standing self-supported on a horizontal surface were taught to the parents. Exercises and progressions were frequently reported using videos to the physiotherapist. This protocol was conducted between 10 and 17 months of age.\nShe resumed her physiotherapy two months after the cardiac surgery. After reassessment, she underwent a standard protocol consisting of 45-minute sessions twice per week. Exercises to stimulate transferring from crawling to standing, standing, and walking were performed during this time. Daily exercises of the home-program protocol were emphasized. This protocol was conducted between 17 and 20 months of age, and she was reassessed at the end of the protocol.\nAt baseline, a mild spasticity in the right side of her body was the only observed abnormality. Her CME motor scale age was 6.5 months (Figure ), and she scored 17 points on the AIMS (Figure ).\nAfter one month of the intensive protocol consisting of 35 sessions, at the age of 10 months, she reached a CME motor scale age of 9.37 months (Figure ) and scored 26 points on the AIMS (Figure ). The child improved head control, began to roll over, started to sit unsupported, began to transfer from supine to sitting independently, improved standing with support at one forearm and self-supported standing on horizontal surfaces, started to stand self-supported against vertical surfaces, and began to take steps with support at one forearm.\nAfter seven months of the home-program protocol, at 17 months of age, her CME motor scale age was 11.71 months (Figure ), and she scored 49 points on the AIMS (Figure ). Her functional improvements included crawling, transferring from kneeling to standing with support on a horizontal surface, and beginning to walk self-supported on horizontal surfaces.\nFollowing three months of the standard protocol consisting of 28 sessions, at the age of 20 months, she achieved a CME motor scale age of 15.48 months (Figure ) and scored 57 points on the AIMS (Figure ). Her functional achievements included transferring from crawling to standing, unsupported standing, and walking. She also began to step over obstacles and walk up and down 10-centimeter steps.
The patient was a 64-year-old woman who presented to her local community hospital emergency department with a complaint of rapidly increasing edema to the right arm. She was noted to have significant right axillary adenopathy and although she denied fevers or night sweats, she had lost over 25 pounds (>10% of her body weight) in the three months prior to presentation. A computed tomography (CT) scan of the chest demonstrated multiple right axillary nodes and a questionable mass in the left breast. She underwent excisional biopsy of a right axillary node which demonstrated DLBCL (). Her bone marrow biopsy was negative. Due to the findings on her staging CT scan and a palpable mass in the left breast, a bilateral mammogram was performed that showed a solid density in the vicinity of the left breast mass, but also showed calcifications in the medial right breast. Ultrasound-guided needle core biopsy of the breast lesions demonstrated ductal carcinoma in situ (DCIS) in the right breast (), and estrogen and progesterone receptor positive, HER2 receptor negative infiltrating ductal carcinoma in the left breast (). Due to issues with insurance and the relatively urgent need to treat her presumably Stage IB lymphoma, systemic chemotherapy with R-CHOP (rituximab, cyclophosphamide, adriamycin, vincristine, and prednisone) was started prior to a staging positron emission tomography (PET)/CT scan. Subsequent PET/CT scan showed a questionable area of “thickening” in the retrocrural area worrisome for lymphomatous involvement. She had a dramatic improvement in the right arm edema after the first cycle of chemotherapy. She continued systemic therapy for three cycles and then underwent a lumpectomy for the DCIS in the right breast (stage 0) and simple mastectomy with 2.1 cm of invasive disease with a negative sentinel lymph node biopsy on the left (stage IIa). Unfortunately, pathology revealed that the anterior margins for both resections were very close at less than 1 millimeter. Her case was discussed at a multidisciplinary tumor board, and a recommendation was made to reresect for clear margins bilaterally, and then due to the unfavorable risk factors for her DLBCL (age greater than 60 and B symptoms) and possible stage IIIB at diagnosis, to continue her systemic chemotherapy for an additional three cycles. PET/CT scan after completion of therapy revealed resolution of the retrocural thickening, indicating possible stage IIIB disease at diagnosis and two remaining PET-avid nodes in the right axilla. She underwent limited axillary dissection to determine her disease status and only necrotic tissue was found with no evidence of malignancy. Completion of her breast conservation therapy with standard breast tangent fields [] allowed for incidental inclusion of levels I and II of the axilla in the treatment field with 88% of the right axilla receiving 3,000 cGy or more (). With a mastectomy and negative sentinel lymph node biopsy for the left breast, local control therapy for this malignancy was considered complete. On the right, she had undergone breast conservation therapy, and her local therapy was completed with radiation therapy to the right breast. Routine followup has shown no clinical or radiographic evidence of any of her malignancies, and she continues on hormonal therapy for her receptor positive infiltrating ductal carcinoma.
A 30-year-old Japanese man was referred to our clinic complaining of pain, tenderness, and swelling on the left side of his palate for the past several months. Our initial clinical examination found that his left palatine mucosa was significantly swollen compared with his right side. The swelling was diffuse, and its borders were unclear (Fig. ). The swelling was especially pronounced in the left molar region of his palate, and his pain was exacerbated with the application of direct pressure to the lesion. The swelling exhibited increased signal intensity on T2-weighted magnetic resonance images (MRI, Fig. ). All of his left maxillary teeth were healthy, and no specific abnormalities in his left maxilla and maxillary sinus were observed on panoramic X-ray and computed tomography (CT) images. His medical and familial histories were unremarkable, and he was not aware of any history of trauma or inflammation of his head or neck. We administered antibiotics orally (cefcapene pivoxil hydrochloride hydrate 100 mg tablet every 8 hours) and non-steroidal anti-inflammatory drugs (loxoprofen sodium hydrate 60 mg tablet every 8 hours) for 7 days because we suspected that his symptoms were due to inflammation secondary to an infection. However, his symptoms did not improve.\nBased on his clinical and radiographic examinations, our initial diagnosis was a soft tissue tumor. An incisional biopsy was performed and histopathologic examination of the lesion revealed haphazard nodes and inflammatory cells in a fibrous stroma (Fig. ). Immunohistochemical analysis revealed significant staining for the neural marker S-100 in the bundles within the node (Fig. ). Factor VIII staining was positive in the fibrous stroma, but not in the bundles (Fig. ). These findings led to the diagnosis of a traumatic neuroma. The patient underwent resection of the tumor with a 5-mm margin using an electric scalpel under general anesthesia. Although the border of the mass was unclear and diffuse, the extent of the tumor could be determined based on the MRI images. As the tumor was conglutinated with a part of his palatine bone, we saucerized the bone surface including the overlying mucosa and the periosteum. His left greater palatine nerve was resected as the possible origin of the tumor. The open surgical wound was covered with a collagen-based artificial dermis (Terudermis, Olympus Terumo Biomaterials Corp, Tokyo, Japan) and a surgical splint. The size of the specimen was approximately 6×3 cm (Fig. ). The pathologic findings of the surgical specimen were the same as those of the incisional biopsy specimen, and the patient’s greater palatine nerve exhibited no pathologic changes. The tumor was not entirely encapsulated and some tumor cells were observed within the surgical margins. We decided to continue strict clinical follow-up without additional surgery because the traumatic neuroma is not a true neoplasm, and his pain subsided immediately after the surgery. No clinical evidence of a recurrence has been observed in the 3 years since the surgery.
The patient was a 68-year-old female, diagnosed to have bipolar disorder in the year 2002 by a psychiatrist. Psychiatrist advised patient to take the tablet MACORATE® CR 400 mg tds lifelong and was advised to get yearly follow-up.\nPatient was being looked after by a primary care physician with consultations of psychiatrist available if required. She was never diagnosed to have any other chronic illness since then. She had a history of annual blood tests being conducted which were reported to be normal. Her bipolar disorder symptoms were reported to be well under control over all these years of treatment. She was taking regular treatment religiously since then with occasional defaults mainly due to supply problems. The advantage of magnesium salt over sodium salt of valproate is not to cause sodium and water retention kept the patient motivated to carry on with the “MACORATE® CR 400.”\nPatient reported to have bilateral pedal edema on April 4, 2016, which was steadily increasing []. On examination, the patient had pitting edema over both feet and legs. On blood examination, she had thrombocytopenia, but there were no clinical events suggestive of bleeding disorder. On history, she had a complaint of easy bruising since childhood. There was no evidence of chronic heart failure, hepatic disease, or renal disease clinically, and liver function test/kidney function test were found to be normal to rule out the possibility of having them. Patient discontinued the medicine on April 10, 2016, due to nonavailability of the drug. Patient planned to go for a specialist consultation, but before she could do so, she observed that the pedal edema was decreasing steadily. Thereafter, pedal edema was assessed regularly and was not assessable clinically June 26, 2016. On literature research, the rare ADR of valproate of delayed onset pedal edema was found. The patient and family decided to withhold drug treatment for bipolar disease. We tried to relate the drug exposure with the development of pedal edema using the WHO-Uppsala Monitoring Centre (UMC) causality assessment scale. Causality was “probable” according to WHO-UMC scale. This case was reported to the ADR monitoring center under Pharmacovigilance Programme of India.
A 73-year-old male patient was admitted to an outlying general district hospital owing to an abscess in his right groin. Medical history-taking revealed open repair of an abdominal aortic aneurysm with an aortobifemoral bypass 3 years prior. Computed tomography angiography (CTA) revealed a pseudoaneurysm of the right common femoral artery at the site of the anastomosis, along with inflammatory perigraft tissue, extending to the retroperitoneal periaortic space and revealing a psoas abscess (). After receiving intravenous antibiotics (ciprofloxacin and clindamycin) for 10 days, he was transferred to our hospital. We urgently proceeded to the operating room where under general anesthesia the graft was completely excised and sent for culture accompanied by the perigraft fluid. The aortic wall and surrounding tissues were debrided, and retroperitoneal irrigation was performed using an antibiotic solution (rifampicin). Subsequently, bilateral femoral veins were harvested in their total length by extending the dissections beyond the adductor magnus tendons. However, the lengths of both femoral veins were inadequate. Therefore, restoration of blood flow was accomplished using an in situ composite graft (). A short segment of a bifurcated silver-coated Dacron graft was proximally sutured to the infrarenal aorta, and the distal graft limbs were anastomosed to the vein conduits, which were eventually linked to the femoral bifurcations (). Owing to this configuration, the use of a prosthetic graft in the contaminated inguinal region was obviated, and the proximal anastomosis was managed with no significant mismatch owing to vein caliber discrepancy. After 5 days in the intensive care unit (ICU), the patient was transferred to the ward. Despite his lymphatic fistula in his right leg, which was treated conservatively with compression, the postoperative course was uneventful. He received intravenous meropenem and vancomycin during his hospital stay, followed by an oral regimen of ciprofloxacin and clindamycin for 6 weeks after his discharge on the 20th postoperative day in a good general condition. However, both the preoperative blood cultures and cultures of the excised graft and perigraft fluid yielded negative results.\nA 64-year-old male patient sought medical attention for recurrent episodes of fever and discomfort in his left thigh. He had a medical history of aortobifemoral bypass owing to aortoiliac occlusive disease 4 years prior. CTA revealed a retroperitoneal periaortic mass mainly on his left psoas extending downward, as far as the mid-thigh (). Graft infection and abscess formation were suspected; however, blood cultures failed to exhibit any pathogenic microorganisms. There was also an inflammation near the cecum in proximity to the right limb of the graft, while the left limb of the graft was thrombosed. Despite the last finding, the patient did not complain of claudication. The patient was administered intravenous meropenem/vancomycin. Under general anesthesia, a long midline incision was made, and transperitoneal access revealed a fistula between the sigmoid colon and the left limb of the Dacron graft along with erosion of the cecum in proximity to the right limb. Thereafter, the entire graft was excised, and the aortic wall with the surrounding tissue was debrided and sent for culture. Retroperitoneal irrigation was performed using an antibiotic solution (rifampicin). Reperfusion was performed via in situ reconstruction of an aorto-right femoral bypass. For this reason, the right femoral vein was harvested in total length beyond the adductor hiatus (). However, the length of the harvested femoral vein was considered inadequate despite preoperative planning. Hence, a composite conduit consisting of a short segment of a silver-coated Dacron graft and his right femoral vein was created (). Considering the thrombosed left limb of the graft, sufficient collateral circulation of the left limb (ankle–brachial index of 0.6), and need to avoid the spread of inflammation and to shorten the operation time as much as possible because of his infirm condition, we proceeded without restoring the blood flow to his left limb. During the same procedure, sigmoidectomy and primary repair of the cecum lesion were performed. On the 5th postoperative day, he developed necrosis of the sigmoid colon, which was treated with Hartmann colectomy. Four days later, the patient experienced a rupture of the cecum repair site, which was confronted with right hemicolectomy. Cultures of the excised graft and perigraft tissue revealed the presence of multiple microorganisms possibly related to the aorto-enteric fistula. Carbapenem-resistant Klebsiella pneumoniae, along with Escherichia coli, Proteus mirabilis, Enterococcus faecium, Bacteroides fragilis, Clostridium glycolicum, and Candida albicans, was isolated. Therefore, the antibiotic regimen was substituted with a combination of culture-specific antibiotics (i.e., daptomycin, metronidazole, ampicillin, anidulafungin, and ceftazidime/avibactam). Regretfully, after 38 days of ICU stay, the patient died of sepsis.
A 72-year-old male patient with low back and right buttock pain was examined. He could not walk more than 100 m because of the pain. He did not have any common symptoms of thyroid disease or malignancy such as weight loss. There were no abnormal laboratory findings. Neurologic evaluation revealed motor weakness in the right leg, especially weakness of big toe dorsiflexion and there was hypoesthesia in the right side below the L5 dermatome. A lumbar spine X-ray revealed only an L4 compression fracture, and the pedicles were preserved (). The whole body bone scan showed an active bone lesion in L4 vertebra, only. MRI findings were suggestive of an infectious spondylitis such as tuberculous (TB) spondylitis associated with a pathologic fracture rather than a metastatic bone tumor because vertebral involvement by metastasis may occur without collapse or subligamentous spread and disks are usually preserved. Additionally, the imaging features that support TB spondylitis over spondylitis caused by other infections include larger paraspinal involvement, the presence of subligamentous spread, more bone destruction, a paucity of sclerosis and local periosteal reaction ().\nAfter the patient was transferred to the department of neurosurgery, a TB study was performed, showing no evidence of TB of any organ. The lumbar spine CT showed a markedly collapsed L4 body with an ill-defined intramedullary mass formation with cortical bone and bone marrow destruction, which suggested a malignant compression fracture with a large anterior epidural mass and perispinal extension. Investigations were performed to rule out multiple myeloma or metastasis. He went through L4 corpectomy with mass removal, and expandable cage insertion with posterior spinal fusion. A frozen biopsy during surgery revealed metastasis of the thyroid glands. Histologically, the mass in the vertebral body demonstrated well-differentiated follicles containing colloid invading the surrounding trabecular bone (). The tumor showed positive immunoreactivity for a protein of thyroid origin (thyroid transcription factor-1 [TTF-1]) ().\nAfter the surgery, whole body fusion PET showed mildly increased FDG (fluorodeoxyglucose) uptake in both thyroid glands (). Three weeks after the spinal surgery, he went through total thyroidectomy. The pathologic findings of the removed thyroid was minimal invasive follicular carcinoma, measuring 1.6×1.5×1.3 cm3, with a negative resection margin and no metastasis out of 6 lymph nodes. Two months after thyroidectomy, treatment with radio-iodine (RI) therapy was begun and the right buttock pain and weakness of right leg resolved. He has not had any debilitating pain for 15 months since the surgery.
A 20-year-old male, farmer presents to the emergency room of the hospital with 5 h of severe abdominal pain after he felt prone from a tractor impacting his abdomen against the stump of a felled tree; the pain was of sudden onset and constant and the site of the impact started to swell progressively. There was no personal history of abdominal wall hernias or chronic diseases.\nHis physical examination revealed a slight abdominal distention with a swelling located above the umbilicus of ~10 by 10 cm with the presence of bruises and abrasions on the left side of the skin; the mass was partially reducible with the presence of subcutaneous emphysema extended to the left flank and hypochondrium (); the rest of the abdomen was very tender with board-like stiffness and rebound sensitivity; the pulse was 104, the BP was 150/90 MMHg. The complete blood count parameters were not remarkable, the erect chest radiograph showed pneumoperitoneum and the abdominal ultrasound free fluid in the cavity. Due to the economic limitation of the patient, we were unable to perform a CT scan of the abdomen. The presumptive diagnosis of TAWH with perforation of the hollow viscus was made preoperative.\nAn exploratory laparotomy was performed through an incision in the supra and infraumbilical midline, as we advanced we found food debris in the subcutaneous tissues and a defect with poorly defined borders of ~3 cm in the rectus muscle fascia with exposure of the abdominal content ( and ); A perforation was identified in the anterior aspect of the stomach towards the gastric body () that was regularized and closed with a Gambee suture; primary repair of the fascia was performed with interrupted suture in the longitudinal and transverse planes (). There were no immediate postoperative complications; the Day 7 postoperative the patient presented a wound infection properly treated and was discharged on Day 12 followed in outpatient consultation with a strong abdominal wall ().
The patient was a 57-year-old man with a history of coming into contact with chemical gases during the war of 1981. He was referred to the emergency room (ER) with an acute abdomen and hemorrhage about 6 years ago. At that time, the diagnosis was acute renal failure and myeloma. The patient's blood abnormality was treated very well in the hematology department and he went under dialysis. He did not come back to the hematology department for myeloma maintenance therapy until four months ago when he came to the ER with hoarseness, tenderness in a hind limb, bone pains, movement limitation in the forelimbs with severe pain (VAS 6) in the left clavicle. He underwent 10 sessions of clavicle radiotherapy before admission to the pain clinic. His clavicular pain did not respond to radiotherapy and opioids.\nIn the physical examination, the patient complained of generalized bone pain especially in left clavicle. There was a 5 × 7 cm mass in 1/3 of the internal part of the clavicle (). There was no redness or edema and the mass was fixed to the bone and in pain on palpation. It was a new localized, deep, uncomfortable pain in the left clavicle.\nBoth shoulders and arms were tender with movement limitation. Bilateral limited elbow extension and flexion deformity were seen. Hind limbs force was decreased (2 from 5). There was no sensory deficit. In the shoulder examination, there was no hypertrophy, heat, erythema and tenderness. Clavicle conventional radiofrequency was chosen as a treatment. The patient's blood test and coagulation test were normal (platelet counts = 7,400 per microliter). In the plain radiography other than widespread lytic myeloma lesions especially in the shoulders and arms, there was a big lesion in the left clavicle which was also detected in the chest X-ray and chest CT scan ().\nAfter IV sedation (midazolam 1 mg and fentanyl 50 mg), prep & drape were done in the supine position. The clavicular mass was antisepticised and the anesthetic was lidocaine 1%. Two radiofrequency needles (OWL, Diros Technology Inc., Ontario, Canada. sharp, 20 gauge, 100 mm, active tip 10 mm), 1.5 cm from each other were inserted into the mass. Under the guide of the fluoroscopy, the needles were inserted into the middle part of the mass and during the pass, the needles were aspirated for any possibility of blood. And then, after passing the bone and feeling a sense of pop in the non-ionic water, 3 ml of soluble contrast media (Iodixanol 320) were injected and its distribution was seen directly and the contours of mass were clear. The patient informed us of any shooting pain in the upper extremity during the procedure. After placing the pads on the patient's arm, the stylet was pulled out and the radiofrequency probe was inserted. Then, two times a radiofrequency current at 90℃ was applied for 60 seconds at the two points 1cm apart from each other. After that, 2 ml of 0.5% ropivacaine along with triamcinolone 40 mg were injected in each needle and then the needle and the probe were pulled out together (-). The procedure went very smoothly without any pain or need for more analgesic injection. In the recovery room, VAS dropped to zero and movement of the hands improved. He could move his shoulder and arms more comfortably. There was no hematoma or sensory and motor deficits or any kind of radiating pain in the extremity. The visual analogue pain score (VAS from 0 to 10) decreased from 8 to 0. In the next 3 months of follow-up, the patient was very satisfied with the procedure and there was no pain at the clavicular site and did not need any analgesic for it. The mass gradually became smaller. There were no complications. He did not suffer from any pain at the clavicular site until he died after 3 months.
A 32-year-old woman sought care at a provincial hospital after passing loose and dark stool about 10 times in a single day. She had been healthy until the diarrhea occurred and was not taking any medications. Her past medical history was unremarkable, except that she had undergone tubal surgery for pelvic inflammatory disease three years priorly. She had one child who was born by vaginal delivery. She had never undergone an instrumental pregnancy termination or intrauterine device insertion, which might lead to uterine perforation. She had no history of amenorrhea or abnormal vaginal discharge. Her initial diagnosis was upper gastrointestinal hemorrhage, but this was changed when bile was observed in the nasogastric tube after which the patient developed exsanguinating hematochezia and severe hypotension requiring 11 units of packed red cell transfusion for stabilization. Soon after, she was transferred to a tertiary care center.\nThe patient's blood pressure was 70/40 mmHg, and her pulse rate was 120 beats/min. The abdominal examination was unremarkable. The per-rectal examination revealed excessive bleeding without any discernible cause. The laboratory tests showed a hemoglobin level of 6.3 g/dL and a platelet count of 28 × 103/µL. Owing to the unstable condition of the patient, an emergency exploratory laparotomy was conducted in order to localize and control the bleeding. During the laparotomy, blood was found in the peritoneal cavity and a segment of the ileum attached to the fundus of uterus (). The intraluminal content was palpated in the adhered ileal segment (). An enterotomy revealed a fetus 7.5 cm in crown-rump length and fresh blood in the ileal lumen (). The placental tissue had implanted at the fundal dome of the uterus and eroded into the small bowel (). A segmental small bowel resection was performed along with reanastomosis. The placental tissue was removed by way of a wedge resection of the uterine wall. The patient had an uneventful postoperative course and was discharged on postoperative day 7.\nHistologic examination of the resected specimens later confirmed the diagnosis of an abdominal pregnancy which included a male fetus of 4 months' gestational age (), normal cord, subserous uterine myoma, and submucosal hemorrhage in the small intestine.
A 46-year-old Asian woman was referred to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She had no history of smoking or drinking alcohol, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable; her general, cardiovascular system, respiratory system, and abdominal examinations were unremarkable. Neurological examination on admission showed that the patient was alert, attentive, and oriented. Her speech was clear and fluent with good repetition, comprehension, and naming. She recalled 3/3 objects at 5 min. All of her cranial nerves were intact. Motor examination revealed no pronator drift of outstretched arms. Her muscle bulk and tone were normal. Her strength was full bilaterally. Her reflexes and sensory were both intact. Her coordination and gait were normal. Laboratory investigations revealed normal complete blood count, serum cholesterol, lipid profile, and renal function (serum creatinine 119 μmol/L). Her left kidney size was normal with measurement of 9.6 cm by 4.8 cm. Renal Doppler ultrasound confirmed renal artery stenosis with renal resistive index of 0.58. The percentage of renal artery stenosis in the two branches of the left renal artery was 70% and 75%, respectively , before the first balloon angioplasty; after the first balloon angioplasty, these percentages remained the same. After the second ballooning and stenting procedure, revascularization was achieved. The patient had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indicated left renal artery stenosis, and the patient was referred to our department (Fig. ). Prior to the diagnosis of renal artery stenosis, the patient had been receiving amlodipine 10 mg twice daily, bisoprolol 10 mg twice daily, and indapamide 2.5 mg every morning.\nThe procedure was performed under the guidance of digital subtraction angiography (floor-mounted Artis zee; Siemens Medical Solutions, Munich, Germany) using the Seldinger technique. With the patient under local anesthesia, the right femoral artery was punctured by a 21-gauge vascular access needle with an angled tip 0.035-inch guidewire, then catheterized with a 5-French introducer sheath (Terumo Interventional Systems, Tokyo, Japan). The first aortogram was obtained using a pigtail catheter (Fig. a), then an 8-French guiding catheter (Cook Medical, Bloomington, IN, USA; Cordis, Hialeah, FL, USA) was used to obtain selective renal angiograms whereby the proximal main flow and the stenosis of both branches and their respective distal flow on the left renal side were revealed. The right renal artery was normal in appearance. The left renal artery angiogram then was used as a reference for further guided interventional procedures in which the individual length and diameter of stenosis were measured. The decision was reached to perform percutaneous transluminal renal angioplasty, and the length and diameter of balloon needed were calibrated. With two balloons of 4 mm × 18 mm (Biotronik, Berlin, Germany), both were was dilated at the same time. Despite expert effort in dilatation, the stenosis was observed to persist (Fig. c). Stent placement was considered, and the procedure was continued. A preprocedure intravenous bolus of 5000 IU of heparin was administered. By using two 0.014-inch guidewires (V14; Boston Scientific, Natick, MA, USA), the interventional radiologist guided the stent to cross the upper and lower branches, respectively, through the same vascular sheath (Fig. b). Two balloon expandable stents measuring 4 mm × 18 mm and 5 mm × 18 mm (Biotronik) were placed in parallel (kissing) and simultaneously inflated both branches. A good angiographic result was revealed (Fig. d) with no need for further ballooning. Angiography contrast media (Omnipaque 350; GE Healthcare, Shanghai, China) were used. Volumes of 25 ml of contrast agent were injected at a flow rate of 5 ml/s. The final angiogram was obtained to confirm the position of the stent, the patency of the lumen, and distal blood flow. Finally, the femoral access site was closed with Perclose ProGlide (Abbott Vascular, Chicago, IL, USA). After the procedure, the patient was admitted in the ambulatory room for further observation. Her blood pressure was monitored and recorded, it showed a significant reduction of blood pressure to 128/87 mmHg. After 24 h of observation, the patient was discharged to home with aspirin (100 mg/day) and clopidogrel (75 mg/day for 3 months). During 12 months of follow-up, the patient remained well with blood pressure of 126/87 mmHg. Renal ultrasound showed bilateral kidneys of normal size and shape with good cortical medullary differentiation. A bilateral renal Doppler study appeared normal.
A 50-year-old female patient visited the department of oral medicine and radiology, with a chief complaint of the pain and swelling over the right lower third of the face for 6 months. Extraorally swelling () was oval in shape, size 7 cm × 6 cm and extended anteriorly from the right corner of the oral cavity to posterior border of ramus of mandible. Superiorly from right tragus of ear to 1 cm below to the lower border of mandible. Intraoral examination () revealed obliteration of the right lower buccal vestibule. The overlying skin of lesion was normal in color without any sinus and drainage, and there was no local rise in the temperature. The patient had poor oral hygiene and numbness of the lower lip on right side. On the basis of history and clinical examination the provisional diagnosis was given as odontogenic tumur and differential diagnosis was given as odontogenic cyst and bone tumur.\nThe details of the procedure were explained to the patient and a written informed consent was obtained. The patient was subjected to routine hematological and radiological examination. Radiographically in orthopentomogram () lesion was multilocular and extended mesially from canine to condylar and coronoid region. The panoramic view revealed expansion of lower border of mandible & anterior border of ramus with perforation. Root resorption of 46 was in favour of ameloblastoma. Expansion of lower border of mandible is evident in lateral cephalogram (). CT scan () revealed bicortical expansion with perforation.\nIncisional biopsy was taken from the site of lesion which shows features of basal cell ameloblastoma. Then the patient was refered to the department of oral and maxillofacial surgery where she underwent hemimandibulectomy and reconstruction was done with a 2.5 mm reconstruction plate; bony reconstruction was not considered due to the advanced age of the patient.\nIn the histopathology () report, a completely resected lesion showed islands of uniform baseloid cells in a mature fibrous connective tissue stroma. Peripheral cells are columnar & showed reversal of polarity. The cells were stained deeply basophilic and nearly equivalent in staining intensity. In some island, the central portion is completely replaced by baseloid cells and some island shows scanty stellate reticulum like areas. Baseloid cells are hyperchromatic and there is no palisading of nuclei. Healing was uneventful and she was discharged after 7 days.
An 86-year-old woman who had been living with her elderly husband was admitted to our hospital with the complaints of nausea, anorexia, and epigastric discomfort. When she was 73 years old, the patient had undergone laparotomy and right hemicolectomy for resection of colon cancer. Five years after hemicolectomy, she had received hernia repair surgery using mesh for an abdominal incisional hernia. There was no history of abdominal or thoracic trauma. Laboratory tests were all within the normal range. Her electrocardiogram showed no ischemic changes. Although chest X-ray revealed an abnormal gas-filled mass in the left thoracic cavity, the patient had no symptom of dyspnea. Contrast-enhanced computed tomography (CT) scan confirmed herniation of the gastric corpus through the left posterior part of the diaphragm (). We diagnosed adult Bochdalek hernia and planned its surgical treatment. As mesh had been placed under the previous upper abdominal midline incision more than 10 years earlier, dense adhesions between the mesh and abdominal tissues were expected. Therefore, we decided to perform diaphragmatic hernia repair by HALS, considering the patient’s safety. After induction of general anesthesia, the patient was placed in the supine position with her legs apart. The previous midline incision was opened carefully to insert a LAP DISC® (Hakko, Nagano, Japan) for a hand port. Dense adhesions, which had to be divided, were found between the mesh used to repair her incisional hernia and loops of the small intestine. The disk for HALS was placed after complete removal of the mesh. Subsequently, a 12 mm trocar was inserted into the inferior umbilical region for the laparoscope. A 5 mm trocar was also inserted into the left upper abdominal region. Herniation of the gastric corpus into the left thoracic cavity through a hernial orifice in the left posterior diaphragm was confirmed. The gastric corpus could not be pulled back into the abdominal cavity because of adhesions around the hernial orifice. After these adhesions were carefully removed by HALS using Harmonic ACE shears (Ethicon, NJ, USA) (a), the stomach was completely freed and could be returned to the abdominal cavity. A 5 × 3 cm hernial defect with sac was observed (b). We decided to perform simple closure of the defect without mesh reinforcement because the rim of the hernial orifice was relatively strong. Accordingly, the defect was repaired with interrupted nonabsorbable sutures (2-0 Nesporen; Alfresa Pharma Corporation, Osaka, Japan) using a 5 mm port on the left upper abdomen and the surgeon’s left hand via the hand port (c). The midline incision for the hand port was closed without mesh reinforcement. A drain tube was placed under the left hemidiaphragm. The operating time was 244 min and there was no significant bleeding. Her postoperative course was uneventful. The patient was discharged on postoperative day 20. There was no evidence of recurrence at 1-year follow-up.
A 38-year-old man presented to the emergency room at our institution with the complaints of dizziness and a near-syncopal episode. This episode was preceded by a 1-week history of nausea, vomiting, and dysarthria. He also reported a 2-month history of new headache. The patient denied any visual disturbances, hearing changes, recent seizures, loss of consciousness, weakness, or sensory changes. Medical history was significant for a diagnosis of TSC with mild mental retardation and seizures in the distant past as well as hypertension. The patient had had a cataract removed remotely. Physical examination revealed adenoma sebaceum on the patient's malar surfaces. Complete neurological examination revealed no focal deficits. The results of laboratory tests were within normal ranges. A computed tomography (CT) of the head from an outside hospital demonstrated a brain mass with high attenuation. The mass appeared adjacent to the left cerebellar hemisphere near the Foramen of Lushka and extending into the foramen magnum. The patient had mild hydrocephalus evidenced by the prominence of his ventricular system. Periventricular calcifications were consistent with his diagnosis of TSC []. The patient was admitted for work-up of this brainstem mass. Magnetic resonance imaging (MRI) of the brain with contrast demonstrated deep cortical white matter changes typical of patients with TSC []. MRI also showed an extra-axial, irregularly shaped, well-marginated mass with heterogeneous enhancement in the left aspect of the medullary cistern with displacement of the brainstem and cerebellar peduncle to the right []. Further careful review of the imaging showed that the majority of the clivus also demonstrated uptake and enhancement of contrast. Increased T2 signal in the brainstem and cerebellum was consistent with edema. The patient was administered steroids and discharged with a plan to return to the hospital for elective removal of the brain mass.\nThe patient was taken to the operating room for a left far lateral approach for removal of the tumor. Upon opening of the dura and release of cerebrospinal fluid, the tumor could be seen under the arachnoid and appeared to originate intradurally. Several cranial nerves were adherent to the mass, eliminating the possibility of a total resection. During the operation, no connection between the intradural mass and the clivus could be appreciated. The tumor was carefully debulked within the limits of safety. A significant amount of cerebellar swelling was encountered during the case and ultimately led to early termination of the operation before subtotal resection could be completed. The patient was then transferred to the ICU. He remained intubated but was following commands with all four extremities. Postoperative MRI showed significant reduction of tumor burden from surgical debulking [].\nGrossly, the tumor was gray-tan in appearance. Microscopic examination of the tumor revealed plump, vacuolated cells within a mucinous matrix []. Tumor cells were positive for pan-cytokeratin (pan-CK) and epithelial membrane antigen (EMA), focally positive for S-100, and negative for glial fibrillary acidic protein (GFAP) and neurofilament (NF). Less than 1% of nuclei labeled positively for Ki-67. These histologic and immunohistochemical staining characteristics were consistent with a diagnosis of chordoma. This diagnosis was unexpected given the location of the tumor both within the lateral medullary cistern as well as under the arachnoid.\nPostoperatively, the patient developed dysphagia and required placement of a percutaneous endoscopic gastrostomy (PEG) tube as well as a tracheostomy. The patient also developed a pneumonia, which was treated with moxifloxacin on the recommendation of the infectious disease team. The patient's pneumonia resolved and his dysphagia improved, and he was discharged with plans to follow up with radiation oncology for radiotherapy of his residual tumor.
A 64-year-old Caucasian male was attended at Clinicians Associates in Terrassa (Barcelona); the chief complaint was a fistula on buccal area of tooth 37. At that time the patient was diagnosed with multiple myeloma stage III asymptomatic and only 2 doses of zoledronic acid (4 mg), once per month, have been administrated via IV. After a thorough clinicoradiological examination, a chronic suppurated apical periodontitis of tooth 37 was confirmed (Figures and ). Considering that the analytical parameters were rather good and in order to avoid any active infectious lesion before proceeding to a bone marrow autotransplantation the extraction of this second molar was indicated. A couple of days before performing the conventional tooth extraction, antibiotic prophylaxis with Amoxicillin 500 mg/8 h and Metronidazole 500 mg/8 h was prescribed for 7 more days. The healing process had a complete satisfactory evolution and one week later sutures were removed. Two months later, bisphosphonate treatment was reintroduced with calcium supplementation and six months after the tooth extraction the clinicoradiological control of this localization was normal ().\nOne and a half year after that tooth extraction the patient came for a routine control visit and he complained of slight pain in the left posterior alveolar ridge, in the lingual area. The patient mentioned that the discomfort started after a traumatic injury during mastication. Although radiologically there was not any relevant findings, clinically only one incipient point of inflamed mucosa was observed, which seemed like a simple foreign body reaction. Chlorhexidine topical gel was indicated and this lesion was monitored every two or three weeks also by the oral and maxillofacial surgeon in the Mútua Terrassa Hospital. The lesion size increased and an osteonecrosis of the jaw was the presumptive diagnosis. According to the clinical features and the presence of a sinus tract (Figures –), antibiotic treatment was initiated, Amoxicillin 500 mg/8 h. In that moment the patient had completed his proposed bisphosphonate therapy after receiving the 6th dose of zoledronic acid (4 mg) via IV. A new panoramic radiography and a mandible computerized tomography (CT) were performed. The radiological report was not conclusive for osteonecrosis images, and only a lingual thin fissure line was observed in the affected area among a high bone density image (). However, after 2-month follow-up the biopsy was indicated and its histopathological analysis confirmed the final diagnosis: osteonecrosis with Actinomyces infection (Figures and ).\nDespite a transitory clinical improvement of the lesion, its size was growing. The bone exposed area was greater concurring with the systemic corticosteroids administration in order to treat an acute exacerbation of the multiple myeloma. In a few days the patient general condition became worse over time and his toxic syndrome evolution was aggravated. About three weeks after the jaw lesion biopsy the patient was admitted to the hospital emergencies with severe hemogram alterations (leukocytes 1.66 × 109/L, erythrocytes 3.1 × 1012/L, haemoglobin 9 gr/dL, and platelets 54 × 109/L). Finally, a pneumonia due to Pseudomonas aeruginosa as an eventual complication of his pancytopenia and a massive haemoptysis episode precipitated his death.
A 68-year-old woman presented with frequent vertigo spells and long-standing dizziness accompanied by right-sided tinnitus after acute sensorineural hearing loss in the right ear several months before. When the patient was 24 years old, her left ear was surgically treated for chronic otitis media. Her pure tone audiometry (PTA) score as measured on her first visit revealed bilateral mixed hearing loss (). An otoscopic examination of her left ear revealed the finding of postoperative tympanic membrane without any evidence of active inflammation and the enlargement of external auditory canal. The right ear was normal in appearance. However, when an otoscope was inserted in her right ear, the patient immediately complained of dizziness. She then admitted to feeling dizzy whenever she put her finger in her right ear. It was assumed that insertion of the otoscope exerted positive pressure to the external auditory canal and thereby provoked subjective dizziness. A charge-coupled device (CCD) camera was used to record all subsequent observations. The application of negative air pressure to the patient's right external auditory canal induced nystagmus toward the right side as well as a dizzy sensation. The patient also felt dizzy when changing her body position, but this sensation was not associated with apparent nystagmus. The patient also complained of tinnitus, which she characterized as similar to the sound of water streaming. The caloric test with ENG indicated canal paralysis of 35% in right ear with 20 degree water irrigation. Temporal bone CT did not reveal any findings of pneumolabyrinth or aerolabyrinth. There were no traumatic events to cause perilymph fistula, e.g., excessive pressure changes to the inner ear such as in deep-water diving, head trauma, or an extremely loud noise, etc. From these clinical findings we could not completely rule out the possibility of underlying idiopathic perilymph fistula.\nAn exploratory tympanotomy was conducted under general anesthesia. During the procedure, the leakage of perilymph was suspected in the round window under the microscope. However, in fact, the leakage of perilymph fluid was not confirmed by an increase of intracranial pressure by postural change (head-down position) or an increase of chest pressure. The tympanic space was irrigated with 0.1 cc of saline. The irrigation solution was collected in order to measure the level of cochlin-tomoprotein (CTP)-a common perilymph marker. The oval and round windows were sealed to the temporal fascia with fibrin glue.\nAfter the procedure, the patient's tinnitus, finger-induced vertigo, and nystagmus resolved completely. This marked improvement of symptoms suggested that her complaints had stemmed from a perilymph fistula. However, a definitive diagnosis of perilymph fistula was not possible without positive CTP results.\nAlthough the surgery seemed to relieve most of the patient's symptoms, she still experienced her constant dizziness, which prevented her full engagement in social activities. In addition, the patient did not regain any hearing in her right ear. She complained of general fatigue, weight loss, and insomnia, which led us to suspect comorbid depression. The clinical evaluation was conducted using self-administered questionnaires. The dizziness handicap inventory (DHI) score was 94 (physical, 24; emotional, 34; functional, 36), implying that she was suffering from severe dizziness. The hospital anxiety and depression scale (HADS) score was 12 for anxiety and 15 for depression, suggesting that she was in a depressive state as well as a state of high anxiety. The patient's postural sway was recorded using static posturography. The total length of body sway over a period of 60 s was 166.08 cm with eyes open and 238.06 cm with eyes closed. The area of body sway over the same duration was 7.63 cm2 with eyes open and 9.86 cm2 with eyes closed.\nOn the basis of the questionnaire results, the treatment for depressive mood was considered to be an important issue before introducing vestibular rehabilitation to resolve a vestibular symptom of this patient. The antidepressant (miltazapiene, 7.5 mg/day) treatment was prescribed. Unfortunately, the patient was forced to stop the treatment owing to an adverse reaction to the medication. Substitute antidepressants (sertraline, 25 mg and sulpiride, 50 mg/day) were prescribed. This course of treatment was free of side effects and effective in addressing the patient's symptoms. Two weeks after starting this regimen, the patient reported an improvement in her clinical symptoms. With the aid of this pharmacotherapy, a program of vestibular rehabilitation was initiated to accelerate the patient's recovery. Four weeks later, the patient achieved a DHI score of 24 (physical, 8; emotional, 8; functional, 8)and HADS scores of 5 and 6, respectively. Her static posturography results improved as well: length of body sway for 60 s, 108.59 cm with eyes open and 148.56 cm with eyes closed; and area of body sway for 60 s, 8.09 cm2 with eyes open and 8.14 cm2 with eyes closed.
A 25-year-old woman presented to our out-patient department with progressive hearing loss and blocked sensation in the left ear for of one and a half months duration. There was no history of ear discharge, ear pain, vertigo and tinnitus. There was no history of nose or throat complaints. Past history revealed a history of left myringoplasty six years prior to presentation. Clinical examination of the ear revealed a smooth, soft epithelium covered bulge in the lateral one-third of the floor and posterior wall of the left external auditory canal which was sensitive to touch and did not bleed on touch (). Examination of the nose, throat and neck was normal. Systemic examination was normal.\nHRCT of the temporal bone revealed a soft tissue density in the lateral one-third of the external auditory canal eroding the posterior wall and extending into the mastoid bone impinging on the sigmoid sinus plate ().\nMRI with Gadolinium contrast of the temporal bone revealed a well-defined lobulated T2W hyperintense lesion () with partial suppression on FLAIR images which appeared mildly hyperintense on DWI images (), not showing post contrast enhancement in the left external auditory canal arising from the external auditory canal extending into the mastoid bone with scalloping with no obvious erosion in the left sigmoid sinus plate denoting the possibility of a benign cystic lesion. Pure tone audiometry revealed a moderate conductive hearing loss with an air-bone gap of 30 decibels.\nThe patient underwent left mastoid exploration under general anaesthesia. Postauricular incision with exposure of the mastoid cortex showed a well-defined sac with keratin debris in the mastoid which was originating from the bony cartilagenous region of the external auditory canal and eroding the mastoid cortex ().\nThe sigmoid sinus plate, mastoid antrum, dural plate and tympanic membrane were intact. The sac was removed in toto and sent for histopathological examination. The defect in the posterior external auditory canal was reconstructed with cartilage, temporalis fascia and periosteum.\nHistopathological examination showed the presence of keratin flakes and lamellated keratin and eroded fragments of bone along with fibro-collagenous stroma. Keratinized stratified squamous epithelium overlying fibro-collagenous stroma was infiltrated with lymphoplasmacytic infiltrate, cystic macrophages and multinucleated giant cells consistent with features of cholesteatoma ().\nFollow-up after three months showed a well-delineated external auditory canal. Post-operative HRCT temporal bone at three months showed a well-healed cartilage graft surrounded by soft tissue without any evidence of residual disease.
The 36-year-old female patient presented to our clinic with the complaints of a pain of the right anterior chest wall (CW) that begun two months ago and a palpable mass under the right breast. In her physical examination, pulmonary auscultation showed a decrease of respiratory sounds on right bottom area and a hard mass of approximately 5 × 5 cm was palpated on midline under the right breast. Other physical features were normal. The medical and familial histories of the patient were normal. The complete blood count and routine biochemical analysis were normal.\nIn the PA chest radiography, right costodiaphragmatic sinus was closed; there was a mass of approximately 5 × 5 cm on the right lung and there was a pleural effusion in the right bottom area. In the thoracic computerized tomography, a heterogeneous mass with lobular contour localized in right mid lobe which shows continuity to outside of chest wall without forming a costal destruction and a pleural effusion in the basal part of right lung was observed. It was observed that the mass was pushing forward the pectoral muscle without invading the breast tissue. An incisional biopsy was obtained from the mass invading the chest wall under the right pectoral muscle and the histopathologic examination of the biopsy showed a malign mesenchymal tumor (rich in vessels). Thereafter, an operation was planned for the patient and the vascular tumor mass disseminating to extrapleural space and the bottom tip of the sternum and the 4th, 5th, 6th, and 7th costae was excised. The histopathologic examination of the operational material showed hemangiopericytoma. In the sections, there was no evidence of a tumor tissue that infiltrates the bone and the cartilaginous tissues. The tumor cells were uniform in appearance with minimal pleomorphism and they had spindle-shaped to round/oval nuclei with vesicular to hyperchromatic chromatin and eosinophilic cytoplasm with indistinct cell borders. The tumors were richly vascularized, including staghorn-appearing vessels (Figures and ). Mitotic activity and cellularity were high in the tumor. Immunohistochemical staining demonstrated that the tumor cells were diffusely positive for CD34 and Mic-2 whereas staining for actin and EMA was negative.\nAfter the operation, radiotherapy was given to the patient. Regular monitoring with computerized tomography was planned for the patient: each 3 months for the first year, each 6 months during the second year, and annually thereafter. In the thoracic computerized tomography performed after four years, a mass localized in the left bottom of the lung was observed. For this mass, which was considered as a metastasis, the patient underwent a mass excision using minithoracotomy. Malign mesenchymal tumor detected in the histopathologic examination of the operational material was considered as the metastasis of the hemangiopericytoma that was previously found to be localized on the anterior CW (). The tumor staining gave a negative result with CD34, actin, and EMA and a positive result with MIC-2 and the tumor showed high mitotic activity. After the patient had received 6 sessions of chemotherapy with iphosphamide and doxorubicin, she started a monthly follow-up. Two years later metastasis was found in the right humerus. The biopsy result of the patient, who showed pathological fracture in the right humerus at the end of approximately 2 years, was reported to show a malign mesenchymal tumor. Thereafter, the patient underwent radiotherapy for the humerus and was taken to be monitored. Then, after approximately 1 year, the patient was given 3 sessions of iphosphamide and etoposide due to the progression observed in the pulmonary lesions. As a progression of 40% was detected in the pulmonary lesions, the patient was given 6 sessions of cisplatin and dacarbazine. During the follow-up, due to the detection of progression in the pulmonary metastatic nodules 1 year after the end of therapy, the patient was begun on high-dose iphosphamide. The patient had 6 sessions of high-dose iphosphamide. After 1 year, we learned that the patient had died, based on a pneumonia presentation coming from an outer center.
A 70-year old woman was admitted from a dermatologist to the Department of Plastic and Breast Surgery, Roskilde, Denmark. A biopsy verified well-differentiated full-thickness squamous cell cancer was found at the right side of the lower lip. The tumour had been present for three years. The patient had a history of ischemic heart disease with a percutanous coronary intervention and implantation of a stent in 2002. She was a heavy smoker. No alcohol overconsumption was reported. By clinical examination, a 15 × 15 mm sore, firm, central ulcerating tumour was seen located at the vermillion border (). At the mucosal side of the lip, leukoplakia was observed.\nNo enlarged lymph nodes in the cervical region was found at the clinical examination.\nSurgical intervention would remove approximately 50% of the lower lip. The patient was offered radiotherapy as an alternative to surgery and chose the former. She underwent a series of radiotherapy for a period of two months.\nFive weeks after the initial clinical examination at our clinic, the patient was readmitted to our department from the Department of Oncology at Copenhagen University Hospital due to recurrence of the squamous cell cancer located to the lower lip. At this point, the patient presented a monstrous, ulcerating tumour, involving most of the lower lip (). No clinical signs of systemic spread to lymph nodes in area was found by thorough clinical examination and palpation of the head and neck. Furthermore, a 18FDG-PET-CT was performed and ruled out further local or systemic spread.\nFirst, a total excision of the lower lip including the commisures during which free resection borders of 1 cm were confirmed by intraoperative frozen section diagnosis. 8 days after primary excision, histopathology confirmed free resection borders, and reconstruction of the lower lip by bilateral Fujimori technique was performed (, , ). Due to paucity of mucosal tissue between the orifice of the parotid duct and commisures of the mouth besides a relatively narrow labial sulcus, the remaining lack of mucosal lining was reconstructed by use of split skin harvested from the right thigh.\nAt a clinical follow-up three months after surgery, palpable enlarged, firm lymph node was found located to the lower jaw. Biopsy confirmed the histological diagnosis of metastasis from squamous cell carcinoma. Position Emission Tomography Scan (PET) confirmed the localisation of metastasis from a squamous cell carcinoma on the left side of the jaw, but as well on the right side. No distant metastases were found. Clinical presentation 5 months after surgery is seen in .\n5 ½ months after the initial admission to our department, bilateral neck dissection was performed. Several metastases with extensive perinodular growth was found on the right side, and infiltrating underlying musculature on the left side. The patient was referred to the Department of Oncology, Herlev Hospital, Denmark, where radiotherapy was given.\nOne months after completed radiotherapy, the patient presented in our clinic a very sore, ulcerated tumour at the jaw line on the left side. The tumour was adherent and dripping with what appeared to be saliva. Punch biopsies were not representative. A computer tomography (CT) scan confirmed local recurrence of aggressive squamous cell cancer. The patient was referred for more extensive surgery and further treatment, which is why eventual defatting of the lip was postponed.
A 28-year-old woman (1.65 m, 85 kg, BMI 31.2) was referred to our department five days postpartum with a bilateral femoral neck fracture.\nDuring the last two months before the delivery of her first child (begin with the sixth month of gestation), she had complained about increasing weakness and pain in both hips and thighs. In the last two weeks of her pregnancy (begin of the 35th week of gestation), she had to walk on crutches, as she was unable to bear her full weight due to the severe pain in her hips. During this time she took paracetamol daily. Her treating gynaecologist did not initiate any clarification of the symptoms by radiologic imaging methods in this period. Considering her severe pain, it was decided to deliver the child per elective caesarean section (37th +4 week of gestation). Three days postpartum, after being released from the hospital, she had an epileptic seizure and fell. She was admitted to a neurological department of another hospital. During her two-day stay in this department, the woman complained of severe pains in both hips. X-rays and a computer tomography (CT) of the pelvis were performed, revealing bilateral femoral neck fractures. Following this diagnosis, the patient was referred to our department for further treatment.\nRegarding her past medical history, she had childhood migraine and epilepsy. She suffered from her first epileptic seizure at the age of 15. She was treated with valproate over 11 years and remained seizure-free during that time. Her treating neurologist stopped the medication two years prior to her pregnancy. The patient did not have any other comorbidities. Particularly, she did not report on any past history of fractures, irregular menstruation, or family history of osteoporosis.\nAt presentation in our department, the clinical examination showed massively reduced hip movement on both sides because of severe pain. Serum laboratory examination was normal.\nBased on the age of the patient, the limited bone quality, the age of the fractures, and their displacement (Figures and ), it was decided to perform a bilateral hip joint replacement with the use of short-stemmed prostheses (). There were no intra- or postoperative complications. Both femoral heads were sent for further histopathological examination. The results of both femoral heads revealed fracture areas with hemorrhagia, proliferation of fibroblasts in the marrow cavities, and formation of focal woven bone as a sign of the bone remodelling, being indicative for a TOH. Postoperatively, the patient was mobilized on crutches under full weight bearing of the operated extremities. After consultation with our Department of Neurology, the patient restarted her valproate medication. Due to this medication, the patient was advised not to breastfeed her child. Since the TOH is regarded to be a self-limiting disorder, no specific osteoporotic treatment was applied. The further course was uneventful, and the patient was dismissed after two weeks.\nAt 1-year follow-up, the patient is free of any complaints and has no limitation in the range of motion of both hips (extension/flexion 0°-0°-100°, abduction 50°).
A 57-year-old male patient was admitted to hospital following a routine medical examination with a history of a mediastinal lesion having been located on examination at his local hospital one week previously. Chest computed tomography (CT) scan had confirmed a circular low-density lesion in the mediastinum. The patient presented with no evidence of fever, or other symptoms such as chest pain, dyspnea, or dysphagia. In order to determine a definite diagnosis and treatment, the patient subsequently visited our hospital. On arrival, the patient confirmed that there was no history of chest lesions in the family. Chest auscultation and percussion were essentially negative. Cardiopulmonary function test was generally normal, and tumor index NSE (neuron specific enolase) was 24.11 ng/mL (normal reference range 0.00–18.00 ng/mL). Chest-enhanced CT (Fig ) displayed an irregular slightly low-density shadow in the anterior trachea and posterior superior vena cava of the mediastinum. The boundary of the lesion was clear, although a small calcification and solid component were visible at the lower edge of the lesion. The scan CT value was approximately 25 HU, enhanced CT value 36 HU, and a small piece of solid component below was clearly enhanced. Diagnosis revealed a slightly lower density lesion of the anterior tracheal and posterior vena cava in the mediastinum, the nature of which was uncertain. Chest MRI (Fig ) of the patient indicated that irregular abnormal signals were seen in the vena cava-anterior trachea space, with uniformly low signals on T1WI and significantly high signals on T2WI. There was no obvious diffusion limitation of lesions on different b-value DWI, the lesion considers vascular lesion. There was a clear indication that the patient be recommended for surgery, and thoracoscopic resection of the mediastinal lesion was recommended as the treatment plan. Following usual preoperative procedures, the patient was anaesthetized and placed on his left side on the operating table .A 4 cm incision was made into the chest, entering via the fourth intercostal space and a thoracoscopy was performed. On visualization, there was no adhesion in the chest, but there was a visible lesion in the middle mediastinum. An ultrasonic knife was used to anatomize the lesion from the superior vena cava and the azygous arch, with careful dissection and separation of the lesion under thoracoscopy. The size of the lesion was approximately 6 cm × 5 cm × 3 cm, with visible localized calcification. The lesion was removed for routine pathology. Postoperative pathology (Fig ) confirmed that it was a mediastinal lesion with fibrous adipose tissue (3 × 2 × 0.8 cm), dilated vascular lumen diagnosis, and the lesion was considered to be a cavernous hemangioma. The patient was successfully discharged from hospital on the fifth day after surgery, with no evidence of recurrence after one year of follow-up.
A 44-year-old Japanese male, an office worker, was transported to our emergency department with a complaint of temporary loss of consciousness. He had experienced fatigue for 3 years and had fallen easily in his daily life starting 2 months before admission. He was feverish and had a cough and phlegm for several days before admission. On the way to work, he felt drowsy and fell down the stairs of the train station, necessitating transport to our hospital by ambulance. The peripheral blood analysis noted mild elevation of white blood cells. The blood chemistry test disclosed mild elevation of C-reactive protein and mild liver dysfunction (). He was thin, i.e., his height was 174 cm and he weighed 52 kg (). Chest computed tomography (CT) showed severe infiltration in the upper posterior fields of both lungs as well as food debris in the esophagus. He was diagnosed as having aspiration pneumonia. His past medical history included diabetes mellitus that had been treated by a local doctor; glycated hemoglobin was approximately 7%. He had experienced ileus six times since age 30 years. He was not married. His father had died of dilated cardiomyopathy at the age of 70 and had also been thin. On the other hand, his mother was healthy but his maternal uncle was diabetic. His younger sister (Case 2) also had mild muscle weakness of the four extremities. Aspiration pneumonia was treated by intravenous administration of antibiotics under conditions of food-take restriction combined with temporary insulin infusion, and the respiratory symptoms subsided. On the neurological examinations after improvement of pneumonia, he presented with typical clinical manifestations of DM1 (), such as forehead balding, hatchet face with bilateral ptosis, nasal speech, mild muscle weakness of the four extremities, handgrip myotonia, and diffuse muscle atrophy. Electromyography performed to test the biceps brachii muscle and femoral quadriceps muscle on the left side revealed frequent myotonic discharges. Because DM1 was strongly suspected, we recommended that, after providing informed consent during genetic counseling, he undergo genetic testing for DM1 together with his younger sister. The number of CTG repeats in the DMPK gene was abnormally expanded to about 600 repeats in the elder brother and about 900 repeats in the younger sister, in contrast to those of healthy individuals who have 5 to 37 repeats (), thereby confirming the diagnosis of DM1 in these siblings ().
An 80-year-old woman who underwent left BCS for breast cancer (IDC, ER+, PR+, HER2-, T2N0M0) 3 years previously complained of skin nodules and color changes on the inferior side of her left breast during a follow-up visit (Fig. ). She was receiving endocrine therapy scheduled for 5 years. Adjuvant RT was omitted because of her old age. The red skin nodules on the left breast were diagnosed as AS by punch biopsy. Magnetic resonance imaging (MRI) revealed solid and hyper-vascularized components with significant enhancement throughout the left breast. No metastasis was observed in other organs. Left mastectomy with extensive skin resection with a margin of 3 cm from the discolored lesion and skin graft surgery was performed. An additional skin resection of 2 cm was performed because several points of the resected stump were diagnosed as positive for tumor cells by intraoperative rapid diagnosis. Pathological findings revealed high grade AS. CD34 and CD31+ spindle tumor cells were detected, and the high-grade tumor cells had a high Ki67 index score of 80% (Fig. ). The high grade tumor cells were locally positive for c-myc although the patient never received RT. Unfortunately, the low grade tumor cells were widely detected in the lateral and deep margins, suggesting that the AS had spread beyond the prediction of the preoperative diagnosis from the MRI. Curative resection was considered impossible, and we decided to follow up without additional resection. Forty days after the surgery, skin nodules and redness appeared on the skin of the contralateral breast and on the skin graft of the chest wall (Fig. ). The skin biopsy diagnosed the recurrence of AS. CT scan revealed recurrent AS extending over the contralateral breast and chest wall (Fig. ). The patient received treatment for recurrence at another hospital. The first-line regimen comprised weekly paclitaxel 70 mg/m2. A dose reduction of paclitaxel was needed because she was 80 years old. She now has maintained clinical partial response 17 months after surgery.
An 84-year-old man accidentally fell at home and was admitted to our hospital. The patient was hospitalized with several problems such as multiple metastases of prostate cancer, chronic heart failure, emphysema, impaired renal function, and biliary stent placement due to idiopathic biliary stenosis. While no fracture was identified, the patient complained of lower back pain and was unable to move. As a consequence, he was hospitalized for the purpose of pain management. On the third day of hospitalization, the patient developed a fever of 38.2°C, and his laboratory data showed high levels of WBC count and CRP. While the source of infection was not identified, a urinary tract infection was suspected because he had purulent urine from previous examination and no symptom of respiratory tract infection. The patient underwent treatment with CMZ 1 g every 12 hrs. Three days after therapy initiation, the fever declined and the laboratory data of the inflammatory response normalized. Although blood culture was negative, we decided to treat according to sepsis because he was frail. We, therefore, planned to administer CMZ for 14 days. During the treatment course, the patient did not develop fever and had a healthy appetite.\nOn the morning of the 14th day of hospitalization, the patient complained of a sudden difficulty in breathing. His peripheral artery oxygen saturation decreased to 74%. No fever, coughing, or sputum was identified. A chest computed tomography (CT) scan was performed, showing the presence of ground glass shadows bilaterally (). While the blood work demonstrated the absence of an inflammatory response, Hb decreased by 1.5 g/dL from the previous day. The BNP value was 103 pg/dL, similar to that at initial hospitalization. Because hemostasis of the blood sampling site was difficult, additional laboratory tests were performed. These showed a marked prolongation of PT-INR (). In the evening, his value of Hb dropped from 6.8 to 5.5 g/dl in six hours. We doubted gastrointestinal bleeding, but there was no black stool. Additionally, he began to spit bloody sputum. We considered bronchoscopy but could not carry out because of his poor respiration. Since the patient had an acute respiratory failure accompanied by blood sputum and progressive anemia without exacerbation of heart failure, he was diagnosed with pulmonary alveolar hemorrhage due to coagulation abnormality. Two units of red blood cell concentrates stored in mannitol adenine phosphate and six units of fresh frozen plasma were immediately administered to the patient.\nWe believe that the pulmonary alveolar hemorrhage was caused by disseminated intravascular coagulation (DIC) due to the prostate cancer. However, the patient did not meet the DIC's diagnostic criteria because each level was fibrinogen 393.8 mg/dL, fibrinogen degradation products (FDPs) 23.0 ug/dl, and platelet count 15.3 × 104/uL, even though PT-INR indicated extremely abnormal value (). We took into consideration the possibility of Vit K deficiency. To overcome this issue, we administered 10 mg menatetrenone per day. Three days later, all coagulation systems had recovered to their normal values (). Protein induced by vitamin K absence-II (PIVKAII) reached 8,884 mAU/mL (normal range below 40 mAU/mL) by the 23rd day of hospitalization.\nBased on these observations, we investigated the cause behind the Vit K deficiency. The prescription drugs had not been changed before and after hospitalization, and antiplatelet and anticoagulant agents had not been used. The only additional drug used during hospitalization was CMZ. Furthermore, the patient's food intake remained unchanged in the course of the hospitalization as well as his hepatobiliary system's laboratory tests. No diarrhea developed during the patient's illness. Based on these observations, the patient was diagnosed with hypoprothrombinemia due to CMZ inhibition of Vit K epoxide reductase. Despite discontinuation of Vit K (menatetrenone) administration, the coagulation activity did not decrease. The pulmonary alveolar hemorrhage gradually improved, and the patient was discharged after one month.\nOne month after discharge, the patient was rehospitalized with pneumonia. He was treated with sulbactam/ampicillin 3 g quaque 12 hrs for 7 days, but hypoprothrombinemia was not observed.
A 57-year-old man presented to our institute for further evaluation following a positive result in an fecal occult blood test. Approximately 20 years earlier, he was diagnosed with congenital agenesis of the right kidney. He was otherwise entirely healthy without any other significant past or current medical problems. A physical examination showed no abnormalities of the genitourinary system. A contrast-enhanced computed tomography of the abdomen indicated the absence of the right kidney and a hypertrophic left kidney [], and indicated the presence of the right testicular vessels located behind the renal fascia [], but no other anomalies were observed. Total colonoscopy revealed the presence of a tumor, measuring 1.5 cm × 1.0 cm in the ascending colon; the tumor could not be elevated by injection of saline into the submucosal layer. Because endoscopic treatment was impossible, we performed laparoscopic colectomy and lymph node dissection.\nThe operative procedures and findings are as follows. The subumbilical trocar was initially placed using the open laparoscopic technique. After CO2 pneumoperitoneum was established, three other ports were placed. No particular findings such as ascites, adhesion, peritoneal seeding, or anatomical anomalies were noted in the abdominal cavity. The right colon was mobilized to the root of mesocolon by lateral-to-medial extension of retroperitoneal dissection between the fusion fascia and the anterior renal fascia. This procedure was performed in the usual manner. The right testicular vessels were observed behind the anterior renal fascia; however, the right ureter could not be detected []. Furthermore, we could not detect the right renal and adrenal vessels within the operative field. The ileocolic and right colic vessels were ligated near these origins using endoscopic clips, and were mobilized divided. After the segment of the colon was completely mobilized, the ileum and colon were extracted from the abdominal cavity via a right pararectal incision and were then divided. After Gambee's hand-sewn end-to-end anastomosis was performed, the intestine was placed back into the abdominal cavity. During laparoscopy, the abdominal cavity was irrigated, a drain tube was placed at the paracolic gutter, and all other ports were removed. The incisions were closed using absorbable sutures and staples. Histological examination showed a well-differentiated adenocarcinoma that invaded to the submucosal layer without infiltration to the vessels or lymph ducts. No lymph node metastases were detected. The postoperative course was uneventful except for ileus, which was treated conservatively. The patient is currently healthy; he is receiving regular follow-up examination, and has no signs of recurrence and other malignancies.
A 2-month-old female infant was admitted due to a fast-growing tumor of the right side of the maxilla, disfiguring the right cheek, nose and upper lip. The first symptoms occurred when the girl was 6 weeks old, when a tooth within the hard palate surrounded by a small, hard, non-painful bulge was found by the mother (). It was diagnosed by a GP as a neonatal tooth and a decision was made to wait and see. However, during the next two weeks, the mass rapidly increased in size. Magnetic resonance (MR) displayed a pathological, well defined, solid mass measuring 23 × 22 × 18 mm, located within the alveolar process on the right side of the maxilla, reaching the midline. The bud of the right incisor was visible within the mass. The tumor bulged outside in the region of the nasal alar and invaginated into the mouth. No evidence of destruction of the hard palate, penetration into the orbital or nasal cavities and no evidence of enlarged lymph nodes (LN) were found ().\nThe tumor was resected in the otolaryngology department; however, clear margins were not achieved. The histopathological examination revealed MNTI with typical morphology and immunophenotype (). Three weeks after the surgery, a local recurrence was observed and the patient was referred to the department of Pediatric Oncology. MR revealed a mass measuring 16.5 × 16.5 × 22 mm visible in the postoperative area (). The mass was invading the nasal concha and reaching the medial angle of the right eye; however, it did not penetrate into the orbit. Because the tumor was deemed unresectable without severe mutilation, a neoadjuvant CHT was introduced to reduce its size and extent. The patient received several courses of CHT according to the protocols for neuroblastoma (NBL) and sarcoma. The responses to particular courses of CHT varied () but eventually, after eight courses, a partial regression of the tumor was achieved which enabled its complete non-mutilating resection. No recurrence was observed within 4.5 years post treatment.

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