text
stringlengths 746
31k
|
|---|
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 60-year-old woman with history of simultaneous pancreas and kidney transplant for diabetic nephropathy presented to the ER 2 years after the transplantation for evaluation of nausea, vomiting, abdominal pain, and minimal urine output. She had an interval weight gain with BMI of 31.8 on presentation, which increased from BMI of 26.6 four months earlier. She was found to be in acute renal failure with severe increase in serum creatinine level to 9.9 mg/dL. She was hemodynamically stable and afebrile. Noncontrast CT of abdomen and pelvis demonstrated an enlarged renal allograft with moderate hydronephrosis and trace pelvic free fluid (). In retrospect, a change in orientation of the allograft was noted with the hilum directed laterally when compared to a contrast enhanced CT performed prior to torsion () when the hilum was directed anteromedially.\nFurther evaluation with ultrasound showed an enlarged, hyperechoic renal allograft with moderate collecting system dilatation. At color Doppler evaluation only a short segment of the proximal renal artery was seen, with the distal renal artery not visualized. No blood flow was demonstrated within the allograft on color Doppler, power Doppler, and spectral analysis (). The renal vein was not visualized. The constellation of findings was concerning for renal artery thrombosis and impending infarct.\nTransplant medicine immediately took the patient to the operating room for a nephrectomy as there was concern the kidney could become necrotic and a nidus for infection. The renal allograft was found twisted 360 degrees on its vascular pedicle and ureter despite prior nephropexy, likely secondary to adhesions in its upper pole. The kidney appeared pinkish-blue indicating minimal blood flow. After taking down the band of adhesions, the allograft was detorsed and the ureter was returned to its appropriate position. A pinkish hue returned to the kidney. Intraoperative Doppler demonstrated excellent flow in the renal artery and vein. Intraoperative biopsy confirmed the kidney was still viable without evidence of infarct or acute cellular rejection. The detorsed kidney was fixed in two positions in the upper and the lower poles.\nAfter surgical detorsion, all laboratory values rapidly returned to normal levels. Doppler ultrasound on post-op day 1 demonstrated normal hilar and segmental arterial and venous blood flow to the renal allograft (). |
We report the case of a 52-year-old Moroccan woman who had been menopausal for 14 years. She presented with a lower abdominal pain. She had not experienced any postmenopausal bleeding and had no bowel or urinary symptoms. She was a nonsmoker. She had no other significant medical history and no sign of virilization. An examination revealed a smooth cystic mass posterior to the uterus. A transvaginal and transabdominal pelvic ultrasound demonstrated a 9 × 3.7 cm heterogeneous mass in her left adnexa. No vascular flow or ascites was seen, the ovaries did not appear to be separate from the mass. A chest X-ray was normal. Serum CA-125 level was 6 IU/mL. Renal, liver, and hematologic parameters were all in normal range. At laparotomy, a large torted left ovarian cyst with small bowel adhesions to its surface was discovered. Her right ovary appeared normal but was adherent to her small bowel; her uterus was normal. Her liver and omentum appeared normal, and there was no pelvic or abdominal lymphadenopathy. There was a small amount of ascites that was sent for cytology. An oophorectomy was performed with no macroscopic residual disease. An omental biopsy was taken. The histology showed a tumor of sex cord-stromal type in the ovary but the tumor was difficult to classify further (Figure ). The main left component comprised dense spindle cells interspersed with small groups of cells with a prominent eosinophilic cytoplasm. Crystals of Reinke, a marker of Leydig cell differentiation, were not identified within the majority of these cells, but there was a group at the hilum at the edge of the tumor. In the absence of unequivocal crystals of Reinke, the tumor was reported as a luteinized thecoma. Features such as the mitotic rate were worrying, and the tumor could not be considered benign and we suspected malignancy. The ascites was free of abnormal cells. No vascular invasion was identified. Immunohistochemistry showed that the tumor was positive for inhibin and vimentin. There was no evidence of metastasis in the other specimens received. Our patient made an uncomplicated recovery and was followed up every six months for five years before being discharged. Soon, she presented with a fresh rectal bleeding and melena. She had not experienced any weight loss or change in bowel habit and was otherwise asymptomatic. The initial examination was unremarkable. Upper and lower gastrointestinal endoscopies were performed, and, with the exception of mild gastritis, no abnormality was detected. A computed tomography scan of the abdomen and pelvis confirmed the mass to be within a loop of small bowel with some dilatation of the bowel proximal to this (Figure ). During laparotomy, a soft intraluminal mass within her ileum was identified. There was no defect in the serosa of the bowel and no evidence of peritoneal or pelvic deposits. A recurrence of the ovarian tumor seemed unlikely. Histology of the lesion showed appearances very similar to those of the previous ovarian tumor except that the endocrine component was more prominent (Figure ). The gross appearances were very unusual in that there was transmural involvement of the small bowel and an ulcerated polypoid mass protruded into the lumen. The mass was a rare metastatic recurrence of an SCST and appeared to be isolated within the small bowel. Our patient underwent three cycles of a BEP chemotherapy regimen, which consists of bleomycin, etoposide, and cisplatin. She has remained asymptomatic with no clinical evidence of recurrence 27 months after the small bowel resection. |
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. |
An 84-year-old male, who had undergone a percutaneous vertebroplasty for a compression fracture of the first lumbar vertebra, was brought to our emergency department from a primary-care hospital. Reasons for the transfer were a growing mass in his left flank and progression of anemia. His comorbidities included hypertension and end-stage renal disease with associated anemia, and he was on regular hemodialysis. The patient had neither prior bleeding disorder nor any anticoagulant treatment. His blood pressure was 94/52 mmHg. His pulse rate was 100/min. He was not febrile.\nTwo days before admission to our institute, he visited an orthopedic clinic with a history of severe pain in the lower back, which started after a slip. He underwent radiological examinations, including computed tomography (CT) and magnetic resonance imaging (MRI). Radiographs revealed a compression fracture at the first lumbar vertebra []. Due to severe pain, the patient underwent percutaneous vertebroplasty that was performed via the left pedicle of L1 using polymethyl methacrylate with fluoroscopy under local anesthesia, and there was no complications during the procedure. The backache improved immediately following the procedure and the patient was able to walk independently. On the next day, he complained of left flank pain and tenderness around the injection site. Swelling developed in the left lower back. The hemoglobin level decreased to 4.3 mg/dL in comparison with the initial level of 7.5 mg/dL. Contrast enhanced CT scan revealed a left paraspinal muscle hematoma [].\nOn admission to our emergency department, the patient presented with a large unilateral back mass, which was firm, combined with severe tenderness. There was no neurological deficit on examination. Followup MRI showed an extensive focus of complex signal intensity in the left paraspinal muscle, suggesting a paraspinal muscle hematoma []. His coagulation profile, including platelet count, prothrombin time and partial thromboplastin time was within the normal range. Thus, angiographic intervention was performed to find and coagulate a bleeding vessel. However, the bleeding focus could not be isolated and there was no pseudoaneurysm []. His initial creatine kinase level was increased to 251 IU/L. After fluid resuscitation and 4 transfusions, vital signs were stable and the hemoglobin level increased to 6.5 mg/dL. On the next day, the hematoma continued to increase, with further progression of back pain. He received conservative treatment, including intermittent compression cryotherapy and pain control and was advised bed rest. After the patient received 10,000 unit of epokine twice a week and 11 transfusions, totally almost 4.4 L of blood in 2 weeks, the hemoglobin level maintained more than 7 mg/dL. After a month of conservative treatment and epokine injection, the patient showed relief from pain and his hemoglobin level maintained more than 10 mg/dL. Subsequently, the flank mass began to decrease in size. Four months later, the flank mass was completely resolved at the followup CT image [], and he could walk without back pain. |
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°). |
The patient was a 70-year-old female with a known history of invasive ductal carcinoma of the left breast. Her primary breast tumor was diagnosed via histologic assessment of an image-guided core biopsy at another facility. The invasive carcinoma was reported to measure more than 5 cm (clinical stage T3) by imaging studies. She was advised to undergo preoperative neoadjuvant chemotherapy. Upon completion of her neoadjuvant therapy, 6 months after the time of her original core biopsy diagnosis of invasive disease, the patient underwent left mastectomy and sentinel lymph node biopsies at the outside facility. No residual carcinoma was identified in the mastectomy specimen (complete histologic response to neoadjuvant therapy/ypT0); however, glandular epithelial structures were identified within one of the sentinel lymph nodes, and the outside pathologist forwarded the slides and tissue blocks from the lymph nodes and the original diagnostic core biopsy sample to our center for expert extradepartmental consultation. The best diagnosis for the glandular elements in the lymph nodes was in question.\nThe outside slides were reviewed, and the original core biopsy diagnosis of invasive ductal carcinoma, nuclear grade 2, was confirmed (). The invasive tumor was 70% estrogen receptor positive by immunohistochemistry and was HER2 nonreactive/negative by IHC, scaled score 1+. The slides from one of the small, postneoadjuvant, excised sentinel lymph nodes demonstrated multiple (at least nine) distinct nests of glandular epithelium within the lymph node capsule (). Some of these epithelial nests abutted the subcapsular sinus. These nodal capsular glandular cell groups were discontinuous and were seen to encircle approximately one-half of the circumference of the 3.5 mm lymph node. The histologic differential diagnosis for these glandular structures within the lymph node included metastatic disease versus benign/reactive heterotopic epithelium.\nHistomorphologic comparisons between the capsular-associated glandular structures in the node and the patient's primary breast carcinoma core biopsy slides confirmed disparate appearances. The primary tumor showed greater nuclear pleomorphism and less overt tubule formation. In addition, the primary tumor was mitotically active, and no mitoses were seen in the nodal capsular epithelioid nests. Ancillary immunohistochemical (IHC) studies performed in our laboratory confirmed that the glandular cell groups in the periphery of the patient's sentinel node were immunoreactive (positive) for PAX8 () and WT1 () and negative for GATA3 (). Slides from the original diagnostic breast core biopsy block were also prepared in our laboratory, and the invasive tumor was found to be positive for GATA3 () and negative for PAX8 and WT1, confirming a pattern of protein expression opposite of the glandular structures in the sentinel lymph node capsule. On 100x oil-immersion microscopy, rare singly scattered ciliated cells could be identified in the capsular nodal rests (). A diagnosis of nodal endosalpingiosis (benign lymph node capsular müllerian inclusions) was rendered, and the patient's disease was then able to be accurately defined as ypT0, ypN0. |
A 46-year-old man presented to the Department of Prosthodontics at Tehran University, School of Dentistry. His chief complaint was deficiency in speech and mastication. His past medical history revealed that he has been under treatment for undifferentiated nasopharengeal carcinoma of neck (NPC). Surgery included a local tumor resection and lymph node dissection. Radiotherapy was accomplished within 100 days postoperatively. He was irradiated with 60 Gray (Gy), at single doses of 2 Gy. Radiotherapy parameters, such as radiation dose and technique used, were recorded. The patient had no muscle tenderness or facial asymmetry and denied any symptoms of temporomandibular joint disorder or myofacial pain dysfunction. Functional manipulation did not show any sign of parafunction, but mandibular range of motion was not within normal limits and there was obvious limitation in mouth opening (30 mm). Intraoral palpation showed submucosal fibrosis like condition of oral mucosa. The saliva was thick and mucous and there was generalized caries and recurrent caries throughout dentition. Clinical examination revealed missing of mandibular posterior teeth except left first and second premolars. All the teeth except maxillary incisors and first right premolar had received endodontic treatment, though all were faulty treatments and needed retreatment. The maxillary left and right canines, first and second premolars and mandibular left second premolar had complete coverage crowns []. Marginal opening of all complete crowns and breakdown and leakage of these restorations were noted. Defective amalgam restorations with marginal breakdown and recurrent caries were present in teeth # 3, 14, and 15, and defective composite restorations with marginal leakage were present in teeth # 8, 9, and 10. The patient exhibited generalized mild gingivitis and minimal bleeding on probing. The patient was referred to the ENT department for evaluation. However, his medical consultation reported that he did not have any current signs or symptoms of NPC. Treatment plan options (fixed versus removable) were presented to the patient. However, considering the patient's desires, complete mouth rehabilitation with tooth and implant supported metal ceramic restorations was suggested. However, the first step was controlling caries. Therefore, diet evaluation was performed and he received daily fluoride treatment with a custom-made carrier and 0.4% stannous fluoride gel. Besides diet survey and diet modification, oral health instruction including informing the patient about disease etiology and oral hygiene instruction, evaluation of salivary flow, and prescribing xylitol products were carried out for the patient. Endodontic treatment and retreatment were done for all the remaining teeth except maxillary second left molar. This tooth was extracted because of limited mouth opening and therefore limited access to it []. The treatment plan included initial preparation and caries removal and complete mouth clinical crown lengthening surgical procedures to expose 1.5 to 2 mm of tooth structure circumferentially for adequate ferrule for resistance and retention forms and to facilitate esthetic gingival levels. Since there was no acceptable posterior support, the diagnostic phase involved a removable diagnostic overdenture. This phase also helped determining the length of teeth and evaluating phonetics and esthetics. After the removal of failing restorations and caries removal, primary impressions were made and esthetic clinical crown lengthening was designed on the diagnostic casts. Then a diagnostic wax up was done and a vacuum formed surgical template was fabricated as a reference for the prospective desired gingival levels during the crown lengthening surgical procedures. Full-thickness flaps with scalloped incisions were elevated to preserve interdental papillae []. Osteotomy was performed according to surgical templates to develop 2.0 mm of biological width and 1.0 mm of sulcular depth. Tooth #12 was extracted during crown lengthening procedure because of vertical root fracture. A centric relation record was obtained with record bases and occlusion rims using an interocclusal registration material (Virtual; IvoclarVivadent, Schaan, Liechtenstein). The casts were transferred into a semi-adjustable articulator (Dentatus ARH, Stockholm, Sweden) by the centric relation record. Prosthetic teeth (Major; Major Prodotti Dentari, Torino, Italy) were arranged for trial insertion. The overlay denture was processed and was adjusted on the remaining teeth []. A radiographic stent for implants was fabricated (lucitone clear resin) by duplicating the overlay denture and coating its teeth surface with barium sulfate. Then, tomographic radiographs were taken to check bone height and width and proper implant position []. Two 4.1 × 10 mm endosteal dental implants (Institut Straumann AG, Waldenburg, Switzerland) were placed in each posterior mandibular quadrant using the surgical guide. All implants were inserted under local anesthesia and were inserted primarily stable. Bulky flaps were thinned in the same session. The following 5 days, 250 mg of cefuroxim (Elobacts, Bad Oldeslohe, Cascan, Germany) was given twice orally and patients rinsed their mouth twice daily with 3% hydrogen peroxide; no specific diet was followed. After 5 weeks, the stability was tested with Osstell (Integration Diagnostics, Gothenburg, Sweden). The teeth were prepared and custom post patterns were fabricated according to a vacuum silicon guide made over overlay dentures. After finalizing cast post in the all remaining teeth, impressions were made of maxillary and mandibular arches. This impression in mandible not only record prepared teeth, but also was an implant level impression. For transferring the exact maxillo mandibular relationship established with overlay dentures to the final fixed restoration, the anterior section of the overlays were removed so that Lucia jig could be made between incisors at the existing vertical dimension of occlusion (VDO). Then, the centric relation was made between posterior maxillary prepared teeth and mandibular record base along with cross mounting with cast made of over impressions of overlay dentures. A custom incisal guide table was made from GC pattern resin (GC America) while overlay dentures were on the articulator. Waxing was done according to the customized guide table on die casts and converted to heat-processed acrylic temporary restorations. The diagnostic interim restorations were modified until the patient was satisfied with phonetics, esthetics, and function. During the evaluation period, the patient's anterior and posterior speaking space and function was assessed. Furthermore, these restorations were used for progressive loading of implants. Acrylic restorations on the implants first were made without occlusal contact, with occlusal contact on the abutments 4 weeks later, and full occlusal contact on the abutments and pontic after 8 weeks. The interim restorations were functioned for about 4 months to assess the patient's adaptation to the proposed new vertical dimension of occlusion and the new clinical crown lengths []. Subsequently, the gingival tissue around the tooth preparations had matured and definitive impressions were made with vinyl polysiloxane impression material (Affinis; Coltène/Whaledent, Inc, Cuyahoga Falls, Ohio). The maxillary and mandibular anterior teeth were restored with definitive restorations. Centric occlusion, even protrusive contacts, and canine guidance were established in the definitive anterior restoration. The complete crowns and fixed partial dentures (FPD) were prepared and completed. Crowns were cast with a gold alloy. After the fit of the cast crowns was verified intraorally, metal-ceramic restorations were completed (Omega 900; VITA Zahnfabrik, Bad Sackingen, Germany). All crowns were cemented with temporary cement. A heat processed hard occlusal guard (Lucitone Clear, Dentsply, York, PA, USA) was delivered to evaluate the patient's tolerance of new VDO and providing the patient with a mutually protected occlusion []. Following the definitive cementation of all restorations, neutral pH sodium fluoride (Previ Dent 1.1% Brush-On Gel; Colgate Oral Pharmaceuticals, New York, NY) was prescribed to prevent secondary decay under the restorations. The patient was advised to return every 6 months for a recall evaluation. The patient was satisfied with the improved esthetics and function of his teeth. The patient has been followed for 8 months since the completion of his treatment and remains free of any complications. Additional instruction was given on the use of floss threaders and superfloss under the FPD. |
A 56-year-old Caucasian Australian woman presented to our facility with a history of unsuccessful surgery for otosclerosis in the right ear approximately 25 years ago. She says that she was told that the surgery did not work as expected, and she became deaf in that ear. At the time of surgery the surgeon reported high pressure and flow of perilymph that he characterized as a ‘gusher’. Her hearing in her left ear was already poor at the time of the operation on her right ear, and it had been deteriorating gradually. She was fitted with a hearing aid in her left ear soon after the surgery. There is no record of imaging or a previous audiogram, and it is thought that an inadequate (unmasked) audiogram was used to formulate the initial diagnosis of otosclerosis.\nOur patient accepted the surgery failure and her misdiagnosis was only corrected when she decided to seek further assessment and a second opinion due to progressive deterioration of her hearing in her better ear to a level that a monoaural hearing aid was not providing enough benefit. She also reported intrusive tinnitus in her right ear and symptoms of imbalance.\nA tympanometry investigation revealed normal type A tympanograms with absent ipsilateral and contralateral acoustic reflexes bilaterally. Her audiogram showed a moderate to severe sensorineural hearing loss in the left ear and a profound sensorineural hearing loss in the right ear. Word discrimination scores in quiet using AB word lists [] were relatively poor at amplified levels. Videonystagmography was performed and caloric testing revealed a significant canal paresis in her right ear.\nImaging of temporal bone (Figure ) revealed enlarged vestibular aqueduct syndrome in her right and left ears. This confirmed the previous stapedectomy in the right ear with a well positioned stapes prosthesis, and a 4 mm bony graft.\nAs part of our pre-cochlear implantation investigation, her hearing aid in the left ear was upgraded to improve performance. Unilateral aided outcome was assessed through speech recognition scores in quiet using the City University of New York (CUNY) sentence test [], presented at 65dBA, 0 degree azimuth with the speaker positioned 1 m away from our patient.\nThe decision regarding cochlear implantation in the right ear was made with strong involvement and support from our patient’s family. They were made aware of the general risks involved in the surgery, in particular the potential for damage to her better ear from possible trauma associated with the extensive drilling during the procedure on her right ear. Our patient was implanted on 1 March 2011 using a CI24RE straight array electrode cochlear implant, and speech processor CP810 from Cochlear Ltd (Lane Cove, Australia). All electrodes were inserted, there were no short or open circuits and impedance was within the normal range. Our patient presented with a narrow dynamic range at switch on, but was able to discriminate all sounds in the Ling Sounds Test presented at soft live voice level without visual cues. Intensive auditory training was provided from day one for four weeks, using the rehabilitation material provided by Cochlear. Audiobooks with different paces of presentation were used for auditory training purposes at home. At six months follow up, open-set sentence recognition was assessed using CUNY sentences and our patient achieved a score of 96% at bimodal amplification against the initial score of 58% with hearing aid only. |
A 16-year old man sustained an open fracture of the left femur after a motorcycle accident. The distal fracture segment perforated the posterior aspect of the thigh, thus lacerating the sciatic nerve proximally of the bifurcation of the peroneal and tibial nerve components, resulting in a gap between the nerve ends of 6–7 cm. The femoral blood vessels were intact. The fracture was treated surgically by insertion of a femur rod. The wound was revisited on the second postoperative day, considered to be sufficiently clean without necrosis to proceed to nerve reconstruction, and the nerve injury was repaired with autologous nerve grafts. The ipsilateral sural nerve was used as a donor for nerve grafting. A two-segment sural nerve graft was used to traverse the gap (maintenance unknown, probably were sutures used). The wound was infected postoperatively, where bacterial culture showed Bacillus cereus and the patient received treatment with clindamycin (Dalacin®). The wound then healed uneventfully. The leg was not immobilized post operatively. He was fitted with a foot-drop brace. Follow-up was conducted at an orthopedic clinic. He was reexamined with radiography to follow the healing of the femur fracture every six weeks during the first three months and then every six months. After 17 months the femur rod was removed due to pain. He had problems with pain during the first six months, which was treated with pregabalin (Lyrica®) with sufficient effect.\nAfter 20 months there was little progress of nerve regeneration. An EMG was performed that showed denervation activity, fibrillations and positive sharp-waves in all the muscles of the lower leg, below the site of lesion. No voluntary units could be seen. In addition, no reaction in the tibial muscle after stimulation of the peroneal nerve at the knee was seen. Thus, there were no neurophysiologic signs of reinnervation of the lower leg. This related to the result of examination at our department 29 months after repair. At this point there was extensive atrophy of the muscles of the lower leg. Tinel’s sign was positive at a point 18 cm proximal to the medial malleolus, but without any detectable subjective or objective signs of sensibility in the lower leg or foot. No function, i.e. no voluntary contraction, in the muscles of the lower leg below the site of the lesion could be seen (Table \n). Different additional surgical procedures, like nerve transfers as palliation in the lower leg, were also considered\n[] and discussed with the patient, but such procedures were declined. |
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 55-year-old gentleman, ex-smoker, presented to our hospital complaining of mild epigastric pain, regurgitation, and heartburn. On top of that, he has a long-standing history of gastroesophageal reflux disease (GERD), which was managed by proton pump inhibitors. His past medical history was significant for hypertension. He was previously diagnosed with a liver hemangioma based on abdominal ultrasound two years before the presentation. He had no relevant family history. Physical examination revealed mild epigastric tenderness with no palpable abdominal mass. Laboratory data showed no anemia but positive stool occult blood test. Tumor markers including AFP, CEA, and CA 19-9 were all within normal range. Upper GI endoscopy revealed mild esophagitis, Los Angles grade A along with Barrett's esophagus without dysplasia and a 1 cm polyp at the GEJ. A sample was sent for histopathology; the rest of the stomach and duodenum were normal. The patient did not have a previous endoscopy prior to this one.\nInfused computed tomography (CT) of the abdomen and chest showed mild GEJ thickness with no evidence of mediastinal or celiac lymphadenopathy and no signs of metastasis. It also demonstrated a large heterogeneously enhancing mass about 6 × 9.5 cm with central necrosis in the upper abdomen that appears to be originating from the gastric antrum (greater curve). The mass was highly suggestive of GIST based on CT; it was the same mass that was previously misdiagnosed as a liver hemangioma (). Endoscopic ultrasound confirmed the previous findings. However, no biopsy was attempted due to the risk of bleeding.\nHistopathological examination of the GEJ polyp revealed tubulovillous adenoma with elements of adenocarcinoma in situ. The patient was admitted with a provisional diagnosis of early-stage adenocarcinoma of GEJ along with the incidental finding of enlarging gastric GIST. A trial of endoscopic mucosal resection of GEJ polyp was attempted but failed because of the polyp location that created a technical difficulty. Therefore, the patient was taken to the operating room with a plan to perform a wedge resection of the gastric mass and a submucosal resection of GEJ polyp through the same gastric opening. We planned to use frozen section (FS) to document negative margin resection and determine the need for a formal esophagectomy. Intraoperatively; a large (10 × 7 × 6 cm), extraluminal pedunculated mass was found at the posterior wall of the greater curvature of the stomach (). Wedge resection of the gastric mass with negative margins was achieved along with a transgastric submucosal resection of the GEJ polyp. Fortunately, the FS examination of the polyp showed negative margins as well with no evidence of deep invasion. Postoperatively, the patient had a smooth course and was discharged home in a stable condition. The final pathological examination revealed a GEJ polyp around 1.7 × 1.4 × 0.6 cm. Microscopically, there was a focus of invasive adenocarcinoma involving the superficial submucosa of the polypoid lesion, negative margins, and no lymphovascular invasion (T1a NxM0). Furthermore, the gastric wall mass measured around 10 × 7 × 6 cm with a 2 × 1.5 cm stalk. Histopathology revealed encapsulated high-grade epithelioid GIST tumor with negative margins (pT3). The mitotic rate of 6/50 HPF and immunohistochemical stains were positive for DOG1 and CD34 but negative for CD117 (c-Kit) ().\nThe final diagnosis was synchronous early-stage GEJ adenocarcinoma and a high-grade gastric GIST. Therefore, the patient was started on adjuvant imatinib treatment, along with endoscopic surveillance every six months and proton pump inhibitors. |
A 69-year-old male was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.\nIn August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.\nA CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetations were thrombi covered with vascular endothelium and that the mitral leaflet tissue was not damaged (Fig. ). On the basis of these findings, the patient was diagnosed as having NBTE.\nAn endoscopic stomach biopsy was performed on the seventh postoperative day, and histologic analysis revealed non-solid poorly differentiated adenocarcinoma with components of signet-ring cell carcinoma and moderately differentiated tubular adenocarcinoma. The patient was definitively diagnosed as having Trousseau’s syndrome and, subsequently, transferred to the department of surgery. A Billroth I distal gastrectomy was performed, and a continuous intravenous heparin drip was employed during the operation. Histologic analysis revealed poorly differentiated adenocarcinoma with a component of moderately differentiated tubular adenocarcinoma and metastatic tumor cells in the dissected lymph nodes (T4aN3bM0; stage IIIb). Further histologic analysis using alcian blue staining confirmed the presence of mucin in the tumor.\nSubcutaneous heparin injection was introduced on day 8 after the gastric surgery, and the patient was discharged from our hospital in October after acquisition of the self-injection technique. During this long hospitalization, no thromboembolic events were observed. Chemotherapy was started in November. The patient has survived for 18 months after the diagnosis of Trousseau’s syndrome without any recurrence of thromboembolism. |
A 36-year-old woman at her third pregnancy was referred to our third level prenatal ultrasound diagnostic center to undergo the first trimester screening exam during the 13th week of gestation. Fetal anatomy was regular, except for the presence of an anomalous umbilical cord cyst. It had a maximum size of 18 mm and regular margins and was adjacent to the abdominal wall. This cyst was avascular, had no internal septa or vegetations, and was within the umbilical cord, embraced by the two umbilical arteries, in communication with the bladder. Its size varied during the ultrasound examination, which lasted several hours, configuring the diagnostic suspicion of an allantoic cyst with patent urachus ().\nAmniocentesis was performed to rule out chromosomal or genomic anomalies. The traditional karyotype study and array-based Comparative Genomic Hybridization- (CGH-) array showed no alterations related to an allantoic cyst, such as trisomies 13 and 18. Subsequently, the patient underwent a second trimester screening exam at our center during the 21st week of gestation. The biometric values appeared overall greater than a week compared to gestational age, and the allantoic cyst showed an increased size, with a maximum diameter of 46 mm; the remaining anatomy explored by ultrasound was regular (). In the following ultrasound check, performed during the 32nd week of gestation, the cyst and the bladder were no longer visible, due to cyst rupture, while an omphalocele of 35 × 31 millimeters appeared, consisting of loops of small intestines coated with membranes (). The patient then underwent fetal magnetic resonance imaging, which confirmed the ultrasound findings and showed a stretching of the bladder dome through the abdominal wall defect.\nGestation was carried out regularly, and delivery was by elective cesarean section in a facility equipped with neonatal intensive care and pediatric surgery unit. Two days after birth, the peritoneum covering intestinal loops broke spontaneously, and the newborn underwent successful urgent surgery (). Subsequent pathological examination found the presence of uroepithelium, confirming the prenatal diagnostic suspicion of an allantoic cyst. |
A 16-year-old male adolescent was referred in our tertiary care hospital with chief complaints of inability to stand or walk for 8 days before which he was apparently asymptomatic. His symptoms began slowly following an upper respiratory tract infection that he had about 10 days prior. His upper respiratory symptoms improved, but 2 days later, he started having bilateral lower extremities weakness. The weakness progressed in his upper extremities. He was hospitalized in a private hospital 3 days later with complaints of difficulty in walking and weakness in all four limbs. He also developed respiratory muscle weakness and was not able to maintain oxygen saturation, so he was kept on mechanical ventilator. There was progressive deterioration in power of all four limbs. He was treated with antibiotics and steroids, but there was no improvement in his clinical condition, then he was shifted to our tertiary care hospital for further management after 10 days of the starting illness with GBS disability score 5, i.e., on ventilator.\nOn physical examination, he was calm, conscious, and oriented to time, place, and person with E4VTM6 on Glasgow Coma Scale. Pulse was 72/min. Blood pressure was 130/70 mm of Hg, and oxygen saturation was 100% with mechanical ventilator continuous positive airway pressure mode. Pupils were bilaterally reactive to light. Deep tendon reflexes were absent in all four limbs. Plantar was mute bilaterally. Power in the upper limbs was 3/5 and that in the lower limbs was 2/5. There was no sensory loss. Cardiovascular, respiratory, and abdominal examinations were unremarkable.\nRoutine studies of blood and urine gave normal results. His cerebrospinal fluid revealed elevated protein count of 200 mg/dl, with normal cell count, which supported the diagnosis of GBS. Nerve conduction studies of the patient showed predominantly motor demyelinating neuropathy with secondary axonal involvement which confirmed the diagnosis of AIDP. TPE was planned. The plasmapheresis regimen consisted of removal of 1.3 plasma volumes in each cycle for total of five cycles, on daily basis. Before starting the treatment, the patient's attendant was explained about the risks and benefits of treatment, and consent was taken. First TPE was performed emergently on the day of admission to our hospital in the Intensive Care Unit (ICU) on Terumo BCT COBE Spectra Apheresis System machine and continued daily for 5 days using plasma only as the replacement fluid instead of albumin due to nonaffordability of the patient. All procedures were completed uneventfully.\nThe patient's condition started improving after three cycles of TPE with power in the upper limbs 4/5 and lower limbs 3/5. The patient was also weaned off from ventilator after the 4th TPE. There was progressive improvement in the muscle power in all four limbs within 10 days of admission to our hospital. He started walking with aid in 20 days []. |
Our patient first presented to us in late 2007. At that time, she was 65 years old, with a significant past medical history of CREST syndrome. She also had overlapping rheumatoid arthritis, for which she was on methotrexate. In addition, she had primary hypertension, left ventricular hypertrophy, and evidence of lung fibrosis on her CT thorax. Her main orthopaedic issue was that of debilitating right dominant shoulder pain and stiffness. This had compromised her already impaired day to day function as she had developed bilateral end stage sclerodactyly. She was unable to reach her buttock or hair and required much assistance for her activities of daily living. Her left shoulder was also affected, but to a less painful degree, and she also had developed other sites of symptomatic (ankle) and asymptomatic calcinosis.\nOn examination, she had multiple soft tissue calcific deposits visible on both hands and feet. She had end stage sclerodactyly with ankylosis of all her proximal and distal interphalangeal joints. She had petechial telangiectasis of her palms, mild clubbing of her fingers, and overall very poor hand function. Both shoulders had a passive forward flexion and abduction of 40 degrees and internal rotation to her buttock. External rotation was 15 degrees on the left side and −10 degrees on the right side. Rotator cuff testing was difficult due to limited movement and pain, but rotation against resistance produced pain. Active forward flexion produced pain and was severely limited to the extent that self-feeding was no longer possible. The severe pain on her right side was localised to the anterior shoulder region. Biceps tendon stress tests were inconclusive at the initial assessment. However, a rotator cuff pathology and intra-articular source of pain could not be excluded clinically.\nHer shoulder radiographs showed widespread calcinosis in the periarticular soft tissues but also suspected intra-articular infiltration (). She was given a local steroid/anaesthetic injection to her intra-articular space and referred to physiotherapy and acupuncture. A CT scan was requested which showed no evidence of joint space narrowing or erosive arthropathy but confirmed both intra- and extra-articular calcinosis (). Incidentally, she was also noted to have significant calcinosis in her right ankle and left knee joints as well ().\nAt her next review, she reported that the injection had given her no relief at all and that her symptoms and presentation remained largely unchanged. Repeat examination confirmed persistent mainly anterior shoulder pain and a positive Yergason's biceps tendon stress test was evident. Given the localised pain and calcific mass in the region of the bicipital groove, which was evident on the radiographs and confirmed on the CT scan, she was given another local steroid/anaesthetic injection to the biceps tendon. The infiltration led to instant pain relief and some improved movement in clinic, and she was advised to continue on with her physiotherapy.\nOver the next year, her symptoms and pain fluctuated and she was given 2 further injections with some prolonged benefit. Self-feeding was restored and she would on rare occasions enjoy “good” function and was able to put on her jacket and do her toileting independently. Her case was discussed with several local and external shoulder specialists. The unanimous opinion was to avoid open debridement surgery due to the extensive nature of the calcinosis and the worry that the capsulotomy performed would give rise to a marked collagenosis response which would lead to increased stiffness and poorer function ultimately. Eventually, should she develop joint arthropathy, shoulder arthroplasty could be a consideration. She was hence given repeat local steroid/anaesthetic injections to her biceps tendon as required and continued with physiotherapy for the time being.\nHowever, by late 2009, her right shoulder pain and stiffness had become constant, unresponsive to injections (with only short term benefit), and significant enough to revisit the indication for surgery. She was counselled regarding the possible risks of infection, failure of the procedure to alleviate symptoms, increased stiffness, and possible recurrence of symptoms.\nShe underwent an open exploration of her right shoulder joint, excision of calcific deposits, and biceps tenodesis in November 2009. This was done under general anaesthetic with an interscalene block and antibiotic prophylaxis. Through a small 5 cm skin incision along the deltopectoral approach, the shoulder joint was approached. The subscapularis was incised and reflected and a capsulotomy was made. A chalky white stained effusion was drained from the joint. The shoulder was not dislocated, but it was inspected and found to have no intra-articular loose bodies. A thorough washout was performed. The biceps tendon was then explored and found to have a degenerative rupture, with massive, hard solid calcific deposits. These were excised to the level of healthy normal tendon, which was then tenodesed with a suture anchor below the bicipital groove. After further washout, the subscapularis was repaired, allowing for neutral rotation. The wound was closed in layers, and she was referred to early postoperative physio (limiting external rotation) for mobilisation.\nAt her clinical reviews at 3 months and 18 months postoperatively, she was extremely pleased with the continued pain relief from the procedure. Her active range of movement in the shoulder was also much better, and she was able to reach her mouth and feed herself. Her surgical wound had healed well and she had no residual tenderness over the anterior aspect of her proximal humerus. At a most recent follow-up in 2016 her status quo in relation to her right shoulder had been maintained with no decline in function and no recurrence of shoulder pain. |
A 4-year-old girl was admitted to our hospital in November 2014 with a large, painful and worsening mass (about 20 × 23 cm) on the left side of the neck (Fig. ). From her past medical history, she initially presented in December 2012 (then aged 2) with a 1-month history of the parents noticing a red left eye and decreased vision. She was found to have cells in the anterior chamber, iris nodules, vitreous opacities and secondary glaucoma. The right eye was normal. Computed tomography (CT) scans showed left intraocular soft tissue density mass lesions with specks of calcifications. Magnetic resonance imaging (MRI) showed a left intraocular mass that was hyperintense relative to the vitreous on T1WI and markedly hypointense relative to the vitreous on axial T2WI (Fig. ). Depending on the calcification, demonstrated well with contrast administration and thin sections with fat suppression, a diagnosis of retinoblastoma stage E was made. There was no positive family history. Enucleation was proposed but was refused by the girl’s parents. After 1 year (in December 2013), the patient presented with periocular oedema and conjunctival chemosis for 3 months. She had been enucleated in another hospital. The CT and MRI before operation are shown in Fig. . Histopathological examination revealed the retinoblastoma and showed that tumour cells had invaded the sclera, but tumour cells were not found at the end of the optic nerve. She did not receive any chemical or radiological treatment after the operation. In May 2014, the patient presented with a growing mass in the left orbit and small hard lump of the left side of the neck (Fig. ). Fine needle aspiration biopsy (FNAB) of the lump was performed, and it was found positive for tumour deposits of retinoblastoma cells in a local hospital. The parents refused chemotherapy once more due to poor financial situation. After 6 months, the patient presented again because the mass of the left side of the neck was growing too large and painful to tolerate (Fig. ). A multidepartment collaboration mode of treatment was applied, which involved surgery, postoperative chemotherapy and/or additional local radiotherapy.\nA systemic workup including bone marrow biopsy and cerebrospinal fluid (CSF) analysis was also carried out. The bone marrow was negative for tumour deposits of malignant round cells. The CSF cytology was within normal limits. Based on this, a diagnosis of stage IVa metastatic retinoblastoma (a distant metastatic retinoblastoma without CNS involvement) was made. The systemic condition of the child was poor.\nA one-stage surgery was conducted immediately. The orbital tumour was completely resected in December 2014. Since the patient had a large tumour invasion range in the left side of the neck not suitable for complete resection, the tumour was resected as much as possible while retaining organ functions. Histopathological examination revealed orbital retinoblastoma and a large intraparotid mass. The immunohistochemical staining results were as follows: Syn(++), β-micprotin(++), Ki-67(++, index 80%), CD56(++), NSE(++), Rb(++), MyoD1(++), Fli-1(+), S-100(-), CgA(-), CD99(-), CD57(-), vimentin(-), EMA(-), myogenin(-), Pax-5(-), CK18(-), LCA(-), and desmin(-). Metastasis of the parotid and submandibular glands was confirmed, and the patient underwent systemic evaluation for any other site of metastasis; however, there was no other organ involvement.\nThe patient was started on a 3-weekly high-dose chemotherapy protocol with vincristine, etoposide and carboplatin (VEC regime). Following six cycles, the left orbital tumour had regressed completely, there was a small residual tumour in the left side of the neck, and additional local radiotherapy was performed on the parotid and submandibular glands (Fig. ). At the most recent follow-up at 28 months, the tumour was inactive and stable as of April 2017 (Fig. ). The girl remained on maintenance therapy and under our follow-up care. |
A 23-year-old female patient was referred to the department for the management of a mandibular partial edentulous area having high muscle attachment. The patient was being considered for an implant placement for missing mandibular right first permanent molar (Teeth no. 46). The high muscle attachment was considered to be an impediment for proper implant placement and in maintaining proper oral hygiene. The patient's main chief complaint was difficulty in chewing food because of the missing tooth and food lodgment due to high muscle attachment in the mandibular region (46).\nOn examination, patient medical history was unremarkable, with no report of incidents of trauma and infections. On examination, the patient was a well-built, well-nourished, well-oriented, and mentally sound adult. No medical history and no extraoral abnormalities were detected. The patient did not indulge in tobacco or alcohol chewing habit.\nIntraoral examination showed good oral and periodontal hygiene. Tooth no 46 was missing, and the extraction was done because of the decayed teeth. The height and width of the edentulous ridge were maintained. On retracting the cheek, a frenum-like band of soft tissue attached at the crest of the edentulous ridge was observed. On closure examination, anatomic reference points and the nature of the attached tissue revealed that it was the buccinator muscle whose attachment was abnormal. The origin of the attachment extended to the crest of the alveolar ridge. The vestibular depth was almost nonexistent in that area [].\nThe attachment of the muscle leads to the difficulty in movements of the toothbrush, leading to suboptimal oral hygiene. The attachment would have definitely created a space problem for the implant placement and, because of the food impaction in that area, may further worsen the situation. A decision to reposition the attachment apically was undertaken. Muscle repositioning treatment was discussed with the patient. The patient accepted the apical repositioning with an acrylic stent treatment option and gave written consent.\nRoutine blood investigations were carried out and were found within normal limit.\nAn alginate impression of the lower arch was taken, and a cast was made in dental stone. It was decided to construct an acrylic surgical stent, as a periodontal dressing would not have stayed in proper apical position due to counteracting forces created by high muscle attachment. Approximating the anticipated loss of tissue resulting from the surgical procedure, the patient's cast was marked and scored to ensure close contact of the acrylic surgical stent with the alveolar ridge []. A passive fit of the acrylic surgical stent was checked in the patient's mouth, and the final adjustments were made. The stent was then smoothed and highly polished to minimize the accumulation of plaque [].\nLocal anesthetic (2% lignocaine with 1:80,000 epinephrine) was administered, and a crestal incision was made, keeping the incision slightly buccal []. The incision was extended anteriorly two teeth and posteriorly distal to the last molar. The muscle attachment was detached from the crest, and dissection was continued inferiorly for approximately 1 cm–2 cm. Deeper to that, the dissection continued apically keeping the periosteum intact. The vestibular depth and muscle repositioning were checked by retracting the cheek []. After adequate depth was achieved, the surgical area was irrigated with normal saline, the bleeding controlled, and the surgical stent stabilized in the surgical area [].\nPostoperative instructions were explained to the patient, and a course of antibiotics and analgesics were given for 5 days. The patient was recalled after 7 days for reevaluation []. The stent was retained in position for 15 days to allow complete healing with regular normal saline irrigations and oral hygiene instructions. The area healed uneventfully without any complication. Adequate vestibular depth was achieved after 2 months of healing [], there was the significant gain in vestibular depth, and the muscle was relocated to an apical position, thus allowing the toothbrush head to be positioned properly for maintenance of proper oral hygiene. The implant placement was done after 3 months of complete healing. |
A 46-year-old woman with morbid obesity, hypertension, hyperlipidemia, active smoking, and bipolar disorder was evaluated for paroxysmal atrial fibrillation as an outpatient. A transthoracic echocardiogram showed a right atrial mass close to the RA-IVC junction. A transesophageal echocardiogram confirmed the presence of a pedunculated right atrial mobile bilobular mass measuring 2.1 × 1.8 cm, not arising from the interatrial septum with extension into the inferior vena cava (Figures –). A secundum atrial septal defect was also identified. The patient was referred to cardiac surgery for resection of a presumed right atrial myxoma given the possibility of embolization. The intraoperative TEE suggested the presence of one bilobulated mass arising low in the right atrium.\nUsing aortic and bicaval cannulation, a right atriotomy was performed and a discrete 2 × 3 cm mass was removed from the IVC-RA junction near the Eustachian valve. The right atrium was closed and the patient weaned from bypass. The specimen did not appear to be a myxoma, so it was sent for frozen section and interpreted as being ectopic liver tissue. In the interim, a repeat TEE showed an additional discrete 2 × 2 cm mass in the IVC near the hepatic veins. Femoral venous cannulation was then performed to allow for visualization of the IVC below the pericardial reflection. Through the same right atriotomy and using additional suction directly in the IVC, the IVC mass was visualized and resected. Both specimens were interpreted as showing partially encapsulated liver parenchyma with mild steatosis, fibrosis, ductal proliferation, and periductal chronic inflammation, consistent with ectopic hepatic tissue ().\nDespite a brief period of cardiopulmonary bypass, the patient had persistent hypoxemic respiratory failure ascribed to her morbid obesity and underlying lung disease. She also developed extensive left lower extremity deep venous thrombosis from a presumed heparin-induced thrombocytopenia for which she was treated with argatroban and placement of an IVC filter. Because of chronic respiratory failure, she underwent tracheostomy and feeding tube placement, and she was placed on warfarin for intermittent atrial fibrillation due to her CHA2DS2-VASc score of 4. She gradually improved and was transferred to rehab where her tracheostomy tube and PEG tube were removed. A few months later, she looked quite well during an office visit. |
A 58-year old woman presented with exertional dyspnea and intermittent chest discomfort. She had no past medical or familial history, and physical and neurological examinations, chest radiography, and electrocardiography findings were normal, although ESR was high at 54 mm/hr. However, echocardiography revealed a huge, immobile mass without pedunculation occupying both atria (Figure A). Due to its atypical characteristics and position, we performed a magnetic resonance imaging scan. Images showed a well-defined mass within the inferior portions of both atria with high signal intensity on T2 weighted images, slightly high signal intensity on T1 weighted images, no fat suppression on fat saturated images, and strong peripheral enhancement on gadolinium enhanced images. In addition, multiple calcified lesions of low intensity were noted within the tumor and the coronary sinus was inferiorly displaced by the mass (Figure B,C). Surgery was performed via conventional median sternotomy. During cardiopulmonary bypass, IVC cannulation was performed through the left femoral vein instead of the lower right atrium because the inferior vena cava was almost totally obstructed and the distal embolization should be prevented. The tumor was resected and the interatrial septal defect was closed with pericardium. The non-pedunculated tumor involved most of the interatrial septum and extended from the orifice of the inferior vena cava to the displaced mitral annulus and the lower left pulmonary vein. The resected specimen weighed 76 gram and measured 80 × 40 × 30 mm and was not gelatinous but solid. The one third of the right side of the specimen protruded into the right atrium, covered with endothelium but the two third of the left side of the specimen was attached to the base of the left atrium. The cut surface showed the multi-focal calcification and hemorrhage. Histologic examination confirmed myxoma without any other malignancy (Figure A,B,C). The patient was discharged without any complications, and during the 2-year follow-up period, she did not complain of dyspnea or show any sign of recurrence by echocardiography. |
An 86-year-old female was hospitalized due to anorexia and a persistent fever lasting for the previous three weeks. She had been receiving regular follow-up care for hypertension and an old brain infarction at our hospital. She had undergone endovascular stent grafting for a thoracic and abdominal aortic aneurysm six months prior to admission. At the last visit three weeks prior to admission, she underwent regular computed tomography, which revealed an aortic aneurysm with stent grafting measuring 55 mm in diameter. This was almost identical to the diameter observed just after stent insertion. At that point, she had no complaints, and no inflammatory responses were observed on a biochemistry analysis.\nOn hospitalization, the patient was alert. Her blood pressure was 148/90 mmHg, her heart rate was 90 beats/min, her body temperature was 37.8°C, and her respiratory rate was 12 breaths/min. A physical examination revealed weak inspiratory coarse crackles in the left lower lobe. The patient's biochemical parameters and urinary findings are summarized in . The white blood cell count was 7600/μL with 80.8% neutrophils. The CRP level was 197 nmol/L. The levels of fibrin degradation product (FDP) and D-dimer were not measured at that time. Laboratory tests related to autoimmune diseases were all negative. Blood cultures for bacteria, the levels of endotoxin and serum -D-glucan, and an interferon-gamma release assay for tuberculosis were all negative. Electrocardiogram was normal. Echocardiography revealed a moderate level of pericardial effusion with a preserved left ventricular ejection fraction and mild tricuspid regurgitation. Plain computed tomography disclosed a moderate level of pericardial effusion, infiltration in the left lower lobe, and a small amount of bilateral hydrothorax and the endovascular stent graft from the middle part of the aortic arch to the upper part of the descending abdominal aorta. The false lumen of the ascending aorta exhibited a relatively high density compared to the abdominal aorta (). However, the diameter of the ascending aorta was 55 mm, identical to that observed three weeks prior to admission. Although we also considered the possible involvement of a stent infection, we were unable to confirm this diagnosis using positron emission tomography or 67Ga scintigraphy; these modalities were not available at our hospital.\nAt that point, we were unable to determine the cause of the high serum CRP level, and we administered 2 g/day of sulbactam cefoperazone under a tentative diagnosis of pneumonia in the left lower lung. Because the result of the serum procalcitonin test performed on admission was negative, the antibiotic therapy was discontinued. Although antibiotic treatment was stopped, the serum CRP level continued to decrease, and the patient was discharged on the 11th day. On day 19, the serum CRP level was 32.4 nmol/L at the outpatient clinic. However, 15 days after discharge (the 27th day), the patient again developed an elevated serum CRP level (161 nmol/L) and high fever.\nOn the second hospitalization, the serum procalcitonin test was again negative. The FDP level was 37 mg/L (N; <10), the D-dimer level was 96.0 nmol/L (N; <3.0), and the fibrinogen level was 19.1 μmol/L (N; 5.8–11.8). CK-BB isozyme was also increased (1.3%). Contrast-enhanced computed tomography was performed on the 27th day, which revealed enlargement of the diameter of the aorta (from 55 mm to 60 mm) and partial enhancement of the false lumen of the ascending aorta (Figures and ). Further, the pericardial effusion had further increased compared to that observed on the first day. The patient was finally diagnosed as having dissection of the ascending aorta, in particular, Stanford type A aortic dissection with thrombosis of the false lumen of the ascending aorta (Figures and ). She was immediately transferred to the university hospital and underwent total aortic arch replacement with an artificial graft. After the operation, the patient's serum CRP level became normal, indicating that the inflammation of the aortic wall was the cause of the high serum CRP level with the negative procalcitonin test (). |
A 64-year-old female patient had been diagnosed with left VGN 4 years before her admission to our clinic and had been treated with carbamazepine, and gabapentin, which are effective on neuropathic pain. Ganglion blockade with radiofrequency ablation (RFA) had been used twice; as a result, the patient had benefited from these procedures for a short time. However, on her admission, she had an electricity-shock-like intolerable pain beginning from the left ear and extending to the larynx. She stated that talking and chewing triggered the pain. The case of the current study described the pain she had as almost the same as the other patients of VGN reported to have in the relevant literature. In other words, no other characteristics of pain caused by choroid plexus compression were described by our patient compared to typical pain described by VGN patients. Moreover, she had neuralgia-related sleepiness, weight loss, and depression. On her cranial magnetic resonance imaging (MRI) [], there was an image suspected as a vascular decompression. The patient underwent an MVD operation and her pain relieved in postoperative period. When the images of MRI [] were analyzed retrospectively, we noticed that choroid plexus could be observed on the images of MRI although it was shown in grey.\nMVD was applied to the 9th and 10th cranial nerves of the patient with the left retrosigmoid lateral suboccipital craniotomy on prone position under microscope. A significant posterior inferior cerebellar artery (PICA) compression was not observed from anterior on the 9th and 10th cranial nerves in intraoperative observation; on the other hand, choroid plexus tissue causing compression on root entry zones [] was identified and it was resected. Afterward, root entry zone compression was seen to disappear, and a clear change of the color of the root entry zones of the 9th and the 10th cranial nerves was observed []. Despite the absence of a significant vascular compression, PICA, and the 9th and the 10th cranial nerves were separated with a Teflon sponge. In the postoperative period, the patient had no pain, which was reported to exist before the operation, related to VGN. No complications were detected in the postoperative course. She had no pain or any other complaints at the end of the 6th month after the surgery. |
A 66 year-old male received a computed tomography (CT) scan of the abdomen one year after resection of a rectal cancer. His rectal cancer had been treated with low anterior resection and neoadjuvant chemotherapy, and pathology demonstrated a T3N1M0, moderately differentiated adenocarcinoma. He was referred to the hepatobiliary service for consultation. At presentation, he was asymptomatic. His past medical history was significant for hypertension. His only prior surgical procedure was low anterior resection for rectal cancer. On examination, he did not appear jaundiced; his abdominal examination was unremarkable and laboratory investigations were normal. His CT scan showed a single metastatic deposit in segment one of the liver. A positron emission tomography – computed tomography (PET/CT) scan was consistent with the CT with no extrahepatic disease found. At our institution, decisions regarding pre-surgery chemotherapy are made on a case-by-case basis. When the wait for surgery is likely to be beyond four weeks, usually patients will be offered chemotherapy. In this case, response to the various interventional radiology procedures was well beyond four weeks and for this reason chemotherapy was offered. A referral was made to medical oncologists for neoadjuvant chemotherapy and the patient received six cycles of FOLFOX. A postchemotherapy CT scan showed stable disease. Liver resection was attempted four weeks after the completion of his chemotherapy. A bilateral subcostal incision was made. After liver mobilization, it appeared that the tumor was larger than initially anticipated and had invaded past the middle hepatic vein and extended to the right of the middle vein, requiring a left trisectionectomy.\nIntraoperative ultrasound (US) confirmed that an extended left hepatectomy would be required to achieve a R0 resection. A decision was made to abort the operation, given the concern that his liver appeared grossly steatotic; his posterior sector would be less than 25% of his total liver volume; and there was potential for hepatic congestion after middle vein ligation, especially with a prominent middle vein tributary draining the right segment (Figure ). His postoperative course was unremarkable. Two weeks later he underwent left portal vein embolization with cyanoaccryalate lipidol without complications. Three weeks later he underwent left hepatic vein embolization. One week after left hepatic vein embolization, a middle hepatic vein embolization was performed in similar fashion without complication (Figure ). Hepatic vein embolization was performed with an Amplatzer vascular plug (AGA Medical Corp.) via a right internal jugular vein access. Position of the plug was confirmed in the angiography suite using a multi-detector limited arc CT (XperCT, Philips Healthcare) with a guidewire within the targeted hepatic vein. Four weeks after middle hepatic vein embolization, an extended left hepatectomy was performed using the same incision. Intraoperatively, an atrophic left lobe was noted and a left extended hepatectomy with total vascular exclusion, five minutes preconditioning and an estimated blood loss (EBL) of 1,000 cc was performed. His postoperative course was uneventful and on postoperative day five, his international normalized ratio (INR) was 1.2 and total bilirubin was 52 μmol per liter. Pathology revealed three tumors in the resected specimen consistent with metastatic adenocarcinoma of colorectal origin, with negative microscopic margins and areas of necrosis together with patchy steatosis and stage two fibrosis. |
A 71-year-old male patient presented to the surgical emergency department of our hospital complaining of abdominal pain and constipation. Basic laboratory tests on admission were within normal range. Clinical examination revealed abdominal distention, dehydration and no evidence of bowel sounds. Systemic and neurologic diseases as well as infections and malabsorption syndromes were excluded by medical history, physical and blood examination. From the patient's history, chronic constipation had achieved 20 points in the Wexner Constipation Scale (WCS) [] since his infancy. He had occasionally received treatment with laxatives and rectal enemas. His last surgery had been 10 years before and included sigmoidectomy. Histopathology analysis of the resected sigmoid colon showed a dilated bowel with no evidence of malignancy, and no other immunohistological analysis was done. The patient stated that the symptoms of constipation had never resolved, while during the last 6 months he had been admitted to hospital twice due to bowel obstruction and treated without surgery.\nDuring the last admission to our hospital, an abdominal X-ray showed a massively distended large bowel (fig. ), and an abdominal computed tomography scan did not reveal any mechanical obstruction (fig. ). Due to excess abdominal tenderness and radiological findings, it was decided that an exploratory laparotomy would be appropriate. During laparotomy (fig. ) no obvious mechanical cause was found and a subtotal colectomy and Hartmann's procedure was performed. The patient had an uneventful postoperative course and was discharged on the 12th postoperative day with a temporary ileostomy.\nIn the pathology department, gross examination showed that the colon and especially the cecum was distended and its mucosal surface appeared flattened, with a polypoid lesion measuring 2.5 cm found in the cecum. Microscopic examination and immunohistochemical study of the polypoid lesion proved that it was a villoglandular adenoma with low-grade dysplasia, and full-thickness analysis of the resected colon revealed enlarged myenteric and submucosal neurons as well as an increased number of giant cells. The nerve bundles appeared hypertrophic, containing increased numbers of thickened disorganized axons. A small number of isolated ganglion cells and giant submucosal ganglia (containing 7–15 ganglion cells) (fig. ) were also detected in the submucosa. Immunohistochemistry was applied by using antibodies against protein S-100, neuron-specific enolase, glial fibrillary acidic protein and synaptophysin. Protein S-100 and synaptophysin revealed an increase in ganglion cells, and glial fibrillary acidic protein staining showed increased nerve plexus around blood vessels. The diagnosis of IND was established.\nThree months later, during his second admission for restoration of bowel continuity, preoperative rectoscopy and rectal manometry showed no significant findings. During surgery for bowel continuity restoration, the upper third of the rectum was removed and an ileorectal (side to end) low anterior anastomosis to the posterior wall of the rectum 6 cm above the dentate line was performed. The patient was discharged on postoperative day 10 and during a 2-year follow-up has remained asymptomatic with normal bowel motility. The WCS score is 8 points, showing a significant difference compared to 20 points preoperatively. |
A 39-year-old female presented with severe excruciating left leg pain to gentle touch and left leg swelling. She had been diagnosed and treated conservatively with warfarin elsewhere for extensive proximal left lower extremity DVT and a small right lower lobe pulmonary embolism a week before. The patient was hemodynamically stable but was uncomfortable due to severe pain. Her left leg was almost twice the size of her normal right leg. Physical examination showed pitting edema, focal bluish discoloration over the anterior lower shin, visible varicosities, and peripheral pulses detectable only by Doppler ultrasonography. She had exquisite tenderness to palpation in the left leg and pain with passive motion. However, she was able to move her legs. Her body mass index was 26.8 kg/m2.\nHer past medical history was not significant and she denied any history of smoking or illicit drug use. She was homeless and had a history of two spontaneous miscarriages in the past with no obvious cause, but she denied a history of any medications including oral contraceptive pills. Family history of hypercoagulable states was absent. Laboratory values including renal function tests and lipid profile were unremarkable except for an international normalized ratio (INR) of 1.6. Human immunodeficiency virus and hepatitis C virus serology were negative. Venous Doppler study showed a large clot extending from the left common iliac vein to the common femoral vein and the popliteal vein. CT venogram of the lower extremity confirmed the clot and showed a small amount of thrombus at the inferior vena cava (IVC)/left common iliac vein junction. The above findings suggested the diagnosis of MTS (Figures -).\nAs she was a suitable candidate for mechanical thrombolysis and thrombectomy, she underwent catheter-directed mechanical thrombolysis and thrombectomy of the complete left lower extremity venous system and the left common iliac vein on the third day of admission. She was monitored in the intensive care unit postoperatively and had no complications. On the next day, angioplasty was done for high-grade focal narrowing (>90%) of the left common iliac vein and the external iliac vein, with near-complete resolution post-treatment (Figure ) and no post-procedure complications. After an additional three days of hospital stay, she has discharged on oral apixaban 10 mg twice a day for one week and outpatient follow-up with a hematologist. After the first week, she was kept on apixaban 5 mg twice a day. One month after discharge, she was readmitted for bleeding and a left mid-foot hematoma, which was evacuated on the bedside. She had no recurrence of thrombosis on six months follow-up (Figure ). Thereafter, she was lost to follow-up. |
A 75-year-old woman (virgo, gravida 0, para 0, body mass index (BMI) = 21) presented with diffuse abdominal pain and enterorrhagia. She entered menopause at the age of 55 and she had regular menstrual cycles with no dysmenorrhea. Her medical history includes hypertension treatment with angiotensin II receptor blocker. She had undergone knee arthroplasty bilaterally and had never complained of bowel or reproductive system symptoms before, while there is no family history of colorectal or endometrial neoplasms.\nThe patient underwent colonoscopy, which was not completed due to bowel intussusception, 28 cm from the anus. It was assumed that intussusception was the result of external pressure. Blind biopsies were performed and the relevant histopathological examination revealed intestinal mucosa with tubular adenoma of low-grade dysplasia. Computed tomography (CT) of the upper and lower abdomen demonstrated a midline pelvic lesion with a transverse diameter of 6.1 cm ( and ). Additionally, two more nodal lesions with a transverse diameter of 2.8 cm each were found in a cephalad and caudal direction (). The caudal lesion was found to be in contact with the anterior surface of the fundus of the uterus. Thus, local expansion of the intestinal tumor to the uterus was hypothesized. Small (diameter <5 mm) local lymph nodes were also revealed. Small cystic lesions were found in both ovaries. The rest of the organs appeared normal (). The lower abdomen ultrasound revealed an atrophic uterus (51 mm × 22 mm × 35 mm) with a thin endometrium (3 mm). The ovaries could not be visualized. No pathological findings were observed in the pouch of Douglas. A thorax CT scan was negative for pericardial or pleural effusion and for any other parenchymal diseases. The preoperative blood test results were normal.\nThe patient underwent sigmoidectomy, with excision of the intestinal mass found preoperatively in CT and colonoscopy, and end-to-end anastomosis with the use of a stapler. Intraoperatively, uterus and adnexa were normal, thus no hysterectomy and/or oophorectomy was carried out. The histological examination revealed a moderately differentiated adenocarcinoma of the colon. According to the morphological characteristics and the immunophenotypic analysis (CK7+ CK20–, Vimentin focally), an endometrioid adenocarcinoma arose from endometriosis while a lesion secondary to endometrioid adenocarcinoma of the endometrium or the ovaries is highly unlike. The carcinoma caused the expansion of the whole intestinal wall and the serosa. The postoperative period was uneventful and the patient was discharged on the ninth postoperative day in a really good condition. |
A 58-year-old Korean female patient had fallen down 4 months previously and suffered a right clavicle shaft fracture. During conservative treatment, the pain continued and open reduction and internal fixation were performed at a local medical center. Preoperative shoulder magnetic resonance imaging showed a pseudoaneurysm around the subclavian artery. However, the pseudoaneurysm was missed. After 1 day, she was transferred to the emergency room because of swelling and pain in the right shoulder, arm and chest areas. She had no past medical history and her vital signs were stable while in the emergency room.\nOn arrival, a tingling sensation in the right arm and pain continued to worsen while the hemoglobin level showed a rapid 4-hour decrease from 8.0 to 4.5 g/dL. We thought that the pseudoaneurysm of the subclavian artery had occurred during the clavicle surgery; thus, three-dimensional computed tomography (3D CT) was performed. Based on the 3D CT findings, we concluded that rupture of the subclavian artery pseudoaneurysm had occurred owing to injury, and emergency surgery was performed (Figure ). From a supine position, under general anesthesia, the right clavicle was removed to expose the subclavian artery. However, the subclavian artery could not be properly exposed owing to a massive surrounding hematoma and large pseudoaneurysm; in addition, a thrill was felt around the pseudoaneurysm and hematoma. Pseudoaneurysm rupture from the subclavian artery injury was suspected preoperatively; however, a subclavian AV fistula with a pseudoaneurysm was suspected intraoperatively, and the area around the sac was thus carefully isolated. During this isolation process, there was a great deal of blood loss that could not be stopped; therefore, we clamped the subclavian and axillary arteries. The thrill was no longer felt, but the bleeding continued. Subclavian vein exposure was difficult, and we could not identify the venous connection site. During compression of the lesion, we decided to perform a median sternotomy for cardiopulmonary bypass and total circulatory arrest.\nThe aorta and right atrium were cannulated to perform conventional cardiopulmonary bypass while lowering the body temperature to 20°C, and the aneurysmal sac was then opened. The artery and multiple venous openings were located inside the sac. The pseudoaneurysm was identified through the downward opening, descending along the chest wall. After removal of the hematoma, graft interposition (end-to-side anastomosis with an 8 mm Ringed Gore-Tex® Vascular Graft) was performed on the subclavian and axillary arteries (Figure A). Warming began while low-flow circulation was initiated, and the multiple venous openings found internally within the fistula were sutured. The total pump time was 150 min, aortic occlusion time was 69 min, and total circulatory arrest time was 51 min. After closure of the sternum, clavicle reduction and internal fixation were performed using a clavicular compression plate. Ventilator care was started in the intensive care unit. Two days postoperatively, the patient was weaned from the ventilator, and transferred to the general ward. Movement of the right hand was normal and the right radial artery pulse was clearly felt. On postoperative day 18, follow-up CT showed that the graft and distal blood flow from the graft were well maintained (Figure B). Swelling of the right shoulder and arm subsided, and the patient was discharged on postoperative day 23 with no further complications. She is currently being monitored. |
A 59-year-old male presented to a chiropractic office with a three-week history of pain in the lumbar and lower cervical spine, which began subsequent to moving boxes in his home. Physical examination findings were consistent with musculoskeletal strain and the chiropractor performed spinal manipulation in both the cervical and lumbar spine without consequence. Later that same day the patient began to experience muscular weakness in his lower extremities and loss of bladder control. These serious neurological symptoms prompted him to seek care within an emergency room. MR scans of the cervical spine and brain, with and without contrast, were performed and initially interpreted as normal. A secondary review of the cervical spine MR noted swelling of the cervical cord, without hemorrhage from C1 to C6 (Figure ), consistent with a clinical impression of “infarction vs. contusion.” Attending physicians at the ER, based on the patient’s history of cervical manipulation earlier that same day, erroneously concluded the patient suffered spinal cord contusion secondary to a manipulation with excessive force.\nThe patient was hospitalized and his neurological status continued to deteriorate over the ensuing days. The continued neurological deterioration, along with the subsequent review of the initial MR scan, called into question the initial etiological conclusions related to the chiropractic manipulation. The widespread edematous changes seen in Figure , extending from the medulla to C5, were inconsistent with a theory that a single manipulation directed to a specific spinal level, could produce such findings. The edematous cord changes, ascending myelopathy and quality of the initial MR, led to acquisition of a second cervical MR (Figure A and B).\nThe second cervical MR scan, performed two days after admission, revealed increased signal intensity along the path of the pontomesencephic vein anterior to the medulla and the anterior spinal vein as it continues along the anterior surface of the spinal cord. These new MR findings also revealed the possible presence of an intracranial DAVF and prompted the performance of a cerebral angiogram. The cerebral angiogram revealed a Type V DAVF draining into the perimedullary venous system. The arterial phase of the angiogram (Figure ) revealed contrast enhancement of the anterior and posterior spinal vein. Surgical inspection, via a retrosigmoid approach, revealed a fistula between the hypophysealmeningeal trunk, a branch off the internal carotid artery, and the pontomesencephalic vein. Arterialized blood within the pontomesencephalic vein was visualized during surgery. A neurovascular clip was placed over the fistula, between the arterial and venous sides and restored the normal venous color within the pontomesencephalic vein. Surgical intervention halted the neurological deterioration. Minimal function returned with rehabilitation. |
An 1-year-old boy was referred to our institution with painful swelling in his mouth. On history taking, his parents reported that the swelling was present for 6–7 months which was earlier small and painless but now has increased in size up to 5 cm × 6 cm. Initially, the patient was seen by a physician who prescribed antibiotic/anti-inflammatory therapy, however, the treatments were ineffective, and he was, therefore, referred to us. Written informed consent was obtained from her parent for further investigations.\nPain is intermittent which arises on eating and feeding and subsides on taking medication. Clinical examination showed severe facial asymmetry []. A mobile tooth is present in upper left posterior maxillary ridge surrounded by large, firm, and tender swelling. The skin had appeared stretched and inflamed. The opening of the mouth was partly restricted. Intra-oral examination showed a 5 cm × 6 cm, red, firm mass with grayish areas of central necrosis, covering the left side of the maxillary gingiva, from the canine to the second molar region [].\nComputed tomography confirmed the presence of an extensive infiltrative lesion accompanied by severe bone destruction and displacement of adjacent structures []. An incisional biopsy was made. Histopathological analysis of the hematoxylin and eosin stained material showed clusters of small round cells with hyper chromatic nuclei and eosinophilic cytoplasm separated by fibrovascular septae []. The neoplastic cells were strongly positive for vimentin, desmin, myoglobin, and muscle-specific actin. A diagnosis of oral RMS was established on the basis of the history, clinical, radiographic and histopathological findings.\nAfter performing the standard diagnostic workup, the tumor was diagnosed as alveolar RMS. He was referred to the Pediatric Oncology Department, and the proposed treatment plan was a combination of chemotherapy, including vincristine, actinomycine, cyclophosphamide, and dexamethasone radiotherapy. The patient's parents refused external beam radiation therapy. Subsequently, patient developed metastatic lesions in bone and lungs. Despite the treatment, the tumor continued to increase in size, and the patient died from lung metastases 6 months after the treatment. |
This patient is a 73-year-old woman who had previously worked as a part-time sales representative. One year prior to the start of this study, she started to experience dizziness, which became progressively worse. As a result, she was unable to work. On the day of assessment, she was brought to the clinic in a wheelchair by family members because she was not able to stand or walk for long periods of time. The caloric test showed bilateral vestibular hypofunction. During the initial assessments, she required frequent rest.\nIn her first 2 weeks of training, she was only able to perform visual stability training for 3 minutes at a time in a seated position. By the end of the 3rd week, she was able to perform visual stability training with speeds of up to 100o/s for 5 minutes at a time. Long periods of rest between trials were still required. During the 3rd and 4th weeks, she was able to perform training in a standing position. A thin cushion was gradually added to interfere with her balance during the training sessions. By the end of training, the patient was able to walk from the parking lot to the training site with only her long-handled umbrella for support. We also observed significant improvements in self-confidence and mood over the course of the training.\nOne month after the completion of training, the patient exhibited significant improvements in both the DGI and POMA assessments. Her degree of body shift was decreased, and she was able to complete the assessments without rest. A slight side-to-side shift was still observed during the DGI assessment, but in general, she was able to complete the assessments without the help of assisting devices. The patient also indicated that she was willing to return to her previous work in sales. She reported large improvements in her ability to perform daily life activities and indicated that her performance had returned to its original state. |
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. |
A 56 years old female presented with history of road traffic accident with resultant avulsion of her left side of face. There was degloving and avulsion of the left hemi-face including the upper lip nose, forehead skin and eyebrow, upper and lower eyelids and the entire left cheek. The zygomatic bone was also avulsed and displaced laterally. The globe was displaced inferiorly towards the maxillary sinus ().\nThe patient was immediately resuscitated airway management, control of bleeding and maintainence of circulation. Other injuries were quickly ruled out and CT scan with 3D CT of the face was done. CT scan showed avulsion of the zygoma with lateral blowout fracture of the orbit. There was no brain injury. The vision was tested for finger counting which was present at 2 to 3 feet. Decision was taken for an immediate single stage reconstruction of the bony as well as soft tissue avulsion.\nThe patient was taken for surgery and under anesthesia the wound was thoroughly washed with normal saline and diluted betadine solution. All contaminants and foreign bodies were removed. Careful debridement was done and crushed nonviable tissues were excised. The orbital cavity was then reconstructed. The globe was seen to be displaced towards the maxillary sinus. The avulsed zygoma still had soft tissue attachments. There was a piece of lateral orbital rim with the soft tissue flap which was repositioned and the lateral orbital wall was reformed. The fractures were fixed with titanium miniplates. The eyeball was thus repositioned to its original position and the volume of the orbital cavity was restored ( and ).\nOnce the bony fixation was done the soft tissue reconstruction was started. The degloved flap was repositioned. Tacking sutures were taken to the periosteum wherever possible to keep the flap in place. The upper lip was repaired in layers after marking the anatomical landmarks. The mucosa and muscle were repaired with absorbable sutures and skin with nylon. The nose was reconstructed with repair of the mucosal lining followed by repair of the cartilage framework. The nasal ala was repositioned and the skin was repaired. The eyelids and forehead were repaired in layers (). The post-operative course was uneventful. The patient had no problems in visual acuity. The patient was on higher antibiotics for five days and discharged. The sutures were removed on 7th postoperative day. All wounds healed well without any flap necrosis (). The patient had normal vision and full facial functions at six months follow up. |
A 31-year-old healthy female suddenly collapsed with short lasting convulsions in January 2015. Patient’s second pregnancy was at gestational weeks 26 + 5. Her first pregnancy had been uneventful and had ended in normal childbirth. At the time of collapse patient was at home with her spouse who immediately called emergency response center. Dispatcher alerted nearest ambulance capable for basic life support within 60 s from beginning of the emergency call. A cardiac arrest was not identified during the emergency call, but after six minutes from beginning of the call the dispatcher alerted the mobile intensive care unit (MICU) according to the alert protocol of unconscious patient. MICU is normally staffed by two paramedics and an emergency physician. However, there was also an extra paramedic in MICU due to rotation of ambulance staff. The emergency physician on duty was a resident of anesthesiology and intensive care.\nThe first ambulance reached the patient 10 min from beginning of the emergency call. Patient was lying on a couch unconscious and not breathing. No CPR was performed by bystander. Patient was moved to the floor by the EMS personnel. The primary rhythm was ventricular fibrillation and cardiopulmonary resuscitation was carried out according to the shockable rhythm protocol. Before arriving to the scene, the MICU emergency physician was informed about the cardiac arrest of a pregnant patient. A plan of first establishing advanced life support and then deciding on the need for prehospital emergency hysterotomy was made. Emergency physician on duty had no previous experience from caesarean sections.\nMICU reached the patient 15 min from beginning of the emergency call. VF had been defibrillated two times and second two minute cycle of compression was going on. A left lateral tilt of uterus was performed. Patient was intubated and intravenous line was established by the MICU staff. Because of long delay of ALS and no bystander CPR fetal heart beats were checked with an ultrasound device (SonoSite M-Turbo) and were found to be approximately 60 times per minute. The examination was performed during establishing of an intravenous line and report of first responder unit and caused no delay for EH. The decision of prehospital EH was made by the emergency physician and the procedure was performed during ALS of the mother. 18 min from beginning of the emergency call a horizontal abdominal skin incision was made followed by blunt approach to uterus. Uterus was then opened with small horizontal incision extended with fingers. A female infant was born two minutes after the skin incision. There was no bleeding during the operation.\nDuring the EH an additional ambulance and the EMS supervisor were alerted by request of the emergency physician. After the arrival of the additional units a total of nine paramedics and emergency physician were on scene. ALS of the mother continued also during the operation. Amiodarone was prepared to be administered but not given due to asystole following the third defibrillation. Adrenaline was given at 1 mg doses according to the protocol in a total of 5 times. Rhythm was mainly a pulseless electrical activity with no ventricular contractions detected by ultrasound. There was no return of spontaneous circulation and resuscitation was stopped at 49 min from the beginning of the emergency call. Cause of the ventricular fibrillation remains unclear even after autopsy.\nThe infant was cyanotic and not breathing. Low pulse rate was still palpable from the umbilical artery. Airways were suctioned and mask ventilation started. Chest compressions were also started after one minute because the rate of pulse was still low. During the resuscitation, an orotracheal intubation was performed and intraosseous needle was set. After two minutes of CPR the pulse rate increased to 120 per minute and spontaneous breathing efforts and body movements were noticed.\nThe infant was transported to the neonatal intensive care unit of the University Hospital. Despite the hard efforts to maintain body temperature, the temperature was only 30 °C at time of arrival to intensive care unit. Her birthweight was 950 g. On admission, the arterial blood gas analysis showed combined metabolic and respiratory acidosis. pH was 7.05, base excess −14 mmol/l, CO2 8.5 kPa, O2 7.5 kPa and lactate 8.8 mmol/l. Blood glucose was 5.3 mmol/l. The metabolic acidosis was successfully corrected within 12 h after admission. Due to low thromboplastin time, also frozen plasma was administered. Pulmonary gas exchange remained impaired and respiratory distress syndrome (RDS) was diagnosed. Surfactant was administered twice. The pulmonary status improved within the first week of life and the infant was extubated at the sixth day after admission.\nAfter weaning from the invasive ventilation intermittent nasal CPAP was applied. Repeated brain ultrasound remained normal until age of five days when a bilateral grade II intraventricular hemorrhage was diagnosed. However, the hemorrhage was almost completely resorbed before discharge from the intensive care unit to a neonatal ward at the age of four weeks. There were no signs of infection. She was discharged from the hospital at the age of two and half months. Brain MRI at the age of four months was normal. At the age of two years she was healthy and her neurological development was normal for her age. |
A 1-month-old female was admitted to our institution with high fever, cough and poor feeding caused by respiratory syncytial virus infection. Two-dimensional and color-flow Doppler echocardiography demonstrated a grossly hypokinetic and dilated left ventricle with mild-to-moderate mitral regurgitation, in addition to reversal of flow from the anomalous left coronary artery into the pulmonary artery (PA) that constituted a left-to-right shunt. Cardiac catheterization and computed tomography coronary angiography showed the single right coronary arising from the aorta and retrograde filling of the left coronary artery with a very short main coronary trunk that originated from the rightward posterior sinus of the PA (Fig. ).\nCardiopulmonary bypass with bicaval and distal aortic cannulation and mild hypothermia were established. Both pulmonary arteries were dissected and looped. Cardioplegic spikes were inserted into both the ascending aorta and the pulmonary trunk (PT), and a left side vent was placed through the right upper pulmonary vein. The aortic crossclamp was placed high, and cardioplegic solution was delivered simultaneously into the aortic root and the PT using a bifurcated cardioplegia delivery system to maximize protection of the left ventricle, after bilateral pulmonary arteries were snared tightly to prevent perfusion steal into the pulmonary bed from the PA cannula. The ascending aorta was transected at a high level more than 10 mm above the sinotubular junction, and the main PA was transected just below the bifurcation. The left coronary artery originated from the rightward posterior sinus of the pulmonary sinus with a single orifice and a very short main trunk. The coronary button was harvested with a generous cuff of the pulmonary sinus wall, and the proximal portion of the coronary artery was mobilized with preservation of branches. A trap-door incision was made in the ascending aorta higher than the aortic commissure (Fig. A), and the coronary cuff was sewn with a 7-0 polypropylene suture, starting at the bottom of the J-shaped incision and the inferior end of the cuff. After partial resection of the superior edge of the J-shaped aortic flap, the superior excess cuff was folded inside and covered with the bay window-like bulged coronary channel (Fig. B). The proximal aortic stump was anastomosed to the ascending aorta with a 6-0 polypropylene suture. The anterior wall of the transverse section of the ascending aorta was anastomosed to the inner edge of the folded-down cuff (Fig. C). The defect in the main PA was reconstructed with a generous fresh autologous pericardial patch.\nThe patient's postoperative course was uneventful, and echocardiography revealed trivial mitral regurgitation after weaning off cardiopulmonary bypass. She had an uneventful postoperative recovery and no kinking and overstretching of the translocated left coronary artery (Fig. D). |
A 20 year old Sri Lankan male who was employed as a helper in a grocery, admitted to our unit with weakness of both hands of 1 month’s duration. He was treated for serologically confirmed (Dengue NS1 antigen positive) dengue fever approximately 5 weeks ago at the local hospital and had made an uneventful recovery. He has been given 5 days of inward treatment and the records from the local hospital revealed that he had simple dengue fever with no evidence of fluid leakage.\nFive days after discharge from the hospital he has first noticed the weakness of his right hand when he dropped a glass of water due to poor grip. Weakness was more in the right hand which was his dominant hand and it was slowly progressive over 1 month. At the time of presentation to us he could not write or button on his shirt due the weakness of the hands. Weakness of the left hand was milder than that of the right. The weakness was confined to hands and did not involve forearms or arms. He denied any accompanying numbness, parasthesia or pain.\nOn inquiry he admitted that there was slight weakness of both feet which did not significantly interfere with walking. There was no associated neck/back pain or bladder/bowel incontinence. He did not complain of difficulty in breathing, diplopia, dysphagia, nasal regurgitation, dysarthria or fatigability. He did not give a recent history of trauma to the spine/neck or any preceding diarrheal illness or skin rash.\nHe had no previously diagnosed long term medical ailments and has not undergone any surgical procedures in the past. He was not on any long term medications and he denied smoking, use of alcohol or illicit drugs. He did not give a family history of any progressive neurological conditions.\nOn general examination he had an average built with no pallor, lymphadenopathy or any signs of malnutrition. No skin rashes or hypopigmented patches were noted. There was minimal small muscle wasting of bilateral hands and feet. No muscle fasciculations were noted. Distal upper limb (hand) power was diminished asymmetrically, right hand demonstrating a power of 3 out of 5 and left hand demonstrating a power of 4 out of 5. All fine finger movements including flexion, extension, abduction and adduction were affected with some degree of weakness in wrist extension as well. Bilateral supinator and biceps reflexes were diminished.\nDistal lower limb (feet) power was also diminished but was less pronounced (power grade 4) when compared to the degree of hand weakness. Bilateral foot dorsiflexion was weak. Ankle jerks were elicited with reinforcement whereas the knee jerks were elicited without reinforcement. There was no objective sensory impairment of touch, pain, temperature, vibration and joint position sensations in both upper and lower limbs. Bilateral plantar responses were down going. No palpable nerve thickening identified. No cerebellar signs were demonstrated and his gait showed a minor degree of high stepping due to weak dorsiflexion. Examination of higher functions and cranial nerves including the fundal examination revealed no abnormality.\nExamination of the cardiovascular, respiratory systems and the abdomen was essentially normal.\nFull blood count revealed white blood cell count: 8.5 × 109/L, platelet count: 274 × 109/L, hemoglobin 12 g/dl with normal red cell indices. Blood picture showed normochromic normocytic cells with some reactive lymphocytes suggestive of a recent viral infection. Serum creatinine 80 μmol/l (60 - 110 μmol/l), serum sodium 138 mmol/l (135 - 145 mmol/l), serum potassium 3.8 mmol/l (3.5 - 5 mmol/l), serum magnesium 0.9 mmol/l (0.8–1.1 mmol/l), serum ionized calcium 1.2 mmol/l (1.05–1.30 mmol/l). Liver profile: AST 21u/l (10 - 40u/l), ALT 13u/l (7–56 u/l), ALP 67u/l (100–360 u/l), serum total bilirubin 0.7 mg/dl (0.1–1.2 mg/dl), serum albumin 36 g/l (35 - 50 g/l), serum globulin 32 g/l (20 - 35 g/l). CPK levels were normal. Inflammatory markers: ESR 25 mm/hour and CRP < 6 mg/dl.\nNerve conduction study revealed findings in keeping with multifocal motor neuropathy with conduction blocks involving the distal upper and lower limb peripheral nerves without any conduction abnormalities in the sensory nerves (Fig. ).\nCSF analysis did not show any increase in proteins or cells and the values were within the normal limits. Anti-GM1 IgM antibody test was not carried out due to the high cost of the test and the patient’s unstable financial background. A sural nerve biopsy (a sensory nerve) was carried out and revealed histologically unremarkable nerve fibres and blood vessels with no evidence of inflammation, atrophy or granulomata formation. Recent dengue infection was confirmed with positive dengue IgM and IgG antibodies with enzyme-linked immunosorbent assay (ELISA).\nAs the patient fulfilled criteria, the diagnosis of multifocal motor neuropathy with conduction blocks was confirmed. He was then referred to the neurologist and was started on intravenous immunoglobulin (IVIg) therapy (2 g/kg/day) which was given for 5 days. He showed a mild improvement of his neurological weakness with the treatment and outpatient physiotherapy was arranged. The next immunoglobulin dose was planned to be given after 2 weeks. |
Presenting concerns
This is a case of a 22-year-old white female who presented at 34 weeks with preterm premature rupture of membranes. She had a history of two prior cesarean deliveries. A left ovarian tumor, not noted during the course of her current pregnancy, was noted on cesarean delivery.
Current pregnancy
When she presented with preterm premature rupture of membranes, repeat cesarean section was performed again. At the time of surgery, another 8 cm mass on her left ovary was diagnosed intraoperatively. This mass was not diagnosed prior to surgery. A second trimester ultrasound was performed that did not show any ovarian cyst. During the surgery, the mass appeared tan with punctate focal hemorrhage. The mass was unable to be separated from her left fallopian tube, so the mass, the left fallopian tube and part of the left ovary were all removed. We were able to leave a small amount of residual ovarian tissue. Pathologic description noted a multiloculated and cystic mass with clear mucinous fluid consistent with mature cystic teratoma (Figure ). Her postoperative course was uncomplicated.
Previous pregnancy
Her antecedent pregnancy was complicated by right ovarian torsion at 13 weeks secondary to an ovarian tumor. A right salpingo-oophorectomy was performed. The right ovary was sent to pathology and noted to be infarcted with no viable tissue from the mass to make a definitive diagnosis (Figure ). During that same surgery, an 8 cm, irregularly shaped mass with a focally hemorrhagic surface was noted on the left ovary. A left ovarian cystectomy was performed, and final pathology showed a benign mucinous cystadenoma (Figure ). At the time of cesarean in the same pregnancy, a metachronous mucinous cystadenoma was noted on her left ovary; cystectomy and partial left oophorectomy were performed.
Follow-up and outcomes
Following her third cesarean delivery, this patient was surprised to learn that she had developed another ovarian cyst in pregnancy necessitating removal. She was concerned about the function of |
A 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active since the time of delivery and is sucking well and she passed meconium. The mother had two ANC visits and was vaccinated according to the national schedule and she reported the whole course of the pregnancy as uneventful. She did not have any known medical illness and has never taken any medication during the entire course of the index pregnancy except iron folate which was prescribed during the ANC visit.\nShe had spontaneous onset of labor and the membrane was ruptured spontaneously intrapartum. She gave birth to a 2330-gram female neonate after 5 hours of labor at a local health center. Baby had good APGAR score. Health care providers at the health center noticed defect at the back of the baby and referred her to Hawassa University Comprehensive Specialized Hospital (HUCSH) with the diagnosis of spinal bifida.\nDuring the initial evaluation at HUCSH the baby was active, vital signs were in the normal limits, and all neonatal reflexes were intact. There was 4x4 cm pink mass protruding through the introitus, cervical os is noted at the tip of the mass, the external genitalia appears normal, no discharge or bleeding from the mass, and the mass was reducible digitally and increases in size when the baby cries (see ). There was also 4x4 cm defect at the lumbosacral region the major portion of which is covered with skin while the lower edge is open, no discharge from the mass (see ). Additionally the newborn had bilateral club foot deformity (see ).\nOn investigation, the complete blood count was normal, creatinine level was 0.4mg/dl, and transfontanelle ultrasound scan shows mild dilatation of the lateral and third ventricles with an index of “mild hydrocephalus” and abdominal ultrasound was normal.\nAfter obtaining consent from the parents, under aseptic technique, the baby was catheterized, the vaginal mass was reduced digitally, and bandage was applied from the lower abdomen, both buttocks and legs were strapped in the bandage to the level of the mid-thigh leaving an opening at the anal orifice for passage of stool (see ). The bandage was removed after 72 hours at which time the mass was completely reduced and there was no recurrence of the prolapse afterwards (see ). Unfortunately one day after the removal of the bandage the baby started to shoot fever and had difficulty of sucking, on examination she had tachycardia and tachypnea and was febrile, she had depressed reflexes, the lower border of the meningocele got ruptured, her fontanels were bulged, and she was diagnosed with ruptured myelomeningocele and meningitis. The plan was to start her on antimeningitis drugs and repair the spinal cord defect after improvement but the parents insisted and went home against medical advice frustrated by her multiple anomalies. We communicated with the parents after her discharge and were informed that the baby died 7 days after she went home, but there was no recurrence of the prolapse throughout her stay. |
The patient was a 22-year-old male who presented to a rural hospital with a presumed high-voltage electrical injury of unclear etiology with an obvious evisceration. By report he was found walking in a dazed state unable to recount the mechanism for his injuries. He was transported via EMS to the local hospital where he was intubated and volume resuscitation was initiated. Based on the severity of his abdominal injuries, he was transported to the nearest regional level 1 trauma center for further management. Aeromedical transport was not available due to weather factors resulting in an approximately 105 min ground transport.\nOn arrival to our facility he was hemodynamically stable, and a primary survey did not reveal any immediately life-threatening physiologic abnormalities. He did have evidence of major abdominal and perineal injuries with evisceration (Fig. ) as well as apparent electrical injuries to his left upper (Fig. ) and bilateral lower extremities (Figs. , ). Given his unclear mechanism, CT imaging was performed to exclude other occult injuries. Imaging excluded major head, thoracic, spinal column or vascular injuries. He was then taken emergently to the operating room for abdominal exploration and other indicated procedures.\nIn the operating room, a midline incision was extended from the superior aspect of the evisceration wound to the xiphoid process. Abdominal exploration revealed full-thickness burns to the abdominal wall musculature with destruction of all muscular layers of the lower abdominal wall including the rectus abdominus, the posterior rectus sheath as well as portions of the internal and external obliques (Fig. ). While running the small bowel, five discrete areas of full-thickness coagulative necrosis were encountered. Examination of the pelvis revealed an intraperitoneal bladder injury to the dome of the bladder (Fig. ) with obvious coagulative necrosis to the area immediately surrounding the intraperitoneal injury (Fig. ). Multiple small bowel resections were performed, and the bowel was left in discontinuity. No attempt was made to reestablish bowel continuity due to the potential for extension of the areas of bowel necrosis and a desire to maximize length of small bowel that remained. Intraoperative consultation with urology was obtained and obvious areas of bladder necrosis were debrided. The bladder dome was closed in multiple layers with chromic sutures. A Foley catheter was left in place for bladder drainage after the repair was completed. No evidence of other hollow viscus injury, significant solid organ injury or retroperitoneal hematoma was observed. A temporary abdominal closure was then performed using a negative pressure abdominal closure system.\nFollowing the temporary abdominal closure, our attention was then turned to the burned extremities. The patient appeared to have full-thickness circumferential injuries to the left upper extremity, left lower extremity, right lower extremity, and right foot with significantly decreased peripheral pulse exams. Intraoperative orthopedic and podiatry consults were obtained. Given the concern for compartment syndrome and potential constriction from the burned tissue, left upper extremity and bilateral lower extremity escharotomies were performed as well as right foot fasciotomies. Dry sterile dressings were applied to all wounds at the completion of the procedure. In its entirety, the initial operative procedure took 125 min. Following the procedure the patient was left intubated and arrangements were then made to transfer the patient to a regional burn center for further management. After a brief delay in setting up aeromedical transport, the patient was transferred via helicopter for further management with a 45-min transport time.\nDuring his subsequent 2-month burn center admission, the patient required additional small bowel resections, but eventually had restoration of bowel continuity. The urinary tract injuries required vesicostomy, ureteral stenting, and revision of the original bladder repair. His clinical course was also complicated by vesiculocutaneous fistula and progression of his lower extremity injuries, eventually requiring right below knee and left transmetatarsal amputations. After successful abdominal wall reconstruction, the patient ultimately survived his injuries and was discharged from the burn center to a rehabilitation facility. More detailed information regarding his burn center hospital course is not available due to privacy issues raised by the burn center. He has subsequently been lost to follow-up at our facility.\nFollow-up regarding the injury mechanism revealed that the patient was the driver of a motor vehicle which struck a power pole resulting in a downed high-voltage power line over his vehicle. By report he was initially uninjured, however when he attempted to exit his vehicle, he contacted the electrified auto frame resulting in his electrical injuries. He initially walked from the scene to a local house where EMS was contacted. |
This is a 50-year-old right-handed male, with 33-year history of T6 AIS A SCI from a gunshot wound complicated by chronic pain, left hip and knee heterotophic ossification, and a chronic dislocation of his right hip, who initially presented to the emergency room with a right shoulder mass in September 2014. While he initially noticed the mass about 2 months earlier, he presented for evaluation now because of acute onset of pain, weakness and paresthesias in the right arm. He was admitted to the general medicine service for pain management and underwent an initial work up for his right shoulder mass, including advanced imaging and a core biopsy. Physiatry was consulted due to his functional deterioration that precluded him from returning to his previous independent living arrangement. He demonstrated diffuse, mild weakness throughout the right arm that was variable and seemed to be correlated with his reported pain level, but his most consistent and weakest movement patterns were his grade 4/5 weakness in finger abduction and distal interphalangeal joint flexion. He had reduced pin prick sensation over the volar surface of digits 3–5, palm and forearm of the right arm and hand. He was not able to perform transfers to or from his manual wheelchair due to his level of pain. The magnetic resonance imaging (MRI) revealed a heterogeneously enhancing mass with a maximum diameter of 6.9 cm (Fig. ) that involved the right deltoid and pectoralis major muscles. His core biopsy demonstrated a STS that was classified as a high grade (III) spindle cell sarcoma.\nOncology recommended treatment for his STS with a course of outpatient neo-adjuvant radiation therapy followed by gross total resection with wide margins. Physiatry pre-operative consult focused heavily on functional prognostication. The patient expressed multiple times that he placed the highest priority on return to his previous modified independent living arrangement and not only survival after his STS treatment course. The patient’s personal values combined with the physiatric assessment informed the pre-surgical planning. In particular a decision was made to take a narrower surgical margin around key muscle group (pectoralis major and deltoids) in order to help maintain the man’s manual wheelchair mobility and his ability to independently transfer himself.\nHe completed neo-adjuvant radiation therapy in November of 2014 and underwent radical excision of his right shoulder mass with flap closure that December. He began intensive inpatient rehabilitation after he was given clearance to weight bear through his arm about 8 weeks later. Initially he required total assistance for most ADL’s, including transfers, manual wheelchair propulsion, dressing and toileting. Despite the extensive surgery and radiation treatments, the gentleman was able to return to a functional level, approaching his pre-morbid status (modified independence). He was successfully discharged home to live alone in his accessible apartment complex. |
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. |
An 82-year-old female presented to our hospital with fever, dry cough, shortness of breath, and poor appetite for three days. She was treated for pneumonia two weeks prior to hospitalization by her primary doctor and had completed a 10-day course of an oral antibiotic. There was no previously reported history of Clostridium difficile infection. She had moved to the United States two years prior. She was ambulatory and functional at baseline.\nAt the time of presentation, her blood pressure was 89/48 mmHg, pulse rate was 101 beats per minute, respiratory rate was 40 breaths per minute and temperature was 101 ° Fahrenheit. On examination, she was found to be obtunded and not moving any extremities. Her abdomen was soft and distended with reduced bowel sounds. Her peripheral pulses were palpable and her pupils were reactive bilaterally. Her trachea was cannulated for acute respiratory failure. Despite intravenous fluid challenge, she remained hypotensive and was started on norepinephrine for suspected septic shock and admitted to the intensive care unit. She was started on intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Her initial laboratory findings have been mentioned in Table .\nX-ray imaging of the chest showed diffuse bilateral pulmonary infiltrates. Computed tomography (CT) imaging of her brain showed no acute large vessel distribution infarction, hemorrhage, mass, or mass effect. Venous Doppler ultrasound of her lower extremities showed bilateral deep venous thrombosis and therapeutic subcutaneous enoxaparin was started. She had multiple episodes of watery diarrhea since arrival in the ICU and she was started on oral vancomycin. The stool was sent for analysis and was found to be positive for the glutamate dehydrogenase (GDH) antigen and Clostridium difficile toxin B. She was noticed to have cold mottled skin and decreased peripheral pulses, first in the right upper extremity followed by the right lower extremity. This has been presented in Figures -.\nCT angiography of the chest revealed a right main pulmonary artery embolism with extension into the lobar branches (Figure ).\nCT of her right upper extremity revealed an occluded right radial artery, patent right ulnar artery and the branch vessels in the right wrist and hand appeared to have a distal tapered occlusion, suspicious for distal arterial embolism (Figure ).\nCT angiography of her right lower extremity revealed a tapered occlusion of all three trifurcation vessels suspicious for distal thromboembolic occlusion. There was no soft tissue gas or drainable fluid collection in bilateral lower extremities (Figure ).\nThe hematology team was consulted, who recommended unfractionated heparin therapy and advised to test for antiphospholipid syndrome. An echocardiogram did not reveal an intracardiac thrombus. Hypercoagulability workup was not remarkable for genetic or other acquired conditions predisposing to thrombosis (Table ).\nMultiple attempts to wean her off the ventilator were unsuccessful. On day 5 of hospitalization, repeat CT of the brain showed multifocal infarctions in the right cerebellum and left basal ganglia/thalamus with other smaller foci of watershed infarcts (Figures -).\nHer condition continued to deteriorate and her family opted for palliative care. |
The first case was of a 72-year-old male whose somatic anamnesis was unremarkable and no prior intake of medications. He was hospitalized for localized zoster in the right groin and front thigh for 23 days. Eight days after tooth extraction, the patient developed a local rash with pinching pain and was diagnosed with extensive HZ of dermatomes T12 to L2 by a dermatologist. The oral medication was initially 200 mg celecoxib twice a day, 75 mg pregabalin, and 250 mg of famciclovir three times a day, for 7 days, respectively. The patient-reported visual analogue scale (VAS) score was controlled, no more than 6. On the 19th day after the appearance of the rash, the patient developed severe breakthrough pain, with more than ten attacks per day (about 5–6 outbreaks at night), each episode lasting 5–8 minutes, accompanied by a tremor of the right lower limb. The VAS pain score was 10 in the onset of breakthrough pain and 0 in the resting. The initial dermatologist tried to increase the dosage of pregabalin, but the patient reported intolerable dizzy and lethargy without any alleviation of his breakthrough pain. Therefore, the patient was admitted and prescribed 75 mg pregabalin three times a day, as well as 100 mg tramadol hydrochloride every 12 hours. Two days after hospitalization, the patient reported no reduction of the intensity and number of episodes of breakthrough pain, after which epidural blockade was performed to resolve the pain. However, during the process, breakthrough pain recurred and the patient was unable to keep his lateral position and switched to a supine position; therefore, the treatment was suspended. The patient received repetitive infusions of 4 g of vitamin C in 250 ml of physiological saline solution, without adjusting the dosage of pregabalin and tramadol hydrochloride. On the second night, there were still 5 episodes of breakthrough pain, but the duration of each attack did not exceed 3 minutes, and the VAS dropped to 8. On the fourth day, although the daily attack frequency did not decrease markedly, the duration had dropped to about 1 minute and the VAS was 6. On the seventh day, the second attempt of epidural blockade using 10 ml 1% lidocaine with 40 mg methylprednisolone was performed successfully. Although the patient suffered an attack of breakthrough pain after lying in the lateral position, the pain intensity was tolerable and lasted for merely 1.5 minutes. During the first 24 hours after the epidural blockade, there were 5 times of attacks, each time lasting for no more than 1 minute and the pain intensity remaining, with a VAS of 3-4. On the tenth day after intravenous administration of vitamin C, the patient had only one attack in the daytime, lasting for half a minute, with a VAS of 1-2. The next day, he was totally pain-free and was discharged from the hospital with an oral prescription for 75 mg pregabalin three times a day for two days. At 1-week and 3-month follow-up, there was no pain recurrence. |
A 65-year-old woman presented with a 5 months history of a soft, enlarging mass in the right frontal region. The scalp mass was painless and there was no history of tauma. On admission, her neurological examination was within the normal range. Skull X-rays and a computed tomography (CT) of the head clearly showed a bony, destructive lesion involving the scalp of the right frontal bone (). Magnetic resonance (MR) imaging revealed a 6×6 cm heterogeneously enhancing, bony expansive mass in the right frontal bone, extending into the intracranial space with little brain edema (). Preoperative diagnosis was a primary or secondary malignant osteolytic mass. We checked the lesions in the whole body of patients using a bone scan, and we performed whole body positron emission tomography CT to rule out metastatic lesions, but abnormal lesions were not found. We performed a craniotomy for excision of the mass. The scalp could be reflected easily and the mass was not adhered to it tightly, but it had partially infiltrated the subcutaneous tissue. The inner and outer table of the skull was destroyed by the well-encapsulated, soft mass. The main tumor appeared to arise extradurally, but definite invasion of the outer and inner dura was observed without brain invasion; therefore we had to remove whole layer of the infiltrated dura including some of the normal dura and we repaired the dura using an artificial component. The mass involving the scalp, skull, and dura was totallyremoved grossly. The calvarial defect was reconstructed with polymethyl methacrylate. The biopsy confirmed the tumor as an atypical (World Health Organization grade II) meningioma (), which caused soft tissue and dural invasion. Pathologic findings showed immunopositive for epithelial membrane antigen, frequent mitosis (Fig. 2A) and necrosis with 10% of Ki-67 labeling index (). Her post-operative recovery was uneventful and she was discharged on the 14th day post-surgery. The adjuvant treatment was not performed because the mass was totally removed and there were no metastatic lesions. The patients was doing well without any symptoms, and six months postoperatively, we performed follow-up brain MR imaging for assessing if there were any recurrent lesions, and no recurrent mass was observed in the skull, soft tissue, and intracranial area (). |
A 71-year-old woman presented with sudden neck pain and weakness in her right upper and lower limbs while she was having a bath at home. Her symptoms resolved spontaneously within 10 minutes. After half past 4 hours later, she had the same onset of right hemiparesis and had full recovery within 15 minutes, and then was immediately admitted to our emergency department. The patient had a 30 years history of hypertension without well-control. She had no previous history of taking any antiplatelet or anticoagulant drugs. There was no recent history of head and spinal trauma or surgery.\nThe initial blood pressure was 210/90 mm Hg. On neurological examination, the patient had a normal cranial nervous system and sensory system. Her muscle strength was grade 5/5 in bilateral upper and lower limbs, but the right knee reflex was hyperactive and Hoffman's sign was positive. Laboratory investigations showed that a complete blood cell count, prothrombin time, and partial thromboplastin time were within normal limits. An emergency brain computed tomography and cervical x-ray scans were unremarkable. A clinical diagnosis of TIA was considered. Then the patient was hospitalized in the neurological wards and treated with antiplatelet therapy (100 mg aspirin and 75 mg clopidogrel, once daily). She did not complain any other symptoms except a mild neck pain in the following 2 days after admission.\nOn the third hospital day, the brain magnetic resonance imaging (MRI) and cervical MRI were performed. The brain MRI showed no signs of acute cerebral infarction. The cervical MRI revealed a spinal epidural hematoma located in the posterior spinal epidural space extending from the C2 to C6 spinal vertebral level. The hematoma was isointense on T1-weighted images and hyperintense on T2-weighted images (Fig. ). Just after returning to the wards, the patient recurred the right hemiplegia (muscle strength was grade 3/5 in right upper and lower limbs), and developed rapidly progressive quadriplegia, loss of pain and temperature sensation, dyspnea, and uroschesis. Neurological examination revealed tetraplegia (the muscle strength was grade 2/5 in left limbs and 1/5 in right limbs) and loss of pain below the C2 level bilaterally. She had neither aphasia nor abnormal cranial nerve signs. Given her progressive symptoms and imaging findings, the diagnosis of spinal cord compression was considered. The patient was transferred to the intensive care unit immediately and treated with trachea cannula and ventilator-assisted ventilation. Her family members did not consent to emergency surgical decompression and the patient became worse in the following days. After a week later, her family members finally consented to the surgical decompression. The findings of operation confirmed a hematoma arising on the dorsal spinal epidural surface and extended from the C2 to C6 spinal vertebral level, and the right was more serious.\nOne week after operation, the sensory deficit above C6 level improved, but there was no improvement in her muscle strength and dyspnea. Unfortunately, she died 1 month later. |
The patient is a 39-year-old female with a past medical history of chronic low back pain, degenerative disc disease of the lumbosacral spine, lumbar radiculopathy, migraine headaches, and hypothyroidism, who presented to our clinic to establish primary care. She stated that she had been suffering from chronic low backache since the age of 26, for which she had been using pain medication on and off. Over the past five years, the patient started using heating pads as an alternative method of pain relief.\nShe also stated that she had undergone physical therapy in the past without much benefit. She informed us that for over five years now, she had been using two heating pads covering her lower back. She stated that she had been using them several hours during the day, especially during the evening. She said she has also been sleeping with them covering her lower back. The electric heating pads were applied at medium to low settings most of the time.\nAt the time of establishing care with us in the clinic, she also presented with a rash, for the last one year, on her back corresponding to the area where she had been chronically using her heating pads. She denied any pain, itching, or any discharge from the rash or any similar rash anywhere else on the body. She also denied any known personal or family history of skin problems in the past.\nOn examination, there was a non-blanching, violaceous, mottled, reticulate patch on her back corresponding to the lower thoracic and lumbosacral area (Figure ). The lesion was erythematous with telangiectasias (Figure ). The patch was not raised and nonpruritic in nature. No other skin lesions were observed anywhere else on the body. Based on the history and physical exam, a diagnosis of EAI was made. The patient was educated about the skin lesion and was advised to stop using heating pads over the affected area. She followed with us six weeks later and stated that she had stopped the use of heating pads. The physical exam was at that time still unchanged from the last visit. The patient was encouraged not to use heating pads again and was informed that it might take up to a few months for the rash to resolve. |
A 67-year-old female patient was admitted with a six-month history of lower back pain accompanied by a two-month history of intermittent claudication. The patient had visited a community hospital when the lower back pain developed and was diagnosed with osteoporosis following assessment by radiography of the lumbar spine. Despite treatment with medication and physiotherapy, the patient’s symptoms did not subside. Two months prior to this admission the patient began to experience progressive intermittent claudication. The patient was referred to the West China Hospital (Sichuan University, Chengdu, China) as an MRI of the lumbar spine had been recommended three weeks prior to the admission. A neurological examination showed no notable changes in the function of the spinal nerve.\nThe patient had previously been diagnosed with a vulvar melanoma (13 years prior to the current admittance) and had undergone a melanoma resection at the West China Hospital. The patient received post-surgical radiotherapy. No local melanoma recurrence or other metastatic melanoma was reported prior to the present admission. The patient had been treated with anti-hypertensive drugs for 11 years, but had no other medical history.\nThe current MRI revealed compression of the lumbar spinal cord in the spinal canal from the posterior direction caused by an extradural mass at the L3 and L4 level. The mass showed a low signal intensity on the T2-weighted images, a mixed low signal intensity on the T1-weighted images and slight enhancement following a gadolinium-contrast injection (). Over the subsequent week, radiography and computed tomography (CT) of the lumbar spine were recommended. There were no clear changes in the radiograph (). CT scans faintly revealed the mass ().\nAlthough the patient had a medical history of vulvar melanoma, a lumbar stenosis resulting from hypertrophy of the ligamentum flavum was suspected instead of metastatic melanoma due to the extended time-period (13 years) since the original vulvar melanoma, the location of the mass and its appearance in MRI scans. Treatment with medication was prescribed to the patient. However, two weeks later, the intermittent claudication was significantly aggravated so the patient was re-admitted. The laboratory data showed normal values.\nA posterior laminectomy and fusion with instrumentation were attempted on the patient. However, during the surgery, a dark gray solid mass was observed under the L3 vertebral plate. The mass was dissected carefully from the surrounding structures and gross total removal with the L3 lamina and inferior articular process was performed. The solid mass (5.0×4.7×3.0 cm) was located between the L3 lamina and dura and was ellipsoid in shape. The mass appeared to be wrapped in a membrane and adhered to the dorsal dural surface (). Spine fixation was subsequently performed at the L2-4 level and interbody fusion was performed at the L3-4 level ().\nThe hematoxylin and eosin (HE) histological analysis revealed a pigmented tumor (), while the immunohistochemical analysis revealed cells stained markedly positive for the monoclonal antibody anti-HBM-45, which is a useful marker of melanocytic differentiation in neoplasms (). The S-100 protein stain, a marker for cells derived from the neural crest, was positive in the neoplastic cells (). Furthermore, the Ki-67 index was positive in ∼25% of the cells. (). The pathological diagnosis based on these observations was one of malignant melanoma.\nSubsequent to the surgery, the general condition of the patient was good with no lower back pain. At two weeks post-surgery, bone scans showed an increased radioactive uptake, not only at L3, but also at the right sacroiliac joint. The patient was subsequently treated with radiotherapy and immunotherapy. The metastatic melanoma was absent in all areas, including the right sacroiliac joint, following this comprehensive therapy. At the final 13-month follow-up, the patient showed no evidence of recurrence and the intermittent claudication had disappeared (). |
A 28 year-old male was found to have a slightly increased serum creatinine (1.7 mg/dl) during the admission to ER because of abdominal pain. Since both his past medical history and an abdominal ultrasound performed on admission were unremarkable he was discharged with the indication to see a Nephrologist. At the Nephrology outpatient clinic, because of the reduced eGFR and of the presence of proteinuria (300 mg/24 h), an hospitalization for further investigations was planned.\nWhile waiting for the admission, a couple of weeks later, the patient was admitted to the emergency room in another hospital for abdominal pain and dyspnea. On admittance the ECG tracing performed showed sinus rhythm with diffuse repolarization abnormalities. Further exams revealed an increase of troponin (54 ng/ml) and transaminases levels (GOT 50 U/L; GPT 125 U/L) and a cardiac ultrasound showed a severe left ventricular dysfunction with right heart failure. Patient was thus admitted to the coronary intensive care unit. During his hospital stay the possibility of acute myocarditis was excluded because of the absence of a recent viral syndrome and the negativity of IgM antibodies against the viruses most commonly affecting the cardiovascular system and because of the low inflammatory indexes. An abdominal ultrasound demonstrated abdominal and pleural effusions, regular size and morphology of spleen and liver, no pancreatic changes; both kidneys had normal size but showed irregular margins and a reduced thickness of the cortex, no hydronephrosis nor stones were observed. A magnetic resonance demonstrated an increased volume of the cardiac chambers with a severe reduction of the function of both ventricles (EF20%), however no signs of reduced myocardial perfusion, valvular defects or other tissue changes such as inflammation, fibrosis or edema could be demonstrated. A chest CT scan confirmed the presence of pleural effusion and showed parenchymal atelectasias mainly involving the lower lobes of the lungs. The patient was discharged after 11 days on diuretics (furosemide 100 mg/daily), B-blocker (carvedilol 37.5 mg/daily), acetyl salicylic acid (Aspirin 100 mg/day) and an Ace inhibitor (Ramipril 5 mg/day) with a diagnosis of dilated cardiomyopathy and severe left ventricular dysfunction complicated with cardiogenic shock and anasarca. Few days later an EKG ergometric test revealed no areas of inducible ischemia. A further admission to the Cardiology Unit to define the effect of treatment was performed a week later. Cardiac ultrasound confirmed the left ventricular dysfunction (EF 23%), a coronary angiography was negative and a right chamber catheterism and endomyocardic biopsy demonstrated no specific lesion nor inflammatory infiltrate. The patient was then admitted to our Nephrology Unit, as planned, to evaluate the cause of the chronic kidney disease. On admission the patient appeared healthy and well oriented, his blood pressure was 110/60 mmHg, heart rate 56 bpm, physical examination was unremarkable except for a 1/6 intensity systolic heart murmur better audible on mitral valve area. ECG tracing showed sinus bradycardia. Laboratory studies revealed an increased serum creatinine (1.87 mg/dl), eGFR 48 ml/min/1.73 m2, hypercalcemia (serum calcium 11.5 mg/dl), hemoglobin 15.1 g/dl, sodium 135 mEq/L, potassium 4.37 mEq/L, phosphate 3.1 mg/dl, serum albumin 4.07 g/dl. The patient denied use of vitamin D analogs thus in consideration of the unexplained hypercalcemia other exams were performed. Thyroid hormones, calcitonin, vitamin D, serum ACE, phosphate and calcium urinary excretion rate were all within the normal range. PTH was lower than 3 pg/ml. To rule out multiple myeloma serum protein electrophoresis, serum and urine immunofixation, and spine and skull x-ray were performed and did not show any pathological changes.\nRenal biopsy was finally performed without complications and the patient was discharged after 24 h. While waiting for the renal biopsy pathology report, medications were not modified, but for an increase of the dose of furosemide because of the hypercalcemia. The renal biopsy contained eight glomeruli none of which was globally or partially sclerotic and no pathological changes were observed at glomerular level, vessels were also unremarkable. Tubulointerstitium was the only affected compartment with a moderate to severe inflammatory infiltrate, some calcium crystals in the tubular lumen and two granulomas with multinucleated giant cells (Figs. and ). No necrosis could be observed within the granulomas. A diagnosis of granulomatous interstitial nephritis due to sarcoidosis was made.\nWhen the patient was called to discuss his kidney biopsy, his serum creatinine had further increased (3.5 mg /dl), eGFR 22 ml/min/1.73 m2 and so had his serum calcium (13.3 mg/dl), serum albumin 4.06 g/dl. For this reason, he was hospitalized again and treated with pulse methylprednisolone (250 mg/day for three days) and then with maintenance dose prednisone (50 mg/day). Serum creatinine decreased in a few days and so did his serum calcium. Since the episode of acute kidney injury the patient has been followed at our unit and at the unit of Cardiology. Renal function returned to normal (serum creatinine 1.1 mg/dl, eGFR 91 ml/min/1.73 m2) and heart function markedly improved over the following two years (EF 49% vs 37% vs 32% vs 23%). The diuretic and cardiologic therapy was significantly reduced to only 25 mg of furosemide and a small dose of beta blocker. The steroid was gradually tapered to 5 mg/day of prednisone for one year and then stopped. |
A 23-year-old male reported to the emergency services 1 hour following road traffic accident. He was riding a two wheeler and was knocked down by a truck, leading to fall on the left knee in flexion. It was followed by immediate onset of pain in his left knee and leg. He had diffuse swelling, and tenderness of the left knee and leg. On examination he had lateral prominence of the fibular head with absent dorsalis pedis and posterior tibial artery pulsations. There was no capillary filling and the limb was cold to touch. Crepitus and tenderness was felt in midleg laterally. Clinically, he also had foot drop and loss of sensation in the areas supplied by the superficial and deep peroneal nerves, suggestive of common peroneal nerve palsy. The sensorimotor component of the tibial nerve appeared intact. There was varus instability of the knee.\nPlain radiographs of the knee, leg, and ankle [Figure , ] showed diastasis of the proximal tibiofibular joint, with the head of fibula being displaced inferiorly and laterally with the fracture of the shaft of the fibula and an overlap of the fractured fragments, further corroborating the inferior displacement of the fibular head. The arterial Doppler scan revealed the complete transection of the artery 2 cm proximal to the bifurcation. The artery was repaired using an interposition graft of saphenous vein with double incision fasciotomy of the leg. The limb was placed in an above knee slab in 15° of knee flexion. Subsequently, split skin grafting of the fasciotomy wounds was performed after 5 days.\nMagnetic resonance imaging (MRI) of the left knee performed 2 days after the injury [Figure –] showed complete disruption of the lateral collateral ligament and the proximal tibiofibular joint. The medial collateral ligament and the anterior and posterior cruciate ligaments were intact. The attachment of the biceps tendon was intact. There was extension of the proximal tibiofibular joint disruption involving the interosseous membrane and also causing a sprain of the anterior ligament of the distal tibiofibular syndesmosis at the ankle.\nDelayed proximal tibiofibular syndesmosis was operated 2 weeks after the injury because the fasciotomy wound had exposed the area adjacent to the planned internal fixation of the proximal tibiofibular joint. Open reduction and stabilization with a cancellous screw [Figure , ] was performed with screw purchase of three cortices. The lateral collateral ligament injury was compensated by doing a biceps tenodesis. The proximal shift of the inferiorly displaced fibular head was achieved by doing the biceps tenodesis. On life size X-rays, the apex of the fibula was proximally shifted in comparison to the lateral tibial plateau 7 mm postoperatively. Postoperatively, he was advised active range of motion exercises after 3 weeks and non–weight-bearing mobilization for 6 weeks. At 3 months followup, he had painless full range of motion of the left knee, was walking unaided without instability, and at 18 months, common peroneal palsy had completely recovered. There was no mediolateral laxity. Presently, 3½ years after injury, the patient is able to comfortably pursue all his day-to-day activities. |
A 48-year-old woman was admitted to the emergency department of a community hospital for an unusual thunderclap occipital headache associated with nausea, phonophobia, and photophobia, reaching peak intensity within one minute. Headache occurred during an emotional stress (while crying after having been informed of the death of a friend). She had never experienced such a brutal and painful headache. There was no prior history of headaches. Brain computed tomography (CT) and CT-angiography performed at the emergency department were unremarkable. On day four, the patient came back to the emergency department, because of the persistence of her headache. She was reassured and was rapidly discharged home without any further brain imaging. On day 11, she presented a sudden left hemianopsia and she was thus hospitalized. A brain magnetic resonance imaging (MRI) with diffusion-weighted imaging was performed the day of admission and showed hyperintense lesions in the right frontal lobe in the territory of anterior cerebral artery and in the right occipital lobe in the territory of posterior cerebral artery indicative of cytotoxic oedema. The same lesions were visible on fluid-attenuated inversion recovery imaging sequence. Images compatible with a cSAH were localised to the cortical sulcus in the right superior frontal lobe (). Magnetic resonance angiography demonstrated diffuse severe arterial narrowing in the anterior and posterior circulations bilaterally. Injection of cervical vessels with gadolinium and fat saturation sequences excluded the presence of cervical dissections. On day 12, the patient experimented sudden weakness of the left upper and lower extremity and was immediately referred to our stroke unit. On admission, her blood pressure was 120/70 mmHg, her pulse 64 beats per minute, and her temperature 36°C. The neurologic examination showed left hemiparesis predominant to the lower extremity, dysarthria, and spatial neglect. The National Institute of Health Stroke Score was 11. A second MRI was performed and showed an extension of ischemic lesions in frontal and occipital lobes and diffuse cSAH. Magnetic resonance angiography showed poor vascularisation of bilateral anterior and posterior circulations. A CT did not show recent cSAH and CT-angiography image showed vasoconstriction of the right anterior cerebral artery and stenosis of bilateral middle cerebral arteries, as well as vasoconstriction of the bilateral posterior cerebral arteries and vertebral arteries. A bedside transcranial Doppler ultrasonography revealed bilateral and asymmetrical elevated mean middle cerebral arteries velocities (right middle cerebral artery: 240 cm/s; left middle cerebral artery: 150 cm/s) and elevated mean anterior cerebral arteries velocities (right anterior cerebral artery: 102 cm/s; left anterior cerebral artery: 190 cm/s). Oral nimodipine (120 mg/day) and intravenous hydration were initiated and the patient was referred to the resuscitation department. Digital subtraction angiography performed on day 13 showed typical segmental vasoconstriction in the anterior and posterior circulation (). There was neither sinus thrombosis nor arteriovenous malformation. A control of the digital subtraction angiography on day 16 showed complete regression of vasoconstriction. A MRI performed on day 24 did not evidence new ischemic lesions and showed a regression of vasospasm. The patient had no neurological residual impairments.\nWe diagnosed her as having RCVS complicated by cSAH and ischemic lesions, on the basis of reversibility of the vasoconstriction and brain imaging findings. |
A male child aged 12 years came to our department with a chief complaint of mouth opening limitation. The patient had no noticeable past medical or trauma history. However, seven years ago, the patient underwent gap arthroplasty and coronoidotomy on the temporomandibular joint. After the surgery, there was a temporary increase in the size of the opening, but as time passed, reankylosis gradually occurred. As a result he was admitted for surgical management ().\nUpon clinical examination, the maximal mouth opening was measured at 5 mm. A lateral excursion to the right of 2 mm and to the left of 0 mm along with protrusive movement of 1 mm with a right side deviation resulted from the right TMJ ankylosis (). The facial computed tomography scan and magnetic resonance imaging (MRI) showed there was ankylotic mass on the right condyle head (, ). The left condyle had a favorable structure of articular disk and joint space in the MRI.\nWe removed the ankylotic mass and performed interpositional arthroplasty with temporalis myofascial flap and coronoidotomy on left TMJ to improve the range of mouth opening.\nThe surgery was performed with general anesthesia. Due to a difficult airway, nasotracheal intubation was performed with a fiberoptic endoscope.\nThe path of the superficial temporal artery was marked and confirmed with Doppler. We performed the Al-kayat-Bramley incision, which extends from the pre-auricular incision upward to the temporal area []. To protect the superficial temporal artery from damage, careful dissection of the superficial temporal fascia was done, and using blunt dissection of loose areolar tissue also was done to prevent facial nerve injury. Upon performing a resection of the ankylotic mass on the right condyle, along with gap arthroplasty, more than a 10 mm gap was formed between glenoid fossa and condyle head.\nCoronoidotomy on the ipsilateral side was performed in a prior surgery. In this surgery, contralateral side coronoidotomy was done by intraoral approach. Increase in the mouth opening to 25 mm was confirmed by hand manipulation during surgery.\nThe superficial temporal artery was used as a feeding vessel for the inferior based temporalis myofascial flap elevation from the infratemporal fossa []. This flap passed above the zygomatic arch and the gap between the glenoid fossa and condyle. The flap was passed to the medial side of the ramus. During the submandibular incision, the inferior border of the mandible was exposed, and an anchoring suture placed at the periosteum at the exposed mandible inferior margin. Another suture was done for fixation of the interpositioned flap through formation of a hole in the condyle head ().\nA compression dressing was applied and the patient given a soft diet. Medication for pain control and muscle relaxants were prescribed. The day following surgery, the physiotherapy program was started to prevent hypomobility caused by fibrous adhesion. Tongue depressor technique self jaw-opening exercise was performed. There was no facial nerve injury after surgery. After surgery, the formation of a sufficient gap on the right TMJ was observed by panoramic view (). The patient was observed for six months. There were no late complications of reankylosis or malocclusion. Intraoperative and immediate postoperative mouth opening was measured at 25 mm. The mouth opening measured at the six month exam was 22 mm (). |
A 45-year-old man presented to our emergency department with sudden onset of sharp epigastric pain. He gave history of hospital admission elsewhere, 6 months back for similar complaint. Upper gastrointestinal (GI) endoscopy performed at that time revealed peptic ulcer, and since then, he had been on antacids. His medical history was also remarkable except for uncontrolled hypertension. At presentation, his blood pressure was 180/100 mm Hg. Routine blood tests and basic metabolic profile including liver, cardiac enzymes, and serum amylase/lipase levels were normal. Emergency ultrasound performed on him did not reveal any significant abnormality. So, a biphasic contrast-enhanced CT of the abdomen was performed on a GE Light Speed Discovery 750 HD, 64-slice scanner, using oral contrast and 80 ml of non-ionic iodinated contrast material 350 mg I/ml, injected at the rate of 3 ml/s. Arterial phase images of the upper abdomen were obtained using smart prep technique followed by portal venous phase acquisition of whole abdomen at 50 s from the start of contrast injection.\nThe CT study revealed celiac artery aneurysm of 1.4 cm, approximately 0.8 cm from its origin with focal dissection as evidenced by true lumen and thrombosed false lumen. The caliber of the true lumen was severely compromised [Figures and ]. Distal propagation of the dissection and mural thrombus into the ostia-proximal hepatic and splenic arteries was seen which were occluded. The left gastric artery was originating from the celiac axis, proximal to the dissecting aneurysm and was normal. Replaced left hepatic artery from left gastric artery was seen as a normal variant. Fat infiltration was seen surrounding the celiac axis and proximal hepatic and splenic arteries []. This finding is a sign of dissection acuity and indicates predisposition toward progressive extension of dissection into adjacent vessels. The abdominal aorta and its other major branches were normal with no stenosis or aneurysm or dissection. There was no evidence of organ or bowel infarction. Subsequent Digital subtraction angiogram performed with therapeutic intent confirmed the CT findings []. Also, superior mesenteric artery injection showed retrograde filling of the hepatic and splenic arteries via the anterior, posterior pancreaticoduodenal arcades and the gastroduodenal artery [].\nSevere abdominal pain present in spite of good collateral flow indicates dissection to be the cause of pain, rather than intestinal ischemia. Also, in view of peri-celiac fat infiltration on CT and the complicating aneurysm with inherent potential risk of rupture, it was decided to treat him either with endovascular stent grafting or coil embolization. Stent grafting can be done if there is good landing zone of 2 cm on either side of the aneurysm. In our case, stent graft would have compromised the flow through the left gastric artery originating just proximal to the aneurysm. Also, in view of the good collateral flow to the hepatic and splenic arteries from superior mesenteric artery, it was decided to occlude the aneurysm distal to left gastric origin to prevent rebleed. Transarterial embolization was performed and the aneurysm was packed with detachable micro coils (Covidien, Ireland). Post coil embolization angiogram [] showed that the parent artery was obliterated except for its proximal portion with left gastric origin and that the intrahepatic branches were supplied through collateral pathways and the replaced left hepatic artery. His initial pain subsided gradually, and he was symptom free during discharge. |
A 53-year-old man with a history of myocardial infarction 6 years ago, right after a carcinoid tumor was found while undergoing work up for symptoms of chronic diarrhea and persisted wheezing. The tumor originated from the appendix, and over the years, the disease progressed to a carcinoid tumor of the liver. At that time, the patient underwent liver embolization with postoperative chemotherapy. The disease was controlled with monthly lanreotide injections, until he developed symptoms of right heart failure 1 year ago, including ascites, peripheral edema and shortness of breath. Upon further evaluation, multiple metastases were found in an abdominal computed tomography (CT) with contrast (with additional images suggestive of severely dilated right ventricle) along with a new diagnosis of liver cirrhosis (, ). Cardiac work up revealed new onset atrial fibrillation in a 12-lead electrocardiogram, and a 2D echocardiogram with evidence of severely dilated right ventricle and severe tricuspid and pulmonary regurgitation (, ). Due to the severity of carcinoid heart disease and profound symptoms, he was referred for evaluation to perform valvular replacement and Maze procedure. Cardiothoracic surgery was consulted, categorizing the patient as a low-risk for open-heart surgery.\nDuring the surgical procedure, the epicardium and the right atrium were found to be enlarged and fibrotic, and the tricuspid and pulmonic valves were sclerotic. The patient underwent a cardiopulmonary bypass with a Maze procedure, and left atrial appendix was excised. Pulmonary and tricuspid valves were replaced with a Biocor prosthesis #27 and #33, respectively. Finally, he was weaned from cardiopulmonary bypass. Postoperative echocardiography demonstrated well-seated and functional valves (). Valve remnants, both the pulmonic and tricuspid, were sent to pathology. After the procedure, the patient was started on octreotide infusion with close monitoring for the development of carcinoid crisis.\nThe final pathological findings included the following: pericardial fluid sac with proteinaceous material with an early organization and clusters of macrophages staining with CD68 by immunohistochemistry and mesothelialm without evidence of malignant cells; pulmonary valve with fibrosis and mild chronic inflammation (the fibrosis replaced the spongiosa layer of the semilunar valve leaflet), without evidence of giant cells or granulomata and no evidence of vegetations; left atrial appendage with findings of histologically normal myocardium. |
A 29-year-old military male basic trainee (71 inches, 200 pounds, BMI 27.89) presented with a one-month history of atraumatic bilateral leg pain. He reported pain within the first week of initiating running at basic training. He was diagnosed with bilateral proximal tibia stress fractures at three weeks with instructions to stop impact activities. After failure of his symptoms to improve, he was referred to our facility. On presentation, he had tenderness about the medial aspect of each proximal tibia. Radiographs obtained at that time demonstrated bilateral proximal tibia stress fractures with varus alignment about each knee and articular collapse of the left tibial plateau. Metabolic labs were obtained and significant for a low vitamin D (15), but the remainders of labs including calcium, thyroid-stimulating hormone (TSH), and testosterone were unremarkable. MRI of the left knee demonstrated a medial tibial plateau fracture with two millimeters of articular depression and extension of the fracture to the tibial spine (). MRI of the right knee demonstrated a hypointense linear T2 signal surrounded by diffuse hyperintense signal suggesting a medial tibial plateau stress fracture with surrounding bone edema, without articular collapse or extension (). These fractures were at the level of the physis, and there was surrounding sclerosis on plain radiographs. Given the collapse of the articular surface in his left knee, the patient was indicated for open reduction internal fixation with allograft bone. The patient underwent the aforementioned procedure without complication, and the patient remained nonweight bearing to his bilateral lower extremities (). At the time of surgery, the bone at the fracture distal to the articular surface was softer and more friable in composition than expected for the stress fracture. It was easily debrided back to stable, healthy bone edges, and we were interested in analyzing its composition, so a biopsy was obtained and sent to the lab for analysis. Histology demonstrated nonossifying hyaline cartilage with admixed fibroconnective tissue consistent with a persistent physis ().\nAt the six-week follow-up visit after the procedure on his left knee, the patient was still having significant pain in his right lower extremity and, after extensive counseling, elected to undergo the same procedure on the contralateral limb in an effort to return to running and continue his military career (). We suspected that a similar pathology of a persistent physis was present in the right proximal tibia and that this was contributing to his slow healing progression. Similar intraoperative pathology specimens were again obtained at the fracture site distal to the articular surface (), and these demonstrated fragments of purple to purple-gray staining matrix with chondroid metaplasia. This presence of cartilage distal to the articular surface was consistent with a persistent physis.\nAt four-and-a-half months from the index procedure (three months from the staged procedure), the patient was ambulating without assisted devices and had painless range of motion from 0 to 120° in each knee with well-healed incisions, maintained hardware and alignment, but had not returned to impact activities. Due to his status as a basic trainee, he was released from active duty at six months' time postoperatively and was lost to follow-up. |
A 51 year-old woman was diagnosed with lung cancer and brain metastases. She received a full course of palliative whole brain radiotherapy (WBRT), and daily dexamethasone was initiated. She was recruited from the outpatient radiotherapy unit after completion of WBRT, and a summary of the participant’s baseline assessment is provided in Table . Her most common reported physical activity over the past week was walking approximately 30 minutes per day, three times per week.\nThe participant was prescribed a daily walking plan of 10 minutes per day at low to moderate intensity, to progress up to a total of 40 minutes per day at the end of the six weeks. All strength exercises were started at 1 set of 8 repetitions, slowly progressing up to 2 sets of 10 repetitions for most exercises. After acquiring an upper respiratory tract infection in Week Three, her subsequent dyspnoea and fatigue resulted in the delay in progression of her daily walking program to 20 minutes per day. The participant completed 17 out of the 18 prescribed strength exercise sessions.\nA summary of the patient’s post-intervention assessment is provided in Table . As monitored by the activPAL™ accelerometer, the average number of steps taken over the baseline week was 11,373, with an average estimated total energy expenditure of 33.3 MET·hours; post intervention, the average number of steps taken during Week Six was 10,868, with an average estimated total energy expenditure of 32.5 MET·hours. The majority of her steps were taken outside the home. It was noted that the participant was being slowly weaned off the dexamethasone over the course of the 6-week program. In follow-up at 60 days post-intervention, the participant had continued her daily walking regimen on her treadmill at home, and was being considered for palliative chemotherapy. Overall, the participant expressed high satisfaction with the physical activity program and identified the home-based location as among its top advantages. The participant indicated her preference for one-on-one training, instead of on her own with the aid of a handbook or DVD. |
A 42-year-old Australian woman posted with the Australian Government to a developing nation during the COVID-19 pandemic experienced the sudden onset of acute severe lower abdominal pain. The acute episode had been preceded by several vague episodes of pain for ~2 weeks. Assessment at the local hospital revealed a right-sided cystic lesion in the pelvis measuring 7.5 × 5.8 × 5.6 cm appearing to arise from the right ovary. The lesion was suggestive either of an endometriotic or haemorrhagic cyst or, possibly, a mucinous ovarian tumour.\nThe pain settled somewhat and the patient contacted an Australian medical team for advice. The clinical picture suggested partial torsion of an ovarian cystic lesion and, due to the risk of a complete torsion and ovarian tumour infarction, advice was given to the Government that the patient be repatriated to Australia in view of the extreme pressure on medical resources where she was. However, the patient suffered another severe episode of pain suggestive of complete torsion and laparoscopy was undertaken. The images were captured on a phone camera and sent to Australia—the surgeons found a large cystic lesion apparently contiguous with the right ovary () that was densely adherent to the small bowel and sigmoid colon. Further conservative management with analgesia was given and the patient was flown to Australia to undergo COVID-19 quarantine. She had an ongoing requirement for analgesics but no further acute episodes. Upon release from quarantine local ultrasound revealed a heterogeneous solid and cystic lesion of unchanged dimensions ‘strongly suggestive of primary ovarian neoplasia’ (). The remainder of the examination was normal Her CA-125 level was 15 kU/L (NR < 36).\nThe following morning laparoscopy was performed with peritoneal washings taken for cytology. Present was a large round mass encased in adhesions to the right ovary and fallopian tube, small bowel, anterior rectum and sigmoid colon. A laparotomy was performed and the mass carefully dissected free. It appeared to arise on a pedicle from the small bowel, ~90 cm from the ileo-caecal junction. Histopathology revealed a largely infarcted solid lesion with areas characteristic for a GIST of the epithelioid type (positive for dog 1/CD 117 (KIT protein), negative for Sox 10/cytokeratin). () The appearances were of a high-grade tumour with clear margins at stage pT3. The adjacent small bowel was normal with no evidence of invasion. The patient had an uncomplicated post-operative recovery. |
A 30-year-old female, 13 weeks pregnant, and her husband acquired a fluorite ore sample. After seven days with this sample on display on their kitchen counter, it was brought to their attention that the rock originated from a mining site in the United States rich in natural uranium deposits and likely contained radioactive substances. This disclosure generated significant distress and anxiety for the couple. In order to attempt to quantify their absorbed dosages and the risk to the fetus, they reached out to various organizations, including the Provincial Centre for Disease Control, Drug and Poisons Centre and the Environmental Health services in British Columbia. The female also consulted her family doctor who discussed a range of possible options including private testing of the ore sample (the results of which would take few weeks to arrive) or preemptive abortion of the fetus.\nA local environmental health officer referred her to an RSO, who then brought the case to the attention of the British Columbia (BC) Cancer Agency administration and the Department of Radiation Oncology. After discussion, it was agreed that the dose rate measurements from the ore sample were required in order to make specific recommendations. It was also apparent that the matter should be dealt with in a timely fashion given the females' pregnancy.\nLogistical difficulties were faced trying to obtain measurements, given that the role of the RSO does not encompass such unique circumstances, such as specifically attending the home of a person in the community to perform the required measurements. Ultimately, the police and the fire department’s hazardous materials (HAZMAT) unit were involved and measured the specific activity of the sample. Throughout the report, all dosimetric quantities have been converted from gray (Gy) to sievert (Sv) assuming purely photon and electron radioactive emissions. The activity was assessed using a Geiger meter and found the dose to be equivalent to the rate of 0.19 to 0.20 μSv/h which would result at “point-blank” range. It was not made clear if this measurement excluded natural background radiation, but the HAZMAT response mentioned that the reading was comparable to the background dose rate. No wipe tests were performed and the rock was confiscated. The female's exposure depends on the proximity to the source and the amount of time spent in its presence; for risk management purposes, a worst-case scenario was employed. If she were to have carried the sample in her pocket for 24 hours for all seven days, her cumulative exposure would result in an equivalent dose of almost 34 μSv. This radiation dose is significantly lower than the yearly permissible limit to the general public (1 mSv), and an even smaller fraction of the permissible limit for the pregnant nuclear energy workers (4 mSv). Furthermore, while a developing fetus is susceptible to radiation at 13 weeks post postconception, the risks of adverse effects are thought to be small and possibly nil under 100 mSv for photon radiation []. A radiation oncologist and the RSO met with the couple in consultation to reassure them that neither they nor the fetus had significantly increased their risk of medical problems from their exposure to the fluorite ore sample. |
A 69-year-old male patient came with complaints of cough and hemoptysis from last one year. The symptoms were not relieved by conservative medications. There was no contact history with any case of pulmonary tuberculosis in the family or neighbourhood. Patient gave no history of any chronic illness, surgery or hospital admission in the past. The patient was a chronic smoker for the past 30 years. The patient was given a trial of anti tubercular treatment for six months but with no relief. Other than crepitations in right inframammary area, rest of the physical examination and routine laboratory work up was inconclusive. Repeated sputa examination for AFB were negative.\nChest X-ray revealed unfolding of aorta, hazy right parahilar and para cardiac area []. USG whole abdomen and the spirometry were normal. CT chest revealed an ill defined soft tissue opacity in the right hilar region encasing bronchus intermedius and causing right middle lobe collapse and consolidation of superior segment of right lower lobe with mediastinal extension with mediastinal lymphadenopathy and peribronchovascular interstitial thickening raising a suspicion of Bronchogenic carcinoma and Pulmonary tuberculosis []. The case was discussed with the radiologist who advised against bronchial biopsy, keeping in mind the vascular nature of the tumor and the possibility of massive bleed during the bronchial biopsy. Routine bronchoscopy was done to confirm the findings and they revealed that vocal cords, glottis, trachea, carina and left bronchial tree were normal. Right upper lobe was showing pigmented and edematous mucosa. Bronchus Intermedius was so much edematous and swollen which made the openings of right middle lobe and right lower lobe bronchii narrow enough from where the bronchoscope could not be negotiated. It was decided to do bronchial artery embolization to stop the hemoptysis. Bronchial artery embolization was done through the right femoral artery. The procedure involved selective bronchial artery angiography and bronchial artery localization using the contrast omnipaque. Bronchial artery angiography revealed right lung bronchial angiogram showing two bronchial arteries which were dilated and had a blush. Selective angiogram was followed by selective cannulation with micro catheter over bmw wire. Embolization was done with sponge gel []. Hemoptysis stopped immediately after the procedure. Check angiogram revealed closure of the artery. There was no complication. Again fiber optic bronchoscopy was done after one week and biopsy was taken which revealed moderately differentiated squamous cell bronchogenic carcinoma. |
This patient was a female in her late fifties visiting a general practitioner for a sick note due to pain after cervical disc herniation; she had a long history of pain due to fibromyalgia. In a previous interview the patient revealed that her son had died a few years ago of an accident. Since then she had withdrawn from social life and suffered from a sleep disorder. The medical history of the patient was comprised of cervical disc herniation, fibromyalgia, and hypothyreosis.\nFigure shows the LAVA self-assessment of the patient.\nThis patient rated eight terms as very important to her life and current situation. She was very satisfied with her partner and quite satisfied with the number of medications she was taking, mental health, and other aspects of life. However, the aspects of physical health, sleep quality, and absence of pain were rated as very unsatisfying. When exploring these aspects of her life, she confirmed that her pain and reduced physical health were mainly related to cervical disc herniation and fibromyalgia. Regarding the sleep problems the patient admitted that she was sleeping maximally 1 h at a time because she always thought of her dead son.\nFor this patient the application of the LAVA tool deepened the discussion about the traumatic life event of losing her son. While the patient had already revealed this major life event and her sleeping problems in the preceding interview, the depth and seriousness of the sleeping problems became manifest only after applying the LAVA tool. We therefore speculated that the rather unconventional way of categorizing and valuing aspects of life triggered the patient’s willingness to talk about the severity of her sleeping disorder and profound mental burden.\nRegarding the sleep disorder, the patient had already been diagnosed with fibromyalgia and received Zopiclone 3,75 mg p.r.n. to improve sleep quality and Piroxicam 20 mg p.r.n. (not prescribed by GP) for the reduction of pain. Following the LAVA self-assessment, a new evaluation of the combined pain/sleep symptomatology would be recommended including a psychological interview to assess possible comorbid depression and, additionally, an adaptation of the medication. This could lead to a change in medication (i.e. termination of Zopiclone treatment and a prescription of a sleep-inducing, pain-reducing antidepressant). In addition, we surmised that psychotherapeutic treatment could be useful for the patient to process the loss of her son; also, that the pain medication with Piroxicam should be checked and possibly altered. |
A 22-year-old woman with a known history of giant cell tumor of the left first metatarsal was evaluated for worsening left medial midfoot pain. She had previously undergone curettage and polymethylmethacrylate (PMMA) cementation of a biopsy-proven giant cell tumor of the first metatarsal two and a half years prior at a different institution. Six months following the index surgery, she had a recurrence treated with repeat curettage, liquid nitrogen local adjuvant, and placement of bone substitute graft. After the second procedure, she was ambulatory, but occasionally used a boot for comfort and avoided high-impact activities. Physical examination demonstrated a prominent first metatarsal base and a well-healed dorsal incision. She exhibited tenderness to palpation throughout the area of the scar.\nRadiographs of the left foot showed an expansile, radiolucent lesion of the first metatarsal base surrounding the known cement implantation of the first metatarsal (). Magnetic resonance imaging showed a large soft-tissue mass surrounding the first metatarsal circumferentially and abutting the second metatarsal (). There was high T2 signal with no T1 signal changes at the base of the second metatarsal. Computed tomography (CT) scan demonstrated an expansile lucency at the proximal aspect of the first metatarsal base toward the dorsal lateral side (). There were some areas of cortical breach, and the bone was expanded and abutting the base of the second metatarsal. There was no evidence of direct extension into the second metatarsal or areas of osteolysis within the second metatarsal base. She was diagnosed with a second recurrence of giant cell tumor of bone of the first metatarsal base. As the tumor was recurrent, with destruction of the articular surface and little residual bone of the first metatarsal base, a wide resection of the tumor was recommended.\nThe procedure began by harvesting iliac crest bone graft (5 cm in length, 2 cm in depth). The prior dorsal incision was extended along the entire first metatarsal and proximally across the tarsometatarsal (TMT) joint. A wide resection was performed by disarticulating the TMT joint, maintaining periosteal coverage surrounding the metatarsal, and osteotomizing the metatarsal about 4.5 cm from the TMT joint. The damaged cuneiform articular surface (from articulation with cement) was resected with a wafer osteotomy. The resection bed was treated with adjuvant thermal necrosis. Margins were extended further with 10% hydrogen peroxide. The first toe was held in appropriate length and rotation and pinned to the second metatarsal. The iliac crest graft was fashioned to fit appropriately, contouring the angles for an appropriate junction. The graft was secured with an anatomic plate and screw construct (Figures and ).\nNonweight bearing was maintained until the three month postoperative visit, at which time she began weight bearing as tolerated through the heel and 50% weight bearing through the forefoot with a removable boot. Four months following her operation, she was advanced to full weight bearing as tolerated in the boot. Five months after surgery, she began weight bearing as tolerated in a regular shoe and nonimpact exercises. Nine months after surgery, plain radiographs and CT demonstrated osseous bridging at both the proximal and distal graft sites with no signs of tumor recurrence (). At one year following surgery, she denied pain in the left foot and was able to complete all activities of daily living without difficulty. Eighteen months following surgery, the patient had no left foot pain, was exercising without difficulty, and there was no radiographic evidence of recurrence. The patient was informed that data concerning the case would be submitted for publication, and she agreed. |
A 53-year-old female developed a urinary tract infection and was started on nitrofurantoin 100 mg twice a day for 5 days by her primary care physician. After two doses of nitrofurantoin, she developed redness and irritation over her left breast (see ). The patient had had no sunlight exposure to the area nor any changes to her other medications. The patient’s only known allergy was hives to dye contrast. On examination, vital signs were stable, and she had a sharply demarcated erythematous and excoriated rash on her left breast.\nThe patient has a prior history of squamous cell carcinoma of the left breast treated with neoadjuvant carboplatin, paclitaxel, and anthracycline chemotherapy followed by surgery and subsequent whole breast radiation 6040 cGy. The breast cancer history began in December 2010 when she developed a left axillary mass. CT chest revealed mildly prominent left axillary lymph nodes. With concern for an occult left-sided breast cancer, a follow-up MRI of the bilateral breasts was completed which revealed a 2.2 × 0.9 x 1.7 cm area of heterogeneous non-mass like enhancement within the 2:00 to 3:00 position of the left breast.\nShe underwent excision of the left axillary mass. Pathology revealed poorly differentiated squamous cell carcinoma of the left breast. The tumor was negative for both the estrogen and the progesterone receptors. She was treated with neoadjuvant chemotherapy with carboplatin, paclitaxel, and anthracycline chemotherapy. A left lumpectomy and axillary node dissection was performed in May 2011. All 18 axillary nodes were negative for metastasis, indicating complete response. Finally, she was treated with adjuvant radiation 6040 cGy in 33 fractions over 6 weeks. She tolerated the radiation course well and only developed mild erythema at the site of the breast irradiation.\nThe patient’s rash that occurred following two doses of antimicrobial therapy corresponded to the prior radiation treatment portals. Given the temporal relationship of the rash with the antibiotic administration, the patient was felt to have RRD to nitrofurantoin. Other differential diagnoses included cellulitis and allergic contact dermatitis. However, the patient was afebrile, without leukocytosis, and her only known allergy was to dye contrast. Nitrofurantoin was immediately discontinued, and she was prescribed oral trimethoprim-sulfamethoxazole 160 mg TMP/800 mg SMX twice a day for three days. The rash quickly resolved within one week. |
A 36-year-old Asian Indian male patient attended our clinical immunology outpatient clinic with a fever of two months duration and two episode of herpes zoster in the last year. He also complained of significant weight loss in the last three months. He had no history of chronic cough or diarrhea. He was not a diabetic and not alcoholic. Our patient had a history of multiple unprotected sexual exposure around eight years ago.\nOn clinical examination his vitals were normal. He had a mild pallor and oral candidiasis. He had no significant lymphadenopathy or any cutaneous lesions. A systemic examination revealed no significant abnormality. Routine investigations were within normal limits. An ultrasound of his abdomen revealed no abnormality. An enzyme-linked immunosorbent assay (ELISA) for HIV-1 was positive and this was confirmed by western blot. Serology for Hepatitis B and C was non-reactive. Our patient's CD4 count was 67/mm3. He was put on HAART therapy consisting of nevirapine 30 mg twice a day, lamuvidine 150 mg twice a day and zidovudine 300 mg twice a day.\nAfter 12 days our patient came back with a complaint of upper abdominal discomfort. An abdominal examination revealed mild epigastric tenderness, no organomegaly and normal peristaltic sound. An ultrasound of his abdomen was normal. He was presumed to be suffering from gastrointestinal side-effects, which is very common during initiation of HAART, and advised to take a proton pump inhibitor.\nOur patient came back after another two weeks with severe abdominal pain, vomiting and abdominal distension. On examination his abdomen was found to be distended with absent peristaltic sound. An ultrasound of his abdomen was done and showed distended bowel loops with an admixture of air and fluid suggestive of acute intestinal obstruction. Routine investigations were normal and his CD4 count was 356/mm3. We put our patient on conservative management with fluids and nasogastric suction. However there was no improvement in 24 hours and our patient complained of increasing pain. A surgical consultation was taken and an exploratory laparotomy was performed with universal precautions. On exploration, small bowel loops were seen matted with a minimal amount of ascites. Purple colored patches, three in number, were seen on the serosal surface of his small bowel. Three thick walled, purple colored rounded cystic lesions adherent to surrounding bowel loops and omentum containing dirty white fluids were seen on the small bowel mesentery. The lesions had prominent veins over their surfaces (Figures and ). The lesions were excised; adhesiolysis was performed followed by peritoneal lavage with normal saline. The excised lesion was sent for histopathology.\nOur patient's symptoms improved after surgery. He was started on an oral diet after five days. The histological examination of the excised lesion showed tortuous blood vessels lined by a single layer of pleomorphic endothelial cells with extra-vasation of red blood cells in the stroma with spindle cells (Figure ) suggestive of KS. His CD4 count was repeated and was 476/mm3. Our patient was started on paclitaxel (eight cycles of 100 mg/m2 intravenously over three hours every two weeks) and the HAART was continued along with supportive management. He responded well to treatment and is doing well on follow-up. |
The patient signed the consent form, therefore written informed consent to participate in this report has been obtained.\nA 47-year-old man was referred for management of a cSCC on the right upper eyelid (). The patient had an 8-year history of a right upper eyelid lesion, which was diagnosed as a cSCC on biopsy. He underwent wide local excision with clear resection margins and reconstruction with Cutler-Beard flap in 2018 under ophthalmology. There was no other significant family and past medical history. The patient had a previous history of intravenous drug use but was not under any regular medications or treatments.\nDivision of the flap was planned but due to patient related factors he was lost to follow up. He was referred to maxillofacial and when he re-attended for division of the flap, he was found to have a new lesion in the lateral aspect of the right upper eyelid and was diagnosed as a recurrent cSCC on biopsy. The patient was subsequently referred to Oral and Maxillofacial Surgery via ophthalmology for further management.\nClinical examination revealed a large 4 × 3.5 cm ulcerated mass in the right lateral periorbital region. The mass compressed the globe and extended from supraorbital ridge to the level of the zygomatic arch. There was also partial loss of vision from the right eye. There was no evidence of cervical lymphadenopathy. A repeat biopsy of the region confirmed poorly differentiated cSCC occupying the entire width and depth (8 mm) of the biopsy specimen.\nStaging scans identified no bony erosion or intracranial extension, but there was involvement of the lateral rectus muscle.\nFollowing an multidisciplinary team discussion, he was managed surgically with wide local excision of the tumour with 1 cm margin with an orbital exenteration, a right superficial parotidectomy and reconstruction by means of placement of orbital implants, an anterolateral thigh (ALT) flap [] and a partial thickness skin graft. A consultant surgeon was the main operating surgeon for this case.\nThe patient received post-operative care at the community hospital and made good recovery. He has healed without complications as shown in .\nThe post-operative histopathological results showed a pT4b, 35 mm × 12 mm SCC with perineural invasion involving bone with tumour present at the deep margin []. Additionally, the histology revealed an incidental synchronous pT1a, 20 mm adenocarcinoma of the lacrimal gland with extra glandular extension and perineural invasion focally present at deep margin. The two tumours within the same histology specimen are shown in .\nFurther management plan involves post-operative radiotherapy and further reconstruction with an ocular prosthesis. |
A 20 year old Sri Lankan male who was employed as a helper in a grocery, admitted to our unit with weakness of both hands of 1 month’s duration. He was treated for serologically confirmed (Dengue NS1 antigen positive) dengue fever approximately 5 weeks ago at the local hospital and had made an uneventful recovery. He has been given 5 days of inward treatment and the records from the local hospital revealed that he had simple dengue fever with no evidence of fluid leakage.\nFive days after discharge from the hospital he has first noticed the weakness of his right hand when he dropped a glass of water due to poor grip. Weakness was more in the right hand which was his dominant hand and it was slowly progressive over 1 month. At the time of presentation to us he could not write or button on his shirt due the weakness of the hands. Weakness of the left hand was milder than that of the right. The weakness was confined to hands and did not involve forearms or arms. He denied any accompanying numbness, parasthesia or pain.\nOn inquiry he admitted that there was slight weakness of both feet which did not significantly interfere with walking. There was no associated neck/back pain or bladder/bowel incontinence. He did not complain of difficulty in breathing, diplopia, dysphagia, nasal regurgitation, dysarthria or fatigability. He did not give a recent history of trauma to the spine/neck or any preceding diarrheal illness or skin rash.\nHe had no previously diagnosed long term medical ailments and has not undergone any surgical procedures in the past. He was not on any long term medications and he denied smoking, use of alcohol or illicit drugs. He did not give a family history of any progressive neurological conditions.\nOn general examination he had an average built with no pallor, lymphadenopathy or any signs of malnutrition. No skin rashes or hypopigmented patches were noted. There was minimal small muscle wasting of bilateral hands and feet. No muscle fasciculations were noted. Distal upper limb (hand) power was diminished asymmetrically, right hand demonstrating a power of 3 out of 5 and left hand demonstrating a power of 4 out of 5. All fine finger movements including flexion, extension, abduction and adduction were affected with some degree of weakness in wrist extension as well. Bilateral supinator and biceps reflexes were diminished.\nDistal lower limb (feet) power was also diminished but was less pronounced (power grade 4) when compared to the degree of hand weakness. Bilateral foot dorsiflexion was weak. Ankle jerks were elicited with reinforcement whereas the knee jerks were elicited without reinforcement. There was no objective sensory impairment of touch, pain, temperature, vibration and joint position sensations in both upper and lower limbs. Bilateral plantar responses were down going. No palpable nerve thickening identified. No cerebellar signs were demonstrated and his gait showed a minor degree of high stepping due to weak dorsiflexion. Examination of higher functions and cranial nerves including the fundal examination revealed no abnormality.\nExamination of the cardiovascular, respiratory systems and the abdomen was essentially normal.\nFull blood count revealed white blood cell count: 8.5 × 109/L, platelet count: 274 × 109/L, hemoglobin 12 g/dl with normal red cell indices. Blood picture showed normochromic normocytic cells with some reactive lymphocytes suggestive of a recent viral infection. Serum creatinine 80 μmol/l (60 - 110 μmol/l), serum sodium 138 mmol/l (135 - 145 mmol/l), serum potassium 3.8 mmol/l (3.5 - 5 mmol/l), serum magnesium 0.9 mmol/l (0.8–1.1 mmol/l), serum ionized calcium 1.2 mmol/l (1.05–1.30 mmol/l). Liver profile: AST 21u/l (10 - 40u/l), ALT 13u/l (7–56 u/l), ALP 67u/l (100–360 u/l), serum total bilirubin 0.7 mg/dl (0.1–1.2 mg/dl), serum albumin 36 g/l (35 - 50 g/l), serum globulin 32 g/l (20 - 35 g/l). CPK levels were normal. Inflammatory markers: ESR 25 mm/hour and CRP < 6 mg/dl.\nNerve conduction study revealed findings in keeping with multifocal motor neuropathy with conduction blocks involving the distal upper and lower limb peripheral nerves without any conduction abnormalities in the sensory nerves (Fig. ).\nCSF analysis did not show any increase in proteins or cells and the values were within the normal limits. Anti-GM1 IgM antibody test was not carried out due to the high cost of the test and the patient’s unstable financial background. A sural nerve biopsy (a sensory nerve) was carried out and revealed histologically unremarkable nerve fibres and blood vessels with no evidence of inflammation, atrophy or granulomata formation. Recent dengue infection was confirmed with positive dengue IgM and IgG antibodies with enzyme-linked immunosorbent assay (ELISA).\nAs the patient fulfilled criteria, the diagnosis of multifocal motor neuropathy with conduction blocks was confirmed. He was then referred to the neurologist and was started on intravenous immunoglobulin (IVIg) therapy (2 g/kg/day) which was given for 5 days. He showed a mild improvement of his neurological weakness with the treatment and outpatient physiotherapy was arranged. The next immunoglobulin dose was planned to be given after 2 weeks. |
The patient was a 47-year-old male who had undergone an Eloesser procedure due to intractable empyema from a traumatic esophageal rupture in our hospital. During outpatient follow-up at the other hospital, he visited the hospital due to multiple raised masses and pain he was experiencing around the open wound boundary of an Eloesser open flap he had undergone 17 months prior. One month before being transferred to our hospital, he was suffering from multiple erythematous nodules around the open window, which became larger and elevated lesions, and then grew rapidly and showed bleeding and pus for the 2 weeks prior to presenting at our hospital.\nThe patient had undergone surgery for the primary repair of the lower esophagus through a left thoracotomy after trauma, which had been performed one month earlier. He was transferred to our hospital because of leakage from the primary repair site on postoperative day 10. After performing a closed thoracostomy in the left thorax, we administered broad spectrum antibiotics for mediastinitis with the patient fasting. On the seventh day after the transfer, we performed a laparotomy and interposed the right colon conduit between the cervical esophagus and the stomach, placing it substernally. He started oral intake on the seventh postoperative day. However, he required surgery for the Eloesser's open flap procedure due to intractable left side empyema, and was transferred to a hospital near his home.\nBiopsy of the masses comfirmed that the diagnosis was pilomatrix carcinoma (). Positron Emission Tomography (PET) () identified lesions with a standardized uptake value over 8.0 on the chest wall around the open wound, the intrathoracic area, and in the left lower lobe. Radiation therapy was therefore initiated. The mass increased in size without responding to the treatment and the patient's condition grew poor. Radiation therapy was discontinued. Treatment was halted and the patient was transferred to a hospital for hospice care. He died in supportive care 6 months after the initial diagnosis. |
Presenting concerns
This is a case of a 22-year-old white female who presented at 34 weeks with preterm premature rupture of membranes. She had a history of two prior cesarean deliveries. A left ovarian tumor, not noted during the course of her current pregnancy, was noted on cesarean delivery.
Current pregnancy
When she presented with preterm premature rupture of membranes, repeat cesarean section was performed again. At the time of surgery, another 8 cm mass on her left ovary was diagnosed intraoperatively. This mass was not diagnosed prior to surgery. A second trimester ultrasound was performed that did not show any ovarian cyst. During the surgery, the mass appeared tan with punctate focal hemorrhage. The mass was unable to be separated from her left fallopian tube, so the mass, the left fallopian tube and part of the left ovary were all removed. We were able to leave a small amount of residual ovarian tissue. Pathologic description noted a multiloculated and cystic mass with clear mucinous fluid consistent with mature cystic teratoma (Figure ). Her postoperative course was uncomplicated.
Previous pregnancy
Her antecedent pregnancy was complicated by right ovarian torsion at 13 weeks secondary to an ovarian tumor. A right salpingo-oophorectomy was performed. The right ovary was sent to pathology and noted to be infarcted with no viable tissue from the mass to make a definitive diagnosis (Figure ). During that same surgery, an 8 cm, irregularly shaped mass with a focally hemorrhagic surface was noted on the left ovary. A left ovarian cystectomy was performed, and final pathology showed a benign mucinous cystadenoma (Figure ). At the time of cesarean in the same pregnancy, a metachronous mucinous cystadenoma was noted on her left ovary; cystectomy and partial left oophorectomy were performed.
Follow-up and outcomes
Following her third cesarean delivery, this patient was surprised to learn that she had developed another ovarian cyst in pregnancy necessitating removal. She was concerned about the function of |
A 21-year-old virgin woman attended at the gynecological outpatient department of our hospital with acute pelvic pain and bladder distension. She was unable to urinate during the previous 12 hours. She had a history of increasing difficulty of passing urine and pelvic pain during the last menstruation two weeks before. She had no history of surgical intervention and her medical history was insignificant. Her menstrual cycles were regular since menarche at 10 years of age.\nOn examination, she had normal secondary sexual characteristics. Examination of the genital area showed almost complete adhesion of the labia minora and bladder outlet obstruction (). Pelvic ultrasound and laboratory work-up were normal. Dermatological examination of the vulva was unremarkable. Upon further questioning she noted that she had vaginal pain, burning, and profuse yellow vaginal discharge three weeks before. Her family doctor indicated that the vulvar vestibule was thinned, sensitive, erythematous, and edematous as a result of irritation from the discharge. She was referred to a gynecologist but she refused to go and to take any medication.\nAfter discussion of therapeutic options and informed consent was taken, a small space was obtained from the weakest point of the adhesion with a thin clamp (). Topical therapy with prednisolone, estrogen, and 2% clindamycin cream was administrated on the labia minora for three days. The labial space was gradually increased with local anesthesia and a thin clamp for this time. After three days we could not manage to achieve the desired result, so the patient underwent surgical intervention with general anesthesia. The labia minora were completely separated from the translucent line of the labial adhesion area. Topical therapy with prednisolone, estrogen, and 2% clindamycin cream was administered for an additional one week after surgery. The postoperative follow-up was uneventful and the patient was discharged on the postoperative 4th day. The punch biopsy of the adhesion area, saline microscopy of vaginal discharge, and culture results were unremarkable. The patient had no complaint at the postoperative 15th day and 6th month control (). |
A 55-year-old gentleman, ex-smoker, presented to our hospital complaining of mild epigastric pain, regurgitation, and heartburn. On top of that, he has a long-standing history of gastroesophageal reflux disease (GERD), which was managed by proton pump inhibitors. His past medical history was significant for hypertension. He was previously diagnosed with a liver hemangioma based on abdominal ultrasound two years before the presentation. He had no relevant family history. Physical examination revealed mild epigastric tenderness with no palpable abdominal mass. Laboratory data showed no anemia but positive stool occult blood test. Tumor markers including AFP, CEA, and CA 19-9 were all within normal range. Upper GI endoscopy revealed mild esophagitis, Los Angles grade A along with Barrett's esophagus without dysplasia and a 1 cm polyp at the GEJ. A sample was sent for histopathology; the rest of the stomach and duodenum were normal. The patient did not have a previous endoscopy prior to this one.\nInfused computed tomography (CT) of the abdomen and chest showed mild GEJ thickness with no evidence of mediastinal or celiac lymphadenopathy and no signs of metastasis. It also demonstrated a large heterogeneously enhancing mass about 6 × 9.5 cm with central necrosis in the upper abdomen that appears to be originating from the gastric antrum (greater curve). The mass was highly suggestive of GIST based on CT; it was the same mass that was previously misdiagnosed as a liver hemangioma (). Endoscopic ultrasound confirmed the previous findings. However, no biopsy was attempted due to the risk of bleeding.\nHistopathological examination of the GEJ polyp revealed tubulovillous adenoma with elements of adenocarcinoma in situ. The patient was admitted with a provisional diagnosis of early-stage adenocarcinoma of GEJ along with the incidental finding of enlarging gastric GIST. A trial of endoscopic mucosal resection of GEJ polyp was attempted but failed because of the polyp location that created a technical difficulty. Therefore, the patient was taken to the operating room with a plan to perform a wedge resection of the gastric mass and a submucosal resection of GEJ polyp through the same gastric opening. We planned to use frozen section (FS) to document negative margin resection and determine the need for a formal esophagectomy. Intraoperatively; a large (10 × 7 × 6 cm), extraluminal pedunculated mass was found at the posterior wall of the greater curvature of the stomach (). Wedge resection of the gastric mass with negative margins was achieved along with a transgastric submucosal resection of the GEJ polyp. Fortunately, the FS examination of the polyp showed negative margins as well with no evidence of deep invasion. Postoperatively, the patient had a smooth course and was discharged home in a stable condition. The final pathological examination revealed a GEJ polyp around 1.7 × 1.4 × 0.6 cm. Microscopically, there was a focus of invasive adenocarcinoma involving the superficial submucosa of the polypoid lesion, negative margins, and no lymphovascular invasion (T1a NxM0). Furthermore, the gastric wall mass measured around 10 × 7 × 6 cm with a 2 × 1.5 cm stalk. Histopathology revealed encapsulated high-grade epithelioid GIST tumor with negative margins (pT3). The mitotic rate of 6/50 HPF and immunohistochemical stains were positive for DOG1 and CD34 but negative for CD117 (c-Kit) ().\nThe final diagnosis was synchronous early-stage GEJ adenocarcinoma and a high-grade gastric GIST. Therefore, the patient was started on adjuvant imatinib treatment, along with endoscopic surveillance every six months and proton pump inhibitors. |
We present the case of a 68-year-old male with a background of psoriatic arthritis for which he was medicated with regular leflunomide and intermittent courses of steroids for symptomatic flares. He had also taken alendronic acid for 10 years before it being discontinued 6 months before his fracture, as his dual-energy X-ray absorptiometry scan confirmed normal bone density.\nFollowing a fall from standing height, the patient had initially been asymptomatic but gradually developed pain in the right hip on weight-bearing over the subsequent 2 weeks, leading to his delayed presentation. On assessment, he had pain over the lateral aspect of his right hip in the subtrochanteric region, with radiographs demonstrating an impending fracture (). At this stage, the patient was advised that a prophylactic nail was indicated but declined surgical intervention at that stage to travel abroad on business matters.\nWhile abroad, the patient suffered another fall which completed the subtrochanteric fracture and was treated locally with a dynamic condylar screw (DCS) (). On his return to the UK at 2 weeks from the index procedure, it was apparent that the metalwork had failed, albeit with no clinical sign of infection. Revision fixation was undertaken 2 weeks later with the DCS being exchanged for a 95° blade plate (). All microbiology cultures sent at the first revision surgery were negative, including for tuberculosis and fungi.\nOne month following revision, the patient presented with wound erythema and discharge. Radiographs were unremarkable but an ultrasound scan demonstrated a large collection along the length of the plate (). This was washed out and antibiotics were commenced, however, samples from this surgery grew no organisms. A second washout a month later for a similar presentation grew Staphylococcus epidermidis on enrichment culture only. Despite 3 months of antibiotics, the patient suffered ongoing issues with his wound and a third washout was performed which grew Staphylococcus haemolyticus. These samples were described as having an “unfavorable antibiogram” by microbiology colleagues. Of note, the radiographs now demonstrated failure of at least two of the diaphyseal screws of the blade plate.\nA computed tomography scan performed 1 week later showed no evidence of bony union and gas within the soft tissues (). Revision was performed with resection of devitalized bone margins, compression, and stabilization with a full-length blade plate (). Unfortunately, 6 weeks after this second revision fixation, he developed tenderness and fullness again in his wound, and at this point, a wound swab grew Proteus mirabilis and Klebsiella pneumoniae. The patient was treated with IV piperacillin-tazobactam, vancomycin, and oral ciprofloxacin. He made steady progress, and in line with the patients’ wishes, it was decided to attempt suppression until union.\nFive months into antibiotic suppression, the patient suffered ongoing pain, wound erythema, and pyrexia. Plain radiography () and cross-sectional imaging showed further gas within the soft tissues and non-union. Revision fixation was felt to be inappropriate due to resistant infection and the lack of union despite stable fixation. Taking into account, the patients’ wishes to be pain free and to regain mobility, the decision was made to proceed with a two-stage proximal femoral replacement. All metalworks were removed, followed by proximal femurectomy and radical debridement with RIA treatment to the femoral intramedullary canal. The”‘Cement-a-TAN” custom proximal femoral spacer was then made as described below and implanted (). All samples obtained at this time grew Proteus mirabilis, and the patient was commenced on a prolonged course of oral ciprofloxacin. Following discharge from hospital, the patient able to mobilize fully weight-bearing reported minimal pain and was able to return to driving. The surgical incision healed uneventfully.\nThe Cement-a-TAN remained in situ until the infection was felt to be controlled, with C-reactive protein persistently below 10 mg/L. After 4 months, the Cement-a-TAN was explanted and converted to a proximal femoral replacement (Stanmore METS, Stanmore, UK) (). At 20 months follow-up, the patient was pain free and mobile, with a stable range of hip movement and a fully healed wound (). |
An 83-year-old man was hospitalized for upper abdominal pain and weight loss of 4 kg over three months. His past history included pulmonary emphysema. A physical examination revealed a hard, palpable mass in the middle upper abdomen of approximately 10 cm in diameter. Laboratory data showed an elevated leukocyte count of 10,800 per mm3, a decreased hemoglobin level of 11.8 g/dL, and a normal tumor marker level of carcinoembryonic antigen and carbohydrate antigen 19-9. Upper gastrointestinal endoscopy showed a large, ulcerated, tumor spanning from the gastric angle to the antrum and extending to the duodenum (). Histological analysis of the biopsy specimen revealed a poorly differentiated adenocarcinoma (). Computed tomography (CT) imaging showed a thickened gastric wall, invasion of the pancreas, and lymph nodes swelling at greater curvature of the stomach but did not show any distant metastases (). Fluoroscopy of the upper gastrointestinal tract allowed visualization of the tumor, which was located in the stomach and was 10 cm in diameter (). This imaging also showed adhesion of the stomach and pancreas. Abdominal ultrasonography also suggested invasion of the pancreas. Based on the above findings, the mass was determined to have invaded the head and body of the pancreas, and the clinical stage was T4bN1M0, stage IIIB (Union for International Cancer Control (UICC)). The patient was diagnosed with unresectable gastric cancer, and chemotherapy with S-1 and paclitaxel was initiated. Oral S-1 (80 mg/m2) was administered for two weeks, and intravenous (IV) paclitaxel (60 mg/m2) was administered on days one and eight. The patient received three cycles of this regimen at 14-day intervals and showed side effect of fatigue (grade 2 based on common terminology criteria for adverse events). Assessment of the patient's response to chemotherapy after the third course of treatment showed a remarkable reduction in tumor size by gastrointestinal endoscopy (). Abdominal CT showed decreased thickness of the gastric wall and a more distinct border between the pancreas and stomach (). Based on these findings, laparotomy was conducted. A weak adhesion was found between the stomach and pancreas during the procedure, but curative surgery was possible. Following the laparotomy, a distal gastrectomy was conducted. The patient's postoperative course was uneventful and he was discharged 20 days after surgery. The patient received adjuvant chemotherapy of oral tegafur-uracil (300 mg/day) for one year without any side effects. He lived for five years after surgery without recurrence.\nThe gross appearance of the resected specimen showed an ulcerative lesion 3 cm in diameter at the antrum of stomach (). Histological examination of the specimen revealed no cancer cells in the primary lesion or lymph nodes (). Fibrosis with marked lymphocytic infiltration was seen in the ulcerative lesion. |
A 44-year-old Japanese woman visited the dental clinic office of the Oral Care Center in Kagoshima University Hospital according to a suggestion by her gynecologist. She complained about pain and bleeding from gingiva by routine toothbrushing. She was diagnosed with ovarian cancer (stage IIIc) and received surgical therapy to remove all of the ovarian and surrounding lymph nodes, including the most malignant lesion. This was followed by chemotherapy to destroy the remaining cancer cells on the 15th day after the surgery. Anticancer drugs selected first were paclitaxel and carboplatin as a combination regimen. This administration was repeated six times approximately every 3 weeks. In addition, bevacizumab was also prescribed in the same day from the second to sixth course, and only bevacizumab was injected an additional 16 times after that. Finally, the total times of prescription during this chemotherapy were 21.\nOn the third day after the first injection, general adverse effects, which were urticarial, flare, and swelling in part, emerged, and she had strange feeling around the gingiva as an oral adverse effect as well. Although a combination regimen of docetaxel and carboplatin was administrated only in the third course, general adverse effects emerged similarly. Fortunately, these general effects have decreased gradually, but the oral problem was remaining and exacerbated gradually in contrast. During the whole period of chemotherapy, the patient did not experience hypertension, proteinuria, thrombosis, epistaxis, or gastrointestinal perforation as a major adverse effect of bevacizumab.\nOn the day of the 11th course of chemotherapy, which was the sixth course of only bevacizumab, the patient visited a dental office for the first time and complained about the oral disorder (Fig. ). Oral examination revealed followings: total number of tooth was 28; DMFT was 16 (16 filled teeth); gingival swelling was scored as grade 2–3 according to Gingival Index (GI); and edematous gingiva associated with serous hemorrhage was detected in many parts. Extensive oral mucositis and xerostomia were not detected. Plaque Control Record (PCR) value as oral contamination was 82.1%. Periodontal probing depths were generally 4 mm or more. Most sites of deep probing depth were bleeding in response to periodontal probing. There were no moving teeth or occlusal trauma. The area of attached gingiva was not a problem in any teeth. The patient was unable to brush her teeth due to fear of pain and bleeding from gingiva for a long time until the first visit to the dental office.\nThe symptoms, which were bleeding and swelling of gingiva, emerged approximately 1 week later from every injection of bevacizumab and lasted for next 10 days. We informed her that the gingival symptoms were derived from insufficient cleaning and bad oral contamination as well as the chemotherapy itself, primarily. Appropriate oral hygiene techniques were indicated, and professional mechanical tooth cleaning (PMTC) was carried out focusing on only supragingival areas to avoid pain and bleeding. The patient brushed her teeth using a very soft-bristle toothbrush and an end-tuft brush for implanted teeth three times or more a day while the gingival symptom came out strongly. After the symptoms were partly reduced, a soft-bristle toothbrush and inter-dental brush were used. Chemotherapy with only bevacizumab was repeated an additional 10 times approximately every 3 weeks. According to the schedule for chemotherapy, the patient visited our dental office regularly. Every time, plaque and gingival evaluations were performed, and the subject received appropriate consultation about toothbrushing techniques and instruments, and finally, PMTC was carried out. The symptoms of gingiva were reduced gradually each time the number of visits increased, and regular toothbrushing and PMTC focusing on the subgingival area also became possible. Moreover, the fear of the bleeding of the gingiva moderated too. However, she had to wait several additional weeks from the end of chemotherapy for complete tolerance of inflammation including the local one in the oral cavity (Fig. ).\nGingival Index, PCR, and concentration of carcinoembryonic antigen (CEA), CA19-9, CA125, numbers of white blood cells, and platelets in serum were monitored after the 11th course of chemotherapy (Fig. ). GI and PCR decreased dramatically after the first visit to the dental office, and CEA decreased also simultaneously. Although CEA increased gradually after the 18th course, the value returned to the reference range 1 year later (CEA: ≤5.0 ng/mL), and recurrence of the cancer was not detected. Values of CA19-9 and CA125 were within a reference range during whole chemotherapy (CA19–1: ≤37.0 U/mL; CA125: ≤35.0 U/mL). Numbers of white blood cells and platelets did not change significantly within the reference value (data not shown). |
The patient was a 36-year-old gravida 0 woman. At the age of 7, she underwent ventricular septal defect closure for the right ventricular outflow tract. At the age of 11, she received a mechanical aortic valve replacement. Since after the replacement, she has been receiving warfarin orally at a dosage of 4.5 mg/day. She conceived naturally and she was referred to our hospital for perinatal management. Oral administration of warfarin was discontinued at 5 weeks of gestation and she began self-injection of heparin. At 21 weeks and 5 days of gestation, she was admitted to our hospital with a high risk of spontaneous abortion and was put on intravenous ritodrine. This successfully prevented a miscarriage. At 21 weeks and 6 days of gestation, we started a continuous infusion of 25,000 units of heparin daily. On the 22nd week, transesophageal echocardiography showed a movable thrombus in the aortic valve. The size of the biggest thrombus was 26 × 8 mm (). We increased the dosage of heparin to 28,000 units daily and restarted the administration of warfarin. Following this, the thrombus reduced in size, and at 23 weeks and 5 days transesophageal echocardiography showed no signs of thrombosis in the patient. At 32 weeks and 2 days of gestation, a routine cardiotocography showed a decreased fetal heart rate; thus, an emergency Cesarean section was performed under general anesthesia because of the presence of warfarin in the blood. The baby was delivered, weighing 1,702 g, with an Apgar Score of l at l minute, and 4 at 5 minutes. The total amount of blood loss during the surgery was 1,410 ml. During the surgery, 16 units of fresh frozen plasma (FFP) was transfused; and after surgery, we continued to infuse 20,000 units of heparin daily. On the 11th day after surgery, owing to continuous genital bleeding, heparin administration was discontinued and uterine artery embolization was performed. This treatment stopped the bleeding and on the 21st postsurgical day; we started warfarin administration at 5 mg/day. She was discharged on the 34th postoperative day due to the stable PT-INR levels ().\nThe newly born infant was intubated and admitted to the newborn intensive care unit. At the time of admission, activated partial thromboplastin time was 180 seconds or more and bilateral intracerebral ventricular hemorrhage was detected using ultrasonography. On the first day of life, anemia was observed in the infant and red cell concentrate and FFP were transfused (). We attempted to reduce the infant's dependence on the ventilator and at 8 days of age the infant was extubated. On the postnatal 10th day, a cranial CT scan showed bilateral intraventricular hemorrhage with ventricular dilation and midline shift (). Although convulsions accompanying the intracranial hemorrhage were observed, the infant's general condition was stable and oral feeding was started on postnatal day 10. The newborn was discharged on postnatal day 54. However, the infant later developed cerebral palsy and is currently receiving treatment at our hospital. |
A 54-year-old Japanese woman visited our ophthalmology department after experiencing proptosis, lid swelling, diplopia, and retro-orbital pain in her left eye lasting for 1 day. She had a medical history of poorly differentiated adenocarcinoma of the stomach, which had metastasized to her ovary and mesentery, diagnosed 2 years earlier. She had undergone four regimen courses of chemotherapy, yet these had failed and she thus received palliative treatment. There were metastases to subcutaneous tissue of her neck and thoracic bone marrow 3 months before her initial visit to our ophthalmic department. She had been admitted to our hospital 5 days previously without symptoms in either eye. She had undergone stenting in her esophagus against eating difficulties but she lived a self-reliant life at home.\nAt her first visit, an external examination showed lid swelling, red coloration, and proptosis of her left eye. A motility examination revealed an adduction deficit of − 4.0 and an abduction deficit of − 1.0. Ophthalmological examinations revealed a best-corrected visual acuity of 20/20 and an intraocular pressure of 15 mmHg in both eyes. No abnormal findings were found in the anterior segment. Her pupils were equally reactive without any relative afferent pupillary defect. A funduscopic examination showed partial optic disc edema in her left eye (Fig. a). No choroidal masses or striae were noted.\nA CT scan performed 10 days before her initial visit to our ophthalmology department revealed enlargement of the left medial rectus muscle. Retrospectively, similar findings were seen on a CT scan performed 3 months previously, and had worsened in the interim. Yet, a CT scan that had been performed 6 months previously showed no remarkable findings (Fig. ). There was no enlargement of other extraocular muscles and no swelling or mass lesion in other orbital tissues during the 6 months. So, gastric cancer metastasis to the medial rectus muscle of her left eye was suspected. Radiation therapy for metastasis to the subcutaneous tissue of her neck and thoracic bone marrow was effective; she received a total of 20 Gy/5 courses of radiation therapy to the orbit. A few days after completion of radiation therapy, lid swelling, red coloring, and pain disappeared. Two weeks post-radiation therapy, a motility examination revealed an adduction deficit of − 4.0 and Hertel’s exophthalmometry measurements with a 108-mm base were 14 mm (right eye) and 19 mm (left eye). At 1.5 months post-radiation therapy, a motility examination revealed an adduction deficit of − 2.0 and Hertel’s exophthalmometry measurements (108-mm base) were 14 mm (right eye) and 13 mm (left eye). A posterior ocular segment examination showed a normal left optic disc (Fig. b). She died 3 months after her initial presentation to our ophthalmology department. |
An 87-year-old woman with a history of hypertension presented with acute heart failure symptoms. She was found to have severe AS with left ventricular (LV) ejection fraction of 38%. She had femoral artery tortuosity and underwent urgent TAVI via a transapical approach using a 23 mm SAPIEN 3 bioprosthesis (Edwards Lifesciences, USA). Post-operative transthoracic echocardiography showed a well seated prosthetic valve with no paravalvular leak and no evidence of pericardial effusion. Chest X-ray showed a left sided pleural effusion that resolved with antibiotics and treatment for heart failure. She was discharged home 30 days after admission.\nShe presented to the breast clinic with a pulsatile mass 4 months after TAVI. Examination revealed a mildly tender, pulsatile mass at the lower aspect of her left breast under the transapical access scar. Cardiovascular and respiratory examination was otherwise unremarkable. She was admitted for further investigations as it was considered to be a LV pseudoaneurysm. Full blood count and C-reactive protein were normal, and no organism was isolated on blood culture after 5 days of incubation.\nUltrasound of the left breast revealed a pulsatile fluid collection measuring 44 mm in diameter, containing echogenic material and suspected to be arising from the apex of the heart. Computed tomography (CT) of the chest showed a 54 × 47 mm multi-loculated fluid collection arising from the cardiac apex and extending along the chest wall into left breast tissue via a communication through the intercostal space (Figure ). Cardiac magnetic resonance imaging (MRI) scan showed a pulsatile mass measuring 30 × 48 × 46 mm in the left breast and 32 × 15 × 11 mm in the extension into the pericardial space adjacent to the anterior wall of the left ventricle. The mass was initially considered to be a LV pseudoaneurysm but first pass perfusion imaging suggested no direct communication between the LV cavity and the mass (Figure , , Videos S1 and S2). Cine views in the sagittal plane showed dyskinetic motion of the anterior wall of the left ventricle, which pushed against the pericardial component resulting in transmission of a systolic pulse to the breast component of the mass (, Video S3). Coronary angiography showed non-obstructive plaque disease but no communication to the pulsatile mass. Contrast aortography did not demonstrate any arterial communication with the mass.\nUltrasound-guided needle aspiration of the mass drained 40 mL of purulent fluid (Figure ). Culture of the fluid did not grow any organisms. She made an uneventful recovery and a repeat CT scan of the chest 1 month later showed no recurrence of the mass (Figure ). |
A 28-year old Caucasian woman (gravida 1, para 0) was referred to our outpatient antenatal clinic at the 6th week of her pregnancy for her booking appointment. She had been trying to conceive for the previous 4 years. She reported that she was suffering from Wilson’s disease since puberty and she had been on penicillamine 1 g/day for more than 10 years. At the time she got pregnant she was completely asymptomatic.\nProper counseling was offered concerning all the possible implications of her pregnancy and the need of continuation of her chelating medical treatment. A low dose regimen of penicillamine 500 mg/day was commenced, according to the hepatologist advice. She attended all the routine antenatal appointments regularly. All her blood tests were within normal range, particularly those indicating liver function. Folic acid supplementation was prescribed during the first trimester in a daily dose of 400 μg, while no iron supplementation was needed throughout her pregnancy. The fetal nuchal translucency was measured 1,1 mm at 12 weeks of pregnancy, while the fetal anomaly scan at 22 weeks showed no obvious abnormality. Another two scans were performed antenatally in 28 and 32 weeks of gestation, in order to check the fetal growth and well-being.\nShe was admitted at 37 weeks in the labour ward with antepartum haemorrhage and constant abdominal pain, which started 1 hour prior to her admission. An ultrasound scan was performed and a large retroplacental haematoma was detected suggestive of placenta abruption. An emergency uncomplicated caesarean section was performed and a male infant weighed 2870 g was delivered. The ultrasound finding of placenta abruption was confirmed intraoperatively. The fetal APGAR score was 8 and 9 at the 1st and 5th minute respectively and did not need any kind of resuscitation. Her post-operative course was uneventful and she was discharged home with her baby on the 4th postoperative day. Her postnatal obstetric and medical appointments revealed no obvious pathology. Shortly postnatally her hepatologist recommenced her with 1 gr/day of penicillamine as before pregnancy. |
In July 2017, a 13-year-old Chinese male experienced intermittent abdominal pain lasting about 10 minutes per stint. The pain could be alleviated without treatment. No fever or diarrhea were observed. The patient subsequently developed vomiting, notably a coffee-like substance, which could not be alleviated by drugs. Gastroscopy results revealed gastric mucosal inflammation, but the patient refused to undergo further systemic examination. On the 30th of July 2017, the patient was diagnosed with an acute intestinal obstruction, with the abdominal CT scan indicating obstruction of the lower intestine and thickening of the splenic flexure (). He underwent an emergency colostomy with a colon tumor resection. No lymph node dissection was performed because of the operation under emergency condition and considering the boy’s young age. Intraoperative findings revealed that an irregular 5cm x 3cm tumor within the intestinal wall near the splenic flexure was the cause of the obstruction. The proximal bowel tube was dilated and multiple lymph nodes were enlarged. The proximal colon was removed 5cm from the edge of the tumor as well as a small mesenteric lymph node. The patient was healthy prior to the surgery with no history of infective diseases, or allergies to food or drugs. His maternal uncle also had colorectal cancer.\nFrom August 2017 to December 2017, the patient underwent six cycles of combined mFOLFOX6 chemotherapy which consisted of oxaliplatin, leucovorin, and 5-fluorouracil. During chemotherapy, the level of CEA and CA199 was stable. An abdominal CT scan evaluation showed that the disease was stable and remained stable after the completion of the mFOLFOX6 chemotherapy regimen (). Oral administration of capecitabine was adopted from January 2018. The disease-free survival (DFS) was 8 months. On April 23 2018, the level of CA199 was significantly higher than before, and the abdominal CT scan suggested the presence of multiple nodules in the greater omentum and peritoneum, peritoneal effusion, and tumor progression (). The patient then underwent one cycle of local intraperitoneal injection of bevacizumab (avastin) + intravenous chemotherapy, and two cycles of a FOLFIRI regimen. On June 19 2018, a targeted intravenous treatment with avastin was added. On the second day of FOLFIRI chemotherapy during the third cycle, abdominal distension was obvious and abdominal pain could not be tolerated. On July 9 2018, one cycle of chemotherapy with the targeted combination of avastin and raltitrexed + oxaliplatin was started. On July 27 2018, the child presented with intestinal obstruction and disease progression, and was hospitalized for support therapy. The patient received palliative care and passed away 2 months later. The overall survival (OS) was 14 months. |
A 41-year-old male presented to clinic with a 2.5-year history of painful right MG atrophy and fasciculations following a previous gastrocnemius tear after a fall from a treadmill. He was initially seen by neurology where his right MG appeared significantly wasted compared to his right lateral gastrocnemius. On examination, fasciculations were present and limited to his right gastrocnemius with no reliable inciting triggers. On motor examination, his strength was MRC Grade 5/5 in all muscle groups, including plantar flexion and inversions, and deep tendon reflexes were 2+ and symmetric. Further workup with electromyography (EMG) revealed a possible focal neuropathy of the right tibial nerve branch supplying the MG, as evidenced by increased insertional activity, 3+ fasciculations, and 1+ spike and wave activity in the MG. All other EMGs on muscle group testing were normal. There was no evidence of radiculopathy, plexopathy, or proximal sciatic neuropathy. Subsequent MRI illustrated his tibial and common peroneal nerve had normal morphology without any structural evidence or injury to explain his EMG findings. Ultimately, the decision was made for a right tibial nerve exploration at the level of the popliteal fossa with decompression and possible grafting of the MG branch.\nOn exploration, both the medial and lateral gastrocnemius muscles were easily identified along with the sciatic nerve and associated tibial and common fibular nerve branch points. Of interest, there were three distinct muscle head contributions to the MG. It was unclear, however, whether this anomaly was congenital or secondary to his previous injury. Nerve identifications were confirmed with intraoperative checkpoint nerve stimulator under direct visualization. Three MG branches were identified arising from the tibial nerve. Unexpectedly, we found large vasculature including, 1 artery and 2 veins, directly abutting deep to the MG branches []. Vascular surgery was consulted intraoperatively, and ligation of these vessels was performed to completely decompress the nerve. After ligation and full dissection of the MG branches, the muscle fasciculations and ongoing twitching had diminished. In addition, EMG stimulation was completed before closure to ensure no injury to the dissected nerves had occurred.\nOn follow-up at 3 months, his incision had healed without complication, he regained more strength, and his muscle fasciculations had decreased. |
A 73-year-old female presented with shortness of breath, dizziness, and gross hematuria. She had a past medical history of cervical cancer requiring radiation and chemotherapy, chronic kidney disease stage IIIB, and chronic normocytic anemia. The patient has a history of left ureteral stricture with severe hydronephrosis managed with a chronic indwelling metal ureteral stent with regular exchanges for four years. She was initially planned to have a left nephrectomy 1 month prior to her presentation, but it was postponed due to a hemoglobin of 4 g/dl, requiring hospitalization at an outside facility. She reported that her stent was most recently exchanged 5 months prior to her presentation.\nOn examination, the patient was hemodynamically stable. Frank blood was found in her Foley bag without suprapubic tenderness. Of note, she had hemoglobin of 3.8 g/dL and her creatinine was 1.51 mg/dL. CT imaging with contrast was unable to demonstrate an active source of bleeding but did show severe left hydronephrosis and hydroureter as well as a segmental pulmonary embolus. Subsequent lower extremity Doppler imaging revealed multiple deep venous thrombi. She was initially managed with blood transfusions and continuous bladder irrigation. Interventional radiology was consulted for the placement of an IVC filter in the setting of pulmonary embolus with active bleeding prohibiting the start of anticoagulation. Arteriogram was done during the placement of the IVC filter but failed to demonstrate any evidence of ureterovascular fistula.\nTwo days later, after continued gross hematuria and sustained anemia, the patient was taken to the OR for cystourethroscopy with left retrograde pyelogram and left ureteral stent exchange. Cystoscopy did not reveal any obvious masses or lesions, but active bleeding was noted from the left ureteral orifice after removal of the ureteral stent. Subsequent left retrograde pyelogram did not reveal any obvious source for continued hematuria; in particular, this was negative for any obvious fistula involving the ureter. The left ureter was markedly dilated, and there were multiple large filling defects, likely clots from the upper tract bleed. A left 6 French × 24 cm Double-J silicone stent was placed under direct visualization. The decision was made to perform left renal artery arteriogram and left lumbar and pelvic angiography which again showed no renal vascular abnormalities or arterioureteral fistula. A decision was then made to embolize the left renal artery. Despite embolization, the patient still had continuous hematuria requiring CBI. Due to continued suspicion for ureteroiliac fistula, a decision was made to proceed with definitive management and perform robotic nephroureterectomy with excision of the ureteroiliac fistula.\nThe patient was taken to the operating room and positioned in a modified right lateral decubitus position. The procedure proceeded accordingly, and nephrectomy was completed uneventfully. At the stage of dissecting the ureter, it began to pulsate, indicating a possible ureteroiliac fistula. A small vessel directly communicating with the ureter and the left external iliac artery was identified and clipped with a Hem-o-lok and divided with good hemostasis (). A much larger vessel was then identified inferiorly. An additional assistant port was placed, and a laparoscopic Satinsky clamp was used to clamp the external iliac artery. An attempt was made to dissect and divide the vascular connection with the ureter, but brisk bleeding was encountered. This proved to be very difficult to control robotically, and the decision was made to convert to open repair using a modified Gibson incision. Heavy bleeding was encountered, and the left common iliac artery was subsequently clamped which controlled active bleeding temporarily. The ureter was separated from the external iliac artery at the level of the fistula leaving a large defect of the fistula in the wall of the external iliac artery. Following temporization of the bleeding, vascular surgery was consulted, and they were able to suture the arteriotomy. With hemostasis maintained, the dissection of the distal left ureter was continued and clipped at the ureterovesical junction. A total of 8 units of packed red blood cells and 2 units of FFP were given with an estimated blood loss of 2500 mL.\nLater that day, the patient was discovered to have faint left popliteal arterial pulse by Doppler with no pulse distally. The patient was taken back to the OR with vascular surgery for angiogram of the left lower extremity due to acute limb ischemia. Acute thrombosis was identified, and thrombectomy of the left common iliac artery and external iliac artery was performed, along with balloon angioplasty of the left common iliac artery and external iliac artery. A four-compartment fasciotomy was subsequently performed. During the course of her hospitalization, a total of 19 units of packed red blood cells, 4 units of FFP, and 2 units of cryoprecipitate were given. The patient progressively improved with resolution of her hematuria and was discharged to an inpatient rehabilitation facility. As of 4 months postoperatively, the patient has been without any adverse events. She had her IVC filter removed and was started on therapeutic anticoagulation without development of hematuria. |
A previously healthy 42 years old male presented to our institute with history of gradually progressive and painless swelling over left calf since two months. He was a non-smoker, laborer by occupation. The patient noticed a firm swelling in calf region of left leg 5 years ago. No history of trauma or infection prior to the appearance of the mass was reported. No family history of any such swelling in the past. Patient was operated for swelling over calf region 20 years back but no records were available. There was a history of gradual increase in deformity of left foot since 3 years and the patient had started walking on toes on left side with no dorsiflexion at ankle joint.\nOn examination, there was a single, non-tender, hyperpigmented scar of size 8×3 cm over mid-calf region fixed to underlying structures. A large, well defined non-tender, firm, swelling was palpable in posterior aspect of left leg measuring about 28×8 cm extending from tendoachilles region up to 5 cm distal to popliteal fossa and medially and laterally up to border of tibia and fibula respectively. The overlying skin was normal with no discoloration and local raise of temperature. Movement of knee joint was normal. There was fixed equinus deformity of left foot (). No inflammatory signs, skin changes or adenopathies were present. No bruits were heard on auscultation. Neurovascular examination of left leg and foot was normal. Laboratory findings were within normal limits. Radiological examination revealed large soft tissue mass with linear and streak-like ossification around the left tibia. MR Angiography () showed arteriovenous malformation in left calf with multiple feeding arteries arising from popliteal, peroneal and anterior tibial artery and large draining veins draining deep into venous system of leg. The tibia and fibula marrow showed normal signal intensity.\nBecause of patient symptoms and with clinical diagnosis of a vascular malformation, a wide surgical excision of the lesion was done. Through a 25 cm longitudinal incision across the calf, posterior compartment muscles were exposed. The mass was found completely involving superficial group of posterior compartment muscles sparing the deep compartment with no attachment to periosteum or bone (). Peroneal artery and vein were found to be embedded in the lesion and thus sacrificed. Plane of dissection was between superficial and deep muscles.\nThe lesion was completely removed along with overlying cutaneous scar with wide surgical margins leaving posterior tibial artery in continuity. Intraoperative, complete dorsiflexion of foot was achieved with intact vascularity of leg. The excised specimen was very hard like bone and had to be cut longitudinally with saw (). Grossly the resected specimen showed ossified tissue covered with skin and soft tissues including muscle, tendons and adipose tissue measuring 15×7×5 cm. The cut surface of the ossified area was grey white, gritty and congested (). Microscopically, it revealed features of a vascular malformation with numerous blood vessels of variable size and shape composed of arteries and veins which were dissecting soft tissues and interstitial planes of skeletal muscle.\nMany of the vessels were thin walled with anastomosing and a sinusoidal appearance. Some of them showed fresh and organized thrombi within this vascular background, extensive osseous metaplasia characterized by mature lamellar bone formation was seen. (). The diagnosis was consistent with arterio-venous malformation with extensive osseous metaplasia. At the time of recent follow up after one year from the operation, no local recurrence of the tumor was demonstrated clinically and radiologically. No restriction of motion of ankle joint was found. Patient is presently walking with a normal gait. |
A female child patient aged 7 years was reported to the Department of Pedodontics and Preventive Dentistry with a complaint of missing tooth in the left back tooth region for 6 months. Clinical examination revealed prematurely missing 75 (). The history revealed that the tooth was extracted owing to gross decay.\nArch space analysis revealed a space discrepancy of 2.5 mm.\nAn Orthopantomogram (OPG) revealed 3 mm amount of bone covering, developing 35 and mesially inclined 36 ().\nThe decision of fixed banded helical space regainer was made.\nBanding of the first permanent molar and first deciduous molar was done.\nMolar tube was welded lingually to molar band.\nWire component was fabricated using 19-gauge wire with helix 3 mm in diameter and active arm of 10 mm was placed across the mesial surface of the first molar and it was engaged into molar tube on the molar band (lingual). The 10 mm of active arm was measured by calculating the space from distal to helix to the end of the molar tube lingually. The measurements of helix, active arm, and the wire were considered to achieve an effective pressure of the appliance on the tooth. The retentive arm of the wire component was soldered lingually to the deciduous molar band (). The additional space of 2.5 mm was included for the aligning of the first molar and the retentive arm was given to avoid the discomfort to the patient by preventing soft tissue laceration.\nThe finishing and polishing of the appliance was done and cemented after activation using GIC luting cements (). Activation was done by opening the coil in the spring to allow the force to be transmitted onto the first permanent molar.\nThe patient was recalled weekly for the followup, within 4 weeks, the required space was regained ( and ). This was further confirmed with OPG (). The appliance was maintained for 2 weeks, after which the lingual arch holding space maintainer was given (). |
A 16-year-old girl was admitted to the neurology department because of severe headaches and skull asymmetry. The patient had begun to notice hearing loss approximately 1 year earlier. An audiogram at that time demonstrated conductive hearing loss in the right ear; the air-bone gap was 60 dB.\nClinical examination additionally revealed a large mass over the right temporal area and obstruction of the right external auditory canal.\nMagnetic resonance imaging (MRI) and computed tomography (CT) were performed. Imaging studies showed a large, extensive, and heterogeneous mass over the right temporal area (Figs. , , and ).These findings initially suggested a temporal bone tumor of unknown origin.\nTo ensure the best outcome, and considering all of the patient’s symptoms including severe headaches, hearing loss, and cranial deformity, surgical treatment was performed by a multidisciplinary team that included a neurosurgeon and otolaryngologist. Intraoperatively, the severely bleeding mass of the temporal bone was suspected to be a tumor. The lesion involved almost the whole temporal bone and extended from the mastoid process to the petrous apex. There was no involvement of the otic capsule. Middle ear exploration revealed a completely obliterated external auditory canal and involvement of the ossicular chain with immobilization. The patient underwent modified petrosectomy with complete removal of the degenerative temporal bone lesion (Fig. ). In spite of the broad surgery and tissue removal, we did not perform blind-sac closure of the ear in an attempt to improve and preserve the patient’s hearing. After partial obliteration of the surgical cavity with a rotated temporalis muscle flap, the external auditory canal was left open and tympanoplasty was performed with mobilization of the ossicular chain and incus interposition. Tissue specimens taken during surgery were sent out for histopathological examination which revealed FD.\nPostoperative CT and MRI were performed with audiometric testing. Some improvement in hearing was observed initially, but with the slow progression of the disease, the patient’s hearing deteriorated and she underwent a second surgery with tympanoplasty. After an initial improvement, her hearing gradually deteriorated to 45 dB (the air-bone gap at 0.5–4.0 kHz) again. The patient was observed for 5 years, and at the time of this writing, MRI demonstrated slow disease progression with a tendency toward stabilization. She complains of periodic moderate headaches. |
A 6-year-old girl presented with neck pain and ataxia. She had undergone surgery for maxillary gum and subcutaneous tumors that were pathologically diagnosed as neurofibromatosis (NF). Magnetic resonance imaging (MRI) revealed bilateral internal auditory canal tumors, a right optic nerve sheath tumor, and an extramedullary spinal tumor on the right side of the occipital bone at the C1-2 level (). She was diagnosed with NF 2, and referred to our hospital.\nNeurological examination on admission showed no abnormalities except slight ataxia. She didn't have café au lait macules or other signs characteristic of NF 1. Preoperative radiographic images revealed no abnormal deformity of the cervical spine.\nWe scheduled a surgery for total removal of the spinal tumor, which was thought to be the cause of her neck pain and ataxia. The operation was performed under general anesthesia with the patient prone with her neck in an anteflex position. A skin incision of about 7 cm was made, and the nuchal fascia was exposed on the right side. The right upper part of the C2 spinous process was cut, and the oblique capitis inferior muscle and the rectus capitis posterior major muscle were retracted laterally. The trapezius and rectus capitis posterior minor were partially dissected from the occipital bone. The C2 lamina, C1 posterior arch, and the occipital bone were exposed only on the right side. A C1 hemilaminectomy was performed, and the upper parts of the C2 lamina and occipital bone were partially removed. The tumor was visible on the dura and at the right side of the spinal canal. Gross total removal of the tumor was achieved. Closure was performed according to standard protocols. Histological examination revealed a grade 1 meningothelial meningioma, as determined according to the World Health Organization classification criteria. Reports of dumbbell-shaped meningiomas in NF patients are very rare. The tumor was difficult to distinguish from a Schwannoma, which is the most common spinal tumor associated with NF, and this distinction will be discussed elsewhere.\nThe postoperative course was uneventful, and no neurological deficit was observed. But on day 6 after surgery, the patient experienced severe neck pain and assumed the Cock Robin posture. Computed tomography (CT) scan revealed an AARS. We subsequently performed a manual reduction followed by external fixation with a neck collar. However, the AARS was refractory and intractable to treatment. About 7 months after the first surgery, it became severe and irreducible. The girl complained of neck pain, and she could not flex her neck. This was an atypical form of subluxation in which the anterior tubercle of C1 had migrated to a cranial position, and the posterior tubercle of C1 had migrated caudally with the occipital bone also leaning in a caudal direction (). The pathogenic process suggested deformity of the occipital condyle and C2 facet; the Fielding classification was type 1 because there was no anterior displacement of the C1 vertebra (, ).\nSeveral measurements were made using the sagittal view of the cervical spine on the CT images. The atlantodental interval (ADI) was 1.94, the Powers ratio 1.26, the basion-axial interval (BAI) 1.16, and the basion-dens interval (BDI) 2.27. There was no basilar invagination because the Chamberlain and McGregor lines were normal. Cervical alignment was kyphotic with a C2-7 angle of -20.3°. An atlantooccipital dislocation was diagnosed because of the abnormal Powers ratio, but the BAI and BDI were normal. A 3-dimensional CT scan showed an anterior dislocation of the bilateral occipital condyles from the superior articular facets of C1. The clivo-axial angle was 160°. A lateral inclination of <20° was observed.\nIt is important to diagnose and treat atlantooccipital dislocations as quickly as possible because neurologic injuries, without treatment, can be devastating. According to the ADI score, there was no apparent AAS. However, the axial images revealed AARS.\nWe performed a second surgery under navigation guided for reduction and occipital plate C2-C3-C4 bilateral screw fixation. Under general anesthesia, the patient was placed in a prone position and lateral radiography was performed. We tried to reduce C1 dislocation, and a partial reduction was achieved. The vertebral level was identified. The C4, C3, C2, and C1 (left half) laminae and spinous processes were exposed. At the right side of C3, a pedicle screw was successfully inserted. At the left side of C3, the lateral mass was fragile and a spinous process screw was inserted. We also added a C4 lateral mass screw to the left side and a pedicle screw to the right side. At C2, an isthmic screw was inserted into the left side and a pedicle screw into the right side. The occipital plate was applied and fixed in place with 3 screws, measuring 6, 10, and 6 mm. Two rods were applied and fixed together. The compression force was applied between the C2 and C4 screws. The occipital bone was harvested as an autograft for Occiput-C3 fusion.\nThe subluxation was stabilized by posterior fixation (). After surgery, the clivo-axial angle improved from 160° to 125°. The postoperative course was uneventful, and the girl was discharged without complications. There has been no recurrence for the past 3 years. |
The patient, an 89-year-old woman, came to our hospital because of pain and 2-month limited mobility in her right hip joint after a fall. Before the injury, the patient was able to walk normally and had no history of other diseases. Two months ago, the patient accidentally fell while walking, and her right hip joint landed 1st during the fall. After the injury, she had pain, limited mobility, and inability to stand and bear weight in her right hip joint. Afterwards, she was laid up at home, without receiving any diagnosis and treatment. Because the condition was not getting better, the patient came to our hospital for examination. Physical examination on admission revealed that: both lower extremities were not swollen, the skin color was normal, and right lower extremity turned outwards for 45° and was 1 cm shorter than left lower extremity; the muscle strength of both lower extremities was at level 5, and the hip, knee, and ankle joints of the left lower extremity were all in normal mobility; there is limited mobility and palpable sensation of fracture friction in right hip joint, with flexion 60°, retroextension 0°, abduction 10°, adduction 5°, outward turning 10°, and inward turning 0°, and the knee and ankle joints are in normal mobility; the dorsalis pedis arteries of both lower extremities pulsed well, and the skin pain and temperature sensation were normal; X-ray examination of bilateral hip joints showed that the patient's bone density had decreased, the bone cortex continuity of the right femoral neck was interrupted, partial bone resorption occurred at the femoral neck and femoral head, the right Shenton line was discontinuous, and right femoral greater trochanter had moved up (Fig. ). Admission diagnosis was as follows: right femoral neck fracture and osteoporosis.\nAfter admission, we conducted comprehensive physical examination, electrocardiogram, cardiac ultrasound, arteriovenous ultrasonography of both lower extremities on the patient before the operation, and no abnormalities were found. On the 3rd day after admission, we treated the patient with artificial femoral head replacement through the posterolateral approach of the hip joint. Considering the patient's osteoporosis, we injected 10 g bone cement into the femoral medullary cavity to fix the femoral stem prosthesis. The operation course was smooth, and the patient's vital signs remained stable: the ECG monitoring indexes were normal, the blood oxygen saturation was 97% to 99%, the heart rate was at 80 to 90 beats/min, the breathing rate was at 16 to 20 beats/min, and the patient had no obvious discomfort in the heart and respiratory system. On the 1st day after operation, the patient's mental state was good, the surgical incision was not red and swollen, both lower extremities were not swollen, and the skin color was normal. With the aid of walking aids, the patient could walk on her own. We performed routine double-hip X-ray examination on the patient and found that the femoral head prosthesis was in good position and the femur was in good shape. However, the image of a massive, dense foreign body, 4 × 4 × 5 cm3 in size, was seen in muscle gap outside the right femoral medullary cavity. Besides, in the inguinal region, there was a high-density strip-like image along the blood vessel, about 0.8 cm in diameter, extending to the pelvic cavity. Density of the foreign body image was the same as that of the bone cement (Fig. ). We further performed computed tomography and vascular ultrasonography on the patient, through which we confirmed that the femoral cortex was good, without fracture, there was a bone cement mass in the muscle gap outside the femoral medullary cavity, in the right femoral vein and external iliac vein, along the intima of vein wall, there was a sleeve-like bone cement, making the venous lumen narrow (Figs. –). We 1st adopted low-molecular weight heparin (LMWH) anticoagulant therapy (41 million IU, subcutaneous injection, once a day) on the patient; and then, 2 weeks later, we used rivaroxaban (10 mg, orally, once a day) for the further treatment. The patient was followed up for 1 year. During the follow-up, the vascular ultrasonography showed that the status of the bone cement in the iliac vein had no change, and the blood flow was fluent. The patient was able to walk with normal gait, without swelling in both lower extremities, and discomfort in the hip. |
RM is a 55-year-old, nondiabetic, male with a history of neurogenic bladder secondary to spinal cord injury (SCI). He was diagnosed with a 3 cm staghorn calculus approximately 18 months prior to presentation. He underwent left ureteral stent placement followed by shock wave lithotripsy by a community urologist. He was lost to follow-up and presented to our institution with recurrent urinary tract infections and a retained ureteral stent. At the time of his office visit, he reported intermittent hematuria, occasional, mild abdominal pain, and persistent pneumaturia for the past one year. He denied any fever or fecaluria over the past year. There was no history of bowel disease or pelvic irradiation. A CT urogram was obtained (Figures , , , and ), which showed gas within the collecting system and a wedge-shaped segment of low attenuation in the lower pole of the right kidney, consistent with pyelonephritis. Urine culture obtained in the office grew Klebsiella pneumoniae. The patient was started on a 2-week course of Ciprofloxacin, and a percutaneous nephroureteral stent was placed in anticipation of definitive stone management with percutaneous nephrolithotomy. A urine culture was obtained from the renal pelvis at the time of nephrostomy tube placement. The renal pelvis urine culture was negative. However due to a high risk of infection-related complication, the patient was continued on Ciprofloxacin empirically until the time of surgery. RM underwent right percutaneous nephrolithotomy without complications, although difficult stent removal due to encrustation resulted in prolongation of the case by an additional 1.5 hours. Renal stone fragments were sent for culture and revealed no growth. Stone composition was a mixture of calcium phosphate (75%) and calcium oxalate monohydrate (15%). CT obtained on postoperative day one showed a residual 9 mm fragment in the upper pole and a 2 mm fragment in the renal pelvis. The patient underwent second look nephroscopy three days following the initial surgery to retrieve the residual fragments. He developed fever to 38.6°C (101.5°F) on post-operative day number one without hypotension or tachycardia. Urine and blood cultures obtained at that time were negative. The patient's post-operative course was otherwise uneventful, and he was discharged on postoperative day three following second look nephroscopy with a nephrostomy tube to gravity drainage. The nephrostomy tube was kept in place for two weeks, at which time an antegrade nephrostogram was performed and the stent was internalized. The internal ureteral stent was removed one week later. Of note, the patient reported that his pneumaturia resolved approximately one week after starting the course of antibiotics. |
A 24-year-old male with HA was admitted to our department with pain in multiple joints on May 23, 2011. The patient had a medical history of hemophilia A since the age of 3 and was intermittently treated with factor VIII. During these years, he sequentially developed left knee, left elbow, left hip, and right knee joint pain and swelling with limited activity and was soon diagnosed as HA. Initially, the joint manifestations could be largely relieved by factor VIII replacement therapy. Factor VIII inhibitor screening remained negative. Later, factor replacement therapy failed to achieve satisfactory effects, so in 2002 and 2006, he received left elbow synovectomy and left total hip arthroplasty, separately. In the subsequent years, the patient still suffered from the recurrent episodes of left elbow and bilateral knee joints hemorrhage, pain, and swelling. In recent 2 years, the frequency of joint hemorrhage had increased to approximately 2 times a week and only slightly relieved after factor VIII replacement therapy. Currently, the activity of those joints was limited to various degrees. Other medical history involved 2 cerebral hemorrhages 18 and 15 years ago, separately.\nOn physical examination, significant tenderness was noted in the left elbow joint with limited pronation and decreased grip strength. The preoperative Mayo elbow performance score (MEPS)[ was 55 for the left elbow. Moreover, knee valgus (left 20° and right 15°) was noted, and hyperextension, hyperflexion, and positive grinding test results were noted in both knee joints with a swollen and warm right knee. The preoperative Hospital for Special Surgery (HSS) knee scores[ were 58 for the left knee and 65 for the right knee.\nBilateral knee joints and left elbow joint exhibit advanced arthropathy on radiographs (Figs. A and 2A). These joints present narrowing of joint space, erosions of the articular facets, and bone deformation to various degrees.\nOur diagnosis was hemophilia A and HA of the left elbow joint, both knee joints, and left hip joint. The patient received left elbow synovectomy and left total hip arthroplasty, but the condition continued to deteriorate over time with worsening of the left elbow and both knee joints. Taking all of these factors into account, surgical methods were our top priority, and simultaneous total multi-joint replacement was indicated. Due to the complicated joint lesions and medical conditions, our preparations for this arthroplasty were far more sufficient than usual. Given that arthroplasty for patients with hemophilia A, particularly the simultaneous replacement of multiple joints, is challenging, the patient and his family were informed in detail of the possible benefits and risks of the surgery. We performed a full musculoskeletal assessment and thorough medical evaluation beforehand. Blood products were prepared for possible bleeding events. Then, our team performed bilateral total knee arthroplasty (Zimmer NexGen) and left total elbow arthroplasty (Zimmer) under tightly regulated factor VIII replacement therapy. Antibiotic prophylaxis was administered 30 minutes prior to surgery, and an additional dose was administered once during the operation. Local hemorrhage was carefully controlled to prevent secondary joint damage. Approximately 1800 mL blood was lost during the entire surgery. The patient received 900 mL blood by autotransfusion and 4 units of red blood cells plus 800 mL fresh frozen plasma by intraoperative infusion. During surgery, we observed hemarthrosis and villous synovial hypertrophy at the joints, and severe erosion of the articular surface and various degrees of bone deformation were noted. These findings confirmed the preoperative diagnosis and preoperative assessments. After surgery, hemostasis management, such as compressive bandage, factor VIII infusion, and rigorous monitoring of coagulation indicators, was performed. An early rehabilitation program was applied to achieve improved regain of function.\nWe managed factor VIII replacement therapy during perioperative period under the guidance of hematologists. On the day of surgery, 3000 U/12 h (the body weight of this patient is 63 kg) factor VIII (ADVATE) was administered intravenously followed by 2000 U/12 h on postoperative days 1 to 3 (POD 1–3). Then, on POD 4 to 6, a dose of 1500 U/12 h was administered followed by 1000 U/12 h over the following 6 weeks. Factor VIII inhibitor remained negative in perioperative tests.\nAt the follow-up, the patient's joints functioned well. The MEPS of the left elbow was 85, and the HSS score of knee joints were 71 (left) and 81 (right). On radiographs (3 months and 5 years after operation), the arthropathy of bilateral knee joints and left elbow joint was significantly relieved (Figs. B,C and 2B,C). |
A 60-year-old male with a history of non-small-cell lung cancer treated with chemotherapy and chest radiation over four years presented in an outpatient clinic setting with three weeks of gait ataxia and significant upper thoracic back pain. Neurological examination demonstrated subtle weakness against resistance in the lower extremities, but ataxia when ambulating. He had diminished sensation to light touch over the C8 dermatome of the left arm. He demonstrated non-sustained myoclonus in the ankles bilaterally. Sample images from a magnetic resonance image (MRI) of the cervical and thoracic spine are provided in Figure .\nThe images are notable for spinal cord compression from an epidural tumor arising from the chest wall. The patient was admitted to the hospital, and a computer-aided tomography (CT) scan of the cervical and thoracic spine demonstrated significant osseous involvement of the tumor and destruction on the left side of T1, T2, and T3 (Figure ). Ribs, one through four, on the left, also show significant destruction from the malignancy. Given the patient’s deteriorating but functional neurological examination, surgery was offered to try and preserve his ability to ambulate for as long as possible; however, it was felt that a combined anterior and posterior decompression procedure might be greater than the patient could tolerate. The kyphotic angle of the cervical spine in relation to the thoracic spine was concerning. The patient’s pedicles measured less than 4mm in the cervical vertebra, making him a less than ideal candidate for pedicle screws at these levels. Given his malignancy and kyphotic deformity, we felt he was at high risk for failure at the top of whatever fusion construct we would create given the difficulty of pedicle screws with a small pedicle diameter.\nThe patient was taken to the operative suite and placed in a prone position in a Mayfield pinion head holder. The neck was slightly flexed but left essentially neutral. A midline incision was carried out from the spinous process of C4 to T6. The laminas of C5, C6, C7, T1, T2, T3, T4, and T5 were exposed. The tumor was encountered on the left side from C7 to T3. The facet joints and lateral masses were exposed laterally at C5, C6, and C7. Lateral mass screws were placed utilizing the Magerl technique at C5, C6, and C7 bilaterally. At this time O-arm navigation was brought in and utilized to place 4.5mm pedicle screws into the right T1 pedicle, right T3 pedicle, and bilateral T4 and T5 pedicles. Once the screws were placed, a decompression of the spinal cord was undertaken by removing the T1, T2, T3, and bottom portion of C7 laminae. The ligament between C4-5 and C5-6 was removed to make room for sub-laminar Atlas cables, which were passed bilaterally. A tapering rod 3.5mm to 5.5mm in diameter was bent and placed to connect the screws at each level. Then a trans-connector was placed atop the C5 lateral mass screws. The sub-laminar cables were then wrapped around the connector as an extra guard against pull out of the lateral mass screws, which would be under greater load in comparison to their thoracic counterparts, especially in the context of the patient’s kyphotic deformity. The cables were then tightened down to 35 pounds of torque. A picture of the final construct can be seen in Figure .\nTwo 10 french round drains were left in the epidural space for the first two postoperative days to reduce the risk of an epidural hematoma. Intra-operative neurophysiological monitoring of upper extremity electromyograms (EMGs), upper and lower extremity somatosensory evoked potentials and motor evoked potentials were utilized throughout the case and demonstrated no changes. Samples were taken of the tumor, compared against previous biopsies and were consistent with a lung carcinoma that was positive for CK7, CK5/6 immunohistochemical stains and negative for TTF-1 and CK20 immunohistochemical stains.\nPostoperatively the patient was placed in a cervical collar with a thoracic extension. He demonstrated continued ataxia with subtle weakness in his lower extremities against resistance. He continued to have numbness in his 4th and 5th digits of the left hand without a change in his pre-operative sensory loss pattern. After just under a week in the hospital, he was deemed a candidate for inpatient rehabilitation and was discharged to such a facility for one month’s duration.\nAfter discharge from rehab, the patient had two falls within two weeks. One of which was not in his brace and occurred when his wheeled walker became caught on a piece of furniture causing him to fall onto his right shoulder. This led him back to the emergency room where on neurological examination, he demonstrated bilateral weakness against resistance in hip flexion, knee extension, and ankle plantar and dorsiflexion. He continued to demonstrate non-sustained clonus in both ankles. Progression of the tumor had furthered cord compression at the T1, T2, and T3 levels. CT of the cervical and thoracic spine did not demonstrate any fracture or failure of the hardware. His CT scan is presented in Figure . The patient, with his rapidly deteriorating neurological examination, decided to pursue hospice rather than further medical, surgical, or radiation therapy options. |
A 57-year-old male visited the hospital for swelling of the right mandibular area and trismus that had persisted for 7 days. The patient's medical history indicated diabetes mellitus as well as habitual smoking and alcohol drinking. Physical examination revealed redness, swelling, and fluctuation around the right mandibular third molar and pterygomandibular area. An abscess pocket was detected by computed tomography (CT) in the right pterygomandibular space (). Immediate intravenous antibiotic treatment was started. Drainage of pus by an intraoral incision under local anaesthesia was planned; however, the patient complained of sudden blepharoptosis, difficulties in eye raising, and blurred vision in his right eye. Abduction was the only possible movement of the right eye in ocular findings. No double vision or pain in the orbital area was reported, and neurological evaluation revealed pupil dilation and blepharoptosis, indicating that right ONP had occurred.\nFor emergency treatment of the abscess in the right pterygomandibular space, an intraoral incision was made for pus drainage. Contrast-enhanced brain magnetic resonance (MR) imaging, brain and neck MR angiography, and gadolinium imaging studies were performed the following day to evaluate the oculomotor nerve. A signal change was detected on the MR images in the right cavernous sinus area about the presence of an abscess in the cavernous sinus area (). With the help of CT, MR images, and clinical evaluation, we were finally able to diagnose the patient with ONP caused by pterygomandibular infection originating from the lower right third molar.\nOn the second day of hospitalization, the patient's clinical symptoms of ONP, including pupil dilation and blepharoptosis, had improved. A spinal tap for cerebrospinal fluid cytology was negative. On the fourth day of hospitalization, the right lower third molar, which was thought to be the cause of the infection, was extracted and curettage was performed on the extraction site. On the ninth day in the hospital on antibiotic therapy, the patient's condition had improved and he was discharged in a state of mild right blepharoptosis after ophthalmologic and systemic evaluation, including MR images (). No complications developed during a follow-up period of 6 months. |
An 8-year-old female patient presented to the outpatient clinic of Gastroenterology with complaints of mild abdominal pain, dyspepsia, flatulence, distension in upper hemiabdomen, vomiting with remnants of food from previous days and chronic constipation with an average of two bowel movements per week. The patient had a past medical history of intestinal obstruction due to foreign bodies for which she underwent an emergency exploratory laparotomy at age 6.\nThe UGI series showed a distended stomach that reached the pelvic cavity (Fig. ) as well as a marked dilatation of the duodenal bulb. The passage of contrast was evidenced up until the second portion of the duodenum. A control at 24 h showed contrast in the colon and rectum, however, contrast was still present in the stomach and duodenal bulb. These radiographic signs were suggestive of partial obstruction.\nThe UGI endoscopy was performed that showed normal structures until the duodenum, whose first portion was partially obstructed with food and foreign bodies (Fig. ). The objects were removed and a mucosal protrusion was observed that limited the passage of the endoscope to the second portion of the duodenum. These findings prompted a exploratory laparotomy where duodenotomy was performed between the second and third portions of the duodenum and an incomplete duodenal membrane with a 2 mm diameter concentric orifice was found and excised (Fig. ). A foreign body (plastic disc) (Fig. ) of ~2 cm of diameter was also found in the second portion of the duodenum.\nThe patient progressed favorably with an established diagnosis of resolved partial intestinal obstruction (intraduodenal membrane in third portion) and follow-up appointments with Gastroenterology, Surgery and Clinical Psychology.\nA 5-year-old female patient was referred to the outpatient Gastroenterology clinic due to abdominal distension, frequent vomiting and constipation with episodes of diarrhea of 1 month of duration. Physical examination showed upper hemiabdominal distention. An abdominal x-ray showed a radiopaque rounded image in the gastric chamber suggestive of foreign body (coin) (Fig. ). Extraction was suggested, however, the patient did not present for the follow-up appointments.\nOne month later, the patient presented to the emergency department complaining of pain in the right flank and abdominal distension that had increased in the last 24 h. Physical examination was notable for an abdominal circumference of 59 cm, with bowel sounds present. A barium enema showed free air in the abdominal cavity (subdiaphragmatic), aerial distention of the bowel, interloop edema, absence of air at rectal ampulla and persistence of rounded radiopaque image at the right flank (Fig. ). Surgical intervention is decided due to diagnosis of acute abdomen accompanied by subdiaphragmatic free air.\nAn exploratory laparotomy was performed where an explosive air release upon dissection of the omentum was evident. Approximately 300 ml of free fluid was quantified in the abdominal cavity and hypertrophy of the duodenum was observed in its first and second portions. The foreign body was removed with no complications (Fig. ). Remarkably, an incomplete duodenal membrane was identified at the proximal third portion of the duodenum, which was then resected (Figs and ). The presence of intestinal pneumatosis was notable and despite a thorough examination of the bowel to justify the finding, no perforation was evident (Fig. ).\nThe patient progressed favorably and is currently being followed up by the services of Gastroenterology, Surgery, Nutrition and Pediatrics. |
The patient is a 56-year-old woman who underwent a surgical treatment of a lateral ventricle meningioma at the age of 29. A month later, she underwent CP shunt placement for cyst formation after resection. The postoperative course was uneventful and she was well without shunt-related problems for 26 years. She developed a brain abscess related to the shunt catheter at the age of 55. A surgical removal of the catheter was attempted, but was not technically possible, and only the segment from the clavicle to the breast was removed with ligation of the two remaining ends. The two disconnected catheter segments remained in situ and were not retrieved. A year later, she was taken to a local hospital with continuous right-breast pain. The diagnosis of acute mastitis was made and she was referred to our institution for further examination. On presentation, her right breast was swollen with erythema (Fig. ). There was no abdominal pain and change in bowel habits. Funduscopic evaluation was normal with no signs of increased intracranial pressure. Her temperature was 36.7°C, and laboratory tests revealed a decreased platelet count of 103 000/μl, elevated AST of 97 U/l, ALT of 72 U/l and C-reactive protein level of 1.4 mg/dl. The breast abscess was drained under local anesthesia. Cultures taken from the abscess showed enteric organisms including Enterococcus avium, Klebsiella oxytoca and Bacillus. Abdominal CT showed that the shunt catheter was in the splenic flexure of the transverse colon with no other abnormalities (Fig. ). Colonoscopy was performed to survey the colon and the shunt catheter was found inside the lumen at the splenic flexure (Fig. ). Acute mastitis caused by enteric organisms which had migrated through the shunt catheter after penetration into the transverse colon was the presumptive diagnosis, and the catheter removed under general anesthesia. The breast to the abdomen segment of the catheter was exteriorized through the right-anterior chest wall without laparotomy. The postoperative course was uneventful. She was transferred to local hospital 15 days later. |
A 34-year-old female presented to the emergency room with upper abdominal pain and epigastric fullness. She had no associated nausea or vomiting and denied any alcohol consumption or cholecystectomy. Blood work showed elevated amylase and lipase levels consistent with pancreatitis. Serum beta-HCG was negative. She was admitted for acute pancreatitis and treated supportively with pain management and hydration. Her amylase and lipase levels returned to normal within 36 hours.\nUltrasound revealed a normal gall bladder and a large cystic mass in the epigastrium prompting further imaging. A contrast enhanced CT confirmed the presence of a large, complex cystic mass with septations measuring 15 × 15 cm in close proximity to the pancreas and extending to the liver and stomach (). No biliary or pancreatic duct dilatation was observed. The mass was suspected to be of hepatic orpancreatic origin; however this could not be determined on CT alone.\nOn MRI of the abdomen, the locules of the cystic mass were shown to be homogeneously T2 hyperintense and T1 hypointense with the mass overall measuring up to 14 cm in greatest dimension. The mass also demonstrated multiple low T2 signal septations measuring up to 4 mm in thickness () and showed enhancement following gadolinium administration (). No nodules were seen. MR images favored the mass to be of hepatic origin. No upper abdominal lymphadenopathy was observed and the suspicion was raised for a biliary cystadenoma or cystadenocarcinoma prompting surgical consultation.\nGeneral surgery described a complex cystic mass on CT occupying parts of segments 3, 4a, 4b, 5, and 8 without any involvement of major vessels. Endoscopic US revealed a normal pancreas and confirmed the hepatic origin of the cystic mass. Tumor markers (CEA, AFP, and CA 19-9) were normal and the patient was sent for definitive treatment with hepatobiliary surgery.\nPatient consent was obtained for a planned central hepatectomy or mesohepatectomy of segments 4a, 4b, 5, and 8 in order to preserve an adequate FLR (Figures and ). Intraoperative US was used to identify and avoid injury to the right and left hepatic veins. The transsection was performed with Conmed ALTRUS, a thermal tissue fusion system. A cholangiogram showed no evidence of a leak or injury. The patient did well in follow-up. |
Hip fracture in a 82-year-old woman needing hip replacement surgery. She weighs 115 kg, is affected by dementia and diabetes, and non-cooperative.\nOn the basis of current DRG systems that do not incorporate nursing intensity weights (NIW), hospitals obtain the same level of reimbursement for these two cases. Instead, from a nursing perspective these two cases require a completely different intensity of nursing care, and where the second case presents a higher level of nursing intensity (). One practical way to measure nursing intensity is to use a set of NIWs for each DRG and apply them at discharge to adjust routine care and intensive care per diem charges. For our scenario, we based our NIW on the North American Nursing Diagnosis Association (NANDA) Nursing Interventions Classification.\nThe patient in scenario 1 requires a much lower intensity of nursing care than the one in scenario 2, who will need a higher intensity of nursing care than the standard on which a healthcare organisation would plan its resources. However, according to current DRG systems the hospital will obtain the same level of reimbursement for the two patients.\nIdeally speaking, if intensity of nursing care was included in the DRG system, these two scenarios would require nurses to assess and document the level of patient complexity upon admission, and then plan and provide care accordingly. This would also entail the availability of appropriate levels of reimbursement and therefore the staffing and resources needed to cover the higher intensity of nursing care.\nHowever, this would require nurse administrators to use up-to-date knowledge and make decisions to implement nursing care models according to evidence-based staffing levels. If it is true that nurses in clinical setting must justify what they do, and how and why they are doing it, then nurse administrators/managers must justify what skill mix, and what nurse staffing level they are ensuring to determine good nursing practice without missed care, thus an evidence-based management approach. |
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. |
We present the case of a 66-year-old man who presented to the emergency department with worsening low back pain. He reported that he started to experience this pain in the last year, but it has been gradually increasing in severity. The pain was non-radiating, constant, and was noted related to posture or movement. The patient could not identify any exacerbating factors for his pain, but he stated that the standard analgesic medications become not fully effective for his pain. He rated the pain as 7 out of 10 in severity and this pain started to affect his quality of daily living. There was no history of preceding trauma. The pain was not associated with weakness or numbness in the lower extremities and there were no disturbances in the urinary or fecal continence. The patient did not experience weight loss, decreased appetite, or night sweats. He reported visiting several outpatient clinics for his pain, which was diagnosed as mechanical low back pain. He was prescribed several oral non-steroidal inflammatory drugs and underwent several sessions of physiotherapy.\nThe past medical history of the patient was remarkable for long-standing hypertension, diabetes mellitus, and dyslipidemia. He was receiving perindopril 10 mg once daily, atorvastatin 20 mg once daily, and metformin 800 mg twice daily. However, his conditions were not well-controlled due to non-adherence to lifestyle modification and pharmacologic treatments. He had a history of laparoscopic cholecystectomy performed after an attack of acute cholecystectomy. He was a smoker with a 30 pack-year history of smoking. He did not drink alcohol. He worked as a school teacher. His family history was non-contributory.\nUpon examination, the patient was alert, conscious, and oriented. He looked in mild distress due to the pain. His vital signs were as follows: pulse rate of 90 bpm, blood pressure of 146/86 mmHg, respiratory rate of 13 bpm, and temperature of 37.1℃. Examination of the lumbar spine revealed tenderness along the vertebrae with mild restriction in the range of motion due to the pain. Neurological examination of the lower limbs showed normal tone and power bilaterally with normal reflexes. The cardiorespiratory examination was normal. Initial laboratory investigation revealed a hemoglobin level of 14.2 g/dL, a leukocyte count of 5600/µL, and a platelet count of 350,000/µL.\nIn view of the aforementioned clinical information, the initial diagnosis was low back pain due to mechanical etiology. However, considering the longstanding history of the patient, a lumbosacral radiograph was performed. It revealed decreased intervertebral disc spaces with multiple osteophytes. Importantly, there was evidence of aneurysmal dilatation of the lower abdominal aorta with atheromatous calcification (Figure ). Subsequently, the patient underwent computed tomography angiography which confirmed the diagnosis of abdominal aorta aneurysm, measuring 8.2 in the maximum diameter (Figure ).\nThe patient was referred to the vascular surgery team due to the risk of rupture. The patient underwent endovascular treatment of the aneurysm. The procedure was performed successfully with no post-operative complications. The patient had complete resolution of his pain. After six months of follow-up, the patient had major satisfaction as he remained symptom-free since the procedure. |
A 40-year-old male presented to the ENT outdoor clinic with complaints of a foreign body sensation in the throat, progressive hoarseness of the voice and difficulty in breathing since the last 7 days. The patient developed the above mentioned symptoms after an acute episode of seizure. He also gave a history of five such episodes in the last two years, but he was not on any treatment for seizures. The patient was using an artificial denture for the upper jaw since one year. The patient became unconscious for 5-10 minutes after the last episode of seizure, after which he could not find his denture. He realized that he had accidentally lost his denture during the episode and ignored the whole event. Subsequently he had sudden onset of foreign body sensation in the throat and, later on, he developed progressive hoarseness and difficulty in breathing for which he consulted our hospital. The patient complained of throat pain, painful swallowing and difficulty in speaking associated with discomfort in the throat. There was no hemoptysis or chest pain. During clinical examination, the laryngeal contour was normal and crepitus was present. There was no stridor or chest indrawing. Examination of the oral cavity and oropharynx was normal. During auscultation, normal bilateral air entry was observed. A diagnostic laryngoscopy was performed, and revealed an inflamed edematous mucosa in the subglottic area with a whitish structure believed to be a foreign body (missing denture) or a growth in the subglottic region. The subglottic area had space to allow for breathing and vocal cords were mobile. A radiograph of the soft tissue of the neck (lateral view) was done, which showed a vague soft tissue shadow and narrowing of air columns (Fig.1).\nA direct laryngoscopy was planned and consent for rigid bronchoscopy and tracheostomy was obtained in view of a large and impacted denture. General anesthesia was induced with Sevoflurane. Standard cardio- pulmonary monitoring and pulse-oximetry were used. Intubation was not possible with such a presentation. After induction, the patient was positioned and the laryngoscope was introduced. The denture was clearly observed to be impacted at the level of the subglottic region of the larynx and trachea (Fig.2).\nAn attempt was made to remove the denture through the laryngoscope but was not succesful due to edema and impaction of the denture in subglottic area. Keeping in mind the possibility of injury to the vocal cords and nearby vital structures by this large irregular sharp denture, forceful removal was not attempted. A tracheotomy was performed. Direct laryngoscope was introduced and the foreign body was gently pushed from above by an assisting surgeon and gradually pulled through the tracheostome (Fig.3). An impacted 3-toothed denture plate was carefully removed by using curved artery forceps (Fig.4).\nCheck bronchoscopy was performed and edema and mucosal injury was observed at the site where the foreign body was embedded. Spontaneous ventilation was maintained throughout the procedure. Post-operatively, the patient was closely monitored. The patient was kept on nasogastric tube feeding for 2 days and tracheostomy was successfully closed on the 4th day. A neurology consultation was performed for the seizure disorder and medical treatment was started. The patient was discharged on the 7th post operative day. During his last follow up, at 8 weeks, he had a normal voice without any breathing problems. |
We present the case of a 40 years old female patient who at the age of 30 underwent right nephrectomy for a clear cell renal cell carcinoma. Five years later she developed lung and osseous metastases and the biopsy of the lung lesion revealed metastatic RCC. Bevacizumab plus interferon-A was administered as 1st line treatment and the disease evaluation after three months revealed disease progression. She was treated with sunitinib malate as 2nd line therapy for one year achieving stable disease as best response. At relapse, sorafenib was given as 3rd line treatment and the patient achieved a remarkable partial response lasting almost for 36 months. Due to disease progression everolimus was initiated as 4th line treatment and the disease evaluation after 6 months revealed progression at her bone metastases, stable disease at lung lesions and no evidence of brain metastases. The ECOG performance status of the patient was 1 due to mild pain at her right hip, she had no history of hypertension and since pazopanib has shown effectiveness also in cytokine-pretreated patients with metastatic RCC \n[], we decided to administer pazopanib as 5th line treatment. Her medical history was insignificant for other diseases than metastatic renal carcinoma. The concomitant medication during pazopanib treatment consisted of fentanyl transdermal at 25mg and tramadol hydrochloride.\nAfter 21 days of pazopanib therapy the patient referred to the emergency department with epileptic seizure, impaired vision at both eyes and bilateral, temporal and pulsutive headache. The physical examination revealed hypertension 165/105 mmHg (grade III toxicity), suspension of both direct and indirect papillary reflexes for both eyes and bilateral blurred vision and diplopia. On neurological examination there was no evidence of lateralizing or focal features. Blood tests, including CBC, blood chemistry, coagulation study and gasometry, were unremarkable. The performed urine analysis showed no evidence of significant proteinuria (dipstick staining: 1+) . Retinoscopy was also insignificant. MRI of the brain revealed subcortical oedema at the occipital and parietal lobes bilaterally (hyperintense signals on FLAIR and T2 sequences, absence of lesions on T1 sequence). These findings are given in Figure. \n: 1.A, 1.B (FLAIR), 1.C, 1.D (T2), 1.E, 1.F (T1), respectively.\nPazopanib administration was withheld and the patient was treated with anticonvulsants (phenytoin), i.v. administration of mannitol and antihypertensives : furosemide 40 mg given i.v on the first date and perindopril 4 mg given orally the following days. One day later the seizures were stopped, her visual ability was restored and the blood pressure was normalized after few hours with furosemide and remained within normal levels the next days. The headache was more intense the first day but after the normalization of the blood pressure it was gradually improved and completely remitted after 5 days. A lumbar puncture was performed and the cerebrospinal fluid analysis revealed no cells, normal physical characteristics, normal chemical tests and negative microscopic examination. In addition the viruses tests for HSV1, HSV2, CMV, EBV were negative. She completely recovered from her symptoms and was discharged on the tenth hospital day.\nThe patient underwent a brain CT scan, two weeks after the onset of the symptoms, which was negative for abnormal findings. A brain MRI performed 3 weeks after confirmed the CT scan findings showing that the subcortical oedema had been subsided from both FLAIR and T2 sequences. (Figure. \n: 2.A, 2.B, 2.C, 2.D). Due to the serious nature of the adverse drug reaction re-administration of pazopanib was not carried out and the patient was re-challenged with sorafenib because of the excellent past response. Unfortunately, the patient died 2 months later because of disease progression in the lungs with no signs of central nervous disease.\nCausality assessment carried out using the World Health Organization-Uppsala Monitoring Centre criteria revealed that the reaction had ‘probable/likely’ relationship with pazopanib usage \n[]. The association was also evaluated using the Naranjo algorithm for estimating the probability of adverse drug reactions and a score of 6 indicated a ‘probable’ relationship \n[]. |
A 48-year-old woman presented to our intensive care unit (ICU) with a 10-day history of myalgias, fatigue, anorexia and progressive dyspnoea. Her initial evaluation in the emergency department was notable for confusion and jaundice. Initial vital signs were notable for hypotension, tachycardia and hypoxaemia with room air saturation of 82%. Laboratory evaluation revealed profound metabolic derangements (see ) including elevated liver enzymes, acute kidney injury and a marked lactic acidosis (14 mmol/L) with a calculated anion gap of 43 mmol/L. Over the course of a few hours, her condition further deteriorated with cardiovascular collapse that required multiorgan support with mechanical ventilation and vasopressor dependence despite fluid resuscitation. Acute kidney injury progressed to anuric renal failure requiring renal replacement therapy. Inpatient work-up in the ICU included CT scan of the chest, abdomen and pelvis which demonstrated bilateral pulmonary consolidations with areas of cavitation (see ), pancolitis to level of rectum and presence of free fluid in the abdomen.\nThe patient’s medical history was notable for a recently suspected but poorly defined autoimmune process. Two years prior to her current presentation, she had been evaluated by otolaryngology for palatal abnormalities. She was diagnosed with an infected palatal polyp that had progressed over several years with development of a defect in her hard and soft palate and recurrent sinusitis. As a result, she had difficulty with oral intake and chronic tooth pain. She reported depression as a result of her medical issues and had begun to use cocaine and alcohol as a consequence. A screening rheumatological evaluation done for evaluation of the palatal defect by her primary care provider revealed a positive antinuclear antibody and a positive antineutrophilic cytoplasmic antibody (ANCA) titre of 1:640 with a perinuclear pattern (see ). She was referred to rheumatology for further evaluation.\nOver a similar time frame, she noted recurrent rashes over her lower extremities with associated pain, erythema and oedema. She had six separate episodes of rash, erythema and pain by the time of her current admission. These episodes initially resolved with elevation of the affected body part and ice packs. With later recurrences, the rashes would continue to cause symptoms despite repeated antibiotic administration and overall she had a poor response to medical therapy. Given palatal abnormalities, positive ANCA and skin findings, she was referred to dermatology where she underwent punch biopsy. While negative for findings of vasculitis, the biopsy demonstrated dermal fibrosis with associated perivascular lymphohistiocytic inflammation and subcutaneous fat degeneration ().\nUnfortunately, she was hospitalised 3 months prior to her current presentation, before her scheduled rheumatology appointment, for new onset seizures with associated hepatitis, leucopenia and electrolyte abnormalities. At that time, she was given a presumptive diagnosis of alcohol withdrawal seizures and possible drug-induced lupus. Due to her abnormal liver enzymes, additional testing included negative serologies for hepatitis B, hepatitis C, antismooth muscle antibody, antimitochondrial antibody and HIV. An ultrasound of her liver was remarkable for a steatohepatitis.\nAt the time of her current admission, she was abstinent from alcohol and cocaine, although prior use of both was noted. She was an active smoker with approximately 20 pack years. She lived alone, had no children, and was self employed. Family history was obtained. Her mother was deceased and had a history of hypertension and arthritis. Father was also deceased. She had two sisters and two brothers, all of whom were healthy. |
We present a case of a 64-year-old woman with a history of secondary biliary cirrhosis after a cholecystectomy. In addition to the cholecystectomy, the patient underwent two attempts to surgically repair a bile duct stenosis using enteric anastomosis. However, she progressed to advanced cirrhosis and reached a child C and MELD (model for end stage liver disease) score of 31. Three months prior to hospital admission, the patient presented with a tender, hyperemic mass in the left perineum and left buttocks and progressed to partial skin necrosis in this region (). Other findings at the time of the physical examination included severe malnutrition, jaundice, anemia, ascites, and an epigastric hernia. She reported pain in the perineum region and developed renal insufficiency after hospitalization. The patient had no history of fever or changes in bowel movements. At the time of admission, the patient had a white cell count of 3 × 109/L with a left shift, total bilirubin of 5.9 mg/dL, and an ascites culture positive for Escherichia coli and Candida tropicalis.\nComputed tomography showed a sciatic hernia () on the left side with a large hernial sac filled with liquid (ascites). Unfortunately, this patient was first seen in a small hospital a few days before admission to our hospital. Believing that it was a perianal abscess, she underwent a surgical drainage of the bulge, leaving an open hole in the hernial sac (). Thereafter, the wound continually leaked ascites fluid, and secondary peritonitis developed. Her clinical condition consequently worsened. The misdiagnosis compromised the patient outcome. After admission, the patient required dialysis because of renal insufficiency. Her hepatic function worsened, and her MELD score reached 31. The patient underwent surgical repair of the hernia because there were no other options. The surgery consisted of a hernial sac dissection, placing sutures at its base. A polypropylene mesh plug was placed, and we used continuous suturing of several layers of tissue to promote impermeability. Postoperative ascites leakage was a concern, but this technique prevented its occurrence. Nevertheless, the patient was discharged from the intensive care unit, but she returned 3 days later because of a pulmonary infection. She subsequently died of sepsis on postoperative day 22. |
A 6-year-old boy with no pathological history accidentally fell from the top of an approximately 3 m climbing pole and injured his right extended elbow and wrist joint. Due to pain and deformity in the right elbow and wrist joints, he visited our hospital. Swelling and a dinner fork deformity of the right wrist joint and pronounced swelling of the right elbow joint were observed. No skin damage was observed. No findings of nerve injury or arterial injury were obtained in the right upper limb. Radiography revealed lateral dislocation of the radial head, a fracture of the proximal ulnar metaphysis, and mild bending deformation at the fracture site. In addition, fractures of the distal radius and ulna, as well as dorsal displacement of the distal fragment, were seen (). Thus, the patient was diagnosed with Bado type III Monteggia injury with ipsilateral fracture of the distal radius and ulna.\nManual reduction under nerve block was attempted on the day of injury. However, because it was difficult to maintain the reduction of the radial head, as shown in , open reduction and percutaneous procedures were performed under general anesthesia. A Kirschner wire was inserted, percutaneously, from the olecranon into the ulnar diaphysis. When the Kirschner wire was in place, the dislocation of the radial head immediately showed good reduction. Further, open reduction and fixation of the fractured distal radius and ulna were performed with Kirschner wires (). A long-arm cast was used for external fixation with the elbow in 90° flexion and the forearm in an intermediate position.\nTwo weeks after surgery, callus formation at the fractured bone was observed. Therefore, the cast was removed, and range of motion (ROM) exercises of the elbow and wrist joints were initiated. Since bone union was achieved at 6 weeks postsurgery, the Kirschner wires were removed. Pain, ROM limitation, and lateral instability were not observed in the elbow or wrist joints at 3 months after surgery. Additionally, plain radiographs taken at the same time showed a radially convex curvature at the proximal portion of the ulna and lateral subluxation of the radial head (). However, a gradual correction in the outward displacement of the radial head was observed during the 3-year follow-up.\nTwenty-one years after surgery, the patient returned to our hospital for another disorder. At that time, we obtained informed consent to perform an examination and take radiographs of the previous Monteggia injury. Neither spontaneous pain, pain during exercise, tenderness, nor ROM asymmetry were observed (). The biocompatibility of the radiocapitellar joint was good, and no malunion was found in the distal radius and ulna (). The patient reports that he has been working as a computer programmer and performs weight training as a hobby without limitations. |
There was a 68-year-old female with past medical history of being diagnosed with colon cancer in 2008. Present status was post colon resection with adjuvant chemotherapy. In 2008, the patient had a recurrence involving metastasis to the liver, which was then treated with metastectomy followed by a chemotherapy regimen. The patient was brought into the emergency room presenting with a sudden onset of facial swelling and pain which had begun before she went to sleep that night. Later, she woke up in the middle of the night experiencing bluish facial skin discoloration accompanied with severe shortness of breath. She had undergone the most recent chemotherapy cycle just 4 days ago to treat colon cancer with liver metastasis. The patient complained of wheezing along with lip and neck swelling. It was noted that the patient had an allergy to pollen extract, cats, dogs and several food items. At the time of the symptoms onset, the patient denied any previous exposure to known allergens or experiencing similar episodes. On the right side of her chest, the patient had a port.\nThe patient was treated in the emergency room with intravenous Benadryl 50 mg, famotidine 20 mg and Solumedrol 125 mg. She was also administered with an intramuscular injection of 0.3% epinephrine and then placed on a Ventimask of 50%. The patient was placed on bi-level positive airway pressure (BiPAP) machine after the initial treatment failed to show improvement. The patient was treated in the emergency room for anaphylactic reaction for unknown reason. The patient was shown to be awake, oriented and alert upon evaluation. She was observed to be in distress and using her accessory muscles to breath. Her heart rate was 104 beats/min, respiratory rate was 30 breaths/min and the blood pressure was 165/100 mm Hg. The general examination was remarkable for periorbital swelling and facial blush discoloration. Symmetrical swelling on the neck was observed. Lung examination was remarkable for tachypnea and using the accessory muscles was noted, no crackles, stridor or wheezing. Cardiac examination revealed tachycardia, no murmur or gallop. The patient had swollen upper extremities and she was asked to elevate her arms till they touch her face. The patient started complaining of increased pain in her arms and shortness of breath and she soon turned blue.\nThe laboratory investigations of the patient revealed hemoglobin (Hb) 13 g/dL, white blood cell (WBC) 29.5 × 103/µL and platelets 159 × 103/µL. Arterial blood gas analysis showed a pH of 7.53, partial pressure of oxygen (PO2) of 161 mm Hg and bicarbonate (HCO3) of 18 mmol/L. Troponin was found to be negative and the basal metabolic panel was observed as unremarkable. Partial prothrombin time of 22.2 s, internal normalized ratio of 1.03 and prothrombin time of 13.4 s were shown by the coagulation studies. Sinus tachycardia with heart rate of 104 beats/min and no ST elevation or depression was shown in the electrocardiogram (ECG). Except for the internal jugular vein port-A catheter, the chest X-ray came out clear. A chest computed tomography (CT) scan with intravenous contrast was ordered, and the suspicion of thrombus within SVC was raised by the presence of abundant collateral vessels revealed in the report ().\nThe patient was immediately started on a heparin drip and then moved to the intensive care unit (ICU). Consultations were sought for thrombectomy from the Interventional Radiology and Vascular Surgery. During the procedure, a focal hemodynamically significant stricture of the SVC was revealed by venography, which was adjacent to the tip of the right internal jugular vein port-A catheter. The antegrade blood flow was restored after successfully achieving near complete interval thrombolysis. Minimal residual clot was analyzed by starting the tissue plasminogen activator (TPA) at 1 mg/h. Further TPA therapy was deferred after successful thrombolysis of the focal thrombus was revealed by the venogram 1 day later along with persistent non-occlusive small thrombus in the SVC. The patient’s condition improved, and her symptoms resolved. The patient was started on oral anticoagulation. Few days later the patient was discharged home on oral anticoagulation. |
A 49-year-old woman was admitted with right lumbar pain and edema of both legs. At admission, she was not very ill looking and had experienced no weight loss. Abdominal computed tomography (CT) showed a large low attenuated mass around and in the S7 segment of the liver: the mass measured 9×12 cm, and it involved the right kidney (). In addition, there were multiple enlarged mesenteric lymph nodes and multiple variably sized discrete nodules in both lungs (). Cavography showed subtotal occlusion of the inferior vena cava (). During cavography, intracaval biopsy was performed and spindle cell sarcoma was found.\nAn operation was performed via midline laparotomy with subcostal extension. Before beginning to resect the tumor, we checked the lymph nodes and the rectal shelf and omental seedings. All were negative on frozen biopsy. During dissection around the tumor, partial bypass (femoro-femoral) was inevitable due to massive bleeding of collateral vessels. Through the right femoral artery and vein, arterial and venous cannulation was done. The pump flow was 3 L/min and the total bypass time was 30 minutes. During en bloc resection of the mass from the hepatic vein to the iliac bifurcation, partial duodenal excision, partial liver resection, and right nephrectomy were performed due to tumor invasion.\nThe left renal vein was clamped for one hour because we had confirmed good drainage of the gonal vein. After resection, the IVC was replaced with a 12-mm vascular graft, and the left renal vein was re-implanted in the vascular graft. The gross findings are shown in . Histological analysis revealed a moderate grade malignant spindle cell tumor that arose in the IVC with intraluminal spread into the vena cava and the right renal vein. No lymph node involvement was found. The tumor border had infiltrated to the renal parenchyma, the adrenal gland, and the IVC, but the resection margins were clear. The patient's postoperative recovery was uneventful except for minor gastrointestinal troubles and the patient was discharged at the 24th day. The patient remained asymptomatic for 8 months when she was readmitted for radiation therapy and pulmonary metastasectomy. At this time, the vascular graft in the IVC was occluded on the CT angiography, but she did not complain of any symptoms such as leg edema or abdominal discomfort. Periodic follow-up is being conducted at the department of oncology. |
A 21-year-old male was referred to the department of orthodontics and dentofacial orthopedics with a chief complaint of asymmetry of the face [] and forwardly placed upper front teeth. He gave a history of restricted mouth opening due to ankylosis on the left side 10 years back, for which he had undergone surgery at the age of 11 years. His left central incisor was sensitive and tender on percussion.\nHe had facial asymmetry with a deviation of the mandible toward the left side and a severe canting of the occlusal plane. The profile was convex with a retrognathic mandible. On smiling, gingival exposure on the right side was increased, indicating an increased posterior vertical growth of the maxilla in compensation to the mandibular deviation. Intraoral examination [Figure and ] revealed an Angle's Class II division I subdivision malocclusion with lower anterior crowding. Both the arches were asymmetric. The maxillary midline was deviated to the left of the facial midline by 1 mm, and the lower midline was shifted to the left by an incisor width. There was an increased overjet of 14 mm. The molar relationship was Class I on the right and Class II on the left.\nThe patient underwent a CBCT scan []. The panoramic view [] revealed condylectomy of the left side as reported in the history. It also showed impacted third molars on the right side. Two metal screws were visible at the left angle of the mandible, which had probably been placed at the earlier surgery to stabilize a graft. Cephalometric analysis [ and ] revealed skeletal class II bases and a horizontal growth pattern. The upper and lower incisors were proclined on their bases. The posteroanterior cephalometric radiograph [] showed a mandibular deviation to the left side.\nThe mandible deviated to the left on opening. The maximum interincisal opening was 39 mm. Based on the history and clinical and radiographic examination, the patient was diagnosed with skeletal Class II malocclusion and severe facial asymmetry secondary to unilateral TMJ ankylosis.\nThe primary objective of the treatment was to address the chief complaint of the patient, that is, the facial asymmetry, and correct the mandibular retrognathism. Dentally, the objectives were to correct the proclination of the upper incisors, resolve crowding of the lower incisors, achieve a normal overjet and Class I molar and canine relation, and correct the midline.\nThe marked facial asymmetry necessitated a surgical treatment plan. Bijaw surgery was planned to correct the severe occlusal cant and mandibular deviation. Presurgical orthodontics was aimed at aligning the arches and removing the dental compensations. A surgically assisted rapid maxillary expansion was performed to expand the maxillary arch and normalize the arch form. A single incisor extraction was done in the lower arch to relieve crowding.\nBefore orthodontic treatment, the patient underwent endodontic therapy in the upper left central incisor. Presurgical orthodontics was commenced with surgically assisted rapid maxillary expansion. A hyrax screw soldered to the bands on the maxillary first premolars and molars was used for the expansion []. The screw was activated one-quarter turn twice a day till overexpansion of 2–3 mm was achieved. The hyrax screw was then blocked and retained for 3 months to stabilize the expansion. The second phase of the treatment was started with the preadjusted edgewise appliance (MBT 0.022“ × 0.028“ prescription) to level, align, and decompensate the arches. The wire sequence was 0.016“ heat-activated nickel titanium (HANT) and 0.018“ stainless steel followed by 0.019“ × 0.025“ HANT. Presurgical records were obtained 1 month after the placement of final stabilizing archwires (0.019“ × 0.025“ SS). The presurgical phase took 12 months. Arbitrary facebow mounting was done on a Hanau articulator. Model surgery was performed on articulator-mounted casts in centric relation []. Two surgical splints were constructed for the bijaw surgery: first after maxillary repositioning and the final after mandibular surgery, in consultation with the oral surgeon. A bijaw surgery was performed according to the values obtained from the model surgery []. Healing after surgery was uneventful. The final splint was tied to the maxillary arch, and the patient was asked to wear guiding elastics to bite into the splint. Postsurgical orthodontic treatment was commenced 6 weeks after surgery when the patient had attained full range of movements and had returned to a normal diet. The stabilizing archwires were removed, and the breakages in the fixed appliance were repaired. A 0.017“ × 0.025“ titanium molybdenum alloy (TMA) wire was placed in the upper arch and 0.016“ NiTi in the lower arch. The patient was asked to wear light elastics (3/8“) for settling the posterior occlusion. At the next visit, buccal root torque was placed in the TMA wire to control the upper posterior segments. The final settling of occlusion was carried out on 0.016“ S.S wires.\nThe combined orthodontic–surgical treatment resulted in a good occlusal and esthetic result. A marked correction of facial asymmetry and occlusal cant was achieved after surgery, resulting in a significant improvement of facial esthetics [Figures and ]. The profile also improved considerably with mandibular advancement. Lip competence was achieved with a normal overjet and overbite.\nPosttreatment panoramic radiograph [] revealed acceptable root paralleling without any significant root resorption. Cephalometric analysis and superimposition [Figures and ] showed correction of the skeletal Class II pattern with a slight increase in the mandibular plane angle. The incisor inclinations and the position of the lower lip to esthetic plane also improved. The posteroanterior cephalogram [] showed a significant improvement in facial symmetry with the mandible nearly in line with the facial midline.\nA clear overlay retainer was delivered for the maxillary arch, and the patient was instructed to wear it full time for the first 6 months and only at night thereafter. A fixed retainer was bonded on all the mandibular incisors. Instructions were provided for oral hygiene and maintenance of the retainers. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.