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A 20-year-old female presented with dyspepsia and pain in her left, upper abdomen for the past five days. The pain was insidious in onset, originated in the left hypochondrium with radiation to the left shoulder, was constant and dull aching in nature, aggravated with fatty foods, and was relieved with analgesics and antacids. There was no history of fever, jaundice, vomiting, urinary complaints, altered bowel habits or weight loss. The menstrual history of the patient was regular. She had experienced a similar episode around three months prior, which was relieved by conservative medical therapy. She did not give any history of any medical or surgical comorbidities and had no significant drug history.\nThe general examination of the patient was essentially normal with no signs of jaundice, fever or anemia. When examining the abdomen, there was mild tenderness from deep palpation in the left hypochondrium, with normal bowel sounds. The rest of the abdominal examination was unremarkable. Examination of the cardiovascular system revealed an apex beat in the right, 5th intercostal space in the right, mid-clavicular line.\nThe patient's routine blood investigation revealed a normal complete blood count, normal liver and kidney function tests, normal thyroid function test and normal glycemic status. The urine examination also did not reveal any abnormalities. The ultrasonography of the abdomen showed as follows: 1) A gallbladder, small in size, with a thickened wall and situated on the left side. The lumen was filled with multiple, small calculi with posterior acoustic shadowing; 2) The liver situated on the left side, normal in size, with a homogenous parenchymal echo pattern. The intrahepatic biliary channels were not dilated; 3) The common bile duct was normal in size and diameter without any intraluminal lesions; 4) The spleen was normal in size and shape without any focal lesions and situated on the right side; and 5) Features were consistent with situs inversus. The electrocardiograph showed a right axis deviation while the chest x-ray (posteroanterior view) showed dextrocardia, the left hemidiaphragm slightly raised compared to the right side and a fundic gas shadow, of the stomach, on the right side, all findings consistent with situs inversus totalis (). The findings were re-confirmed with a computed tomography of the abdomen and the diagnosis was established to be a case of cholelithiasis in a patient with situs inversus totalis ( and ).\nAfter obtaining necessary anesthetic fitness, the patient was scheduled to undergo an elective laparoscopic cholecystectomy. The procedure began by adjusting the theatre equipment, including the carbon dioxide insufflator, the diathermy set and the monitor, which were placed on the left side of the patient, almost mirroring their normal positions. The patient was then positioned in the reverse Trendelenberg position after adequate anesthesia. The primary surgeon and the first assistant stood on the right side of the patient, whereas the second assistant was on the left side. A total of four ports were made - the two 10 mm ports were placed in the infraumbilical and subxiphoid regions, respectively and the two 5 mm ports were placed in the left hypochondrium in the left mid-clavicular line and in the left anterior axillary line at the level of the umbilicus ().\nThe technical challenges anticipated included creating a pneumoperitoneum from the left side, dissection of the Calot's Triangle with the right-handed surgeon using the non-dominant hand and chances of the surgeon's arms crossing during retraction of the Hartmann's pouch. The pneumoperitoneum was induced using a Veress needle through the infraumbilical incision, by the surgeon on the left side of the patient, as done conventionally. An inspection of the abdominal cavity was done and the diagnosis of situs inversus was confirmed. The camera was maneuvered from the infraumbilical port by the first assistant and the fundus of the gallbladder was retracted by the second assistant, with a toothed grasper, from the 5 mm port in the left, anterior axillary line. In order to prevent the primary surgeon from crossing arms while retracting the Hartmann's pouch from the right side of the patient, the assistant retracted it from the left side. This not only prevented the primary surgeon from crossing arms, but also enabled him to dissect the Calot's Triangle with his right hand using Maryland dissecting forceps inserted through the subxiphoid/epigastric port. The cystic duct and artery were identified and dissected free from the surrounding structures. They were clipped using titanium clips, the applicator being introduced through the 10 mm epigastric port. The gall bladder was dissected from the gall bladder fossa using a hook diathermy and was delivered outside through the epigastric port. Adequate hemostasis was ensured and the port sites were closed with non-absorbable sutures ().\nThe estimated operating time was around 70 minutes and the postoperative period was uneventful. She was discharged on the second postoperative day and the sutures were removed on the seventh postoperative day, in the outpatient department. She followed up one month after surgery and was found to have recovered well. She has not developed any postoperative complications to date. |
A 51 year old man presented to the ED for the third time in 2 weeks with complaints of flank pain and hematuria. He had complained of left sided flank pain during the initial 2 visits. During the first visit, the patient was diagnosed to have renal colic. X-ray KUB did not show any renal stone. He was treated symptomatically with analgesia and discharged. During the second visit with complaints of persistent left flank pain despite taking analgesia given at discharge, he was admitted to the emergency observation ward for pain management. Bedside ultrasound done then was noted to have mild left sided hydronephrosis. He was pain free at the end of the observation and was then discharged with analgesia and an outpatient follow-up with the urology department. He was also scheduled to have an outpatient computed tomography scan of the kidneys, ureters, and bladder (CT KUB). However, 2 days before the scheduled CT, he represented to the ED with right sided flank pain since morning on the day of his visit. The pain radiated to the right groin and was associated with hematuria. He was not passing blood clots. He denied any other complaints of fever, weight loss, vomiting, diarrhea, or constipation. He had a past medical history of hypertension, diabetes mellitus, and hyperlipidemia. He had previous surgeries for appendicectomy and cholecystectomy.\nHis vital signs were stable. There was tenderness over the right flank on physical examination. There was also a palpable tender mass measuring about 5x5cm over the right lumbar region. There was no renal angel tenderness. Bedside ultrasound in the ED showed an appearance of a 6 cm cystic lesion around the inferior pole of the right kidney with internal echogenicity within the cyst. The provisional diagnosis was a bleeding renal cyst versus a tumor. Blood tests done in the ED showed a mildly elevated white cell count 12.64 × 10(9), hemoglobin of 14 gm/dL, and creatinine of 109 Umol/L.\nPatient was seen by the urology on-call in the ED and his bedside ultrasound done by the urologist revealed a 10 cms cystic lesion anterior to the lower pole of the right kidney with irregular internal echogenicity. Patient was admitted to urology department for further evaluation and management.\nInpatient CT Intravenous Pyelography (IVP) was done and the left kidney showed relative hypoenhancement and reduced excretion of contrast, associated with diffuse ureteric thickening and periureteric fat stranding which could be related to a passed left renal calculus or a differential diagnosis of ureteropyelonephritis which was less likely due to diffuse involvement of left kidney. There was a tubular cystic structure in the right flank with inferior tip at the same site of previously inflamed appendix stump base which could represent mucocele of the appendix stump ().\nPatient was then transferred under the care of the general surgery department, where he underwent a colonoscopy which demonstrated an extrinsic compression at the caecum and appendiceal orifice and a smooth pedunculated polyp measuring 10 mm in the sigmoid colon (). Exploratory laparotomy was done, the mucocele was resected, and patient recovered well. Histopathology revealed a benign mucinous cystadenoma. The patient was discharged well with an outpatient surgical follow-up. |
An 18 month old boy presented to our ocular oncology referral center with the diagnosis of leukocoria in the left eye. He had no other past medical or past ocular history and family history was negative for retinoblastoma. Upon initial examination, there was no light perception (NLP) vision in the left eye. The patient was able to fix and follow normally with the right eye. Intraocular pressures were within normal limits in both eyes. Ocular examination was normal in the right eye. In the left eye, the retina was visible on external examination through the pupil (Fig. ). Fundus exam through the pupil revealed a total, exudative, retinal detachment with diffuse retinal telangiectasias, leading to a diagnosis of Coats' disease. Given the stage of the disease and poor prognosis, the family agreed to defer treatment and chose comfort care only for the left eye.\nTwo weeks after his initial presentation, the child returned to the hospital with a red, painful, left eye. His family denied any other changes systemically. External ophthalmic examination at this time revealed conjunctival injection and xanthocoria (yellow pupil), both new findings (Fig. ). Slit lamp examination revealed an anterior chamber occupied by a turbid, yellow, proteinaceous fluid. The material was reflective and filled the entire anterior chamber, completely obscuring any view to the pupil or the posterior segment. These findings were consistent with an interval development of anterior chamber cholesterolosis. The intraocular pressure at this time was 52 mmHg. There was no view to the posterior segment due to the anterior segment opacity. B-scan ultrasonography revealed no masses or calcifications but did corroborate his previous retinal exam by showing massive subretinal exudation (Fig. ).\nThe patient returned one week later for follow up exam. In that week the right eye had developed a complete hyphema with continued evidence of anterior chamber cholesterol (Fig. ). The intraocular pressure in the right eye was still 45 mmHg. The patient's exam findings at this time, including glaucoma, hyphema, and anterior chamber cholesterolosis, were consistent with Stage 5 Coats' disease []. Due to pain, NLP vision, and inability to examine the posterior segment, the eye was enucleated. Pathologic examination of the enucleated globe confirmed the diagnosis of Coats' disease with evidence of thickened and dilated capillaries as well as intraretinal and subretinal exudation (Fig. ). His course has been uneventful since enucleation.\nIncluding this case, there are four specific reports of anterior chamber cholesterol in patients with Coats' disease. The characteristics of these four patients are outlined in Table . All four patients are male. One other patient presented in an acute pain crisis as our patient did, while in the other two patients the cholesterol was noted incidentally.\nThree patients had no light perception vision while the other had bare light perception vision. Interestingly, all four patients carried a diagnosis of Coats' disease prior to the development of anterior chamber cholesterolosis. All four eyes were enucleated. |
A 61-year-old man presented with a 3-month history of increasing pain in his left groin, and numbness and radiating pain in the anterior and medial thigh without any injury. He reported that he was in constant pain and that his pain continued during sleeping hours. The pain and numbness were markedly increased when he was in a sitting position. Although he had opportunities to sit in his job as a factory manager, he was unable to do so due to the increased pain and numbness that he experienced while sitting. At the medical examination, he was unable to sit on the chair in the consultation room. A physical examination revealed tenderness in the femoral triangle and radiating pain and numbness. There was no palpable mass or muscle atrophy. The patient was observed to limp from the time of start of walking. His range of motion was observed to be restricted to 100 of flexion, 10 of extension, and 10 of internal rotation due to an increase in the radiating thigh pain and numbness. Plain radiographs showed no osteoarthritic changes (, ). Computed tomography showed a bump and bone cyst in the anterolateral aspect of the femoral neck (, ). The presence of cam type femoroacetabular impingement was indicated. Magnetic resonance imaging (MRI) showed a cyst situated at the medial side of iliopsoas muscle and tendon. Its dimensions were 56 mm in the coronal view and 22×24 mm in the axial view. The mass, which was compressing the neurovascular bundle, was continuous with the hip joint (, , ). Based on these findings, a ganglion cyst arising from the hip joint and femoral nerve palsy associated with the ganglion were diagnosed. Initially, the patient was treated conservatively for 2 months with a nonsteroidal anti-inflammatory drug. However, his pain and numbness worsened, leading us to perform surgery. Hip arthroscopy was performed under general anesthesia in thesupine position with traction. Three portals (anterior: A-portal, mid-anterior: MA-portal, and anterolateral: AL-portal) were used. A Vulcan and Shaver (smith and Nephew: London, UK) were inserted through the MA-portal, and a 70° arthroscope was inserted from the AL-portal. Capsulotomy was performed to connect the AL-portal to the MA-portal. From the MA-portal, the joint capsule (which was adjacent to the iliopsoas tendon) was dissected, and the iliopsoas tendon was identified. The capsule dissection was continued in the cranial direction to expose the iliopsoas tendon. The arthroscope from the AL-portal was used to partially resect the articular side of the iliopsoas tendon. The A-portal was used to secure visualization and the operation space. The arthroscope was changed from 70° to 30° to observe the more medial side of the iliopsoas tendon and an incision was made on the medial side of the tendon using the Vulcan. The fluid contained in the ganglion was discharged, and the ganglion stalk connecting the ganglion to the joint was cut open (see Additional file 1: Ganglion movie). Synovectomy, labral partial debridement, and osteochondral plasty for cam deformity were also performed in this surgery, The patient’s groin pain and the radiating pain and numbness of his thigh disappeared immediately after surgery. On MRI, the ganglion shrank at 3 months after surgery and had almost disappeared at 6 months (, ). At the final follow-up examination(9months postoperatively), the patient became aware of slight groin pain when he twisted the hip joint. The modified Harris hip score was improved from 58 points preoperatively to 87 points postoperatively. |
A 69-year-old male patient, with a three months history of abdominal pain asthenia and macroscopic hematuria, was admitted to the outpatient clinic. Abdominal CT revealed an 8 cm left renal growth suggestive of neoplasia, with the involvement of the tail of the pancreas, tumor thrombus in the left renal vein and multiple left para-aortic adenopathies (). A biopsy was performed and showed to be inconclusive regarding the possibility of renal cell carcinoma. Radical left nephrectomy with distal pancreatectomy and splenectomy was proposed.\nThe procedure (Video 1 in Supplementary data) started with an extensive Cattel-Braasch Maneuver, allowing exposure of the inferior vena cava and the aorta, and thus isolation of the left renal vessels. The tail of the pancreas and spleen were freed, and a no-touch approach [] was adopted to minimize the spread of tumor cells with proximal splenic vein ligation. Caudal splenopancreatectomy was performed with section of the pancreas with a GIA 80 (vascular load), followed by proximal ligation and section of the splenic artery and what was thought to be the left renal artery (). The junction of the left renal vein with the vena cava was opened, and the tumor thrombus was resected, followed by caval suture. The renal vessels were, at this point, presumably controlled. The nephrectomy was continued with the release of the kidney and para-aortic lymphadenectomy, during which only the stump of the left renal vein could be identified, lacking the previously ligated renal artery stump. The renal artery was located inside the mass of lymph node tissue in the left para-aortic space, and the stump belonged to the superior mesenteric artery, ligated flush with the aorta. There was no arterial pulse in the mesentery confirming the injury. After removing the specimen, the distal stump of the superior mesenteric artery was exposed, and a repair with a terminoterminal anastomosis was performed from the proximal stump of the splenic artery (). The viability of the gut was assessed by palpation of an arterial pulse in the superior mesenteric artery.\nThe postoperative period went uneventfully. Histological examination showed a renal sarcomatoid carcinoma pT4N1M0G3. Control imaging at three months showed permeability of the celiac trunk and the superior mesenteric artery (). |
A 68-year-old Caucasian male presented with a 2-mo history of worsening intermittent dysphagia, persistent cough, and postprandial retrosternal pain. He also complained of persistent dull pain on the left side of his neck, radiating to his left ear, which was not related to meals.\nSuspecting gastroesophageal reflux disease, the patient was started on proton pump inhibitor pharmacotherapy. Upon no relief of symptoms, the patient was referred to an otolaryngologist to evaluate the pharynx with a laryngoscopy; no abnormalities were seen, and therefore the patient was referred to a gastroenterologist. An esophagram was first performed, which showed a voluminous intraluminal lesion within the thoracic esophagus, possibly being a neoplastic process such as a leiomyoma (Figure ). An esophagogastroduodenoscopy was then performed, identifying a polypoid mass, which started at the level of the upper esophageal sphincter with a single stalk and extended all the way down to the esophagogastric junction. The polyp occupied about a third of the esophageal lumen, was heterogeneous in surface appearance, and consistent with a giant fibrovascular polyp; concurrently a small hiatal hernia was also seen. Biopsies from the head of the polyp exhibited benign squamous mucosa with mild acute and chronic inflammation. A computed tomographic (CT) scan of the chest showed a large mass along the entire course of the esophagus (Figure ). After an endoscopic ultrasound excluded the presence of major vessels within the main stalk, endoscopic resection was pursued. While using a flexible esophagoscope to visualize the mass, a snare was passed around the distal end of the polyp on retroflexion and then pulled up around the stalk, which was located on the left side of the esophagus just at the level of the upper esophageal sphincter. The proximal stalk was cauterized and divided with the snare, causing the polyp to drop into the distal esophagus. The polyp was then retrieved transorally using the endoscope and the snare to bring the mass to the level of the upper esophageal sphincter, followed by a laryngoscope and a clamp to extract it from the hypopharynx.\nPathology identified the 13.0 cm × 6.0 cm × 2.6 cm specimen as a well-differentiated liposarcoma arising in a giant fibrovascular polyp. Grossly the polyp had tan uniform surface without stigma of hemorrhage or necrosis (Figure ). Histologically the polyp showed a central core of adipose and fibrovascular tissue surrounded by overlying squamous mucosa (Figure ). An immunohistochemical stain for MDM-2 supported the diagnosis of liposarcoma (Figure ). Focal areas of ossification were noted. In addition, there were scattered atypical cells with abundant eosinophilic cytoplasm, positive for desmin and also focally myogenin positive (Figure ). The rhabdomyomatous differentiation is considered a low grade lesion (Figure ).The final resection margin was uninvolved by the tumor. Patient recovered uneventfully and was discharged from the hospital on postoperative day 1. On follow up visit at 4 years, patient still has complete resolution of dysphagia, cough, neck and chest pain. He has been eating well and gained 15 pounds to date. Annual endoscopies and CT scans confirm no reoccurrence thus far. |
A 25-year-old female had a history of painless swelling around the left knee for 6 months, which was progressively increasing in size. There was no associated history of trauma. Clinically, a firm tender swelling of size 5 × 5 cm arising from patella was palpable. The range of motion of the knee was 15–110° degrees. Atrophy of the left thigh muscles was noted. A plain radiograph revealed enlarged left patella with irregular, thinned out cortical shell along with multiple osteosclerotic lesions in patella with a soft-tissue mass ().\nMagnetic resonance imaging demonstrated a tumor mass of size 4.5 × 8 × 10.2 cm (AP × TR × CC) involving tendon of quadriceps femoris, patellofemoral ligaments, and patellar ligament. Post-contrast images demonstrated an enhancement in muscular plane of anterior compartment in axial cuts. Sagittal STIR images showed heterogeneously hyperintense signal within the tumor and multiple hypointense areas which are likely due to calcification and increased signal intensity in muscular planes of anterior compartment. It was reported to be a case of osteoblastic osteosarcoma on histopathology (). According to the Enneking classification system, the tumor was categorized as Stage 2a.\nThe patient underwent three cycles of neoadjuvant chemotherapy consisting of cisplatin, doxorubicin, and ifosfamide as recommended. After excluding any surgical contraindications and taking informed consent from the patient, surgical excision of tumor was planned using a standard anterior midline approach to the knee. A midline incision of 15 cm over the anterior aspect of the left knee centering the tumor was made. Subsequently, separation of the tissue layers, including subcutaneous tissue, superficial fascia, and deep fascia, was performed until a thin periosteal shell was identified. An extensive invasion of the surrounding soft tissues and a fuzzy margin was observed. Tumor resection was done laterally up to the intermuscular septum. The tumor was excised 12 cm proximal to superior pole of patella and distally, tibial tuberosity along with the patellar ligament was removed. The tumor was found to be involving patella, patellar tendon as well in the distal 6 cm of quadriceps tendon. As the tumor was involving only the extensor compartment, resection of the tumor along with 4 cm of normal tissue cuff was done. The defect was covered by suturing back the deep fascia and subcutaneous tissue. Reconstruction of the extensor mechanism was not done. Postoperatively, the patient was managed on a cylindrical slab for 6 weeks.\nPostoperatively, the patient received three cycles of chemotherapy as per protocol. At 1-year follow-up, the patient was able to perform activities of daily living without any discomfort. The range of motion was 0–90° degrees. The patient is still under regular follow-up with no evidence of recurrence. She could ambulate unaided with no extensor lag. |
A 23-year-old male without previous medical history presented to the emergency department of our institution for evaluation because of sudden and painless vision loss in both eyes of over 1 week without any other systemic complains like headache, dizziness, nausea or vomiting. At evaluation, the best-corrected visual acuity in the right eye was 20/800 and 20/400 in the left eye. Anterior segment examination showed no abnormalities for both eyes. The bilateral intraocular pressure was 16 mm Hg. At fundoscopy, both eyes showed mild papillary edema, rectified retinal vessels, with loss of the normal retinal-vein relation due to arteriolar narrowing, macular edema, cotton wool spots all over the arcades and involving the peripapillary area, flame-shaped hemorrhages and vascular tortuosity in the retinal periphery (fig. ). In the left eye, the presence of lipid exudates with macular star pattern was also relevant (fig. ). Fluorescein angiography was evident for vascular tortuosity and hyperfluorescent areas with late leakage in the temporal and peripapillary areas in both eyes (fig. ), and the right eye showed capillary closure in the foveal avascular zone (fig. ). No optical coherence tomography was required at this moment of the evaluation. On systemic evaluation, the patient had an arterial blood pressure of 220/140 mm Hg confirmed on several occasions. Considering the diagnosis of secondary hypertension due to the age of the patient, he was referred for a multidisciplinary approach, not requiring any ophthalmic therapy at this moment. The laboratory tests are shown in table , while other examinations including liver function tests, coagulation tests and serum electrolytes were within normal limits.\nA renal ultrasound showed smaller than normal kidneys, the right kidney had dimensions of 65 × 35 × 50 mm (normal size 100 × 50 × 30 mm), with loss of corticomedullary differentiation and increased echogenicity. The left kidney had dimensions of 66 × 40 × 42 mm, with poorly defined edges, with loss of corticomedullary differentiation and increased echogenicity (fig. ). A renal biopsy showed glomeruli with open capillary loops and normal basement membranes, a well-preserved interstitium without fibrosis nor tubular atrophy, preglomerular interstitial arteriolar vessels with nodular hyaline wall thickening, and mild reduction of lumen. The diagnosis of chronic renal failure was made, and the patient underwent kidney transplantation from a living related donor. The visual acuity of the patient gradually improved to a best-corrected visual acuity of 20/50 in both eyes after normalization of the blood pressure. |
A 26-year-old male patient resident of Nagpur reported at a private E.N.T clinic with a chief complaint of a mass in the right nasal cavity since 3 years. The patient also gave history of right nasal blockage and nasal discharge since 3 years. It was a slow growing growth since onset. The patient gave similar history of right sided nasal mass 5 years back, for which he was operated upon in a private clinic and the mass was removed. The histopathological examination was not performed at that time. He remained alright for 2 years postoperatively. After few months, patient started experiencing intermittent nasal obstruction and nasal discharge in the absence of upper respiratory tract infection. However, as the time passed by these symptoms aggravated and he started experiencing some nasal mass inside right nasal cavity. On anterior rhinoscopy, a solitary, pinkish, pedunculated, irregular, firm mass was located in right nasal cavity. On probing, mass was attached to lateral wall of right nasal cavity and mass did not bleed on touch. Computed tomography (CT) scan was advised and it revealed that the tumor was arising from middle meatus of right nasal cavity and there was widening of osteomeatal complex of right side. On contrast, there was mild to moderate enhancement seen. This mass was quite large and measured approximately 7 cm × 6 cm. Based on the clinical features and radiographic findings, a provisional diagnosis of papilloma was given. The mass was surgically excised by lateral rhinotomy with medial maxillectomy [] and the excised tissue was sent to the Department of Oral Pathology and Microbiology for histopathological examination. Gross examination revealed a single bit of soft tissue specimen of size approximately 3 cm × 2 cm, pinkish-white in color, irregular in shape, firm in consistency with rough surface texture. On histological examination, the hematoxylin and eosin stained section showed polypoid tissue covered with pseudostratified columnar ciliated epithelium with admixed mucocytes (goblet cells) and intraepithelial mucous cysts at places, which showed inversion into the underlying connective tissue stroma to form large clefts, ribbon and islands. The connective tissue cores were fibrocellular in nature with chronic inflammatory cells chiefly lymphocytes. Clinicopathologic correlation was suggestive of final diagnosis of inverted papilloma [Figures –]. |
The subject was a 26-year-old male Air Force pilot and a foreign state officer. The pilot had some individual flight experience, with a flight time of 120 h in the last 2 years on a L-39 Albatros, aircraft type designation. He reported no health problems before the training, nor in his medical history. He is a non-smoker and denies drug abuse. A clinical examination before the incident showed normal findings and the beginning of the practical training was normal. Problems arose the moment after the explosive decompression – the pressure inside the chamber was already stable. The pilot signaled to stop by waving his arm, than he crouched down in the seat, holding his head. Then, he produced a few grunts or cough-like sounds. He did not respond to questions about what had happened or what the problem was. After 7–8 s, an emergency descent was ordered to access the pilot. During the descent, the pilot started to respond normally. This emergency descent was likely the reason for the mild iatrogenic barotrauma of the middle ear. This issue was resolved in the next few days and is not connected to the purpose of this report.\nOnce on the ground, the pilot did not report any major symptoms at first. He said the main problem was sinus pain, that he did not feel any chest pain or have trouble with breathing. He described the coughing sounds as a verbalization of his pain and remembers us talking to him. In other words, he did not understand our concern in regards to lung trauma and did not seem anxious or worried. He also clearly stated that he did not hold his breath during the decompression. After finishing, he was eupneic, with normal hemodynamic parameters and a normal chest examination. After a few minutes, he developed retrosternal pain during deep inspiration and his tolerance of being in a horizontal position was reduced. These symptoms did not worsen, however, he was sent to our emergency department on suspicion of lung barotrauma.\nThe first chest X-ray and CT showed diffuse emphysema of the superficial and deep parts of the neck, continuing to the proximal section of the ventral chest wall (Fig. a, b). Diffuse pneumomediastinum signs are apparent paratracheal right, around right pulmonary artery, junction of left pulmonary veins and left atrium further are present signs in right cardiophrenic angle (Fig. c). A small bilateral pneumothorax was found apically and basally with pneumoperitoneum. The pneumoperitoneum was concluded to have been caused by passing gas through the hiatus in the diaphragm. There was no evidence of free fluid in the chest, no dislocations of mediastinal structures, no traumatic skeletal changes. A bronchoscopy was recommended for suspected airway injuries, but the patient refused. Conservative protocol without thoracic drainage was followed during his hospital stay. A two-day interval chest CT scan showed regression of the bilateral pneumothorax, regression of soft tissue emphysema, as well as pneumomediastinum regression. The patient stated he felt well and did not exhibit any additional symptoms, so he was discharged. After the discharge, follow-up examinations were recommended and a 2 month no-fly period was ordered. However, after 3 days, the patient left to his homeland and a contact at required medical level was lost. Pilot reported that he is doing well, without any problems and will be fit-to-fly soon.\nA report done by the technical staff ruled out technical malfunction. A breathing mask was used before and after the incident without problem. All of the equipment used had required official certifications. There were not any suggestions of problems with the used equipment. |
A 51-year-old woman with a past medical history of migraine presented in the clinic with complaints of severe and throbbing pain on the right side of her head. The pain was episodic and lasted for 12-18 hours followed by a short period of relief. The pain had no association with aura, and the patient was symptom-free between headache. She was having this pain for the last three weeks. She had a history of migraine headaches since her adulthood. She had not experienced any headaches in the past several years. In the past, she was prescribed sumatriptan and naproxen sodium to treat migraine, but she had not needed them for years. After a few weeks of her new headache, her doctor prescribed migraine pills, which she took over the course of three days, but she did not get any kind of relief. The patient was overweight. Otherwise, she was in good health with no obvious problems.\nThe initial evaluation showed a temperature of 37°C, blood pressure of 120/70 mmHg, heart rate of 91 beats per minute, respiratory rate of 20/minute, and oxygen saturation of 99% on room air. On physical examination, the patient appeared healthy, alert, and oriented with intact cognition. Her skin, extremities, and pulses were normal, and her abdominal examination was normal. However, she appeared to be in pain and the area of head involving pain is highly sensitive to light touch. On her neurological examination, her power, coordination, and gait were intact, and her toes were down going. The sensation was intact bilaterally, and the reflexes were also intact on both sides of the body. Her cranial nerve examination was also normal. There was no evident deformity on her face or eye, and she did not have any facial muscle weakness. MRI revealed no abnormality.\nThe initial laboratory analysis is shown in Table . The patient’s platelet count, hemoglobin, hematocrit, and white blood cells were within normal ranges. Her serum chemistry was unremarkable.\nThe patient was treated with tegral (carbamazepine) at a dose of 200 mg twice per day with a possible diagnosis of trigeminal neuralgia after ruling out other possible causes carefully. Her symptoms improved gradually, but she experienced severe drowsiness and nausea as the side effects of carbamazepine. After a few days of treatment, the pain resolved, and she quit taking medication. Four weeks later, the patient presented again with the same signs and symptoms. Her pain again subsided within two weeks with the same dose (200 mg x 2/day) of carbamazepine, but she was too drowsy. She experienced a similar reaction when she was switched to lamotrigine, which also improved symptoms but also resulted in excessive sleepiness. She continued on carbamazepine for five weeks further, and her symptoms eventually resolved. At her most recent follow-up six months after the recurrence, she had not had any more symptoms. |
A 38-year-old male patient who was unhappy with his smile presented with lateral incisors out of proportion with the central incisors. His main wish was to improve the esthetic appearance of his maxillary incisors.\nDuring the clinical examination, the facial aspects, the smile harmony, the gingival contour, and the dental characteristics were evaluated. Two lines were placed in the center of the initial page of the DSD program, making a cross, and the facial photograph was placed behind the lines []. The interpupillary line was used as an initial reference to establish the horizontal plane. Next, the midfacial line was projected based on the facial characteristics such as glabella, nose, and chin. The purpose of this initial tracing was to find the best facial position relative to the horizon while determining the midfacial line with no interference from the dental position, angle, or midline. For clinical smile design, the overall proportion of the patient's face was assessed, and then, the length of the upper lip at rest and in a smile was checked to determine the gingival display. It was established that crown lengthening was not necessary. After this preliminary facial analysis, the condition of teeth, parafunctional habits, oral hygiene, occlusal plane, interocclusal distance, and incisal edge were checked. The initial tracing (the cross) was transferred to the smile region, allowing the positioning of the smile []. This overlapping allows a comparative analysis of the teeth and face. The relative proportions between teeth are important for smile esthetics and depend on the relationship between their length and width, as well on how teeth are arranged in the arch and the smile configuration. A commonly cited method to establish dental proportions is the golden proportions.[] Based on these proportion rules, it was possible to prepare simulations to improve the positioning of the teeth and their proportion for the ideal smile. The dental contour was defined according to the lower lip proportions and the anteroposterior curvature of the teeth. After finishing the drawings [], it was observed that it would not be possible to obtain smile harmony following exactly the anteroposterior reference line of the teeth. To find an adequate proportion, the length of the incisal edges was decreased []. At the initial planning, an increase of 1.8–1.9 mm of the incisal third length was proposed. However, this much incisal lengthening was judged to be excessive and incompatible with the width-to-height ratio of 0.75–0.78 for the maxillary anterior teeth.[] Therefore, it was decided to reposition the incisal border of the central incisors to the same level as the maxillary canines, resulting in an incisal length of 1 mm for the maxillary central incisors. Due to the differences in the virtual simulation (DSD), a mock-up was proposed with composite resin to improve the communication between the clinician and the technician and to facilitate the visualization of the final result by the patient. Many times, the DSD simulation is not enough for the patient to understand and observe the changes that will be performed on the anterior teeth.\nUsing the diagnostic wax-up as a reference [], a silicone guide was prepared (Zetalabor, Zhermack, Badia Polesine [RO], Italy) to make the mock-up with bis-acryl resin (Protemp, 3M ESPE, Seefeld, Germany) [ and ]. After the functional evaluation, such as anterior and lateral disclusion and effect on phonetics, esthetic evaluation was also performed (smile, positioning of the lower lip, and harmony of the new teeth design). Then, it was observed that adequate lateral guidance, with canine function occlusion, occurred at the superior and inferior canines. Porcelain veneers requiring minimal tooth preparation were proposed for teeth #s 7, 8, 9, and 10, using refractory porcelain (creation). Initially, horizontal slots in the region of the middle and cervical third with the spherical diamond tips (1014 and 1012, KG Sorensen, Cotia, São Paulo, BR) were performed with a 45°. Following this, the preparation was completed with a cylindrical diamond burr (2135, KG Sorensen, Cotia, São Paulo, BR). The polishing of the preparation was done with sequential disks (Sof-Lex, 3M ESPE, Seefeld, Germany) and polishing rubber points (Exa-Intrapol Edenta AG, Heidelberg, Switzerland).\nA retraction cord was inserted and a silicone addition impression was performed (Futura, Nova DFL, Rio de Janeiro, Brazil) with the double-step technique. The color selection was made with Vita classical shade guide (A2, A1, B1, and B2), followed by digital photographs. After the preparation of the ceramic veneers, they were tried using a try-in paste (Ivoclar Vivadent, AG, Schaan, Liechtenstein). The restorations were conditioned with 10% hydrofluoric acid (Condac Porcelana 10% FGM, Joinville, SC, Brazil) for 90 s, washed with air/water jet, and conditioned with 37% phosphoric acid (Condac 37 FGM, Joinville, SC, Brazil) for 60 s for the removal of the residues resulting from the first acid conditioning and then dried. Silane coupling agent (Monobond Plus, Ivoclar Vivadent AG) was applied for 60 s and dried.\nBefore bonding, the restorations were tried in to determine the correct luting shade with try-in pastes. A modified rubber dam technique was performed for isolation. The teeth were cleaned with pumice and water, etched with 37% phosphoric acid (Condac 37 FGM) for 30 s, washed, and dried. A simplified adhesive system was applied (Excite F DSC, Ivoclar Vivadent AG) without photoactivation. The light-cured resin cement (color 0, Variolink Veneer, Ivoclar Vivadent AG) was applied to each veneer, which was carefully positioned on the preparations. The cement excess was removed with brush and dental floss, followed by photoactivation (Bluephase N, Ivoclar Vivadent AG) for 40 s on each side.\nThe final result immediately after cementation can be seen in , in which it is possible to observe that the esthetic parameters were established satisfying the expectations of the patient. Afterward, the patient was instructed on oral hygiene and was informed about the probability of stains appearing on the cementation line. The patient was called for periodical control. shows that in the 12-month follow-up, there was no alteration in color, shape, or gingival tissue. At the end of the rehabilitation, the patient was stable without any parafunctional habits and as such did not require an occlusal guard [ and ]. |
The patient was a 69-year-old man. Two years prior, he developed an ulcer of the right cheek and received treatment with liquid nitrogen at a local clinic. The patient presented to our hospital, as he recently developed a subcutaneous mass on the right cheek, which gradually grew in size (Figure ). He had a history of diabetes. He was receiving oral hypoglycemic agents and had good glycemic control, and we continued to administer these drugs to him.\nA mass of 1 cm in size with unclear margins was observed on plain computed tomography. The mass was in contact with the zygomatic bone (Figure ). A biopsy was performed in March 2019, and the patient was pathologically diagnosed with SCC (Figure ). As part of the mass was adhered to the zygomatic bone, we performed an extended radical excision with a 1.5-cm margin from the excision scar in April 2019. The excision involved partial removal of the zygomatic bone. At that time, his glycemic control was satisfactory, and, therefore, we provided only oral hypoglycemic agents for diabetes. No residual SCC was observed in pathological examination. Therefore, this case was diagnosed as stage I with T1N0M0 in TNM staging. As complete excision of the tumor was confirmed, we performed a reconstruction of the tissue defect of the right cheek by using a cervicofacial flap. The incision line was drawn from the lateral side of the tissue defect through the area below the sideburn toward the earlobe (Figure ). The skin flap was elevated above the superficial musculoaponeurotic system (SMAS) for the cheek and below the platysma for the neck. When elevating the skin flap, it is necessary to consider the marginal mandibular branch of the facial nerve, especially under the neck region, because the area under the platysma is exfoliated. The flap could completely cover the tissue defect. We placed a drain and closed the wound to prevent hematoma and seroma. Fourteen months have passed since the surgery, and no tumor relapse or ectropion of the lower eyelid has been observed. Additionally, very favorable outcomes have been achieved in terms of the color and texture match of the skin flap (Figure ). |
A 36 year old man sustained a degloving injury to his right, middle finger (which he caught in a machine, while at work) resulting in a large volar soft tissue defect extending from the tip of the distal phalanx to the mid portion of the middle phalanx. Bone and part of the profundus tendon was exposed (Fig. ). The tip of the distal phalanx was crushed, without any other bony injury.\nA primary debridment was done on the day of injury, because the wound was contaminated with grease and grit in the emergency operation theatre. The exposed tendon and bone was covered with a collagen dressing.\nWhen the wound was inspected on day 3, it was found to be healthy and a flap was planned to cover the exposed tissues.\nWe have had a lot of experience with cross finger flaps and free flaps from the toe and foot. However, they have been associated with lack of patient compliance, morbidity to the donor areas and immobilization in the case of cross finger flaps. Therefore, we planned to do a free thenar flap, based on the superficial branch of the radial artery. We had carried out cadaver dissections and found the vascular supply consistently associated with this fasciocutaneous flap. This fasciocutaneous flap would have a texture similar to the pulp tissue. The other main advantage of the free thenar flap would be its sensory supply by either of the nerves (palmar cutaneous branch of median nerve, lateral antebrachial cutaneous nerve or branch of superficial radial nerve).\nOn day 4, a free fasciocutaneous thenar flap was performed under regional block. A blue print of the flap is shown in the figure . No upper limb exsanguinations was done, which helped in identifying the thin vessels under the loupe. An upper limb tourniquet was used to minimize bleeding. A thenar flap measuring 4 × 2.5 cms was dissected with the vascular and neural pedicle (a branch of the superficial radial nerve). The tourniquet was released intra-operatively after the neuro-vascular anastomosis was completed. Blood flow was adequate (figure ). The donor site over the palmar aspect was primarily sutured. The operation took approximately 6–7 hrs. A rigid dressing was applied to reduce post operative edema. The middle finger along with the wrist was immobilized (4 days) to reduce postoperative pain and to help in initial wound healing.\nOn day 9 (post-operative day 5), the digit was redressed. Both the donor and the recipient site were found healthy. Sutures were removed on day 15 (11 days after the operation). Physiotherapy was started for the middle finger and wrist, from the 4th post-operative day.\n6 months after the injury, the patient is satisfied with the flap. He is happy about the texture of the flap which matched the other fingers\n(Figure and figure ). He has 90% deep touch sensations and approximately 50% soft touch sensations. The only uncomfortable sensation he has had was transient tightness over the palmar scar which had disappeared with time. |
A 10-year-old girl was brought to the Department of Psychiatry with complaint of oozing of blood from the intact skin of scalp for the past 1 week. First episode of bleeding started following the incident when she fought with a co-student in school and was punished by making her stand outside the class for an hour and was threatened to inform her parents about her behavior. Child stood outside the classroom and cried for an hour. Her teacher noticed bleeding from her scalp after about half an hour and informed her parents. Meanwhile, the teacher looked for any physical trauma at the bleeding site but none was found.\nSince then, the bleeding occurred about once or twice a day, lasted for about 3–5 min, from any part of the scalp. No associated pain was present. No history of bleeding from any other site, drug intake, or hair plucking was present. No bleeding disorder or any skin infection was found. History of bed wetting at night for past 2 years about once or twice a week, almost daily during exam time and when scolded by parents. She had a previous period of continence for 5 years before the nocturnal enuresis.\nFamily milieu patient was fearful of her father since childhood. He would scold her frequently, comparing her academic performances with her younger sibling. Mother would also scold and punish her physically for the same reason almost every month during exam results.\nWhen examined, the child was alert, oriented, comprehends, and communicates relevantly. No psychotic symptoms were elicited. The child was euthymic and reactive. Her intelligence was within normal limits. When enquired about her school and scholastic performance, child's affect changed immediately. She became anxious and expressed fear about her academic performance. Child reported that she was often punished for her academic performances. Punishment was usually as a result of comparison of her performance with that of her younger sibling who scores 99% while she scores 90–95%. Child expressed that she regrets coming home with exam results, cries on and off at night when alone both fearful of the punishment and also about being compared with her sibling. Analysis of stress with Response to Stress Questionnaire-Child/Adolescent version showed that the child was definitely stressed.\nProvisionally, the child was diagnosed as mixed anxiety and depressive disorder. She was started on tablet imipramine and clonazepam, reassured and advised to come after a week for review with her mother and father. During the next visit, the child was seated beside her parents and interviewed. She started elaborating that she was punished physically the day before by her father for scoring 85% in mathematics when suddenly a red-colored secretion was noted oozing from her scalpas shown in . It was sent for biochemical examination which tested positive for bloodwith no other abnormalities as shown in . Skin underneath the bleeding site was normal as shown in Figures and , no cuts, abrasions, or tenderness was present. Bleeding stopped by itself in about a minute.\nParent management training and psychoeducation for parents regarding the disease and the etiological role of stress were informed. Parents were taught about positive and negative reinforcement techniques and their advantages over punishment. Child was taught relaxation exercises and pharmacotherapy was continued. Bleeding gradually reduced in frequency and stopped completely after 4 months. Child was followed up for the next 1 year during which she was in complete remission. |
A 56-year-old male farmer was presented to the emergency department (ED) complaining of right hand discomfort, pain and swelling of 2 days duration. The patient did not report any history of recent trauma. His past medical history was significant for alcoholism and insulin-dependent type 2 diabetes. The right hand demonstrated marked swelling, fluctuation, erythema and associated lymphangitis tracking to the volar aspect of the right forearm. His hand and forearm radiographs were significant for soft tissue edema (). His comprehensive blood work was significant only for an elevated glucose level, however, other signs of infection, including erythrocyte sedimentation rate and C-reactive protein, were absent from laboratory testing.\nA localized soft tissue abscess of the right hand was considered and the patient was taken to the operating room for incision and drainage. An abscess involving the middle phalanx of the 5th finger extending to the mid-forearm was incised and drained. Patient was initially administered piperacillin/tazobactam postoperatively. Streptococcus pneumoniae, Klebsiella oxytoca, Pseudomonas aeruginosa and coagulase negative Staphylococcus were identified in the wound cultures that were obtained during the operation. Blood cultures also grew Streptococcus pneumoniae. Despite antibiotic therapy and surgical debridement, the infection progressed to involve the entire fifth digit and amputation of the digit was performed on post-operative day 4.\nDespite medical and surgical treatment, the purulent infection progressed and wound cultures confirmed Sporothrix schenckii. The patient was then started on itraconazole after culture results confirmed the organism. During the course of treatment and follow-up, the patient continued to experience right index finger swelling for several weeks. The patient was seen in the outpatient clinic and completed 3 months of therapy. There was no reason to suspect non-compliance in this patient at this time.\nTen months following the course of his treatment, he returned to the ED with complaints of bilateral knee pain, swelling and weight loss. He reported a loss of his insurance and a lack of access to insulin for 4 months. His vital signs were within the normal range and exam findings were notable for 2+ pitting edema and effusions involving bilateral wrists, fingers and knees. An indurated poorly defined 3-cm mass was found in the right popliteal fossa. Significant laboratory values from a complete blood count and comprehensive metabolic panel were glucose 636 mg/dl, C-reactive protein 1.5 mg/dl, white blood cell count 1400 cells/μl and absolute neutrophil count 890 cells/μl. CT scan of the chest, abdomen and pelvis in the ED demonstrated splenomegaly and diskitis involving L4 and L5. The patient was found to have leukopenia but all laboratory tests for the differential causes of polyarthritis were found to be negative including: Antinuclear antibodies (AB), Rheumatoid factor, Anti-citrullinated protein AB, Anti-Ro AB, Anti-La AB, Anti-DNA AB, Serum Protein Electrophoresis, Urine Protein Electrophoresis, Beta-2-microglobulin, Peripheral Smear, Lactate Dehydrogenase, Human Immunodeficiency virus AB, Thyroid Stimulating Hormone and Parvovirus B19 serology. Subsequent bone marrow aspiration indicated only pancytopenia and negative potassium hydroxide preparations and cultures for fungi. CT-guided biopsy of the lumbar spine was performed demonstrating 1+ WBCs but without evidence of organisms, including fungi, through both cultures and staining. Subsequent left hand debridement, right elbow olecranon bursectomy, bilateral open debridement and synovectomy of bilateral knee joints, and removal of left knee mass were performed to evaluate the swelling and pain each location. Cultures from the right elbow and left finger grew Sporothrix schenckii. The patient was started on 3 mg/kg daily dosing of liposomal amphotericin B following the first confirmation of repeat sporotrichosis infection.\nIn addition to the soft tissue, joint and bone infection with sporotrichosis, pulmonary and ophthalmologic complications also developed during the hospitalization. After 2 weeks into the hospitalization, the patient began to complain about decreased visual acuity of the left eye; ophthalmology was consulted and full examination revealed panuveitis with posterior synechiae. There was concern for endogenous endophthalmitis of the eye, and the patient was taken to the operating room for vitrectomy and posterior synecheolysis of the left eye. Perioperatively, a 12 mm ×9 mm retinal choroidal infiltrate was found, consistent with fungal infection. Cultures, polymerase chain reaction (PCR) and cytology of the vitreous fluid demonstrated not diagnostic which may have been due to the patient having received amphotericin. Additionally, the patient developed epistaxis with hemoptysis, and CT scan demonstrated scattered ground glass opacities throughout the lungs with bilateral pleural effusions, consistent with an infectious process. Thoracocentesis was performed and cultures of the pleural fluid were non-diagnostic. However, the patient continued to improve clinically while receiving liposomal amphotericin.\nThe patient was discharged following clinical improvement of his conditions, ∼1 month of hospitalization at the time of discharge on oral itraconazole. Despite close follow-up instructions, the patient did not return to clinic and was lost to follow-up. |
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up. |
A 67 year-old male patient was referred for coronary angiography because of intermittent episodes of chest pain accompanied by severe sweating during which ECG showed transient LBBB. Physical examination was unremarkable and lab tests were within normal limits except borderline diabetes mellitus for which no specific treatment had been given. ECG at stable patient condition was normal and echocardiography showed no abnormality at rest. After prep and drape, 7F sheath was inserted in right femoral artery. Left coronary angiography showed significant stenosis of LAD midportion. Selection of RCA was impossible due to severe tortousity of right external iliac artery and kinking of right Judkin's catheter. So a 135 cm, 0.035 inch guidewire was inserted, deformed catheter was removed and replaced by another right Judkin's catheter. But advancement of guidewire and the second Judkin's catheter was difficult and the patient had extreme discomfort, so sheath angiogram was performed ().\nRight iliac artery dissection and perforation was diagnosed, procedure was prematurely terminated, sheath was removed and firm compression was applied to puncture site for about 30 minutes. Several minutes after release of compression, the patient developed severe right leg pain which was accompanied by coldness and absence of pulse in distal portion. Duplex sonography confirmed weak arterial impulse in right leg and patient was transferred emergently to operating room with the impression of acute arterial occlusion. Arteriotomy was done and several pieces of arterial clots were extracted by Fogarty catheter. A small hole which was attributed to arterial puncture and sheath insertion was primarily repaired in common femoral artery. No other site of perforation was found in external iliac artery exploration. The patient had an uneventful post-operative course except wound infection which was managed successfully by IV antibiotics and debridement. Two weeks later, PCI was done on LAD via left femoral artery. RCA angiography showed no significant stenosis. Abdominal aortography was done and external iliac artery revealed to be patent and free of disease (). |
A 28-year-old woman presented with an insidious onset of upper abdominal pain and this was accompanied by sour regurgitation and eructation, and this had all started two months ago. She had been treated under the diagnosis of having gastritis for four weeks at an outside hospital, but the symptoms had not improved.\nAn air-barium double-contrast upper gastrointestinal series disclosed wall stiffness in the lesser curvature of the stomach and broadening of the incisura, suggesting an extrinsic compression. The gastric mucosal surface appeared smooth and regular. No obvious niche sign or filling defect was detected (). An unenhanced CT scan showed a large well-circumscribed mass of heterogeneous attenuation between the lesser curvature of the stomach and the left lobe of the liver, and the mass was about 11 × 7 × 10 cm in dimension, as measured on CT. The lesion was generally hypodense compared with the liver and there were even lower density regions scattered within the lesion (). After intravenous contrast enhancement, the tumor was moderately enhanced and it was somewhat heterogeneously enhanced on the arterial phase. Several prominent feeding vessels were noted in the periphery of the tumor (). The mass was heterogeneously hypodense compared with the hepatic parenchyma during the portal phase (). No enlarged lymph nodes were found in the retroperitoneum.\nA gastrointestinal stromal tumor was suspected and so radical subtotal gastrectomy was then performed. The excised mass measured 15 cm in diameter and it was found to have originated in the submucosa of the stomach. Central necrosis was observed in the tumor. The overlying gastric mucosa was intact. The histopathological and immunohistochemical findings () confirmed the diagnosis of follicular dendritic cell sarcoma.\nThree months after the surgery, a follow-up MRI showed a 1.7-cm nodule in the right lobe of the liver, and the nodule had low signal intensity on the T1-weighted images () and hyperintensity on the T2-weighted images with a hypointense center (). On the T1-weighted gadolinium-enhanced images, the nodule showed homogeneous enhancement during the arterial phase, making it appear isointense compared to the surrounding normal liver (). The lesion appeared slightly hypointense compared to the liver during the portal venous phase (). Wedge lobectomy of the liver with including the tumor was performed and this was followed by adjuvant chemotherapy. Pathological examination confirmed a metastatic follicular dendritic cell sarcoma. Metastases re-developed in the liver nine months thereafter. The MRI features of the new metastatic lesions were similar to those of the prior metastasis. The patient has been alive with the disease for the following two years. |
The patient was a 33-year-old woman who had had a mildly limited range of motion in her left hip for a long time. In October 2012, she experienced sudden, severe pain in her left hip without any antecedent trauma or episode. The pain affected her not only when she moved the hip but also when she was at rest. Her condition had been diagnosed at another hospital as synovial osteochondromatosis of the hip, for which she was given an anti-inflammatory drug (loxoprofen, 60 mg, three times daily for 10 days). Although the severe pain disappeared about 10 days after onset and only vague discomfort and pain in a specific posture had remained, she was referred to our hospital for a surgical treatment at 3 weeks after pain onset. The range of motion in the affected hip was 130° in flexion, 15° in extension, 30° in abduction, 20° in adduction, 45° in external rotation, and 15° in internal rotation. Findings on the Patrick test were positive, the anterior impingement sign was present, and she had mild tenderness of the Scarpa triangle. Preoperative blood tests revealed no evidence of diabetes, rheumatoid arthritis, infection, or abnormality in renal or liver function. Although initial radiographs, obtained 1 month after pain onset, revealed no significant findings, magnetic resonance images showed marginal enhancement of a mass located inferior to the hip joint (). We performed surgical dislocation of the joint using the technique described by Ganz et al. [] for tumor excision, with the patient receiving general anesthesia. We excised a whitish-yellow encapsulated tumor, 4 × 2 × 1 cm3, arising from the anteromedial synovium (). We assumed that the pain was not caused by the tumor putting pressure on the surrounding area because the tumor was a soft elastic mass and could move easily. The mobility of the tumor was seen preoperatively in the enhanced stress radiographs (). Synovectomy in the fossa acetabuli was also performed. Microscopy revealed cells of mononuclear stromal origin with hyalinization and multinucleated giant cells. There was hemosiderin pigment in macrophages and in the extracellular space. The nuclei of the mononuclear stromal cells and multinucleated giant cells had disappeared because of tumor necrosis (). |
A 52-year-old male with a one-year history of renal cell carcinoma was admitted for routine follow-up. The general physical examination and laboratory tests were normal. We observed hypodense-hypovascular cystic lesions with thin septi in the uncinate process and body of the pancreas, and the pancreas measured 5 cm in diameter on the abdominal CT scan (). Contrast-material enhanced MRI revealed numerous diffusely distributed cysts with thin septi, and these cysts ranged in size from a few millimeters to 14 mm in diameter in the body and uncinate process of the pancreas. Contrast-material enhancement in the pancreatic lesions was not observed on the postcontrast (arterial and portal venous phase) T1 weighted (W) images (). The main pancreatic and extrahepatic bile ducts were normal on the T2W sequences. Our preoperative diagnosis was "cystic neoplasm of the pancreas", and pancreaticoduodenectomy was performed by general surgeons.\nMacro- and microscopic examination revealed numerous cysts ranging from 2 to 12 mm in diameter with a thin translucent wall in the body and head of the pancreas. The tumor was 5 cm in diameter. The internal surface of the cysts was pink, smooth and glistening and the surface of the cysts had no solid areas or papillary projections. There was no discrete tumoral lesion, necrosis, calcification or hemorrhage observed on further examination of the pancreas (). The duodenum was normal in appearance.\nMicroscopic examination revealed numerous small and large cysts diffusely distributed throughout the pancreatic tissue. The cysts seemed to develop from the surrounding acinar tissue and they were lined by cells with the typical features of normal acinar cells. There were disseminated patchy acinar structures within some small and large cyst walls (). The small cysts were lined by a single layer of bland cuboidal or columnar acinar cells with tendency for crowding. Their nuclei were basally located and regular, and they contained small nucleoli. The cells' cytoplasm was typical for acinar cells with deeply eosinophilic granules in the apical part. The large cysts were lined by a single layer of flattened, low, cuboidal acinar epithelium and these cells had basally oriented nuclei. The cysts were generally connected to small clusters of acinar cells forming acini, which opened into the cyst lumen. Eosinophilic secretion was demonstrated in some cystic structures.\nA foveolar metaplasia-like area was seen in a minute focus. Immunohistochemically, the acinar cells of the cysts (small or large) and areas of cystic transformation were positive for cytokeratin 7, while the normal acinar cells were negative for cytokeratin 7. Both the normal acinar cells and the epithelial lining cells were positive for cytokeratin and epithelial membrane antigen, but they were negative for S-100 and progesterone. Histochemically, the eosinophilic apical cytoplasm of the cuboidal acinar cells and the acinar cells of the cysts were PAS-positive. Both the normal acinar cells and the acinar cells associated with the cyst epithelium were negative for Alcian blue pH 2.5. The acinar cells of the cysts (small or large), the acinar structures with cystic transformation and the normal acinar structures were negative for synaptophysin and chromogranin, while the normal islet cells were positive for synaptophysin and chromogranin. The acinar cells associated with the cyst epithelium and the normal acinar cells were negative for p53, and their Ki67 index was less than 1%. As a result of these findings, the histopathologic diagnosis was ACC of the pancreas. The patient is still alive at the postoperative sixth month with no evidence of pancreatic cystic lesion. |
A 26 years old female patient presented with the chief complaint of swelling in the right lower back region of the jaw for 1.5 years. The swelling was associated with pain for the past 6 months. The pain was intermittent and dull aching in nature. The patient also complained of loosening of the teeth in the region of swelling. On extraoral examination swelling measuring approximately 3cm x 2cm in size was present which was causing mild facial asymmetry. The swelling was involving the right angle of the mandible and submandibular region and it was firm on palpation (). The right submandibular lymph nodes were palpable but not tender. Intraoral examination of the lesion revealed swelling of about 5cm x 5cm in size in the right retromolar triangle region. The swelling was causing the obliteration of the buccal vestibule and was also involving the right mandibular second molar. The overlying mucosa appeared normal without ulceration (). The swelling was firm on palpation and was involving 47 which was grade III mobile.\nA panoramic radiograph revealed mixed radiolucent and radiopaque lesion extending from the distal root of 46 anteriorly to ramus of mandible posteriorly. The lesion had distinct sclerotic border anteriorly and posteriorly with an indistinct border superiorly. Loss of continuity of the lower border of mandible could be noted inferiorly. The presence of a tooth-shaped radiopacity in conjunction with the inferior margin of the lesion suggestive of impacted 48 could be appreciated. The associated tooth 47 was displaced occlusally and both of its roots were resorbed. The lesion was also causing resorption of the distal root of the 46 ().\nBased on the clinical and radiographic findings, a differential diagnosis of Calcifying odontogenic cyst (COC) and a Dentigerous cyst was given. An incisional biopsy of the lesion was performed along with the extraction of 47.\nOn gross examination, multiple pieces of soft to firm tissue whitish in color together measuring 1.5cm x 1.5cm were received. Histopathological examination revealed tumor mass composed of closely packed sheets of polyhedral cells. The tumor cells had a well-outlined border with eosinophilic cytoplasm and central round nucleus. The presence of homogenous eosinophilic material could be appreciated within and between sheets of tumor cells. Small areas of basophilic calcification could also be noted ( and ). The diagnosis of the dentigerous cyst was excluded in the absence of cystic nature and reduced enamel epithelium like lining. The presence of polyhedral cells instead of ameloblastomatous epithelium and ghost cells differentiated it histologically from COC.\nBased upon these histological findings a final diagnosis of Calcifying epithelial odontogenic tumor (CEOT) was given. Segmental resection of the mandible followed by reconstruction was planned for treatment. |
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 76-year-old woman presented to our hospital with a mass occurring on the skin of her right chest wall. She had been diagnosed with right breast cancer (T1N0M0, stage I) 9 years previously and had received breast-conserving surgery, sentinel lymph node biopsy, and adjuvant chemotherapy and radiation therapy for the residual whole right breast at a previous hospital. She then developed pigmented skin on her right breast 6 years after surgery, and this lesion was diagnosed as an angiosarcoma. The patient underwent a breast mastectomy to treat for RAAS. Following this, however, the angiosarcoma on her chest wall recurred three times within 2 years. The angiosarcoma was resected each time, and she received radiation therapy to her chest wall after the third operation. Four years after the first occurrence of RAAS, we observed light pigmentation and a dark red tumor (gross diameter of 5 mm) on her right chest wall (Fig. ). Clinically, recurrence of RAAS was suspected, and recurrence of angiosarcoma was diagnosed by biopsy. We considered that it was necessary to remove the irradiated skin as much as possible in order to cure the RAAS. After extensive resection of the irradiated skin and tumor, new skin collected from her right thigh was grafted to the site (Fig. ). Pathologically, the tumor size was 6 mm and the surgical margin was negative. Histologically, there were many spindle cells and dilated vascular channels. Immunostaining showed that the tumor was CD31-positive and mildly positive for CD34 (Fig. ). Ki-67 index was also high. It was revealed that there is no inconsistency as recurrence of RAAS is pathological. After the operation, the patient was hospitalized for 30 days and did not experience any complications. Although some reports suggest chemotherapy can be used to treat RAAS, we considered that this option would offer little benefit in this case, because the patient was elderly and had a history of cerebral infarction. Indeed, the patient has remained angiosarcoma-free for the last 3 years following our intervention, even without chemotherapy (Fig. ). |
The patient involved provided written consent for reporting of this case.
A 63-year-old woman with medical history of super morbid obesity (BMI 54) and atrial fibrillation for which she was anticoagulated with apixaban presented for an open reduction internal fixation (ORIF) of an ankle fracture. Significant medical history included diabetes mellitus type 2, obstructive sleep apnea, chronic obstructive pulmonary disease, and diastolic heart failure. The patient's last dose of apixaban was 48 hours prior to surgery. Other than moderate anemia (hemoglobin 8.8 g/dL), all laboratory studies, including a coagulation profile, were normal.
Prior to surgery, the patient was offered a sciatic nerve catheter and an adductor canal block as part of a multimodal postoperative analgesia strategy. Because of her many, serious medical conditions, we concluded that a peripheral nerve block offered the best opportunity to provide satisfactory postoperative analgesia. Specifically, we were concerned that the postoperative pain management primarily with opioid medications would pose increased cardiopulmonary risk to the patient. We were careful to explain the risks associated with peripheral nerve blocks, including the risk of bleeding and hematoma formation, and verbal consent was obtained.
The surgery was performed under general anesthesia and her intraoperative course was uncomplicated. Upon arrival to the recovery room, our acute pain service was contacted to evaluate her for peripheral nerve blockade. We positioned the patient in the lateral decubitus position and placed a sciatic nerve catheter. Though technically challenging due to body habitus, this sciatic nerve block was performed successfully and without any complication. The patient was then positioned supine for the adductor canal block. The leg was externally rotated and the knee slightly flexed for optimal positioning. A high-frequency linear array ultrasound transducer was applied to the mid-thigh in short-axis and the adductor canal was identified. Imaging was again challenging given the patient's habitus, but with firm compression of the ultrasound transducer, the important anatomical structures were clearly identified. The superficial femoral artery (SFA) was visualized |
A 72-year-old male presented to emergency department with tender mass on lower back and posterior aspect of neck. Apparently, he had noticed it on his lower back 6 months ago and had grown in size with another similar swelling appearing on his neck, also they were increasingly painful and sore to touch. He had a history of ongoing sore throat for 3 years for which he was extensively investigated by ENT services. His CT neck and mediastinum did not show any abnormalities at that time. This was followed by laryngoscopy which showed a white patch on the right vocal cord, biopsy of which showed non-specific chronic inflammatory changes and cultures grew candida. Background history included COPD; he was heavy current smoker and smoked about 60 cigarettes per day. His medications included salmeterol/fluticasone propionate and ipratropium bromide inhalers. Vitals were within normal range. On examination, 4 cm nodular, firm, tender, immobile mass on lower back and 3 cm mass on posterior aspect of lower cervical spine were noted.\nHis laboratory investigation including renal and liver function, full blood count and coagulation profile were normal. A CT of thorax, abdomen and pelvis was arranged which showed 2 × 2 cm mass in right lung lower lobe likely malignant with no hilar or mediastinal lymphadenopathy, also 3 × 3 cm soft tissue mass at C6-C7 level posteriorly and 4 × 2 cm mass was noted on lumbar region with multiple prominent inguinal lymph nodes ().\nA referral for bronchoscopy was sent and biopsy of the nodule was planned. While awaiting bronchoscopy appointment, biopsy was taken from mass in lower back and send for histopathology. Histology showed poorly differentiated tumour cells in cohesive groups and sheets with moderate pleomorphism and eosinophilic cytoplasm; immunohistochemistry was positive for AE1/3, cytokeratin 7 and carcinoembryonic antigen antibody stain and periodic-acid schiff. Weak nuclear positivity for TTF-1 was also seen. Overall features were consistent with poorly differentiated adenocarcinoma likely of lung origin.\nHe was then referred to oncology services and unfortunately passed away within 5 months of diagnosis. |
A 70-year-old woman, hailing from Kashmir in India, presented to us with progressively increasing abdominal mass since 11 years. This was associated with progressive appearance of jaundice and dull aching pain in abdomen since 3 months with pruritus for one month that worsened nocturnally. She neither complained of fever, bleeding diathesis, chest pain, cough or palpitations, and altered bowel habits nor did she suffer from anorexia. There was significant unintentional weight loss secondary to early satiety since last one year. There was no history of swelling of legs or puffiness of face during this period. There was no history of swelling over other parts of the body or associated skin changes. The patient is a known case of diabetes mellitus on oral hypoglycemic agents with adequate glycemic control since the last 20 years. Eleven years ago, the patient underwent an open laparotomy for complicated symptomatic gall stone disease and was incidentally detected to have a space occupying lesion of the head of pancreas. The lesion was highly vascular on intraoperative analysis and was left alone at that time with a fine needle aspiration cytology evaluation, which was later confirmed to be that of benign microcystic adenoma. The patient thereafter started noticing progressive enlargement of an epigastric mass which was initially seen 8 years ago. This mass progressed to involve the whole of the abdomen with associated lethargy and early satiety and difficulty in performing routine works. Multiple fine needle aspiration cytology of the mass lesion was done at various hospitals outside, before presentation to our facility. All those reports were noncontributory and confirmed the presence of only blood and cystic elements. On examination, at our center, the patient was found to be conscious and alert but emaciated with temporal hollowing and facial muscle wasting, with good performance status (ECOG-PS 0). Pallor was evident, as were icterus and scratch marks over the abdomen and arms. There was no cyanosis, clubbing, lymphadenopathy, or edema. The abdominal examination revealed the presence of a large epigastric mass, extending towards the right iliac fossa and trespassing on the left lateral aspect of umbilicus with a rough nodular surface, being firm in consistency, nontender, and without visible pulsations. A palpable bruit and a venous hum were also evident. There were areas of engorged, nontortuous veins over the stretched skin surface of the mass. No other organomegaly was appreciable and free fluid in abdomen was difficult to ascertain. The rest of the systemic examination was essentially normal. On further evaluation, the patient was found to have hemoglobin levels of 10 g/dL (normal 12–15) with normal total leukocyte and platelet counts. The ESR was 30 mm in the first hours (normal 0–2). The liver function tests revealed normal bilirubin levels with normal transaminases, in the presence of alkaline phosphatase of 326 IU/L (normal 32–92) and gamma glutamyl transpeptidase of 228 U/L (normal 7–64). The kidney function tests were normal and so were all the viral markers and autoimmune markers. The serum tumor markers, including CA19-9, CEA, AFP, tumoral Beta-HCG, Chromogranin A, and CA-125, were all within normal limits. Computed tomography imaging of the abdomen subsequently followed by angiographic studies in triple phase and magnetic resonance imaging in triple phase revealed the presence of a large lobulated heterogenous mass in the retroperitoneum extending from the undersurface of the liver to the whole of lower abdomen (Figures , , , and ). The mass measured 26 × 26 cm in size and contained hyperechoic and hypoechoic areas which were hypointense on T1 and hyperintense on T2 weighted images.\nMultiple hypodense septation (which was T2 hypointense) was noted within the heterogenous mass. Contrast administration revealed moderate heterogenous enhancement with enhancing septation. Compression and displacement of structures at the porta and compression of common bile duct with upstream dilatation of the CBD and bilobar intrahepatic biliary radical dilatation were also evident. The CBD measured 2.7 cm. The inferior vena cava was compressed posteriorly with displacement of the bowel laterally. The tumor derived its supply mostly from the celiac axis with extensive tumoral angiogenesis (). Multiple well defined T2 hyperintense and T1 hypointense lesions were noted in both lobes of the liver showing enhancement suggestive of metastases. The liver was otherwise normal and the pancreas could not be delineated. Subsequently the patient underwent a ultrasonography guided percutaneous biopsy from the SOL liver, the histopathological examination of which revealed features of a neoplastic lesion composed of cells arranged in acinar microcystic pattern around the small vessels. These acini and microcysts were lined by single cell layer of uniform cuboidal and Hobnail cells (omit type).\nThese cells also showed features of monomorphic round hyperchromatic nuclei and moderate amount of clear cytoplasm with inconspicuous nucleoli. The intervening stroma contained several vascular channels with hyalinised stroma. The tumor cells were positive for CK-7, SMA, CD34, and focal EMA. They were negative for focal S-100, CD10, HMB45, MUC1/2, and calretinin (Figures , , , and ). The glycogen content was documented by PAS positive reaction on histology.\nWith these clinical, imaging, and histopathological features, a diagnosis of microcystic adenoma was made and the carcinomatous transformation was confirmed by the presence of liver metastases. The patient was not a candidate for surgical or interventional therapy and hence was managed medically for symptom relief. According to the patient's family's wishes, she was then allowed to follow up at her hometown at a nearby center and was lost to follow-up from our side. |
A 77-year-old male presented with palpable abnormality on the right breast. The past medical history was significant for a recent complicated parapneumonic effusion requiring right thoracotomy and pleural decortication with benign pathologic findings eleven months prior to presenting with the breast mass. The patient also had a history of squamous cell carcinoma and melanoma in situ of the skin. The patient reported an occupational history of asbestos exposure. Family history was significant for breast cancer and BRCA1 mutation positivity in two siblings; the patient's own BRCA status was unknown. On physical examination, there was a fixed, firm mass in the right breast measuring approximately 5 cm in greatest dimension.\nAnteroposterior chest X-ray showed pleural thickening along the right lateral chest wall and blunting of the right costophrenic angle (). A chest CT scan with contrast demonstrated a contracted right hemithorax with an irregular pleural-based process that extends through the intercostal muscle and into the subcutaneous adipose tissue indicating direct spread rather than a metastasis in breast tissue. Bronchiectasis of right middle and lower lobes, right middle lobe atelectasis, and prior granulomatous disease have been also reported (). A diagnostic breast mammogram revealed predominantly fatty breast parenchyma and no morphologically abnormal lymph nodes in the axilla. A diagnostic breast ultrasound revealed an irregular, hypoechoic mass in the right breast with angular margins measuring 5.6 × 2.9 × 3.6 cm. A portion of the mass appeared to involve the pectoralis muscle and possibly extended into the intercostal muscles (). Fine needle biopsy was recommended.\nBiopsy from the right pleural decortication described grossly as a fragment of red-tan tissue measuring 0.9 × 0.7 × 0.2 cm was entirely submitted in one cassette. Microscopic examination was performed at an outside facility and reviewed by expert lung pathologists in consensus at our institution subsequent to the diagnosis of the breast lesion and reported as pleural plaque with dense fibrosis, minimal inflammation, and dystrophic calcification with no evidence of malignancy (). Breast needle core biopsy revealed a proliferation of neoplastic epithelioid cells in cords and nests infiltrating breast parenchyma and skeletal muscles. The neoplastic cells were round to polygonal in shape with moderate cytoplasm, moderate cytologic pleomorphism, and occasional nucleoli mimicking an infiltrating pleomorphic lobular carcinoma (Figures and ). There were focal gland-like and micropapillary structures. Rare mitotic activity was present.\nIHC studies showed the tumor cells to be strong and diffusely positive for WT1 (inset in ), calretinin (), CK5/6 (), and CK7. The cells were negative for MOC-31, BerEp4, ER, PR, S100 protein, and HMB-45. Based on the morphologic and IHC findings, a final diagnosis of malignant mesothelioma, epithelioid type, was rendered. |
A 20-year-old Chinese woman first visited our hospital when she was 28 weeks pregnant. She was mentally retarded with typical features of trisomy 21. She had regular menstrual cycles before pregnancy. She had dyspnea, chest pain and fatigue with mild physical exertion. She also had trouble lying down in a supine position.\nDuring the examination, her electrocardiogram showed sinus tachycardia and right atrial and right ventricular hypertrophy. Her heart rate was 115 beats per minute. Her symptoms were suggestive of an unrepaired ECD. She had severe left and right common valve insufficiency. Color flow imaging and pulsed wave Doppler demonstrated bidirectional cardiac shunting with dominant left-to-right shunting. Her left and right heart pressures were nearly equal. Based upon the natural history of an unrepaired ECD, we suspected that our patient had severe pulmonary hypertension.\nBecause of the extreme high risk of mortality for our patient, the obstetrician, cardiologist and anesthesiologist of our hospital offered to terminate the pregnancy. Our patient’s family refused the advice and insisted on continuing the pregnancy. Our patient was also advised to stay in our hospital for close monitoring and proper treatment, and again her family refused our advice.\nOur patient returned at 33 weeks and six days of pregnancy because of lower abdominal pain accompanied with vagina fluid outflow for two hours. Her physical examination on admission showed a temperature of 35°C, pulse of 130 beats per minute, blood pressure at 140/80mmHg, respiration 33 breaths per minute (provided with 5L oxygen per minute), severe dyspnea, cyanosis, lower extremity edema, grade three to six heart murmur at her left intercostal space, and grade two to three systolic murmur at the apex of her heart. Her oxygen saturation was 19.4%.\nHer baby was in breech presentation. The fetal heart rate was 120 beats per minute. Our patient had regular uterine contractions with an interval of three to four minutes. Her cervical dilation was 10cm with rupture of the fetal membranes. An ultrasound showed that her fetus was in the left sacral anterior position with a biparietal diameter of 72mm and femur length of 56mm. The amniotic fluid index was 20mm. An analysis of the fetal blood gas showed 48.8mmHg carbon dioxide and 22.1mmHg oxygen, with pH 7.15. A male baby was delivered by gentle traction. The weight of the baby was 1110g. His one-minute Apgar score was 5. His five-minute Apgar score was 10. Our patient died 10 minutes after delivery. When her heart stopped beating, standard cardiopulmonary resuscitation was performed. Our patient was not on a ventilator. The premature infant had a normal human karyotype and had intrapartum asphyxia and hypospadias deformity. The baby was treated at the Neonatology department of our hospital and discharged two months later with a body weight of 2055g. The baby does not have congenital heart disease. |
A 79-year-old Greek woman was referred to our department for the management of discomfort in the upper abdomen over the last 2-3 weeks, aggravated after food ingestion. The patient was not a smoker or an alcohol consumer and appeared healthy and well nourished. The physical examination and laboratory examinations including tumor markers were unremarkable.\nAn abdominal ultrasound (US) showed multiple stones in the gallbladder without features of cholecystitis and a multilocular cystic mass in the neck of the pancreas, with max diameter 4 cm. For further clarification of the US findings, Computed tomography (CT) () and Magnetic Resonance Imaging (MRI) (, & ) of the abdomen were also performed and revealed a homogenously hyper-intense multi-locular cystic lesion with max diameter 4 cm, located in the neck of the pancreas. Since it was difficult to conclude preoperatively whether the mass of interest corresponded to either a serous cystadenoma or a mucinous neoplasm or a cystadenocarcinoma we scheduled to perform a typical laparoscopic cholecystectomy in combination with laparoscopic evaluation of the mass in order to obtain a diagnosis and treatment if possible.\nUnder general anesthesia with the patient in the supine position, a pneumoperitoneum was created by carbon dioxide insufflation and four trocars were placed in the typical locations for cholecystectomy. After typical laparoscopic cholecystectomy, a fifth 12 mm trocar was placed at the outer verge of rectus abdominis muscle, in order to ease further surgical manipulations. The gastrocolic ligament was divided by Ligasure™ vessel sealing system and a tumor of exophytic nature protruding from the pancreatic parenchyma was noticed at the upper pancreatic margin at the pancreatic neck. Because the tumor was quite mobile and lacked adhesions with the neighboring tissues, it was considered it could be excised en bloc laparoscopically without harming the main pancreatic duct. After dissection of the tumor, ENDO GIA™ was used for tumor excision from the pancreatic parenchyma and ENDO CATCH™ was used to collect and remove the mass from the peritoneal cavity ( & ).\nSince the rapid histologic evaluation was negative for malignancy, a drain was placed in the excision area. The postoperative course was uneventful with a minor pancreatic leakage for the first two days. The drain was removed on the fourth day and feeding was started at the same day. The patient was discharged from the hospital seven days after surgery.\nThe standard histopathological study of the removed mass showed a serous microcystadenoma of the pancreas with no evidence of malignancy. There were not any late postoperative complications, while the patient remained asymptomatic and exhibited no sign of recurrence 6 months after the operation. |
The patient was a 48-year-old Japanese woman who was diagnosed 30 years previously with schizophrenia according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, previously used the Third Edition). She was delivered with forceps due to maternal fatigue (birth weight 2,500 g). Her mother had pregnancy-induced hypertension during her pregnancy. No cardiovascular abnormalities had been detected at any routine medical examinations. She had no history of feeding problems, such as regurgitation, nor did she have symptoms of hypocalcemia in early infancy. Her neuromotor development was slightly delayed, with particular delays in the emergence of language. She was a slow learner and finished regular junior high school with the lowest levels of achievement. Since childhood, she was disposed to catching colds, suggesting immunodeficiency resulting from thymic hypoplasia. She had a large cleft palate causing a hypernasal voice and underwent surgery for the cleft palate at 10 years of age (Figure a). Her parents and three siblings were alive and well, and no other family members or relatives are clinically affected. Since childhood, the patient had been easily and unpredictably irritated and emotionally labile. At the age of 18, she suffered from auditory hallucinations. Her family was troubled by the unpredictable agitation and behavioral changes associated with the hallucinations and delusions. At the age of 22, she began going to a psychiatric hospital regularly due to her agitation and behavioral changes. She was diagnosed with schizophrenia, and antipsychotic medication was initiated. For transient symptoms associated with hallucinations, delusions, insomnia, and agitation, she was admitted to the hospital at the age of 30. She had been hospitalized for a long time at Yamato Mental-Medical Center. Although she had no history of epilepsy, she experienced a generalized spasm when she had a lumbar vertebral fracture at age 46. At the time of this report, she was 48 years old and was being treated with antipsychotics (risperidone 12 mg/day), with a relatively good control of psychotic symptoms. However, she had persistent irritability, emotional lability, and unpredictable agitation. She underwent surgeries for Basedow disease at 17 years old and for uterine corpus cancer at age 38.\nThe patient's height was 153 cm, and her weight was 63.5 kg. She had the following typical features of craniofacial anomalies: a low anterior hairline, swollen eyelids, malar flatness, a nose with a bulbous nasal tip, hypoplastic nasal alae and a square and flat nasal root, a small mouth, and a thin upper lip (Figure b), as previously reported []. Her voice was hypernasal, and she had cavities due to enamel hypoplasia. No abnormality was found on neurological examination. Laboratory examinations revealed hypocalcemia (8.1 mg/dl in serum, normal range 8.7–10.3 mg/dl, serum albumin-corrected calcium level 8.3 mg/dl) and thrombocytopenia (7.2×104 μl−1, normal range 13–35×104 μl−1). Her intact parathyroid hormone (PTH) level was within normal limits but slightly low (27 pg/ml, normal range 10–65 pg/ml), indicating that the secretion of PTH from the parathyroid was not adequate despite her hypocalcemia. The spectrum of immunodeficiency ranges from absent T cells due to thymic aplasia to normal T cell numbers []. In this case, the numbers of CD4+ and CD8+ T lymphocytes were within normal ranges. Brain CT showed bilateral basal ganglia calcification (Figure c), which suggests deposition of calcium related to hypocalcemia. Her premorbid intelligence quotient (IQ), assessed by the Japanese Adult Reading Test [], was 80. To assess current intellectual ability, we used a full-scale IQ of the Japanese version of the Wechsler Adult Intelligence Scale, third edition (WAIS-III) []. The WAIS-III did not yield a full-scale IQ (<50; unmeasurable), suggesting that she showed cognitive deterioration. No evidence of cardiovascular disease was found on radiography or electrocardiograph.\nThe karyotype of this patient was normal (46,XX by G-banding). Fluorescence in situ hybridization analysis with the commercially available TUPLE1 (22q11.2) or ARSA (22q13.3) probes indicated that the patient was hemizygous for the TUPLE1 probe (represented by the red region in Figure d) and was homozygous for the ARSA probe, represented by the green region. According to the findings, we diagnosed the patient as having 22q11.2 deletion syndrome. |
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 25-year-old male from Northwest Puerto Rico, with past medical history of ocular albinism, presented to the outpatient clinic to establish care. Patient reports that as a child, he experienced episodes of epistaxis and easy bruising, requiring hospitalization. He was worked up for coagulation disorders such as hemophilia, which were negative. He also reports requiring blood transfusions as a child. Patient denied any family history of bleeding disorders. His teenage years and early adulthood years were uneventful as he did not require hospitalizations or transfusions.\nIn 2014 at the age of 22, he had a dental surgical procedure performed and reported excessive bleeding for 2 days after the procedure. The patient was hospitalized at that time to undergo a thorough evaluation. A diagnosis of HPS was considered, based on the external and ocular features of albinism, visual disturbances, and bleeding diathesis. A blood smear specimen was sent to a special coagulation laboratory at the Mayo Clinic for platelet electron microscopic studies and revealed the platelets had virtually no dense bodies. This finding in conjunction with other platelet EM findings was consistent with a variant of HPS ( and ).\nHe remained stable up until 2016 when he experienced epistaxis and hematemesis. No blood transfusion was required during the hospitalization. He was advised to establish care with a primary care provider and to see a hematologist.\nDuring his initial hematology evaluation, a special genetic test from GeneDx was ordered to possibly confirm the diagnosis of HPS in this patient. The result was positive homozygous for 3.9 kb deletion in the HPS3 gene. The 3.9 kb deletion in the HPS3 gene identified in this analysis could occur in persons of any heritage but is particularly common among individuals of Puerto Rican ancestry who originate for the central region of the island. Homozygosity for this deletion is consistent with the clinical diagnosis for HPS. Genetic counseling was recommended.\nAt our office, the patient presented with subtle signs of albinism but was otherwise unremarkable. On laboratory analysis, complete blood count showed all cell lines within normal ranges, and platelets specifically were 220,000/µL. We referred him to pulmonology as there is an association with developing pulmonary fibrosis in patients with HPS; however, those with type 3 generally have milder disease. He has not yet had preliminary pulmonary function tests or chest imaging done, but he is currently asymptomatic. |
A 20-year-old married HIV-seropositive woman was referred to our service for the evaluation of a painless swelling on the hard palate that had appeared 2 months earlier, with the rapid evolution. The patient informed the deferment of antiretroviral therapy for 4 months. Extra-oral examination revealed no significant findings with respect to area in question. Palpable cervical lymphadenopathy was present; with the lymph nodes being firm and non-tender on palpation [].\nOn Intra-oral examination, diffuse bluish-red nodular enlargement on the left side of the hard palate was verified, extending anteriorly from the left maxillary canine to the tuberosity region posteriorly. The nodular enlargement was observed crossing the midline, involving almost the entire hard palate and protruding at the level of the occlusal plane, thus interfering with the mastication. On palpation, the swelling was firm in consistency; non-tender and exhibited surface ulceration []. None of the regional teeth exhibited mobility. Panoramic radiograph revealed no significant changes in the adjacent bone. No other similar lesions in any other region of the body were detected. In view of the history and clinical findings, a diagnostic possibility of KS was hypothesized with differential diagnosis of bacillary angiomatosis and lymphoma.\nSubsequently, an incisional biopsy was performed and the specimen was submitted for the histopathological examination. Light microscopic examination of the sections stained with hematoxylin and eosin revealed fibrous connective tissue stroma with numerous irregular slit like spaces containing extravasated red blood cells and surrounded by ill-defined fascicles of spindle shaped cells []. Chronic inflammatory cell infiltrate was evident beneath the surface epithelium. The histopathological features confirmed the clinical diagnosis of KS.\nFurther to rule out distant metastasis, chest radiography [] and ultrasonography of the abdomen were performed that revealed no pathology. The patient was classified as a good risk according to the staging classification system for AIDS-related KS proposed by the AIDS Clinical Trial Group.[] The patient was referred to the medical oncologist for the completion of the treatment. The oncologist suggested the re-establishment of highly active antiretroviral treatment (HAART) in order to control the progression of KS and to allow Immune restoration, since the suppression of viral replication and restoration of immunity by HAART has been effective in tumor control in most patients considered to have a good prognosis. After that unfortunately, we lost communication with the patient for follow-up. |
A 30 year-old man referred to the emergency department with loss of consciousness and a stab wound in the right para-spinal region at about the level of the T6 vertebra. On admission, the patient was confused, agitated, and had automatism in his lips and mouth. There were no obvious signs of head trauma. Vital signs were stable, and lung and abdominal exams were normal. The brain computed tomography (CT) scan showed large amounts of air in it (). Thus, we transferred the patient to the intensive care unit (ICU) and administered high doses of oxygen (10 Liter/min) with mask, while laying him in the trendelenburg position. Consciousness of the patient improved rapidly with these treatments. Although primary lung examination revealed no abnormal findings, the patient gradually went into respiratory distress. A lung CT scan uncovered that a tension pneumothorax has been developed (). A subsequent thoracotomy was performed, during which tearing of a large branch of the left bronchial tree was detected and sutured. A thoracostomy tube was then established to evacuate the excess air from the pleural cavity. A second brain CT scan showed that all the air bobbles were gone. After one week, the patient was discharged in good condition. In this case, after bronchial tear, intra-pleural pressure was increased and led the air to pulmonary veins, the heart, aorta and finally the cranial arteries.\nCerebral air embolism is a threatening condition that could be caused by isolated penetrating chest injury. After chest injury, air may be introduced into the pulmonary arterial system. If the arterial gas embolism occurs, the smaller arteries or arterioles will be obstructed by air bubbles. This leads to ischemic and hypoxic changes. In addition, air bubbles may induce some inflammatory reactions. Loss of consciousness and convulsion are two of the most severe symptoms that could happen. CT scan reveals the bubbles in the brain. Hyperbaric oxygen therapy is recognized as a useful way to decrease bubble size and remove the obstruction of vessels. |
A 52-year-old male patient, who was moderately built and moderately nourished, was complaining of swelling in the right side of the face, involving middle third for the past 2 months. He gave a history of tooth pain in relation to upper right third molar before 3 months, for which he had previously visited a dentist. The pain was diagnosed to be due to acute periapical abscess, and the patient got the tooth extracted under local anesthesia. One month later, the patient developed pain and swelling in the middle third of the face, and he was referred to our institution by a private practitioner for further investigations.\nDuring the day of the presentation, he had throbbing pain, moderate to severe in intensity, which was increasing during the night time. He also gave a history of watery discharge from the nose for the past 2-3 months. His medical history revealed that he was a known type II diabetes mellitus patient, and there was surgical history of appendecectomy 15 years back, without any complication.\nOn clinical examination, a diffuse swelling was noted extraorally, extending from nasolabial fold to pre auricular region in anterio-posterior direction and from infra orbital region to angle of mandible in superio-inferior direction. The overlying skin surface appeared smooth and shiny, with no ulceration or secondary changes, and bilateral submandibular lymph nodes were palpable. Intra orally, an oval shaped opening, with a diameter of approximately 1 cm was observed in the anterior palatal region []. The underlying bone was seen through the opening, and the surrounding palatal mucosa appeared edematous, with raised, irregular border. His right maxillary central incisor was missing due to mobility and the socket was continuous with the palatal opening. On palpation, foul smelling pus was oozing out from the labial and palatal gingival crevices of maxillary anterior teeth and on palatal mucosa near the opening. Nonhealing extraction socket, with visible underlying bone, was seen in relation to 18, with no bleeding or pus discharge. On radiographical examination, water's view [] revealed haziness in the right maxillary region and perforation in the anterior palatal region. With these clinical details, provisional diagnosis of chronic suppurative osteomyelitis of right maxilla was given.\nThe incisional biopsy specimen showed extensively necrotized tissue with no features of dysplasia under microscopic examination. Under general anesthesia, the lesion was treated surgically by hemimaxillectomy of the anterior palatal region, accompanied by debridement and curettage of the necrotized tissue. The excised specimens [] were multiple in number, including hard and soft tissue components and were sent for histopathological examination. During grossing, the soft tissues were examined macroscopically, tissue processed, sectioned and stained with hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), Gomori's methenamine silver (GMS) and Ziehl-Neelsen stain. The hard tissues, sent along with the soft specimens were subjected for decalcification and routinely processed, sectioned and stained with H and E stain. H and E stained sections of demineralized bone revealed bony trabeculae with fibrosis and inflamed bone marrow. The bony trabeculae were exhibiting many resting and reversal lines and the osteocytic lacunae were empty in numerous places. On soft tissue examination, highly necrotized tissue was seen under H and E staining. GMS staining revealed fungal organisms, branching at right angles, with large nonseptate hyphae [], along with round to ovoid spores. These hyphae were PAS-positive []. No acid-fast organisms were seen on Ziehl–Neelsen staining. With these histopathological features, the final diagnosis of “chronic osteomyelitis of the maxillary bone with fungal infection (mucormycosis), causing extensive tissue necrosis” was made. The patient's blood glucose level was controlled and monitored by the physician, and antifungal treatment (amphotericin B) was included under medical regime. |
A 61-year-old white female patient with a history of dyspnea on moderate exertion since adolescence. About 12 years ago, she also presented precordialgia on moderate efforts, associated with dyspnea, and progressive worsening without electrocardiographic changes at rest. At the time, the patient underwent an ergometric test, which was terminated by precordialgia and fatigue, and coronary angiography was requested. Coronary catheterization revealed atherosclerotic arteries, but three arteriovenous fistulas were present: two major fistulas, originating from the proximal portion of the anterior descending artery, draining into the pulmonary artery, and a third thin fistula, originating from the circumflex artery, also with pulmonary artery drainage.\nAfter a discussion of the heart team, percutaneous treatment was indicated, with embolization using coils inside the two fistulas originated from the anterior descending artery, but with an unsatisfactory result and residual flow through both fistulas.\nThe patient had considerable improvements in symptoms for about eight years. After this period, once again she reported symptoms of precordialgia and dyspnea on moderate exertion. Therefore, a new coronariography was indicated, which demonstrated an increase in the caliber of the three already known fistulas and complete absence of restrictive effect of the coils, with slow flow through the anterior descending artery and large flow sequestration by the fistulas, draining into the pulmonary artery ().\nThis time, a surgical approach was indicated to correct the fistulous pathways, since the patient presented progressive worsening of the symptoms.\nOn 08/27/2018, coronary fistula correction surgery was performed, by median sternotomy access, using extracorporeal circulation and cardioplegia. We found not only the three fistulas described in coronary angiography, but also a hemangioma involving the root of the pulmonary artery. The fistulas derived from the anterior descending artery, ending in a single drainage ostium in the anterior wall of the pulmonary artery. The three fistulas were properly identified, resected, and occluded with polypropylene monofilament stitches in three segments along their length. The hemangioma approach was performed with the same type of ligature in its major branches and cauterization of the other segments. A longitudinal incision was made in the pulmonary artery, also an identification of the fistulas’ drainage ostia and the ligation of the ostia with polypropylene monofilament stitches ().\nThe postoperative evolution was quite satisfactory, with no need for blood transfusion. The extubation was performed at the 6th hour after the surgery end time. The patient was discharged from the intensive care unit (ICU) on the 2nd postoperative day, leaving the hospital on the 5th postoperative day.\nOutpatient follow-up showed complete remission of precordialgia and dyspnea symptoms within the first month after surgical correction, presenting only symptoms related to post-sternotomy healing. |
A 34-year-old female patient reported to the department of Periodontics with exposed root in relation to maxillary right lateral incisor. The patient's general medical condition (American Society of Anesthesiologists 1) was good. History revealed previous endodontic treatment in tooth no. 12 performed by a private practitioner 2 years back. On intra oral clinical examination, crown of tooth no. 12 showed distinct discoloration. Apical portion of the root was seen perforating the buccal cortical plate and overlying mucosa with the fenestration defect measuring approximately 4 mm × 3 mm []. The patient was unable to recollect the period of its occurrence but confirmed the presence of exposed root since 1-year. The patient had also not sought any dental treatment for the past 1-year despite being aware of the existing defect. Plaque and calculus were seen deposited on the exposed root but no pus discharge was evident in the area []. Probing depth in the gingival sulcus above the fenestration defect was within normal limits. Palatal examination revealed presence of a palatal groove possibly extending onto the root and an isolated periodontal pocket of >5mm [Figure and ]. The tooth presented with grade I mobility.\nRadiographic examination of the concerned tooth revealed faulty root canal treatment in right maxillary lateral incisor and a lateral radiolucency on the mid mesial aspect of its root []. A thin parapulpal radiolucent line was observed on the radiograph which confirmed the presence of a palato gingival groove. It was decided to repeat endodontic treatment in the affected tooth, treat the palato gingival groove and perform periodontal surgical correction of the fenestration defect by raising a full thickness flap.\nThe exposed root tip of right maxillary lateral incisor was cleared of the deposited plaque and calculus []. Endodontic treatment was reinitiated in the tooth. Previous gutta percha filling was removed from the canal with the help of a hand file and working length established. The canal was thoroughly cleaned and shaped using step back technique with 15–80 stainless steel K files (Dentsply Maillefer, Ballaigues, Switzerland) under copious irrigation with 2.5% sodium hypochlorite. Apical preparation was done until master apical file (MAF) size 40. The canal was medicated with calcium hydroxide paste and the access cavity sealed for 1-week with a temporary restoration (Cavit, Premier Dental Co., Philadelphia, PA, USA). On subsequent visit, the paste was flushed out of the canal using thorough irrigation with sterile water and dried. Need for odontoplasty with respect to palato gingival groove was anticipated hence mineral trioxide aggregate (MTA) (ProRoot MTA; Dentsply Tulsa Dental, Tulsa, OK) was used to fill the entire canal. Wet MTA was carried into the canal using amalgam carrier, advanced apically to the working length with a K file, 1 size smaller than the MAF, and condensed properly using finger pluggers. Incremental placement and compaction of MTA was continued from apical to coronal area using subsequently larger hand files and pluggers until the level of cemento enamel junction. A moist cotton pellet was placed on MTA and the cavity sealed with intermediate restorative material. Retrograde filling was also done at the apex by direct access using MTA. On third visit after 1-week, the cotton pellet was removed. Flowable compomer (Filtek Flow 3M/ESPE, St. Paul, MN, USA) was placed over exposed MTA and the access cavity permanently restored with bonded resin restoration [].\nOn fourth visit, the patient was prepared for periodontal surgery. 2% lignocaine anesthetic with 1:1,00,000 adrenaline was given to anesthetize the maxillary anterior region. Palatally, a full thickness flap was raised using sulcular incision and the pocket curetted with Gracey Curettes number 1, 2 and 5, 6 (Hu-Friedy Manufacturing Co., Chicago, USA). The palatogingival groove was saucerized and blended with the root surface using a fine diamond. The coronal extension of the groove was chemically conditioned using 10% polyacrylic acid and restored with type I glass ionomer cement (GIC) (Fuji 1, GC Corporation, Tokyo, Japan).\nFacially, a full thickness mucoperiosteal flap was reflected. On raising the flap, it was observed that the entire labial surface of the root was denuded of bone. The mesial, distal and intercrestal bone were intact, but a bone defect was seen circumscribing the root apex []. The root tip was minimally resected and smoothened with a high speed diamond. The area around root tip was thoroughly curetted to remove all pathologic granulation tissue. Postpreparation of the recipient site with 17% ethylenediaminetetraacetic acid (Pulpdent Co., Watertown, MA, USA); porous biphasic bone graft material containing hydroxyapatite and β tricalcium phosphate (OssiFi, Equinox) to aid in bone regeneration was packed into the defect and over the denuded root surface []. A bio resorbable collagen barrier membrane (Healiguide®, Advanced Biotech Products (P) Ltd., India) was placed over the bone graft and the flap repositioned and sutured to the adjacent tissue using interrupted sutures with 3-0 black silk [Figure and ]. The pre existent defect in the soft tissue was additionally sutured.\nPeriodontal pack was placed over surgical site for protection and the patient prescribed a course of antibiotics and antiinflammatory medications. He was advised to rinse with 0.2% chlorhexidine twice in a day for 4 weeks and discharged after giving proper postsurgical instructions. Patient was recalled after 2 weeks for suture removal and evaluation. The pocket depth had resolved. Complete closure of mucosal defect could be appreciated at follow-up appointment of 1-month [Figure and ]. At 6 months, the patient continued to be comfortable without any complaint. Radiographic examination revealed a sound periapex and resolution of lateral radiolucency []. All probing depths around the tooth continued to exist within normal limits and the tooth was no longer mobile. |
The patient is a 54-year-old married male who presented for the treatment of alcohol dependence (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR]). Patient had been consuming alcohol in the form of spirits for the past 38 years. Patient was admitted in the ward and was detoxified with diazepam. By the end of the 1st day of abstinence, the patient started developing involuntary movements of fingers of both hands. The movements involved dyskinetic movements of fingers as if playing an imaginary piano. There were no other involuntary movements in other parts of the body. The abnormal involuntary movement scale severity score was 3 with awareness and moderate distress. Patient's past history was carefully reviewed. The patient had been admitted for the treatment of alcohol dependence 4 times in the past 6 years. During each of these admissions, patient reports that similar involuntary movements of the fingers had occurred starting from the 1st day of abstinence. The movements would spontaneously subside after about 10-14 days of abstinence. The patient's past psychiatric history was also explored into. Patient had three episodes suggestive of alcohol-induced psychotic disorder (DSM-IV-TR) respectively 35, 33, and 22 years ago. The duration of each episode varied between 3 and 6 months and was prescribed chlorpromazine 100-300 mg for the same. The medication was taken irregularly for a period of 2-3 years after the onset of the first episode and for a period of 6 months after the third episode. The patient has been free of all antipsychotic medications for approximately last 21 years. The patient was observed in the ward and detoxification was completed over a period of 10 days. He was started on acamprosate 1998 mg as an anticraving agent. Aspartate transaminase and alanine transaminase levels were 105 and 95 International Units respectively with serum bilirubin being in the normal range. The involuntary movements continued until the 12th day of abstinence before subsiding completely. The patient was followed up in the outpatient services of the hospital on a fortnightly basis for a period of 3 months. During this period, he was abstinent to alcohol and no involuntary movements were noticed. |
A 57-year-old asymptomatic man with no significant past medical history was found to have an enlarged cardiac silhouette on a routine chest radiograph (). Magnetic resonance imaging (MRI) revealed a 9 cm pericardial cyst in the right cardiophrenic angle that was associated with right atrial compression (Figures , , and ). Although the pericardial cyst wall showed contrast uptake, no uptake within the cyst was observed on first-pass or delayed images. There was no compression of the airway or superior vena cava (SVC) and the pericardial cyst had not eroded into the heart. The patient was not at high risk for hydatid cysts and he did not have any history of fever, suggesting that an infectious cause for his pericardial cyst is unlikely. He did not have any history of chest trauma or intrathoracic surgery. The absence of hypertension, hematuria, and a positive family history made a diagnosis of autosomal dominant polycystic kidney disease (ADPKD) unlikely. The patient was scheduled for resection of the pericardial cyst using VATS. Preoperative electrocardiographic findings, complete blood count results, serum creatinine levels, liver function tests, and serum electrolyte levels were normal.\nOn the day of surgery, the physical exam, including heart and lung auscultation, was unremarkable and the vital signs were within normal limits (blood pressure of 119/75 mmHg, heart rate of 83 beats per minute, respiratory rate of 14 per minute, blood oxygen saturation of 97% on room air, and temperature of 36.9°C). A left radial arterial line and two large-bore intravenous catheters were placed. The patient was adequately hydrated with intravenous administration of normal saline. He was transferred to the operating room and placed in the supine position on the operating table. The standard American Society of Anesthesiologists monitors were placed on the patient. The pericardial cyst did not compress the patient's right bronchus or the SVC, and therefore, he was able to tolerate the supine position with no shortness of breath or hemodynamic instability. The patient was preoxygenated and general anesthesia was induced by slow intravenous administration of etomidate 0.2 mg/kg and fentanyl 1 μg/kg. Neuromuscular blockade was achieved by intravenous administration of succinylcholine 1.5 mg/kg. Ephedrine 0.1 mg/kg was administered following induction to minimize the hemodynamic effects of the induction agents and positive pressure ventilation. A 37-French left-sided double-lumen endobronchial tube (DLT) was placed. The patient was placed in the left lateral decubitus position. Anesthesia was maintained with oxygen (fraction of inspired oxygen of 0.6), air, and sevoflurane (1 minimum alveolar concentration). The right lung was collapsed and neuromuscular blockade was induced with rocuronium 0.6 mg/kg. A 1-cm incision was made in the posterior axillary line at the fifth intercostal space. A metal port was placed and a 10-mm, 30° thoracoscope was placed through the incision. A 2-cm incision was made above the fifth intercostal space at the mid axillary line to access the cyst. The pericardial cyst was found to be firm, and had some calcifications on the surface (Figures , , and ). The cyst was easily separated from the pericardial fat. However, it was attached to the anterior chest wall. Following separation of the cyst from the anterior chest wall some bleeding occurred from the distal right internal mammary artery. The bleeding was controlled with Enseal and clips. The cyst was large, and hence, access to the superior aspect of the cyst was difficult. Therefore, an 18-gauge needle was used to aspirate the cyst fluid. Approximately 300 ml of brown, murky, nonodorous fluid was aspirated from the cyst before it was completely resected (). The patient remained hemodynamically stable throughout the procedure and the DLT was removed in the operating room at the end of the procedure. Postoperative pain was managed with an intercostal nerve block using 10 ml of 0.5% bupivacaine and patient controlled analgesia pump using hydromorphone (intravenously, 0.2 mg every 10 minutes). The patient's postoperative course was uneventful, and he was discharged on postoperative day 1 in a stable condition. Cyst fluid cultures were negative. |
A 23-year-old female gravida 2 para 1 was referred to our hospital with a 1-week history of mild vaginal bleeding. She had already been diagnosed with a cesarean scar pregnancy via transvaginal ultrasonography and magnetic resonance imaging (MRI) that showed the pregnancy 2.5 mm from the bladder wall. Two years prior to presentation, the patient had had a cesarean delivery for macrosomia without complications. Repeat ultrasound at the current presentation showed a single viable gestational sac corresponding to 7 weeks’ gestation at the cesarean scar site (). Endometrial thickness was 12 mm, and blood was seen in the uterine cavity at the level of the fundus. Abdominal examination was unremarkable. Speculum examination revealed minimal blood in the vagina. Laboratory workup showed normal hemoglobin level, platelet count, white blood count, and C-reactive protein. After the risks of cesarean scar pregnancy and benefits of treatment were explained, the couple chose termination of pregnancy; informed consent was obtained.\nThe patient was positioned similarly to infertility patients for office-based ovum pickup. A transvaginal probe fitted with a suction double lumen needle (Kitazato Corp) was introduced into the vagina, and the sac content was aspirated until no cardiac activity was detected. Methotrexate 50 mg was injected into the sac, and a 25-mg methotrexate injection was administered intramuscularly. The patient was hospitalized for 1 week after the procedure. During the first 2 days postoperatively, the patient had minimal vaginal spotting associated with mild lower abdominal pain. Her vital signs were stable throughout her hospital stay, and she was discharged on postoperative day 7.\nOne week after the procedure, transvaginal ultrasound showed a well-defined soft tissue mass that was inhomogeneous in texture with surrounding vascularity at the site of the cesarean scar and a small collapsed gestational sac without a yolk sac or embryo (). Beta human chorionic gonadotropin (hCG) was measured on postoperative days 1, 4, and 7 and increased on day 4, followed by a decline of 16.4% on day 7. Another 50 mg of methotrexate was administered intramuscularly 1 week after the procedure, and the patient was followed on an outpatient basis for 2 weeks with weekly beta hCG surveillance until a negative beta hCG level was established. The patient reported no side effects or complications. |
An 18-year-old man referred for ASD repair to our hospital. He was moderately cyanotic but reported no chest discomfort, dyspnea, or hemoptysis. He was in New York Heart Association functional class I. On physical examination, the patient had no dysmorphic features but had moderate central and peripheral cyanosis, stage II clubbing with drumstick appearance of the fingers and toes, pulse rate of 90 beats per minute, and blood pressure of 130/70 mmHg. Blood gas analysis demonstrated oxygen saturation of 85% in room air. Cardiac examination showed a normal apical impulse, no right ventricular heaves or thrills, and normal first and second heart sounds. Chest examination was unremarkable apart from lower-limb cyanosis. Laboratory examination revealed serum hemoglobin of 18 g/l, hematocrit of 55%, and normal serum electrolyte levels and renal function. The electrocardiogram and chest X-ray were normal. Transthoracic echocardiography showed normal left and right ventricular functions and dimensions. Also, no tricuspid insufficiency jet was identified from which a systolic pulmonary arterial pressure could be estimated. However, the estimations of the mean pulmonary arterial pressures using acceleration time and pulmonary regurgitation were normal. No persistent left SVC was seen, and nor was there a report of an anomalous drainage of the IVC into the left atrium. Cardiac angiography was not performed to visualize the anatomy of the ASD and IVC.\nThe patient underwent ASD repair with bicaval and aortic cannulation. Gross examination revealed that the left SVC drained into the left atrium at the entrance of the left superior pulmonary vein into the left atrium. After an antegrade aortic injection of cardioplegia and the subsequent cardiac arrest and local hypothermia, the right atrium was opened and there was an unroofed coronary sinus to the left atrium, which was treated via extracardiac ligation of the left SVC. Moreover, there was a large low-lying secundum type ASD in the vicinity of an undiagnosed anomalously displaced IVC orifice in the left atrium. The defect was repaired with a pericardial patch, with continuous running suture. The patch was wrongly placed over the upper margin of the Eustachian valve and sutured to the lateral and inferior margin of the defect; this completely diverted the IVC into the left atrium. After repair, the right atrial incision was closed and the aortic cross-clamp was opened. Weaning from cardiac pulmonary bypass was complicated by a low cardiac output and central cyanosis. The volume of ringer lactate and normal saline was increased, but the patient's central venous pressure was not elevated and remained below 5 cm H2O.\nWith a low cardiac output, low arterial saturation, and inotropic drug support, the patient was transferred to the Intensive Care Unit, where he was connected to the ventilator with 100% fraction of inhalation oxygen (FIO2). Despite this high fraction of inhalation oxygen, however, blood gas analysis revealed a pressure of arterial oxygenation (PaO2) of 56 mmHg and saturation of 70%. Lactic acidosis was treated using a repeated dose of bicarbonate.\nThe following day, when the anesthesiologist tried to wean the patient from the ventilator, the patient's hemodynamic and blood gas analysis was compromised and he complained of severe epigastric pain. He was, therefore, sedated and reconnected to the ventilator. Transthoracic echocardiography illustrated the diversion of the IVC into the left atrium ( and ). The patient underwent reoperation, during which the pericardial patch was removed, the upper margin of the Eustachian valve was excised, and the lower margin of the patch was sutured to the wall of the left atrium below the IVC orifice. After diverting the IVC into the right atrium and opening the aortic cross-clamp, the patient was weaned from cardiopulmonary bypass uneventfully.\nOn the following day, the patient was fully conscious and was weaned from the ventilator. Nevertheless, he complained of severe epigastric pain. Physical examination revealed a tense and tender abdomen. In the semi-setting position, abdominal X-ray showed gas-fluid level below the diaphragm. The patient was, consequently, subjected to laparotomy, which revealed a perforated duodenum. The duodenum was repaired and the abdomen was closed.\nThe recovery of the patient was uneventful and he was discharged 2 weeks later from the hospital. At one-year follow-up, there was no recurrence of cyanosis or presence of a residual ASD. |
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). |
Our patient is a 19-year-old Caucasian female, G5P0040, who had routine prenatal care at our clinic. Her pregnancy had been complicated by a history of a seizure and bipolar disorders and personal history of ADDEB with documented COL7A1 gene mutation. The patient reported a family history of the disease in her maternal great aunt who was deceased; however, accurate information pertaining to the manifestations of her skin disorder could not be confirmed. The patient herself was born through a vaginal route and had been told that she had blistering and bullae formation that covered the vast majority of her body surface shortly after she was born. Throughout her early childhood years, she had recurrent skin blistering, particularly in her hands and fingers. By the age of three, she underwent surgical release of interdigit webbing between the fingers of both hands. Her disease activity diminished with advancing age thereafter. Her gingiva, buccal mucosa, teeth, and hands were normal at the time of her current pregnancy. Occasional blistering occurred with mechanical stress; however, perineal and vaginal epithelium sustained no blistering with normal vaginal intercourse. She was otherwise healthy. Her partner had no known family or personal history of EB (—Pedigree). Throughout her prenatal care, the patient adamantly expressed her desire to undergo an elective cesarean delivery. Her desire stemmed from the fear that her infant would suffer from generalized body skin blistering if delivered vaginally as she had when she was born. She had an uneventful prenatal course. Despite having no absolute indications for a cesarean route of delivery and after proper counseling, she received intrathecal spinal anesthesia and underwent an elective low transverse cesarean delivery at 39 weeks of gestation. She delivered a male infant weighing 3000 grams with Apgar scores of 8 and 9. The immediate postoperative period was unremarkable for both neonate and mother. The patient sustained no blisters on or around her skin incision throughout her hospital stay and remained to be blister-free on her 2-week postoperative check-up. Her infant however exhibited signs of skin erythema and blistering over its back (0.5 cm), inguinal (1 cm), and right buttock areas (0.5 cm) by day 1 of life. Within 3 days, diffuse erythematous and bullous lesions progressively appeared and covered the neonate's chin, forearms, face (), thumbs, fingers, left buttocks, remaining area of the back, and both legs covering approximately 30% of its total body surface. There was evidence of blistering and ruptured bullae but no secondary bacterial infections. Guidelines for skin care of neonates with suspected EB were implemented. These include using bland emollients, avoiding restrictive clothing and overheating, minimizing skin trauma, and rupturing of blisters using sterile needles, with topical antibiotics when needed. The differential diagnosis in this particular case was that of EB simplex versus ADDEB. A skin biopsy from the infant's back was performed and immunofluorescence mapping confirmed the suspected ADDEB in this neonate with low expression of type VII collagen in the basement membrane (). Both patient and neonate were discharged on hospital day 4 in a stable condition. She elected to bottle feed to avoid possible nipple blistering. As of this writing, maternal health has been stable and unchanged. Except for occasional blister and bullae formation, the neonate had what seems to be a mild phenotype of ADDEB with progressive resolution of the skin lesions over the course of 4 weeks after birth. By the third month of life, the newborn had been attaining all developmental milestones and had minimal blisters and bullae with normal fingers and nail beds. |
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. |
We report a case of a 66-year-old man who was diagnosed in 2010 of sigmoid-rectal adenocarcinoma.
At the moment of the diagnosis CT scan revealed a bulky mass (8 × 7 cm) in the sigmoid colon with no cleavage plane with the bladder and the abdominal wall and perilesional fat micronodulations. First operation was performed in another hospital. In that occasion the cancer was entirely removed and colostomy in the transverse colon was created. Local resection was followed by chemoimmunotherapy since there were no more signs of progression.
On December 2011 the patient came to our hospital. The cancer remained focal with no signs of metastasis. CT scan, indeed, showed a voluminous solid mass localised in the sigmoid colon that infiltrated the bladder and the abdominal wall including fascia and muscles up to the subcutaneous tissue. General surgeons proceeded with an anterior pelvic exenteratio removing the sigmoid colon en bloc, part of the ileum, the bladder, and the area of the abdominal wall infiltrated by cancer. Abdominal wall was reconstructed with a monofilament abdominal mesh in the lower abdominal quadrants, together with a ureterocutaneous stomy.
Afterwards, the presence of an enteric fistula caused a retroperitoneal pool and another surgery was needed. A relaparotomy was performed with abdominal mesh removal, enterorrhaphy, and an extended viscerolysis. Abdominal wall was finally closed with a macroporous polypropylene mesh.
Four days later signs and symptoms of peritonitis were diagnosed and the patient underwent a third surgery: the mesh was removed for the second time and another explorative laparotomy was made, followed by drainage of peritoneal cavity, viscerolysis, and creation of a lateral ileostomy in the left iliac fossa. Primary closure of the abdomen was not possible to achieve and an open abdomen negative pressure therapy system was applied over the peritoneal organs with a pressure of −125 mmHg in order to reduce edema. Dimensions of cutaneous dehiscence were, at the moment, 16 × 10 cm.
Three days later |
A 70-year-old female presented with a one-month history of right upper quadrant abdominal pain. She noted a 20-pound weight loss and significant loss of appetite over the previous three months. On physical examination, the liver was palpable 4 cm below the right costal margin and was firm and tender. She underwent an ultrasound of the liver that demonstrated a large mass in the right lobe of the liver that was heterogeneous, predominantly hypoechoic, with internal vascularity and measuring 10.5 x 7.4 x 12.2 cm. There was no intra- or extrahepatic biliary ductal dilatation. She then underwent an MRI of the abdomen that demonstrated a mass within the anterior segments of the right lobe of the liver measuring 7.1 x 4.6 x 5.2 cm that had heterogeneous decreased signal T1 images with slightly increased signal on T2 imaging. She underwent an upper GI endoscopy and colonoscopy that demonstrated no evidence of primary tumors. Her liver function tests revealed an AST 23, ALT 24, alkaline phosphatase 169, total bilirubin 0.5, CEA less than 0.5, and CA 19-9 34.\nThe patient received induction gemcitabine and capecitabine chemotherapy and portal vein embolization to induce left lobe hypertrophy. Restaging scans showed no evidence of metastasis and significant response with decreasing size of the lesion. She then underwent a right hepatic resection of the gallbladder fossa and the involved liver. Fiducial seeds were placed in the liver bed. It is our institutional practice to place fiducials in the liver tumor resection bed in all liver tumor resections at the time of surgery. The pathology showed that the patient had a poorly differentiated adenocarcinoma in the gallbladder with secondary involvement of the liver making this T3 disease. The cauterized liver margin was involved with invasive carcinoma; perineural invasion was absent. None of the lymph nodes was involved. She was thought to be a candidate for adjuvant postoperative radiation therapy since she had high-risk factors of a positive margin, T3 stage, and high grade. Because she had little residual liver, SBRT was advised.\nThe planning target volume was a 1.5 cm deep segment of the liver resection margin, which included the fiducial seeds. She received 24 Gy in three consecutive fractions to the liver resection bed. She completed the therapy with minimal side-effects, including fatigue and tiredness for a week and was well at her last follow-up 24 months later.\nA representative treatment plan is shown in Figure . The treatment prescribed to the 79% isodose line using the CyberKnifeTM technique with Synchrony respiratory tracking. The max dose was 30.4 Gy and the V21 (volume of residual liver receiving 21 Gy) and V15 (volume of residual normal liver receiving 15 Gy) was 11% and 21%, respectively. The maximum dose received by the < 1 cc of bowel was 17 Gy in three fractions. |
A 28-year-old Indian man presented to our Out-patient Department with complaints of pain and pus discharge from his left proximal leg for four weeks. He was unable to bear weight on his left leg and had a stiff left knee. He had sustained a left frontal extra-dural hemorrhage with depressed frontal bone fracture and an open fracture of his left proximal tibia in a road traffic accident five weeks ago. He was treated elsewhere with excision of the depressed skull bone fragment and evacuation of the extra-dural hematoma. Open reduction and internal fixation of the proximal tibia fracture with a medial locking compression plate (LCP®; stainless steel) was performed on the same day using a ‘Mercedes-Benz’ incision. Post-operatively, he was given a knee brace. Our patient developed pus discharge from the surgical wound in the proximal third of his leg three to four days after surgery. As the infection could not be controlled with antibiotics, he was referred to us for further management.\nOn examination, there was a Y-shaped scar over the left knee reaching up to the middle third of the leg with three sinuses on the suture line. There was an infected wound of size 4×4cm over the proximal third of the leg exposing necrotic, infected patellar tendon. The medial LCP® implant was also exposed (Figure\n). The left knee was mildly subluxed posteriorly and he had a 10° fixed flexion deformity of his left knee with minimal further flexion. He also had an equinus contracture of his left ankle. A pus sample was sent for culture and sensitivity testing and it showed heavy growth of Pseudomonas, sensitive only to imipenem and meropenem. We decided to perform a single stage debridement, with removal of the exposed LCP® implant, reconstruction of the extensor mechanism and fracture stabilization with a knee-spanning external fixator. He was counseled about the need for surgery and the proposed treatment plan and the prognosis was also discussed.\nUnder combined spinal and epidural anesthesia, our patient was positioned supine with a sandbag under the opposite buttock. The left lower limb was slightly externally rotated and flexed at the knee. The entire left lower limb was prepared and draped, and a sterile tourniquet was used. The right lower limb was also prepared and draped. The old scar over the left knee and the proximal leg including the three sinuses was excised and radical debridement was performed down to the bone. The patellar tendon was exposed and necrotic and hence had to be removed. The proximal medial LCP® implant and screws were removed and the screw holes curetted. The knee joint was also infected with arthrofibrosis and erosions on the articular cartilage. The menisci and the cruciate ligaments were destroyed and hardly identifiable. The proximal tibial fracture had not united and so was fixed with one 16mm partially threaded cancellous screw (6.5×75mm; Synthes GmbH, Switzerland) with a washer. There was a soft tissue defect of 12×7cm over the anterior and medial aspect of the upper third of the tibia with loss of the extensor mechanism of the knee (Figure\n).\nA 15cm longitudinal incision was made 3cm behind the posteromedial border of the tibia; the medial gastrocnemius muscle was raised as a flap along with its distal tendinous portion (hemi-Achilles tendon) through this incision and was used to cover the antero-medial side of the knee and the upper part of the defect (Figures \n and\n). The distal hemi-Achilles tendon was sutured to the remnant patellar tendon and the remaining part of the extensor retinaculum with the knee in full extension using Number 1 Vicryl™ (Ethicon, Inc, Somerville, NJ, USA). The bridge of skin between the raw area and the posteromedial skin incision was raised as a proximally-based fasciocutaneous flap, based on the saphenous artery, and was rotated laterally to cover the middle of the defect.\nThere was still a residual soft tissue defect of 3×3cm over the junction of the upper third and the middle third of the leg. The posteromedial incision was extended down and the medial hemisoleus was released progressively from the deep flexors and from the lateral hemisoleus at the median raphe. The proximal pedicles from the posterior tibial artery were ligated and divided. The muscle was released as far as the secondary pedicle located at the middle of the leg and was rotated anteriorly as a distally-based flap to cover the residual defect. A split thickness skin graft (STSG) was harvested from the contralateral thigh and was placed over the muscle flaps (Figure\n). The sterile tourniquet was removed and a knee-spanning external fixator applied with three pins each in the tibia and femur. The external fixator was kept in place for four weeks until soft tissue healing had occurred.\nOur patient was started on a quadriceps rehabilitation program and assisted knee range of motion exercises with a hinged knee brace after fixator removal. At one-year follow-up, the flaps had fully healed (Figure\n). The fracture had also completely healed (Figure\n) and our patient was able to walk with full weight-bearing on his left lower limb without pain and without crutches. He was able to stand on the operated leg alone without support (Figure\n). He had an extensor lag of 20° and knee flexion up to 80°. He had some residual posterior subluxation of his left tibia. He may require a knee arthrodesis in the future because of articular cartilage damage caused by pre-existing infection. |
A special needs 16-month-old Saudi boy. The chief complaint was a large ulcer on his tongue that caused pain, bleeding overnight, lack of sleep, and feeding difficulties. The mother reported that she noticed the ulcer 2 months ago and clinically examined by eight separate dentists. One of them thought that the lesion was a fungal infection and prescribing Daktarin oral gel 40 mg but in spite 1 month of treatment, the ulcer got bigger with more feeding and sleeping difficulties.\nThe mother also reported that the child was having a repetitive forward and backward movement of the tongue. The parents were very anxious as some dentists informed them that this lesion could be cancer.\nRegarding familial history, the parents are first cousins and the mother has hypothyroidism. This boy was her only child after two abortions; one born with anencephaly (absent brain). The medical history revealed that he was born preterm (36 weeks) with microcephaly. After delivery, he was hypoactive, hypotonic and had respiratory distress, neonatal convulsion, and poor sucking reflexes. Before their visit to me, they had visited 12 local, national, and international medical centers for clinical examinations and laboratory investigations [].\nOn the first visit, he was not responding, and no eye contact. It was difficult to open his mouth as he had a strong bite and uncontrolled tongue thrust. The intraoral examination revealed an ulcer approximately measuring about 3 cm × 2.5 cm on the dorsal surface of the tongue extended from the tip to the middle of the tongue []. Smoothing the sharp edges by removing mamelons of the lower primary incisors using a diamond bur in a high-speed dental handpiece was completed. A month later, the RFD ulcer had healed successfully []. After 1 year, a follow-up visit disclosed that the boy had stopped the habit of repetitive tongue thrust and no signs of ulcer reoccurrence. A written informed consent had been obtained from the child’s parents. |
We report a case of an 11-year-old girl who presented to the Emergency Department for diffuse pain of the left hip after a fall. Her medical and family history was unremarkable. A clinical examination showed mild, diffuse swelling of the left hip. The swelling was firm and non-tender, with moderate to severe painful manipulation. This was associated with pain-related decreased mobility of the hip. The patient was unable to walk. Plain radiography of the left hip in the frontal and lateral views showed an extensive osteolytic lesion in the proximal metaphyseal femur and femoral neck with thin sclerotic margins, with no invasion of the growth plate (). Magnetic resonance imaging and a computed tomography (CT) scan of the hip showed the presence of an ABC in the proximal third of the left femur, with no extension in the adjacent soft tissue. Selective arterial embolisation was performed to devascularise the tumour, promote healing, and decrease the risk of high bleeding during the biopsy procedure. For this purpose, absorbable gelatine sponge particles were used. A biopsy was achieved through a lateral approach centred on the greater trochanter. A hole was drilled at the inferior pole of the cyst, thus reaching the haemorrhagic lesion where blood and cystic soft tissue were obtained for a histopathological exam. After the diagnosis was confirmed, we performed a second selective arterial embolisation to limit development of the ABC. The patient’s progress was favourable, with decreased local pain, and she gradually regained mobility.\nOne month later, local progression of the ABC was favourable. Radiographic findings showed osteosclerotic margins at the tumour site. Pain in the left hip was further diminished and the full range of motion was regained. At the 8th and 12th weeks of check-up, plain radiography was performed and showed no progression of the bone cyst. After approximately 16 weeks, the patient experienced moderate local pain. An X-ray showed that the osteolytic process was expanded (). A second biopsy was performed to exclude a potential malignant diagnosis, which could have been missed. A biopsy specimen was also sent to another histopathological diagnosis centre and the initial diagnosis was reconfirmed (ABC vascular type). Furthermore, progression of ABC was unfavourable. Massive growth of the lesion had resulted in total destruction of the proximal third of the femur. The lesion expanded from the growth plate to 1 cm distally of the lesser trochanter, with severe local pain and functional impairment. Three-dimensional CT reconstruction showed massive destruction of the proximal left femur (.\nBefore surgical treatment, a CT scan showed disappearance of the cortical wall and differentiation of the cyst from the adjacent soft tissue by a fibrous membrane. We injected contrast agent to confirm under fluoroscopy that the cystic walls were breached. Unfortunately, the cyst communicated with the surrounding soft tissues. Therefore, sclerotherapy was contraindicated.\nConsidering the fulminant evolution of the lesion throughout 8 months (), we decided to perform radical treatment for the tumour. We chose to excise the tumour (). We used a reconstructive prosthesis of the proximal femur and total hip arthroplasty. The resection was wide, reaching approximately 2 cm distally to the inferior pole of the cyst. The implant had to insure the possibility of needing to reinsert the local muscular structures. For hip arthroplasty, we used a total uncemented prosthesis. The acetabular cup was attached without a requirement for any particular preparation of the acetabulum.\nAt the 3rd week of follow-up, the patient’s recovery was favourable and passive movement of the left hip was regained. Eight weeks later, the full range of motion and full weight-bearing were achieved (). The 1-year follow-up showed good progress with total recovery of function, no local pain, and total weight-bearing.\nThe patient provided verbal consent for inclusion in this report. Approval for this report from the ethics committee was not required. |
A 48-year-old woman was admitted to the hospital due to cortical cerebral venous thrombosis with small areas of hemorrhage. She had been previously admitted to a medical center in her hometown in suspicion of stroke, where she was initially stabilized, and then referred to our hospital for further evaluation. Her first symptoms consisted of generalized seizures for which she was started on phenytoin 100 mg t.i.d. On admission to our institution, she complained of left leg pain and dyspnea and was subsequently diagnosed with bilateral pulmonary thromboembolism and left iliac and femoral vein thrombosis.\nShe had no family history of thrombosis nor cancer, or toxic habits. She referred to changes in her bowel movements but had not been further studied. She denied weight loss, fever, headaches, or dyspnea. As a single thrombotic risk factor, she had been taking contraceptives for menorrhagia for several months prior to admission and received no other drugs.\nAt presentation, the patient was oriented and hemodynamically stable and needed no oxygen supplementation. Physical examination revealed slight weakness of her left lower limb and tenderness to palpation of the left lower abdominal quadrant. Her body mass index was 27 (weight 60.3 kg). Her creatinine clearance calculated by MDRD (Modification of Diet in Renal Disease) formula was 118 ml/min and platelet count was 231,000 mm3. Liver enzymes and coagulation assays were reported within normal ranges (prothrombin time, Kaolin activated Partial Thromboplastin Time (KPTT), and thrombin time (TT)). She was admitted to general wards and was started on anticoagulant therapy with low molecular weight heparin (LMWH). Phenytoin was not discontinued due to previous seizures. A thrombophilia panel ruled out Protein S deficiency, Protein C deficiency, antiphospholipid syndrome, and activated Protein C resistance. A CT scan of the abdomen showed a left lower quadrant mass, so she underwent laparoscopic resection of the mass on the third hospital day. Histopathology of the mass revealed a low-grade gastrointestinal stromal tumor of the gut. Twelve hours after surgery, she resumed enoxaparin and at fifth hospital day, she was started on rivaroxaban 15 mg b.i.d. because the patient came from a small city with rather difficult access to VKA monitorization.\nAfter the second dose of rivaroxaban, a peak anti-Factor Xa—3 hours after taking the medication—showed levels of 70 ng/ml (reference value: 100–300 ng/ml). While waiting for rivaroxaban to reach a steady state, the patient was discharged under supervision of home-care service, both on rivaroxaban 15 mg b.i.d. and on phenytoin 100 mg t.i.d. A week later, she visited the Vascular Medicine Service and at that time, a chromogenic anti-Xa level, measured 3 hours after taking rivaroxaban, was 90 ng/ml. Upon further questioning, the patient denied noncompliance with the medications. Even though the patient had remained asymptomatic, she was switched to dabigatran because of concerns about recurrent thromboembolism associated with low rivaroxaban plasmatic levels. During follow-up visits, she remained asymptomatic, showing good clinical response, and a TT >180 seconds, 4 hours after taking dabigatran, was measured in three separate opportunities along 2 months as an indirect index of dabigatran activity. |
A 68-year-old Japanese man was referred to our hospital for thorough investigation of right hypochondriac pain and painless swelling on the right side of his neck. He had a past history of a transverse colon cancer operation about 18 years earlier and underwent distal gastrectomy and cholecystectomy due to duodenal ulcer 30 years earlier. He had gone to another hospital for diabetes mellitus follow up. One month earlier, he was referred to the same hospital because of right hypochondriac pain and anorexia. Plain abdominal computed tomography (CT) scanning revealed a low density area in his liver segment 8. At first, because of his cervical swelling, hepatic carcinoma with neck metastasis was suspected. He was admitted into an affiliated hospital for further examinations. Esophagogastroduodenoscopy and colonoscopy were performed, but both revealed no malignancy. Enhanced abdominal CT scanning showed no tumor in his liver and other abdominal organs. Enhanced thoracic CT scanning showed enlargement of right cervical lymph nodes (Figure ), but no primary tumors could be detected. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) could not be taken because of the patient’s poor systemic condition and there was no instrument in our hospital. Subsequently, fine-needle aspiration cytology (FNAC) of the right cervical mass was performed, and it suggested poorly differentiated carcinoma. Metastatic carcinoma was suspected, but primary organs could not be detected. For further examinations, he was transferred to our hospital after 3 weeks. He had a poor systemic condition and showed multiple metastases of the spine. Then, disseminated intravascular coagulation gradually developed. He died of cancer 5 days after his transfer to our hospital.\nBecause the primary carcinoma was unknown, autopsy was performed after his death. At autopsy, a tumor of about 5cm was found in the right submandibular gland. No other primary malignant tumor was detected, except metastasis to the bone marrow and spine. Histological examination of the submandibular tumor revealed a solid growth formed of large polygonal atypical cells. An organoid structure, and palisading, rosette growth were seen, and the tumor had focal squamous differentiation (Figure ). The tumor showed diffuse necrosis and many mitoses (about 40 cells/10 high-power field). It was difficult to distinguish poorly differentiated SCC, basal cell adenocarcinoma, mixed SCC, and basaloid SCC. Immunohistochemically, CD56 and synaptophysin were positive (Figure ), whereas chromogranin A, p63, alpha smooth muscle actin, and thyroid transcription factor-1 were negative. There is no report of salivary basaloid SCC. And basal cell adenocarcinoma or mixed SCC were ruled out because of positive synaptophysin which is expressed on neuroendocrine tumors. Based on these findings, the tumor was finally diagnosed as large cell neuroendocrine carcinoma of the submandibular gland. |
A 55-year-old man sustained bilateral below-knee crush injuries after being run over by a bus. He sustained bilateral severe lower extremity trauma, including a Gustilo IIIB tibial and fibula fracture, medial femoral epicondyle fracture and first metatarsal bone fracture in his left leg and a Gustilo IIIC tibial and fibula fracture in his right leg.\nDuring admission, the patient’s right foot showed early signs of ischemia that were confirmed by angiography showing arterial occlusion at the level of the popliteal artery. A stent was placed at the level of the occlusion and perfusion of the extremity was achieved. Surgical exploration of the right leg showed extensive avulsion injury and swollen muscles with the sign of ischemic injury, and fasciotomy was performed in all compartments. Foot sensation was preserved. Fracture repositioning and external fixation was applied bilaterally. On the second day after admission, the patient suffered lung emboli that required treatment with anticoagulants, and, therefore, delayed the definitive reconstruction.\nIn the next three weeks, the patient underwent serial revisions of necrotic tissues. On the right side, a large portion of the skin from the thigh to the distal third of the lower leg as well as the gastrocnemius and soleus muscles were debrided, resulting with a large circular defect of the leg with exposure of the posterior tibial neurovascular pedicle and the tibia bone. On the left side, after debridement, the soft tissue defect measured 18 × 16 cm on the lateral lower leg with tibia exposure (). A temporary coverage with split-thickness skin graft was performed in the right side, and vacuum-assisted closure (VAC) device was placed in the left lower leg. Reconstruction was planned in two stages by spare-parts surgery with preservation of the knee in the right side and free-muscle flap on the left side.\nA below-knee amputation of his right leg with a pedicled fillet of foot flap reconstruction for length preservation was performed three weeks after trauma. The flap was based on the anterior tibial neurovascular bundle and dorsalis pedis skin. All bone was dissected from the flap, the sole and remaining gastrocnemius and soleus muscle where excised because of inadequate circulation. The dorsal site of the foot was used as a cover over the proximal tibia stump. Remaining wound surfaces were tread with vacuum therapy. Six days after amputation, the patient got a split-thickness skin graft on the remaining wound surfaces on the stump ( and ). Internal fixation with an endomedullary nail was performed simultaneously in the left tibial fracture.\nFive weeks after admission, a free gracilis muscle flap was used to reconstruct the defect on the left lower leg. The flap was raised with a 9-cm pedicle and connected end to side to the anterior tibial artery 5 cm from the proximal wound edge. The muscle was then covered with a split-thickness skin graft.\nEight weeks after the trauma, stable coverage was achieved and the patient started a physiotherapy program, including prosthesis fitting and was discharged from the hospital. Six months after surgery, the patient regained a stable, independent and painless gait. ( and ). |
A 30-year-old male patient was admitted with pain in the lower back and left leg. There was no motor deficit on neurological examination. Laseque was 40 degrees in the left and 60 degrees in the right. Lumbar Magnetic Resonance Imaging (MRI) revealed an extruded disc fragment in the midline of at L5-S1 level ().\nSurgical treatment was considered because the low back and leg pain was irresponsive to medical treatment and physical therapy and because of the very large midline disc. Bilateral hemilaminectomy was performed due to the midline disc. Dura injury was observed on the ventral surface when left discectomy was being performed. A certain amount of CSF leakage was observed just after the dura tear and it was seen to stop spontaneously after a while. A sponge was placed and no other treatment was performed (as Tissel). An unsettled vacuum suction device was placed under the fascia on the left considering that a future CSF fistula might develop as bilateral hemilaminectomy was performed, and abundant haemorrhage developed during discectomy. Fascia and subcutaneous tissue were tightly sutured. A total of 200 cc CSF-blood mixture was seen to flow from the vacuum suction device of the patient who had bed rest for two days. The patient was mobilized on postoperative day two and, experienced headache and nausea, vomiting, but he did not have a stiff neck or fever, so infection was not considered after evaluation by an infectious diseases specialist, and bed rest was recommended again. Cranial and lumbar computed tomography (CT) was obtained on postoperative day four. When his complaints continued, cranial CT revealed intracranial pneumocephaly () and lumbar CT revealed air under profound fascia and at the wound site ().\nThe vacuum suction device was removed on postoperative day five as no flow or wound problem was observed and the skin was sutured. The patient’s complaints completely regressed on postoperative day six and he was discharged on postoperative day eight. |
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube insertion. There was granulation tissue visible sprouting through the tract externally (Figure ). The patient had no signs of peritonitis and the abdomen was soft. On flushing the tube with saline, peritubal leakage was noted and there was resistance to flow. Endoscopic examination was performed to visualize the position of the internal bumper. On endoscopy, the internal bumper was not visualized. Only a small dimple was seen in the mucosa of the anterior wall of the stomach (Figure ). The internal bumper appeared to have migrated through the tract and was entirely covered by the gastric mucosa with only a small dimple seen at the site of the tract. An ultrasound of the abdomen was performed which showed that the internal bumper was in the intramuscular plane of the rectus abdominis muscle (Figure ).\nAs the patient’s GCS was still poor with no mature swallowing reflex, we planned to remove the old PEG tube and replace it with a new one for continued enteral feeding. The procedure was performed under general anaesthesia. Under fluoroscopic guidance, a guide wire was passed through the previous PEG tube from outside piercing the gastric wall. Then the old PEG was removed by gentle firm traction and the tract was dilated using dilator passed over the guide wire. The position of the dilator inside the stomach was confirmed by injecting a contrast dye under fluoroscopic visualization. Since the tract was well formed, a 20 Fr balloon replacement gastrostomy tube was inserted from outside and secured (Figure ). Once again the position was confirmed by fluoroscopy and free flow of saline. The patient was started on PEG feeds later on the same day and had no complications. The patient was followed up for a month and was on continuous PEG feeds without any complications. |
A 15-year-old female with no significant past medical history presented after being struck in the face by a ball while playing water polo. The patient felt pain in her jaw, which was the chief complaint when she presented to the emergency department. Upon neurological assessment, the patient complained of midline tenderness from the skull base to midline cervical spine over C3; denied headaches, changes in vision, speech or swallowing, extremity weakness or paresthesias. A maxillofacial computed tomography (CT) scan did not show evidence of an acute facial fracture. However, the CT scan did reveal a radiolucent, ovoid-shaped lytic lesion arising in the left lateral mass of C1, between the anterior tubercle and the transverse process. Magnetic resonance imaging (MRI) studies further confirmed an enhancing osseous lesion at the left lateral mass of C1, with cortical breach and extension into the left lateral atlantodental joint space (). Of note, three years prior, patient had a CT cervical spine which, upon retrospective review, demonstrated a similar but much smaller lesion.\nDifferential diagnoses underlying this vertebral cortical erosion included those of infectious etiology, as well as oncologic lesions, such as giant cell tumor of bone, aneurysmal bone cyst, osteoblastoma, osteosarcoma or even Langerhans histiocytosis (LCH). Oncology recommended that the cervical spine lesion be biopsied for tissue diagnosis. Due to the unusual location of the lesion and risk of locally aggressive pathology, or possible tumor seeding along the biopsy track, interventional radiology was unable to perform a CT guided needle biopsy. It was therefore decided that the patient would require open neurosurgical biopsy for diagnosis.\nDue to the anterior and lateral location of the vertebral lesion, an anterior transoral approach to the C1 lesion was performed, in order to obtain a sufficient amount of the contrast enhancing component of the mass for pathologic diagnosis. The transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization, as well as stereotactic navigation, to expose the C1 anterior tubercle on the left side. Once exposure was completed, neurosurgery team utilized a matchstick burr to then drill the anterior outer cortex of C1. Multiple specimens from the fibrous tumor were taken, with curettes and pituitary forceps.\nThe sampled tissue did not show features of osteoblastoma or osteosarcoma, nor were there features of LCH or signs of infection. In the sampled region, the lesion consisted of a proliferation of nondescript stromal cells with intermixed multinucleated giant cells, and occasional clusters of foamy histiocytes (). Special testing for giant cell tumor of bone (G34W staining) was negative, as was fluorescence in situ hybridization (FISH) testing for Ubiquitin Specific Peptidase 6 (USP6), making a primary form of aneurysmal bone cyst unlikely. However, due to the aggressive nature of the patient’s osteolytic lesion and the significant risk for atlantoaxial instability associated with its location, it was decided to start the patient on Denosumab. Denosumab is an osteoclast inhibiting pharmaceutical agent, which was administered to the patient in order to stabilize and consolidate the lesion. Samples of the patient’s lesion were also sent out to a nationally recognized expert bone pathologist, whose findings were most consistent with benign giant cell rich lesion with histiocytes.\nThe patient was re-assessed three months postoperatively and MRI studies revealed that there was no interval decrease in the size of the tumor. In fact, there was a slight progression of the lesion anteriorly, despite treatment with Denosumab. After presenting the patient’s case at our institution’s multidisciplinary tumor board, it was decided to offer the patient a gross total resection of the offending lesion. This would inherently lead to significant atlantoaxial instability, therefore a posterior occiput to cervical three instrumented fusion was also warranted.\nThe transoral approach was performed in a multidisciplinary fashion, during which the otolaryngology team used direct visualization as well as stereotactic navigation, to expose the cervical vertebrae through the posterior pharynx. Fibrous tumor was identified and dissected until superior, inferior, and lateral margins of tumor resection were confirmed grossly, with fluoroscopy, and neuronavigation. Additional C1 anterior tubercle eccentric towards the right side was also taken, to include a normal bony margin. A small rim of tumor adherent to the vertebral artery was left behind. After the otolaryngology team closed the posterior pharynx, the patient was carefully turned prone, maintaining spinal precautions. Base of the occiput to cervical three was then exposed. C2 pedicle screws were placed. C3 lateral mass screws were placed. An occipital plate was sized. Screws into the occiput were placed. Fluoroscopy confirmed excellent position and spinal alignment. There were no post-operative complications and the patient was discharged home in good condition. Pathologic examination of the resected material at this time showed complete disappearance of the giant cells, due to Denosumab therapy, with the remaining lesional tissue resembling benign fibrous histiocytoma (). Post-operative imaging studies revealed a stable posterior cervical spine construct, along with minimal rim-enhancement along the vertebral artery, as expected (). At a three-week follow up visit in clinic, the patient’s incisions were healing well, she was neurologically intact, tolerating regular diet, and was eager to return to school. |
An 81-year-old female patient was admitted through the emergency department for abdominal pain and suspected small bowel obstruction. Intravenous access was established through an antecubital catheter in the right upper extremity. Additionally, the patient was placed on a heparin drip with access through the right antecubital fossa for atrial fibrillation. On the second day after admission, she complained of significant pain and swelling in the right upper arm. It was noted the intravenous catheter placed in the antecubital fossa had infiltrated, so it was subsequently removed. The patient’s pain progressed, and she began to develop numbness and tingling in the right hand, accompanied by a wrist drop. There were no signs of bruising or other evidence of any previous injury to the area, and the patient did not have pain in her shoulder or neck. There were no signs of extrinsic compression from the bedrail, blood pressure cuff, or the patient's clothing. An orthopedic consultation was called to evaluate for possible compartment syndrome. The patient was lethargic following Ativan administration but was able to comply with the examination. The upper arm anterior compartment was tense and not compressible, with pain reproducible with palpation. A passive stretch of the biceps induced significant pain. She was unable to extend her right wrist or fingers against gravity and had diminished light touch sensation over the dorsal and volar surfaces of the right hand. Wrist flexion was intact, the posterior compartment and forearm were soft and compressible, and a 2+ radial pulse was palpable. Based on the clinical diagnosis of impending anterior arm compartment syndrome, the patient was taken emergently to the operating room. Compartment pressures were not measured preoperatively as the senior author was called in to assist the on-call orthopedic surgeon who had already prepped, draped, and made skin incision upon arrival into the operating room.\nDue to the predominance of elevated pressure in the anterior compartment and the presence of suspected radial nerve palsy, a lateral incision was made so that the radial nerve could be identified and decompressed as needed []. Careful hemostasis was maintained with electrocautery. The radial nerve was identified and was found to have no obvious defects. The deep brachial fascia over the anterior compartment was found to be tense. An approximately 30 cm long incision was made with subcutaneous undermining distally and proximally to obtain a full-length fasciotomy. The incision was made laterally at the level of the intermuscular septum, and the nerve was identified anterior to the septum. This resulted in bulging of the biceps muscle belly, although the muscle tissue appeared completely normal. Dissecting more medially, we encountered a jet propulsion of clear fluid that burst from the anterior compartment (Video ). Approximately 100mL of intravenous fluid was identified isolated within a pocket between the brachialis and the long head of the biceps, which was then rapidly evacuated, decompressing the entire upper arm. The muscle bellies did not have any edematous tissue, and the soft tissues of the arm felt to be back to their regular consistency at this point. As the pressure was relieved and the radial nerve had no obvious defects, extensive neurolysis was not found to be necessary. Since the muscle bellies, fascial layers, and skin were no longer under any pressure, the skin was easy to reapproximate without tension, and primary skin closure was performed. Compartment pressures were not remeasured due to the complete relief of tension exhibited. The patient was discharged in a wrist splint.\nUp to one month postoperatively, the patient was found to have minor swelling of the anteromedial aspect of the right arm, with all compartments soft and compressible. On motor examination of the right side, she displayed 0/5 finger and wrist extension, 1/5 wrist flexion, 2/5 flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) flexion, and 5/5 biceps and triceps activity. Her sensation was diminished to light touch over the dorsal and volar surfaces of the right hand. A follow-up electromyography (EMG) one and a half months postoperatively revealed absent voluntary motor unit recruitment in the right pronator teres, brachioradialis, first dorsal interossei, and abductor pollicis brevis. Her right flexor carpi ulnaris, paraspinal, and proximal muscles were found to be normal. Nerve conduction studies revealed abnormal motor responses in the right median and ulnar nerves and abnormal sensory responses in the right ulnar, median, and radial nerves. At her two-month follow-up, she was noted to have absent pain and improving sensation, with a slight reduction to light touch over the dorsum of the hand and the first two digits on the volar surface. On motor examination, her FPL and FDP flexion improved to 3/5, but the rest of the examination was unchanged. Five months postoperatively, she was noted to have a return of light touch sensation over the volar surface. On motor examination, her wrists and fingers were now able to flex to 45° passively, and motor strength improved to 5/5 flexion in the wrist, FDP, FPL, and flexor digitorum superficialis. This suggested that her median and ulnar nerve palsies were resolved, but her radial nerve palsy had persisted. The patient returned to the office 14 months postoperatively for an unrelated complaint of metacarpophalangeal joint osteoarthritis. Her neurologic function was retested, and she displayed 5/5 flexion and extension in the wrist, FDP, and FPL suggesting total motor recovery. She complained of slight paresthesias in the right forearm and hand but displayed intact light touch sensation in all nerve distributions. |
An 83 year old retired Caucasian lady was admitted to a UK hospital with a recent history of back pain without any trauma. She had no significant past medical history of note and her only regular medication included a statin for cholesterol. She was a non-smoker and drunk only minimal amounts of alcohol. X-rays on admission demonstrated severe osteoporosis with multiple collapsed lumbar vertebrae. Whilst awaiting a brace and social support she developed diarrhoea and vomiting. An initial stool sample was negative for clostridium difficile serotoxin. Over the next few days her clinical condition deteriorated and by day 6 her C-reactive protein was 357. She developed abdominal distension, pain and a plain x-ray showed centralised dilated small bowel loops. A subsequent CT scan of her abdomen revealed small bowel obstruction together with mural thickening of the distal ileum (see Figure ).\nFollowing CT the patient developed signs of localised peritonitis and underwent a laparotomy. At surgery necrosis and ischaemia was seen in a large portion of mid-ileum together with large quantities of pus and a localised perforation. A small bowel resection of 60 cm was performed. Histology revealed an acute gangrenous ileitis. Blood, urine and stool cultures were all negative but reverse transcription polymerase chain reaction (RT-PCR) of stool cultures revealed Norovirus genogroup II. Immunoassay of the stool was negative for rotavirus and adenovirus. No specific testing for astrovirus was performed. Immunological testing of the histological specimens was not performed.\nThe patient had no prior history of vascular disease to suggest the cause of the ileitis was ischaemic enterocolitis. Furthermore despite the patient's back pain she had been mobilising around her bed in the hospital therefore it is unlikely that the cause of the ileitis was paralytic ileus secondary to immobility. The patient received only as required opiate analgesia and this was co-administered with appropriate laxative cover to avoid constipation. A diagnosis of acute gangrenous ileitis secondary to Norovirus was therefore made. It was postulated that the virus had triggered a localised inflammatory response leading to necrosis which had continued despite clearing of the virus by host immune responses. The virus was thought to be a nosocomial infection as there was no recent history of foreign travel or contact with individuals demonstrating the symptoms of gastro-enteric disease prior to admission. However antibody testing for IgG and IgM was not performed therefore the length of infection with the virus was unclear.\nFollowing surgery the patient developed a pelvic collection requiring CT guided drainage which matured into an enterocutaneous fistula. The fistula was treated conservatively and sealed spontaneously at 10 weeks at which point she was discharged. |
A 35-year-old man initially presented in February 2008 with nausea, vomiting, and weight loss. He was found to have a meningioma in his posterior fossa, compressing his cerebellum. He underwent resection and within a month, a second resection for residual tumor. He was then followed with serial imaging and in early 2009 underwent a third surgery for progressive tumor, this time followed by fractionated radiation.\nHe then did well until January 2013 when he suffered neck pain and the rapid onset of right-sided arm and leg weakness. Imaging found him to have a 1.4-cm enhancing mass at the cervicomedullary junction compressing his cervical spinal cord (Fig. ). Resection of this mass was complicated by subacute hydrocephalus necessitating the placement of a ventriculoperitoneal shunt 3 weeks later. Pathology on the resected mass described its similarity to rhabdoid meningioma, although with a low mitotic rate and without cellular atypia; the pathologists noted that although it did not meet histologic criteria for grade II, “the clinical history of this lesion suggests aggressiveness commensurate with at least WHO grade II.”\nOne-week postop imaging showed that the enhancing mass was smaller but there was concerning residual disease (Fig. ). By March 25, 2013 the mass had clearly grown (Fig. ), with increased pressure on the cervical spinal cord. At that time, he remained wheelchair bound and hemiplegic, although he felt no worse than at the time of his hospital discharge 2 months prior. Because he was thought to have exhausted surgery and radiation options, he was referred to us for consideration of systemic treatment. He began liposomal doxorubicin at 30 mg/m2 every 3 weeks, and he was tapered off his dexamethasone and started on testosterone replacement.\nTwo months later, repeat MRI showed no change in the mass representing his tumor. By 4 months, he could walk using a leg brace and could climb stairs. At cycle 6 (18 weeks), his interval was stretched out from every 3 to every 4 weeks. He continued on monthly liposomal doxorubicin for a total of 26 cycles over 22 months. His toxicity was limited to grade 1 hyperpigmentation of the palms. He received his last chemotherapy in November 2015 and we have continued to follow with surveillance imaging. At the time of this report (May 2017), he is well and can walk with a cane and drive, 4 years from his last progression event. Although serial MRIs have all called stable disease at the tumor of his cervicomedullary junction, the tumor there has actually slowly regressed over the years (Fig. ). |
An 82-year-old Japanese man presented with swelling of the gingival in the molar region of the left mandible. Approximately 2 weeks prior to the first visit, the patient noticed swelling of the gingiva, and panoramic X-rays were taken at a dental clinic. The images revealed radiolucent findings at the site, and the patient was referred to our facility for examination. The patient had a moderate physique and was well nourished, but he was taking medication for hypertension.\nIntraoral findings showed that the upper and lower jaws were edentulous, with a relatively irregular border from the centre of the mandible to the gingiva of the molar region on the left side. Diffuse swelling and surface ulceration were observed. There was neither tenderness nor numbness of the lips ().\nPanoramic radiographs revealed a barely perceptible, polycystic radiolucent area with slightly irregular margins in the left molar region of the mandible ().\nComputed tomography showed a radiolucent area with little radiopacity. Internal uniformity was observed at the site, with thinning of cortical bone which lacked continuity in some areas (). After 1 month, a biopsy and a needle aspiration were performed. Five millilitres of yellow-white content was aspirated. The results of bacteriological analysis were negative. Histopathological findings revealed that the squamous epithelium was accompanied by chronic inflammatory cell infiltration. Based on these findings, a diagnosis of benign tumor of the mandible was made, and after 2 months, excision and curettage were performed under general anaesthesia. The lesion partially adhered to the bone, and the surface of the peripheral bone was slightly rough. An inferior alveolar neurovascular bundle was also observed below the tumour, and this was preserved. After excision of the tumor in one piece, curettage was performed and the wound was left open. Seven months after surgery, there has been no recurrence of the tumour, and the patient is currently being monitored as an outpatient.\nThe extracted tumour measured 3 × 2.5 cm and was milky-white in colour, with a slightly rough surface. The transverse section was mostly cystoid, but solid portions were also observed (). Histopathological diagnosis was follicular-type ameloblastoma. Haematoxylin-eosin staining revealed alveolar cell hyperplasia with a funicular structure in the fibrosing interstitial tissue, as well as a palisade arrangement (). |
This 35 years old indigenous man, with no stable accommodation for 10 years, identified the street as where he most frequently sleeps. His highest level of schooling was year 8. His first contact with the adult hospital healthcare system was in 2005 when he was hit by a car at the age of 22 years old, causing severe injuries. By this time, he already had severe ataxia (unsteady gait) and intellectual impairment from heavy solvent and alcohol abuse during his teenage years. In 2012 he had a further major car accident causing multiple leg fractures and by 2013, he was permanently wheelchair bound, homeless and a frequent user of street drugs, solvents and alcohol. He reports being regularly assaulted and having had multiple interactions with police, at the age of 30 years old, he was approved for permanent supported care but always left hospital to return to the streets before this could be found. His combination of permanent physical disability, lack of mobility, brain injury and vulnerability to attack and coercion resulted in him scoring 14 on the VI-SPDAT questionnaire in August 2016, reflecting high vulnerability. When asked ‘what do you need to be safe and well’ he simply answered ‘a house’.\nHospital use by this patient for a 27 months period (January 2015 to March 2017) is summarised in and the costs of these ED presentations and inpatient admissions have been computed using the sources described in the methods section. His total estimated costs for the 51 ED presentations over the 27 months period January 2015 to March 2017 was $33,456, and the cost of the 28 inpatient admissions amounted to $299,460. In total, this represents a cost to the health system of almost $333,000 or $12,333 per month over a 27 months period.\nIn early April 2017, this patient was found a place in a supported psychiatric care facility. Since then, he has not presented to any hospital or been admitted as an inpatient in the 7 months since being housed. The comparative cost of his past hospital use with the cost of case worker support and housing is discussed at the end of this results section. |
A 47-year-old woman diagnosed with type 1 diabetes at the age of 15 years and on subcutaneous insulin injections (insulin analog aspart) was admitted to the hospital with complaint of unsightly painless swelling in the lower abdomen at the injection site, which she noticed to be gradually increasing in size over the past 10 years. She also gave past history of recurrent abscesses at the same site.\nOn examination, the patient was of lean build with a body weight of 69 kg and a height of 167 cm with a body mass index of 24.7 kg/m2. Blood pressure and pulse were normal. No pedal or sacral edema or lymphadenopathy noted. Chest and the cardiovascular system were normal. Abdominal examination revealed the presence of a large mass measuring 8 × 8 cm in left lower paraumbilical region []. The mass was firm to hard with irregular surface and in the subcutaneous plane with restricted mobility. Overlying skin was scarred. No other clinical abnormality was evident. Hematological and some biochemical investigations were practically normal (complete blood count, blood urea, creatinine, liver function tests, electrolytes, and and thyroid function tests). Glycosylated hemoglobin was 12.0% and fasting blood glucose was 371 mg/dl. Serum calcium and phosphorous levels were 9.3 mg/dl and 3.7 mg/dl respectively. Lipid profile revealed cholesterol of 178, triglycerides 81, high density lipoproteins 39, and low density lipoproteins 123. Electrocardiogram and X-ray chest was normal. A diagnosis of lipodystrophy at insulin injection site was made in view of the past history, clinical, and laboratory investigations. Patient was posted for a mini abdominoplasty to remove redundant skin and for cosmetic purpose after control of blood sugar. Intraoperative findings showed necrotic subcutaneous fat with calcified areas corresponding to the swelling in the left lower abdomen. Partial excision was done as the swelling was found to be attached to the overlying skin. Histopathology revealed areas of fat necrosis with foreign body giant cell reaction along with thick fibrocollagenous tissue with extensive deposits of calcium (dystrophic calcification) [].\nPostoperatively, the patient was advised to avoid the abdominal site for injecting insulin and was instructed to use the multiple rotation method for injections. Subsequently, the glycemic control improved marginally with fasting blood glucose falling to 179 mg/dl. |
A 17 year-old male presented with a 1-year history of chest pain and dyspnea on exertion. During the past 2 weeks, he had experienced an exacerbation of his symptoms with shortness of breath even at rest, palpitations, pain in the right hypochondrium, abdominal distension, and progressively increasing jaundice.\nOn clinical examination, he was found to be icteric with hepatomegaly and ascites. There was jugular venous distension and bilateral pedal edema. Cardiac auscultation revealed a pansystolic cardiac murmur in the aortic region and along the left lower sternal border suggestive of aortic and tricuspid regurgitation. On transthoracic echocardiography, he was found to have a large blood-filled sac arising from the aortic root with peripheral thrombus and obstruction of the right ventricular out-flow tract (RVOT). There was severe aortic and tricuspid regurgitation.\nContrast-enhanced CT of the thorax was performed to delineate the anatomical relation of the aneurysmal sac and its level of origin. CT showed a large aneurysmal vascular structure measuring 11.8 × 10.1 × 9.2 cm arising from the right coronary sinus. The lumen of the aneurysm was partially opacified by the contrast, with a large eccentric non-enhancing thrombus noted along the dome of the aneurysmal sac []. There was associated thin peripheral rim of calcification around the wall of the aneurysmal sac. The aneurysmal sac was causing marked compression and attenuation of the RVOT and the main pulmonary artery. The aneurysm was extending along the right atrio-ventricular groove. There was resultant gross asymmetric dilatation of the right atrium and ventricle and associated dilatation of the inferior vena cava and hepatic veins suggestive of congestive changes []. The left cardiac chambers were displaced posteriorly and toward left.\nThe right coronary artery was seen to arise from the tip of the aneurysmal sac. The left coronary and non-coronary cusps appeared normal in morphology. The left coronary artery appeared normal in course and caliber []. Rest of the aorta, arch and its branches were normal in enhancement and morphology.\nThe patient underwent repair of the aneurysm with a prosthetic patch. Patient had an unremarkable postoperative period. He was discharged on the seventh postoperative day. On follow-up, there was significant improvement of the patient's symptoms. |
A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. A physical examination was conducted which showed his blood pressure to be normotensive and his measured pulse rate and body temperature to be within normal limits. His initial laboratory results showed an increased hematocrit level of 69%, a hemoglobin level of 23g/dl, and a white blood cell count of 15.5×1000/μL. Initially he seemed to be hemodynamically stable with no signs of dyspnea. He experienced a rapid decrease of total proteins (5.67g/dl decreasing to 2.02g/dl within 72 hours) and began to exhibit hemodynamic instability, at which point he was admitted to our intensive care unit (ICU) and treated with catecholamines. Due to an increasing pulmonary insufficiency an endotracheal intubation was performed immediately. A massive emission of fluids and proteins from the intravascular to the extracellular compartments caused a generalized compartment syndrome to develop. Over 24 hours after admission to the ICU our patient developed compartment syndromes in both his upper and lower limbs and the abdominal compartment. The abdominal compartment syndrome was diagnosed by measuring the intra-abdominal pressure through a urinary catheter. The highest measured intra-abdominal pressure (IAP) was 26mm/Hg and therefore a diagnosis of abdominal compartment syndrome Grade IV was made. His abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen. The surgeries were performed 24 hours after admission to the clinic. Vacuum-assisted dressings were placed first on his lower limbs. During a second revision operation vacuum-assisted dressings were placed on his upper limbs to assist with monitoring the edema and in preparation for the definite closure of the fasciotomy wounds. The dressing of his abdomen included putting the intestine into a sac and covering it with a transparency dressing. Continuous renal replacement therapy (CRRT) was required three days after admission due to acute renal failure. Continuous venovenous hemodiafiltration (CVVHD) was applied for a total of four days. The blood levels of creatinine and urea returned to normal after three days of CVVHD and he gained back full renal function. Before CVVHD the highest creatinine level amounted to 1.4mg/dl and after renal replacement therapy (before discharge from the hospital) it decreased to 0.6mg/dl. The urea levels also decreased from 80mg/dl to 17mg/dl. The hematological parameters returned to their normal limits by the fourth day of admission (Figure ). The clinical diagnostics included cultures of the blood, urine, stool, sputum, and intra-operative tissue samples which were all analyzed for aerobic and anaerobic bacteria, as well as for fungus. The results of the samples were all negative. After ruling out the differential diagnoses the diagnosis of a SCLS was confirmed, with secondary abdominal compartment and compartment syndromes in all four limbs. The secondary closure of the abdomen had been performed 16 days after admission and 23 days after admission we were able to remove the vacuum-assisted pumps and proceed in closing all wounds (Figure ). His upper limbs required skin grafting (Figure ). His lower limbs showed weakness in the dorsal flexion of the feet and toes, therefore peroneal splints were adjusted to his feet. His upper limbs showed residual deficits of fine motor skills, especially the left upper limb. These deficits had been improved with hand therapy. Our patient was moved to the rheumatology ward after 23 days in our ICU. He was started on medical prophylactic treatment with theophylline and terbutaline in combination with steroid therapy (prednisolone). During remission induction therapy the dose of theophylline ranged between 1200 and 1600mg per day in order to achieve serum concentrations between 20 and 25mg/dl. Before discharging him the theophylline dose was reduced to 1000mg/day. In order to obtain the remission advised to achieve peak serum concentrations between 10 and 20mg/dl, terbutaline was first given at a total dose of 20mg per day in divided doses. Before he was discharged the dose was reduced to 10mg per day. We recommended that he should continue to take theophylline and terbutaline for the rest of his life. Methylprednisolone was applied intravenously while in remission induction therapy at a dose of 40mg per day. After remission was induced the prednisolone was gradually reduced to 15mg/day. We recommended maintaining the gradual reduction of that dose.\nAfter 60 days of treatment he was discharged from the clinic. He was able to return to his previous place of work and reached the same level of athletic activity as before the illness. |
Consent for publication was obtained from the patient. A 25-year-old woman (height 152 cm, weight 49 kg, American Society of Anesthesiologists physical status I) was admitted to our hospital for surgery of traumatic fifth cervical spine fracture with SCI. The operation was uneventful and without any complications. After surgery, she was transferred to the intensive care unit with continued sedation and intubation. On the fifth postoperative day, her trachea was extubated without dyspnea.\nTen days later, the patient was referred for surgical treatment of bilateral elbow fracture. Her medical history was unremarkable. No abnormalities were seen in the laboratory tests. However, chest x-ray showed an elevated right diaphragm and consolidations of right lower lung field that were not present on the chest radiograph at admission. On arterial blood gas analysis, pH was 7.427, partial pressure of oxygen was 65.6 mm Hg, and partial pressure of carbon dioxide was 33.5 mm Hg. Unfortunately, no pulmonary function tests were performed due to her condition. She had an impaired ability to cough and to clear the airway secretions effectively. Despite these findings, she complained of no dyspnea at that time. Preoperative neurological examination was normal for the left upper extremity. Although motor function was nearly absent in the radial, musculocutaneous, median, and ulnar nerve distributions of the right upper extremity, the sensory function was nearly intact in all nerve distributions. After a thorough discussion regarding the potential risks and benefits and approval of the patient, we decided to provide anesthesia with US-guided bilateral axillary BPB with neurostimulation, which avoids airway manipulations and respiratory failure associated with general anesthesia.\nStandard monitors including noninvasive blood pressure, pulse oximetry, and electrocardiogram were applied and supplemental oxygen was administered using nasal prongs throughout the procedure. No sedatives or premedication were administered to avoid any interference with her lung function. While pre-procedural US examination of the right diaphragm showed no movement with the sigh and sniff test, a normal left diaphragmatic movement was observed (deep inspiration and sniff test, 7.6 and 4.2 cm, respectively).\nBilateral BPB was performed with US (Aloka Prosound SSD-3500SV, Hitachi Medical Ltd., Tokyo, Japan) and a 5 to 10 MHz linear probe with a nerve stimulator (Stimuplex HNS 12, B. Braun, Melsungen, Germany). The procedure was performed first on the right side. Since movements of the right elbow were impaired due to pain, we decided to perform infraclavicular BPB instead of axillary BPB. The US probe was positioned in a parasagittal plane medial to the coracoid process just below the clavicle and was adjusted to provide a transverse view of the axillary artery. Using an in-plane technique, an insulated needle (UniPlex NanoLine, Pajunk, Geisingen, Germany) was advanced to the posterior of the axillary artery and 25 mL of 0.5% ropivacaine was slowly injected with frequent aspiration. Thirty minutes later, the operation was commenced.\nFive hours later, left axillary BPB was performed to reduce the risk of LAST. Under US guidance, an insulated needle was advanced until its tip was positioned dorsal to the artery. Twenty milliliter of 0.5% ropivacaine was slowly injected at this location. Subsequently, the needle was advanced toward the musculocutaneous nerve and 5 mL of 0.5% ropivacaine was deposited around it. Twenty minutes later, a complete sensorimotor block of the left arm was confirmed. No symptoms or signs of LAST were noted.\nSince the patient was unable to cough effectively and unable to clear the secretions adequately, frequent oropharyngeal suction was required during the procedures. Her vital signs were stable and no opioid supplementation was needed during the surgery. Surgery was carried out uneventfully on both the sides. The patient required supplemental analgesics for postoperative pain on the right and the left side after 642 and 874 minutes, respectively. The postoperative pain was satisfactorily treated with ketorolac and tramadol. |
A 45-year-old male motorcyclist with a history of hypertension, hyperlipidemia, and coronary artery disease was brought to the emergency department after being struck by another car on the highway at speeds of at least 40 miles per hour. Upon presentation, the patient was evaluated using Advanced Trauma Life Support (ATLS) principles. He had a patent airway on arrival and was breathing spontaneously on room air. His initial heart rate was 87 beats per minute, and his blood pressure was 124/63 mmHg without signs of significant hemorrhage. He had an initial Glasgow coma score (GCS) of 15 with equal and reactive pupils. The patient admitted to consuming alcohol and had a serum alcohol of 243 mg/dL. A later CT of the head demonstrated a subcutaneous hematoma without any intracranial abnormalities. His remaining physical examination revealed left lower quadrant abdominal pain without signs of peritonitis, ankle deformities bilaterally, pain with hip range of motion, and blood at the urethral meatus. Given his physical examination findings, subsequent imaging confirmed an unstable pelvic fracture with diastasis of the symphysis pubis of 6 cm, widening of the left sacroiliac joint, a left ischial pubic ramus fracture, and a urethral injury (). He also had a left ankle dislocation and a right compound fracture of the distal tibia and fibula. No intraabdominal injuries were identified on CT imaging of the abdomen. The pelvis was stabilized with a binder by the orthopedic surgeons with subsequent emergency irrigation, debridement, and open reduction and internal fixation (ORIF) of the open ankle fracture as well as reduction of the left ankle dislocation. He was extubated after the procedure and monitored in the ICU while the remaining preoperative medical workup was completed including X-rays and CT scans with 3D reconstructions of the pelvis reconstructions. A hydromorphone patient-controlled analgesia (PCA) pump was utilized for pain control.\nOn hospital day 2, the patient was deemed fit for surgery and was taken to the operating theater for a combined operation by the orthopedic surgeons for ORIF of the pubic diastasis, sacral fracture, and sacroiliac joint followed by the trauma surgeons to reconstruct the abdominal wall and inguinal canal. The trauma team performed the exposure of the pubic symphyseal region and the pubic diastasis. A Pfannenstiel incision was made, and the planes were dissected exposing the left spermatic cord. The orthopedic team then performed a gentle open reduction of the pubic diastasis taking care to ensure that the bladder and urethra were not incarcerated. The Asnis III cannulated screw system and a Matta pubic symphyseal plate (Stryker GmbH, Switzerland) were utilized under C-arm fluoroscopic guidance with appropriate alignment of the AP and inlet and outlet pelvis views. Once the Mata plate was in place and the orthopedic reduction was completed, we proceeded to reconstruct the anterior abdominal wall. Since the Cooper ligament was destroyed, it was dissected to allow direct visualization of the pubic rami. The abdominal wall defect was measured to be 10 × 12 cm. We then used a modified Stoppa technique by placing the 6 × 6 in Prolene mesh under the damaged internal inguinal ring, making sure the spermatic cord on the left side was not injured or pinched, securing it in place using sutures, including direct suturing to the periosteum of the repaired pubic symphysis and the plate as needed. The medial borders of the mesh were tucked inside the opened rectus sheath on the right side and secured laterally with fires of a 5 mm Covidien Endotack (Medtronic, MN, USA) to the remnants of the conjoint ligament. The midline was then repaired with sutures, including the mesh as reinforcement. The patient did well postoperatively with postreduction films demonstrating appropriate alignment (). He was discharged to rehab on postoperative day 5. There were no recurrences during the follow-up period of 10 years. |
A 66-year-old female with a history of mucinous adenocarcinoma of the cervix presented to the neurosurgery outpatient clinic for evaluation of a sellar mass found during workup of adrenal insufficiency and hypothyroidism. The patient did not have unusual headaches or vision problems. Three months prior to discovery of the sellar mass, she was diagnosed with stage IIb mucinous adenocarcinoma of the cervix and was treated with chemotherapy. At the time of neurosurgery clinic presentation, she was neurologically intact, including full visual fields. Laboratory work-up demonstrated pituitary insufficiency with central hypothyroidism.\nThe initial magnetic resonance imaging (MRI) revealed a 1.8 × 1.1 cm contrast-enhancing mass within the sella, with extension to the suprasellar cistern and optic chiasm abutment. Preoperative imaging obtained the following month in preparation for surgery demonstrated that the mass had grown to 2.2 × 1.5 cm ().\nThe patient underwent an endoscopic endonasal approach for resection of the intradural sellar mass. Intraoperative findings demonstrated a very firm, infiltrative, vascular mass with dense adherence to surrounding structures, including the dura, medical cavernous walls, and diaphragma. Intraoperative frozen section pathology was consistent with metastatic carcinoma. The tumor was debulked until normal appearing pituitary tissue was identified and the margin of tumor adherence to the diaphragma was reached. Postoperatively, the patient did well without new hormonal deficiencies or vision problems. A subtotal resection (>80%) was achieved (). Gross histology and immunohistochemical staining ultimately confirmed the diagnosis of metastatic mucinous adenocarcinoma of the cervix (Figures and ).\nThe patient's immediate postoperative course was unremarkable. Given the diagnosis and intraoperative/postoperative findings of subtotal resection, adjuvant chemoradiation therapy was encouraged but the patient refused additional treatment. She was discharged home two days after surgery. She developed decreased left eye visual acuity and ptosis one week after surgery. A CT of the head at this time did not show any intracranial hemorrhage and a repeat MRI showed new enhancement suggestive of tumor recurrence within the sellar and suprasellar regions. The patient was started on steroids but declined any further treatment, including repeat surgery. Her ophthalmic symptoms ultimately progressed to a complete left cranial nerve III palsy four weeks after surgery. Follow-up MR imaging at five weeks after surgery revealed significant progression of the tumor to 2.9 × 2.4 cm with significant suprasellar extension (). Though a computed tomography scan of the chest, abdomen, and pelvis at this time demonstrated no new neoplastic burden, a radiotracer bone scan demonstrated likely new metastatic lesions in the skull, bilateral humeri, bilateral acetabula, bilateral femurs, and the lumbosacral vertebrae. After further discussion with her gynecologic oncologist and radiation oncology, the patient again refused pursuing any further treatment, including palliative radiation or systemic therapies and elected to pursue home hospice. The patient died approximately two months after surgery. |
The first case we present is that of a 29-year-old woman who presented to the clinic with the complaint of an enlarging left breast mass. She first noticed that this mass almost 2 years ago and mentions that it has been growing in size and becoming more erythematous and tender. She did not report any recent weight loss or change in appetite. She is married with 2 children, and she does not have any illnesses. She smokes hubble-bubble almost 4 times per week and does not drink alcohol. Surgical history is significant for 2 previous Cesarean sections with no complications. History of her current illness dates back to June 2016 when the patient felt a mass in her left breast; upon further investigation, she was diagnosed with idiopathic granulomatous mastitis and later (December 2017) developed an abscess that drained on its own. She was initially treated with methotrexate and later switched to prednisone and mycophenolate with minimal improvement. At the clinic, her vitals were within normal limits, and on physical examination, there was a left breast lump found at the upper inner quadrant with some erythema and inflammation surrounding it. Moreover, there was some skin retraction in this area.\nCore biopsy done at an outside hospital in June 2017 revealed no granulomas. Ultrasound done at that time showed a persistent ill-defined hypoechoic mass that appeared initially subdermally and was spanning more than 4 × 1.4 cm. Moreover, multiple deeper masses were seen, one of which was not located within the breast measuring 12.3 × 8.5 mm. Axillary nodes were insignificant and not well appreciated on imaging.\nFine-needle aspirate done in July 2017 was negative for malignancy and was reported to have abscess formation. The slides revealed a heavy inflammatory infiltrate predominantly composed of polymorphonuclear leukocytes. No ductal epithelial cells were seen.\nCore biopsy done in November of the same year showed multiple noncaseating epithelioid granulomas composed of epithelioid histiocytes, lymphocytes, neutrophils, and occasional multinucleated giant cells. Some granulomas contained neutrophils forming microabscesses with surrounding empty microcysts ().\nThe Ziehl–Neelsen stain for acid-fast bacilli was negative. This leads to the diagnosis of idiopathic granulomatous mastitis which is a diagnosis of exclusion.\nA repeat MRI done during June 2018 showed heterogeneous fibroglandular tissue with mild background enhancement. There are also numerous tiny rim-enhancing fluid collections in the left breast, the largest measuring 8 mm involving the upper inner and lower inner quadrants, some of which are fistulizing to the skin. Findings have regressed compared to the prior MRI.\nAs with the previous MRI, no enlarged axillary or internal mammary adenopathy was seen.\nThose findings are consistent with biopsy-proven idiopathic granulomatous mastitis extensively involving the upper and lower inner quadrants of the left breast. |
A 40-year-old woman was referred to Chonbuk National University Dental Hospital for evaluation of pain in the tooth on chewing. The symptom had begun 3 months after restoration of the lower right first molar with a metal crown at a local dental clinic. The patient had no systemic disease and the extraoral examination was within normal limits. Intraoral examination revealed a metal crown on the right mandibular first molar, and the overlying gingiva and mucosa were normal, with no clinical signs of inflammation. The pulp vitality test in the right mandibular first molar was not performed due to the metal crown.\nOn a panoramic radiograph, multiple radiopaque masses surrounded by radiolucent halos were observed in the apical regions of the lower right first, second, and third molars and the lower left second molar. All the lesions were separated from the adjacent teeth by a radiolucent line without root resorption or displacement. Another completely radiopaque lesion was observed in the apical area of the right maxillary first molar ().\nCone-beam computed tomography (CBCT) with a small field of view for further investigation showed the lesions more clearly. The lesions were non-homogenous sclerotic masses with radiolucent rims, and were involved with the apices of the right mandibular second premolar, the first and second molars, the left mandibular second premolar, and the first and second molars. All the lesions were separated from the adjacent teeth by a radiolucent line without root resorption or displacement. Of particular note, diffuse sclerosis had progressed around the lesion at the lower left first molar. The lesions at the left mandibular first molar and the right mandibular first molar had invaded the cortical bone without expansion or perforation ().\nA Tc-99m MDP scintigraph demonstrated high uptake in the posterior maxilla and mandible, suggesting that the lesions were growing, and the uptake was higher in the right mandible ().\nBased on the clinical examination and radiographic evaluation, a diagnosis of mixed and end stage of FCOD was made. Because the patient's clinical symptoms persisted for more than 3 months and the patient continued to complain of discomfort, some mandibular lesions, including those near the right mandibular first and third molars and the left mandibular first molar, were removed. Postoperative histopathologic findings revealed multiple small fragments without any fibrous capsules. Multiple areas of irregular woven bone were distributed in dense fibrous tissue with no signs of inflammation (). A definitive diagnosis of FCOD was established based on the histopathologic examination.\nOn periodic radiographic examinations performed every 3 months after surgery, the remaining lesions adjacent to the right mandibular first molar that were not totally removed gradually grew. The apical lesion at the right mandibular second molar, which had not been removed, also showed a growth pattern in comparison to its previous appearance, displacing the mandibular canal downward. During the third year of follow-up, these lesions combined, accompanied by perforation of the lingual cortical plate. Similar findings were observed in the left mandible ( and ).\nThe patient underwent a re-operation for the right posterior mandible because her clinical symptoms persisted. All the affected bone in the right mandible, including the right mandibular second premolar and the second molar, was removed (). As the left mandibular region remained asymptomatic, that area was not included in the operation.\nA postoperative histopathologic examination showed numerous areas of woven bone in fibrous connective tissue with infiltration of inflammatory cells, implying secondary infection of the lesion ().\nDuring periodic follow-up that extended for 18 months after secondary surgery, sclerotic masses surrounded by radiolucent halos appeared again at the previous surgical site, suggesting recurrence of the lesion ( and ). The clinical symptoms had slightly subsided in comparison with the patient's previous state, but intermittent pain persisted in the right mandible. |
Patient: a 55-year-old Japanese female.
None of the factors contributing to lateral compartment knee disease, such as obesity, complications, or psychiatric disorders, were present in the patient. During hyaluronic acid (HA) treatment, although we prescribed strength training to the patient, she did not perform it frequently enough because of severe pain. As the knee pain was caused by tripping while playing tennis, the possibility of trauma cannot be ruled out.
In 2013, due to pain in both knees, she visited our hospital and was diagnosed with OA of the knee.
In December 2017, while playing tennis, the right knee developed a knee collapse. She was examined at the hospital, and an MRI of the right knee was performed. Horizontal dissection of the lateral meniscus and cartilage defect on the lateral condyle of the femur were observed.
Since 2018, injections of hyaluronic acid have been administered every 2 weeks, but joint edema and pain recurrence have been remitted.
The patient had already undergone HA treatment and received multiple steroid joint injections; however, these interventions were not very effective. Moreover, the patient was unwilling to undergo these treatments. The patient was aware that our hospital would start providing regenerative medicine treatments and had been waiting for a year before the start of the treatment. During that period, the patient received HA treatment, which proved ineffective. Therefore, the patient requested ASC treatment in April 2018.
In April 2018, MRI of the right knee was performed. A cartilage defect was found in the external condyle of the femur, and the patient desired ASC transplantation. The range of motion of the right knee is 0–145. Anteroposterior (AP) and lateral radiograph of the right knee are shown in Fig. .
On 28 April 2018, 20 mL ASCs were collected from the abdomen.
On 11 June 2018, the first ASC transplantation was performed on the right knee.
On 2 July 2018, although the effect was experienced after 1 week |
A 23-year-old Caucasian woman, 22 weeks into her first pregnancy, presented to an outside hospital following the sudden onset of severe headache associated with nausea and vomiting. She denied weakness or numbness, but reported occasional double vision. Her past medical history was significant for an irregular heartbeat, gastroesophageal reflux disease and hypertension. Our patient's only physical exam finding was a right lower visual field deficit but otherwise she was intact. Non-contrasted computed tomography of her head revealed an acute left parieto-occipital hemorrhage with mild mass effect. Magnetic resonance imaging (MRI) revealed a 5 × 2.6 cm hematoma in the left parieto-occipital region abutting the ventricle with flow voids, characteristic of an AVM (Figure ). Mild mass effect was noted with no midline shift or effacement of basilar cisterns. Digital subtraction cerebral angiography demonstrated that the nidus was being supplied by the posterior branches of her left middle cerebral, left anterior and posterior cerebral arteries. The majority of the venous drainage was via her superior sagittal sinus. No intra-nidal or flow-related aneurysms were noted. Our patient was counseled with regards to her options and opted for endovascular embolization followed by surgical resection of the AVM.\nOur patient was brought to the endovascular suite three weeks after her initial hemorrhage. The procedure was coordinated with obstetricians as well as anesthesiologists to ensure the safety of both the mother and fetus. During the procedure, various measures were taken to minimize exposure of the fetus to ionizing radiation. Our patient's abdomen was fully covered with lead drapes. In addition, instead of performing a full angiogram prior to the embolization, we used a prior MRI scan to determine the primary pedicle with the greatest promise of having nidal feeders and then selectively targeted that vessel during the embolization procedure. The guide catheter was positioned in her distal left internal carotid artery. A microcatheter was navigated over a guidewire to select the inferior division of the middle cerebral artery feeding the AVM. Visipaque™ 320 (iodixanol) contrast agent was used at half strength. After ensuring the selected branch was feeding the nidus, Onyx-18 (Onyx Liquid Embolic System®) was used in the standard fashion [-] to embolize the AVM. Control runs after embolization revealed the successful reduction of the nidus by approximately 50%, preserving venous outflow (Figure ). After the procedure, our patient was transferred to the neurosurgical intensive care unit for close observation. She had an uncomplicated postoperative course.\nThree weeks later, our patient was brought to the neurosurgical operating suite and anesthetized by obstetric anesthesia. The obstetrics team was also in the room and was monitoring the fetus during the entire procedure. After insertion of a right femoral sheath in the standard fashion, our patient was put in the prone position for the craniotomy. Stealth guidance was used to plan our craniotomy prior to incision. The craniotomy was centered over the left parieto-occipital AVM and using the standard microsurgical technique we proceeded to safely and effectively resect the AVM. Once we were satisfied with our resection we performed an intraoperative cerebral angiogram. Once again, all possible measures were taken to reduce radiation and contrast exposure to mother and fetus. The angiogram revealed complete resection of the AVM. The wound was closed in the standard fashion and our patient was transferred to the neurosurgical intensive care unit.\nOur patient recovered well without complications and was discharged home on postoperative day two. At the time of this submission, our patient had delivered her baby at 39 weeks via a normal vaginal delivery at an outside hospital without the need for high-risk obstetric personnel. Both mother and baby are healthy and with no complications related to the procedures. |
A 30-year-old man presented to our ED by ambulance after being involved in a high-speed motor vehicle collision. On arrival, he was intubated and mechanically ventilated as he was unstable with a head injury. Initial physical examination revealed a visible deformity of the right lower extremity, with an approximately 10-cm laceration along the medial aspect of his ankle and a totally extruded and rotated talar body through the skin (Figure ). The patient was diagnosed with a Type III open fracture and a right-sided total talar extrusion. The distal vascularity of his right foot was intact, and there were no associated fractures in both upper and lower limbs.\nAfter closed reduction failed, the open fracture was initially irrigated with normal saline and splinted with sterile dressing. In addition, he was started on preventive antibiotics and given a tetanus toxoid booster. He was scheduled for open reduction and intraoperative irrigation as soon as possible.\nHis general condition did not allow initial radiographic and CT scanning of his extremities. Because the patient had a severe traumatic brain injury, with trauma brain CT showing an acute subdural and subarachnoid hemorrhage, he was taken immediately to the operating room to undergo an urgent decompressive craniotomy, and open fracture management and dislocation reduction. The patient was placed under general anesthesia and administered another dose of prophylactic antibiotics. After preparing and draping the patient's open wound, his extruded talus was cleaned and irrigated copiously with sterile normal saline. Devitalized tissues were debrided, with intraoperative radiological and clinical evaluation showing the talus was completely extruded from its articulation without any significant fracture. However, the inferior surface contained a small area of articular cartilage injury, loosely held by a few strands of the deltoid ligament, which were preserved. Excessive soft tissue stripping was avoided to prevent complete devascularization of the talus. Several trials were required to reimplant the extruded talus through the open wound. The first trial failed because the talus was blocked by stretching of the tibialis posterior and flexor hallucis longus tendons laterally over the neck of the talus. The tibialis posterior tendon was released to prevent reduction blocking, and a single Schanz pin was inserted from the medial to the lateral direction into the calcaneus for distraction, to open the ankle and subtalar joints and to maintain the gap of the joint surface (traction and counter traction technique). Another Schanz pin was inserted through the talar head to control the manipulation of the talus. Unfortunately, this Schanz pin became loose and reinserted in the talar body, which showed better manipulation of the talus. Reduction was achieved when the talar body was introduced initially, followed by the talar head by manipulation.\nIn contrast, the reverse technique failed. The tibialis posterior tendon was repaired subsequently. Medial malleolus osteotomy was not needed and not performed after reduction. The ankle and subtalar joint examined were stable intraoperatively without inserting any Kirshner wires. After final irrigation with normal saline, the wound was closed, and sterile dressing applied (Figure ). Repeat surgery was not required, as the wound remained clean and dry after dressings were changed in the ward.\nPlain radiography (Figure ,B), and CT scans (Figure -C) showed no evidence of talar neck or body fracture, with only a small area of fragmentation involving the inferior surface of the talus. Also, a small round defect appeared in the talar head and body, representing the sites of temporary intraoperative implantation of the Shanz pins.\nOutpatient follow-up was routine; after six weeks, his cast was removed, and the wound healed without complication. The patient underwent a rehabilitative protocol to recover right ankle range of motion and muscle strength, with nonweight bearing strictly maintained. Two months after surgery, he was allowed protected weight-bearing using crutches; after three months, full weight-bearing was allowed. After four months, the patient was able to walk while bearing full weight without the use of an assistive device. No postoperative complications occurred.\nApproximately one year after surgery, the patient reported no pain with weight-bearing and range of motion of the right ankle. A physical examination showed 30° plantar flexion and >15° dorsiflexion of the right ankle, markedly greater than the dorsiflexion observed in the contralateral extremity. He also displayed unrestricted subtalar joint motion (Figure ,C). Plain radiographs showed no evidence of increased radiodensity of the talus, with a viable talus reduced in the ankle mortise. Some mild posttraumatic changes were noted more prominently in the subtalar joint (Figure ,B). Noncontrast sagittal MRI showed normal T1 marrow signal involving the talar body, neck, and proximal head when compared with the marrow signals of adjacent calcaneus and navicular, results consistent with talar revascularization (Figure ). Sagittal T2-weighted imaging showed a healed intact tibialis posterior tendon with reactive edema in the subtalar portion of the calcaneus and tibial plafond. Again marrow signals in the talar body and neck were normal (Figure ,C). The patient experienced no complications during his one-year follow-up, with no evidence of increased sclerosis of the talar body, no narrowing of tibiotalar joint spaces, and no signs of avascular necrosis. The patient could walk without aids, pain-free. |
A 40-year-old female patient reported to our institution with a chief complaint of gradually enlarging, painless swelling of both the jaws of 1-year duration with difficulty in speech. The patient was apparently alright 1 year back when she noticed a swelling in the right mandibular region which was painless and caused no discomfort, except for unesthetic appearance. Subsequently, the patient had consulted an oral health care center and underwent radiological examination followed by excisional biopsy along with the extraction of 47. The mass was diagnosed histopathologically as a peripheral ossifying fibroma. However, 1 month after the mass was excised; patient had developed a swelling in the same region again.\nThe patient suffered from hypertension since past 12 years and was taking beta blockers ad aspirin 75 mg regularly for the same. In addition, she was suffering from chronic kidney disease and was undergoing regular dialysis since past 4 years. She also had a history of tuberculosis 7 years back for which she had taken dots therapy for 6 months. She had no habits, and her family history was unremarkable. On general examination, the patient had a small built and normal gait. On extra-oral examination, there was a gross expansion of the midface. The expansion in the maxilla was more pronounced than that in the mandibular region giving the impression of a cherubic face [].\nOn intraoral examination, a generalized bony hard, nontender expansion of maxilla and mandible arches was observed. No pulsations or fluctuant areas were noted. In the mandibular arch, severe buccolingual expansion was seen which was more pronounced in the lower right posterior segment in the 46, 47, and 48 region []. The maxilla revealed buccopalatal expansion which was more pronounced in the anterior part of hard palate [].\nThe mucosal coverage of maxilla, as well as mandible, was smooth, shiny and normal; except on the right side mandibular region where the opposing teeth had caused indentations [Figures and ].\nOn examination of the teeth, 46, 47, 48, 18, and 28 were found to be missing, and there was generalized Grade I mobility with increased interdental spacing in the remaining teeth.\nAfter clinical examination the following list of differential diagnosis was considered:\nCherubism Fibrous dysplasia Pagets disease Osteopetrosis.\nThe orthopantomogram (OPG) was taken 1 year back and on OPG, it was noted as the generalized loss of lamina dura with thinning of cortical outlines of maxilla and mandible [].\nOn histopathological diagnosis (H and E stained slide), proliferative stratified squamous epithelium with underlying fibrous connective tissue was observed. Lesional zones having multiple irregularly shaped bony spicules of woven bone in a fibrocellular stroma, as well as plump fibroblasts and occasional giant cells, were present in the surrounding fibrocellular connective tissue [].\nOn biopsy of parathyroid gland, hyperplasia of right and left inferior parathyroid glands was noted. Left inferior parathyroid gland was associated with focal metaplastic ossification and hyperplasia of right and left superior parathyroid gland was also seen. The radiological examination was performed again subsequently. On Maxillary occlusal radiograph, the loss of lamina dura with a displacement of anterior teeth was noted. Decreased trabecular density and blurring of bony trabeculae with multiple foci of radiolucencies in between were noted [].\nOn mandibular occlusal radiograph, similar findings with bone expansion being evident as a prominent feature was noted [].\nOn OPG, it were noted as the generalized loss of lamina dura, decreased trabecular density, and blurring of normal trabecular pattern causing ground glass appearance. Loss of cortication of superior and inferior border of the mandible was noted along with demineralization and thinning of cortical boundary of mandibular canal [].\nOPG also shows the generalized haziness of maxillary and mandibular arches and superio-inferior expansion of the mandible on right side. Cortication of lower border of mandible, inferior alveolar canal, and posterior wall of maxilla and floor of the maxillary sinus were not seen. A dome shaped radiopaque shadow was encroaching upon the left maxillary sinus was appreciated. On closer scrutiny, the cortices of the anterior border of the ramus and posterior border of the maxilla were not traceable on the right side and hence could not be delineated radiographically. On hand, wrist radiographs, signs of subperiosteal erosion, or any other bony changes were not seen []. Cone-beam computed tomography (CBCT) examination was performed [Figures –] and on CBCT, it was seen as the generalized osteoporosis involving maxilla, mandible, and visualized skull bones. Maxilla and mandible showed bicortical expansion; however the cortical outlines were hypocalcified.\nInternal of the lesion showed both the radiopacities and radiolucencies. Multilocular radiolucencies were seen in the posterior mandible. There was an expansile mass involving the floor and posterior wall of left maxillary sinus, and the mass was found to protrude into the antrum as dome shaped radiopacity in coronal and sagittal sections.\nAfter clinical and radiographic examination and correlating it with the history of patient (chronic kidney disease and dialysis), a provisional diagnosis of secondary HPT was made.\nOsteoporotic changes were noted in the long bones, spines, and chest radiograph [Figure –]. In Figure and it was noted as:\nBoth lobes of thyroid show uniform tracer uptake. Both lobes appear slightly elongated with left lobe extended slightly inferomedially.\nThere are foci of retention is seen in inferior pole region of both lobes of thyroid with normal washout of tracers from rest of the gland.\nThe foci of tracer retention in both lobes of thyroid localize to its anterio-inferior aspect with soft tissue nodularity on fused single-photon emission CT-CT images.\nBoth the lobes of thyroid appear normal in size and shape There is normal uptake of tracer in both lobes of the thyroid gland The salivary uptake is normal.\nThe following differential diagnosis was considered:\nCherubism: At the first impression, diagnosis of cherubism was considered but later ruled out as cherubism is more common in younger age, is familial, regresses after certain age and has no relation to kidney disease Fibrous dysplasia: Fibrous dysplasia will appear as localized radiopacity after maturation. Features such as generalized loss of lamina dura and cortical thinning are not seen. No association with systemic condition is seen Pagets disease: Pagets’ disease is a disease of elderly normally seen after 60 years. Radiographically it will appear as areas of increased radiopacity. Generalized loss of lamina dura is not seen.\nThe patient was subjected to following blood investigations [].\nThus, the laboratory investigations confirmed the changes in blood chemistry, which could be attributed to secondary HPT. The patient was referred to Endocrinology Department of a Government Institute for further management and follow-up was carried out after 1 month.\nPatient was prescribed a combination of sodium alendronate (bisphosphonate) 35 mg 1 tablet once a week, calcitriol 0.25 mcg once a day (OD), cinacalcet 30 mg OD, and sevelamer (phosphate binder) 400 mg three times a day by the endocrinologist and her alkaline phosphatase levels were reduced to 637 IU/L from 1047 IU/L after 1 month of starting the medications. |
A 17-year-old Iranian girl who was born in Isfahan, Iran was referred to the private office of the correspondent author in 2009. She had sparse, low density, curly, dry hair. She was born with absent lateral half of eyebrows and low dense hair in medial eye-brows (). She had hypodontia, with the absence of central incisors in the upper and lower arches. In addition, all her teeth were cone-shaped. Her facial appearance was malformed because of the hypoplastic mandibular and maxillary bones. Further signs were mild hypohydrosis and sever xerosis of the skin. Her mother reported several episodes of intractable high grade fevers and pneumonia during her infancy. The patient's older sister had had the same manifestations but in milder degrees and she was also a known case of ED. The sister had also hypodontia and hair impairments. The intelligence quotient (IQ) of both sisters was in normal range and their educational achievements were normal as well. Ophthalmic and auditory evaluation showed no abnormality. Among their family members, only the two sisters suffered from ED and their parents had no signs of this disorder. However, they had relative marriage. In general physical examination, the patient had quite dry and scaly skin. She also had several idiopathic atrophic scars in her facial area. She had dental prostheses for upper and lower mandibular incisors. Histopathology examination of skin biopsy revealed normal epidermis with very sparse primitive sweat glands. Topical emollients and several sessions of fractional Co2 lasers for idiopathic atrophic scars in the face had been used for her skin problems. The patient was so depressed and anxious about her appearance and had about 2 years of partial social withdrawal because of her malformed facial appearance (). She was quite ashamed because of eyebrow hair loss and had been seeking for medical treatment for a long time.\nAfter examination, we advised the patient to undergo a hair transplant surgery. After obtaining an informed consent, we planned to perform FUT for hair transplantation. The patient was sedated by oral benzodiazepines. The donor region for transplantation was the occipital scalp. After tumescent anesthesia, the follicular units were removed from the donor area using an elliptical excision. They were carefully divided into small follicular units under a microscope. The donor tissue was separated into one to two haired follicular units in order to provide a natural appearance.\nWe transplanted the follicular units which contained one or occasionally two hairs into tiny incisions that were previously made by 19-and 20-gauge needling of the eyebrow skin at the same direction of the normal hair growth. We used appropriate lighting and magnification to achieve maximum precision. The whole procedure lasted 3 hours and we transplanted 60-100 hair in each lateral part of the eyebrows. The donor site was sutured with simple separate sutures which were removed after 8 days.\nAfter 3 days, tiny crusts were made around each follicle in the recipient site. The crusts disappeared after 6 days. The hairs began to shed after 2-3 weeks but in three months follow-up most of the hairs were regrown and the patient was quite satisfied with her appearance ().\nThe patient was advised to trim the transplanted hairs regularly once a month. After 6 months and 2 years fallow-up, the density of hair increasingly improved. The improvements were evident by comparing photographs which were taken using the standardized automatic option of a camera (Figures and ). The patient was quite satisfied with her appearance and also liked to have full eyebrow transplantation in order to increase hair density. The dentition was also restored with maxillary and mandibular implant prostheses.\nThe girl's quality of life was measured before and after the treatment by dermatologic quality of life questionnaire (DLQI). The SLQI score significantly improved after treatment. Due to her depressive symptoms and the impairment of her social functions, we advised her to visit a psychiatrist before operation. He prescribed fluoxetine 20 mg daily but because of the improvements after hair transplantation the drug was discontinued.\nHer parents decided to use FUT method for eyebrow transplantation for their other daughter as well. |
A 26 year-old woman was referred to our maternal and fetal unit for detailed ultrasonographic examination because of triplet pregnancy with threatened abortion at 15 weeks of gestation. Her obstetric history included two first trimester abortions. The patient had taken no medication or drug for ovulation induction. An inquiry into the family history revealed that her mother had delivered triplet babies all of whom died in the early neonatal period. In the present case, the attending obstetrician had performed an ultrasonography at 6 weeks of gestation demonstrating a single, 17 × 20 mm gestational sac (chorion) (Figure ).\nDetailed ultrasonography at our maternal and fetal unit revealed a monochorionic triamniotic triplet pregnancy. Three thin amniotic membranes and an ipsilon zone were detected. The biometric measurements of the three distinct fetuses were appropriate for 15 weeks of gestation. The parents were informed about the risks of a multiple pregnancy and monochorionic placentation. After three days' hospitalization, the vaginal bleeding ceased and the patient was discharged to follow-up.\nThe obstetric course was unremarkable until 24 weeks, when ultrasonographic examination revealed that one of the triplet fetuses had developed a multicystic lung lesion suggestive of CCAM, with the largest cyst measuring 10 mm in diameter (Figure ). Until 30 weeks of gestation, the fetuses had appropriate growth, and follow-up of the pregnancy was uneventful except that the fetus with CCAM developed mild polyhydramnios. At 30 weeks, the patient presented with preterm uterine contractions that ceased after tocolysis with nifedipine 60 mg per day. Betamethasone (12 mg × 2 doses in 24 hours) was administered intramuscularly to the mother to promote fetal lung maturation. The patient was readmitted to our unit at 34 weeks for uterine contractions and impaired fetal growth. The size of the lung lesion remained the same at that time. At 35 weeks of gestation, the patient underwent a low-transverse caesarean section and delivered three live male babies with birth weights 1560 g, 1580 g and 1590 g. Apgar scores were 7/9, 6/8 and 7/9 at 1 and 5 minutes, respectively. A single placenta weighing 1080 g and three distinct membranes were demonstrated (Figure ). Pathological examination confirmed monochorionic triamniotic placentation. The postnatal course was uneventful and the patient was discharged four days postpartum. Two newborns were admitted to the neonatal intensive care unit for respiratory distress, the third one died due to sepsis on day 7 postpartum. One of the triplets was discharged healthy 42 days postpartum.\nThe newborn with multicystic lung lesions developed unilateral pneumothorax which was treated by inserting an intercostal drain, and was discharged from the hospital after one month. Computerized tomography (CT) of the infant at 3 months demonstrated two cystic lesions in the middle lobe of the right lung (25 mm and 15 mm in diameter) (Figure ). A repeat CT of the infant at 6 months showed a 30 mm solitary cystic mass (Figure ). |
Patient 2 is 54-year-old female non-smoker, who was diagnosed with adenocarcinoma of lung with liver metastases in May 2012. Molecular analysis revealed EGFR (Epidermal Growth Factor Receptor) mutation on exon 21. She was mostly treated at a different institution and visited us a few times for second opinion. She was initially started on erlotinib and she went to her home country where it was switched to gefitinib due to skin rash. She had marked improvement on follow-up PET scan. She underwent stereotactic body radiation therapy (SBRT) to the primary lung lesion in right lower lobe and to the hepatic metastases. She returned to United States in March 2013 when therapy was switched back to erlotinib without any side effects. In June 2013 she developed pleural effusion on the right side and underwent thoracenteses. Cytology was positive for malignancy. She decided to bring gefitinib from Taiwan and started using it due to progression. In November 2013, she developed pericardial effusion with tamponade and underwent pericardiocentesis. Therapy was switched to afatinib. She showed objective response, however in April 2014 she developed progression with metastases to uterus. She was treated with bevacizumab plus afatinib. She had stable disease for about a year when she progressed in May 2015.\nIn July 2015, she was started on nivolumab (3 mg/kg every 2 weeks). She developed recurrent right pleural effusions requiring four thoracenteses over the next 8 weeks (Fig. ). She also developed pericardial effusion with cardiac tamponade and underwent pericardiocentesis 7 weeks after initiation of nivolumab. Both pleural and pericardial fluid cytologies were positive for malignancy. Lymphocytes accounted for 30 % of cells in pericardial fluid analysis. She was also treated with prednisone for the possibility of immune-related Adverse Effect (irAE). Doses varied between 20– 60 mg daily due to successive tapering schedules with recurrent effusions. Although her metastatic thyroid nodule and metastatic skin nodules showed clinical response after 3 treatments, the patient declined further treatment with nivolumab after she was admitted to intensive care for 4 days due to pericardial tamponade on week 7 of therapy. Unfortunately further attempts to restart nivolumab by her providers after a good recovery were also declined by the patient. Within 3 months of discontinuation, the patient again had progressive disease and is currently on therapy with osimertinib (due to detection of EGFR T790M mutation). |
A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.\nThe baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment. |
A 22-year-old female came with the chief complaint of swelling over the left front side of the face since 4 months []. Patient gave the history of extraction in the same region 1 year back. There was no significant contributing family and medical history. The patient gave a history of rapidly enlarging swelling which attained the present size of 3 cm × 4 cm. There was associated history of difficulty in speech and mastication. Extraorally, the swelling extended superoinferiorly from infraorbital margin to the upper lip and anteroposteriorly from midline to the corner of the mouth. Swelling was round to oval in shape with well-defined borders. Skin over the swelling was stretched but was normal in color. The swelling was firm and fixed to underlying structures. Intraorally, the swelling appeared to be arising from the labial vestibule extending up to the second premolar of the left side []. The buccal cortical plates were expanded but intact. There was displacement and Grade II mobility in relation to 21, 22 and 24.\nThe orthopantomography revealed unilocular radiolucency associated with 11, 12, 21, 22, 24 and root resorption in relation to 21, 22, 24 with missing 23 []. The computed tomography scan also revealed perforation of the cortical plates. Chest X-ray and hematological investigation were within the normal limits.\nInformed consent was taken from the patient and surgical excision was done and the tissue was sent for the histopathological examination. The hematoxylin and eosin stained sections revealed the presence of parakeratinized stratified squamous epithelium overlying the connective tissue stroma. The connective tissue was fibrocellular in nature with numerous spindle-shaped cells. The cells were arranged in fascicular pattern with few areas showing herringbone pattern of arrangement []. The cells were dysplastic in nature with most of them showing cellular and nuclear pleomorphism. The cells showed immunoreactivity for vimentin []. There were few areas showing round cells []. Under low power the lesional cells were separated from the overlying epithelium by a zone of connective tissue. []. Under high power the typical herring bone pattern was seen []. Based on the histological assessment, the final diagnosis of intermediate grade fibrosarcoma was made. Patient is under follow-up from last few months without any complications. |
In December 1999, a 64-year-old man underwent a cemented left total knee arthroplasty using a sigma PFC posterior cruciate retaining total knee prosthesis (DePuy Orthopaedics, Warsaw, IN, USA) for degenerative changes in relation to osteoarthritis using a medial parapatellar approach in a different centre. The patient recovered uneventfully and was doing well. In July 2009, the patient presented to us with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma and since was mobilising with difficulty using crutches. The patient weighed 89 kgs and had no other medical comorbidities. Clinical examination revealed a severe antalgic gait and a significant amount of rocking with metal on metal noise in 20 degrees flexion. Passive movements ranged from 0 to 90 degrees. At that moment, the knee was quiescent. AP and lateral radiographs (Figures , , and ) of the left knee revealed a fracture of the posterior condyle of the femoral prosthesis with rotation and evidence of further loosening. Given the patients symptoms and the radiographic evidence, a decision to perform a revision of the total knee arthroplasty was made after a fully informed written consent.\nRevision surgery was performed as an elective procedure in August 2009 revealing the broken prosthesis (Figures and ). A TC3 RP PFC revision prosthesis was used with a medial parapatellar approach. A size 4 tibial prosthesis with a 53 mm sleeve and 12∗75 mm stem and a size 4 femur with 31 mm sleeve and 14∗75 mm stem along with femoral metallic augments and a 12.5 mm RP insert were used. Intraoperative range of motion was from 0 to 120 degrees and the procedure was uneventful. The patient recovered well and was mobilised with touch weight bearing for 6 weeks. Checking the X-ray revealed a satisfactory prosthesis and the patient was discharged on the 8th postoperative day. Follow-up at 6-week and 6-month period revealed a satisfactory progression with no instability and the patient was pain free.\nA metallurgical analysis of the failed prosthesis revealed no weakness in its strength. |
A 46-year-old African-American male presented to the admissions clinic at Penn Dental Medicine with the chief complaint of needing a check-up due to left neck tenderness. The patient's medical history revealed that he had been involved in a brawl 4 months previously, which resulted in an injury in the left infraorbital and malar regions. The patient went to the emergency room, where he received a consultation from an otorhinolaryngologist and a primary care physician. The medical team diagnosed the patient with left orbital fracture, which was reduced and surgically treated with bone plating and screws.\nFollowing surgery, the patient complained of unilateral left-sided jaw and neck pain along with mild swelling for a duration of 3 weeks. The patient reported constant, dull, pressure-like pain that transformed to sharp pain on percussion. The pain was elicited by chewing, swallowing, and lateral neck movements. These sharp pain episodes lasted for a few minutes, and the patient reported that cracking his neck relieved the pain. The patient experienced swelling and tenderness in his left cervical area, which was also associated with similar pain episodes occurring for the past few months. Due to this pain, the patient revisited the otorhinolaryngologist at the local hospital. He was sent for magnetic resonance imaging (MRI) of the cervical spine. MRI showed intact vertebrae with mild degenerative changes, as well as mild canal stenosis. In addition, a parotid salivary gland biopsy and submandibular fine needle aspiration were performed on the left submandibular salivary gland tissue. These procedures were done because it was thought that the pain originated from the salivary glands, specifically the left parotid, as the pain was radiating to that region. The biopsy results revealed normal glandular tissue and no evidence of malignancy. Aspiration of the swelling only managed to provide short-term symptom relief for a period of 2 weeks.\nWhen the patient presented to Penn Dental Medicine for a re-evaluation, he reported a long history of xerostomia, pain with deglutition, and dysphagia. He denied dysgeusia. His further medical history included hypertension, hepatitis C, HIV infection, and epileptic seizures, all of which were medically managed. He reported that although his most recent seizure was after the altercation, his last unprovoked seizure was in 2007.\nA repeated clinical exam showed mild diffuse swelling with tenderness on the left posterior auricular area, tenderness on the left side of the submandibular and parotid area, and pinpoint tenderness near the gonial angle at the level of the C3/C4 vertebrae. No tenderness or salivary gland enlargement was noted on bimanual manipulation of the right submandibular and parotid glands. The range of motion for jaw opening was within normal limits and without myofascial pain on the right side. The temporomandibular joint exam was bilaterally within normal limits. However, due to multifocal tenderness and diffuse swelling, it was difficult to appreciate definitive objective findings on the left side. Cranial nerves II-XII were intact. Intraoral examination showed dental caries on tooth #15 with sensitivity to percussion, mild oral dryness, and clear saliva that was scant when milked from the parotid and submandibular ducts.\nA panoramic radiograph was obtained to rule out any odontogenic pathology and to visualize the immediate vicinity of the submandibular region. The radiograph showed bilaterally elongated styloid processes and what appeared to be a horizontal lucency right through the left styloid process at the level of C3 and C4. CBCT was then performed to evaluate the extent of the mineralization and to review the suspected fracture 3-dimensionally. The CBCT images (,,,,) revealed multiple pseudo-jointed bilateral elongated styloid processes, a well-mineralized stylohyoid process with an almost uniform thickness of 11mm, and a confirmed fracture on the left side at the level of C3/C4. Based on the radiographic findings and the patient's symptoms, he was eventually diagnosed with a left fractured styloid process as the source of his neck pain. The fracture site was clearly evident on all multiplanar reconstructions (included here are axial, sagittal, and coronal slices) and was clearly different from the pseudo-joint formations and pseudo-articulations. Although pseudo-joints have a central radiolucency, they are covered by ossifications all around, demonstrating the presence of a joint. Fractured bone can be easily identified radiographically, as the area is devoid of any pseudo-joint formations (). The patient was then referred to the Department of Oral and Maxillofacial Surgery at the Hospital of the University of Pennsylvania for left styloidectomy. |
A 74-year-old man initially presented to our office with severe bilateral knee pain and radiographs revealing significant arthritic changes. The patient’s past medical history at that time included only asthma and benign prostatic hypertrophy for which he was receiving regular medical treatment. Standard preoperative medical evaluation and laboratory testing revealed no further abnormalities, and he subsequently underwent bilateral TKA. During the immediate post-operative period, the patient was diagnosed with non-insulin dependent diabetes, but otherwise progressed normally and was discharged to an in-patient rehabilitation unit without complication.\nTwo weeks post-operatively, the patient developed acute swelling, redness and pain of the left knee. Aspiration of the knee was sent for cell count and culture. The cell count demonstrated 39,000 white blood cells per cubic millimeter with 71% of white blood cells identified as neutrophils. Based on the local signs of infection and the significantly elevated synovial fluid white blood cell count, the patient was taken urgently to the operating room for an irrigation, synovectomy, debridement and polyethylene exchange. Cultures were sent from the operating room, and the patient was started on Vancomycin while cultures were pending. Synovial fluid cultures identified the presence of C. septicum, Enterobacter and coagulase negative Staphylococcus and blood cultures also revealed growth of C. septicum. C. septicum was found to be susceptible to Clindamycin and Penicillin. Given the presence of a clostridial species, consideration was given to proceeding with an urgent aggressive debridement with removal of implants, however the patient’s knee had appeared quite well since the debridement, and there were no signs of a worsening clinical picture. The intravenous antibiotic was changed to Penicillin G and was continued over a standard six week course. A future colonoscopy was scheduled by the department of infectious diseases, considering the presence of Clostridium septicum, and the patient was discharged back to an inpatient rehabilitation unit with an uncomplicated hospitalization.\nTwo weeks after irrigation and debridement, the patient had an episode of hematochezia and was subsequently hospitalized. During this hospitalization, the patient was diagnosed with an obstructive colon cancer, located at the hepatic flexure and distal transverse colon. The patient underwent a right transverse and partial left colectomy with nodal biopsy. Final pathology demonstrated both lesions to be adenocarcinomas, which were moderately differentiated and invasive, without nodal disease. There were no distant metastatic lesions seen on CT scan of the chest, abdomen and pelvis. Given this patient’s histologic grade, lack of metastatic disease and gross pathologic findings, he was not deemed a candidate for post-operative chemotherapy. The patient’s post-operative course was complicated by the finding of bilateral popliteal deep venous thrombi, which were treated with a retrievable inferior vena cava filter and warfarin for six months. At six months follow-up from hemi-colectomy, blood work and CT scan of the abdomen and pelvis demonstrated no evidence of recurrence or metastatic disease.\nNine months after the irrigation and debridement, the patient presented with a reinfected TKA, requiring a two-stage revision procedure for persistent chronic infection. C. septicum was not identified in the synovial fluid or tissue cultures at the time of antibiotic spacer block implantation. The patient underwent reimplantation of a revision knee arthroplasty, has now been off of antibiotics and asymptomatic for seventeen months. |
A 70-year-old obese male presented to the emergency room (ER) with fatigue and shortness of breath. He reported that during the past few weeks, he had developed progressive breathing difficulties and weakness. He had no fever and only mild right upper quadrant and right chest discomfort. On physical examination, diminished breath sounds in the right lower lung were found. The patient was anaemic (haemoglobin 8 mg/dl), and leukocyte count was normal. The CT scan showed a large Morgagni-type hernia with the entire right hemicolon, parts of the transverse colon and terminal ileum, and ample omentum trapped in the chest (), causing atelectasis of the right lower lobe. After stabilization in the ER, he was admitted to the hospital, and workup for the blood loss anaemia was initiated. He had a positive stool guaiac test and underwent a colonoscopy showing a large mass in the right colon (). During colonoscopy, the endoscope was maneuvered with extra care to avoid any injuries; the colonoscope entered the right chest but could ultimately be advance to the ileocecal valve. Biopsies of the mass in the proximal ascending colon revealed an adenocarcinoma.\nHe consented for laparoscopic repair of the diaphragmatic hernia and resection of the right colon. Surgery was done in the supine position and was initiated by insertion of a 5 mm 1st entry port in the left upper quadrant. An additional 5 mm port was inserted in the left lower quadrant and a 10-12 mm port above the umbilicus. A large right-sided diaphragmatic defect (7 cm diameter) was encountered anteriorly to the liver with the entire right hemicolon and terminal ileum and omentum trapped inside. The hernia contents were gently reduced from the mediastinum (). The peritoneum at the anterior aspect of the defect was incised using an Enseal, and the entire hernia sac was carefully mobilized out of the mediastinum, avoiding injury to the pleura or phrenic nerve. The Valsalva maneuver was applied to protrude the hernia sac from the chest facilitating exposure. The anterior portion of the hernia sac was resected and placed into a retrieval bag. The hernia defect was closed with multiple transfascial sutures. As this was a clean contaminated case, a 10 × 7 cm bioabsorbable Phasix™ ST Mesh (Bard, Warwick, RI, USA) was placed to protect the reconstruction (); and the mesh was extraperitonealized using the dorsal flap of the hernia sac.\nThe redundant and partially twisted ascending colon was completely mobilized. The mesentery and omentum were thickened and chronically inflamed from displacement in the chest. The vascular pedicle was isolated and stapled. A 4 cm periumbilical incision including the 10-12 mm port site was made, and the colon was eviscerated and resected, with creation of an extracorporeal ileocolic anastomosis using two loads of the 75 mm GIA. The hernia sac was then removed from the abdomen. Pathology revealed pT3N1M0 moderately differentiated adenocarcinoma (4 cm diameter) with one of 50 harvested lymph nodes being positive.\nThe patient had no postoperative complications and was discharged after three days, with returned bowel function. A port-a-cath was placed two weeks later, and chemotherapy was initiated. He did well, and chest X-ray showed no evidence of a recurrent diaphragmatic hernia. He died five months later from a cardiac event possibly associated with chemotherapy. |
A 35-year-old male patient visited the hospital because he was unable to remove an anally-inserted foreign object. According to the patient, one day before visiting the hospital, he had been "drinking and playing with friends when he anally inserted a glass ball," and because he couldn't remove the glass ball, he visited the hospital. The first hospital he visited attempted to remove the object, but failed; therefore, he underwent a first laparotomy, but the finding was that because the object was completely stuck in his anorectum, it could not be removed. Thus, the patient was moved to our hospital for a second surgery.\nThe findings during the exam at our hospital showed that the object was completely stuck in the lower rectum and anus, and the patient complained of lower abdominal pain and abdominal rebound tenderness. There were no hemodynamic findings or any blood abnormalities. In a simple abdominal shooting, there was a finding of a ball-shaped foreign object impacted in the pelvic cavity (); through the anus, the removal of this foreign object was attempted. Visibility in the anal canal was attained through the use of an anal examination retractor, and the object was located, after which a removal attempt was made by hand. However, it was not easy to remove the object, which was completely stuck in the anus and the lower rectum. Because the patient complained of excruciating pain, the attempt to remove the object through the anus was stopped; instead, surgical treatment was attempted.\nUnder general anesthesia, an attempt to remove through the anus was made again, but it failed, so a laparotomy was commenced. During the laparotomy, the foreign object was found to be completely stuck in the anus and lower rectum, and the proximal colon was occluded. From within the peritoneal cavity, an attempt was made to carefully push the object in the direction of the rectal canal, but it was again not possible to remove it through the anus. To avoid any additional damage to the rectum and anus, we detached and mobilized the rectum and gently pushed the object into the peritoneal cavity, and after which we made a linear incision in the upper rectum and removed the object. A simple suture was made (), but the incision was too large. Due to the fact that the object had not been removed immediately and a considerable amount of time had elapsed since the object's insertion, much fecal matter was found to have accumulated in the rectum and the proximal colon, and an edema was found in the rectum. Therefore, additionally, a sigmoid colostomy was performed to prevent any complications that might occur in the peritoneal and the pelvic cavities from future leakage.\nAfter the surgery, the patient recovered without complications, and although a mild ulceration in the rectal mucosa was found during the outpatient follow-up observation period, the condition improved without any special treatment, and there was no damage to the anal sphincter. Hence, after verifying about 3 months later, through radiation imaging test, that there was no leakage in the incision or rectal damage, we performed a recovery procedure for the sigmoid colon. |
A very active 84-year-old male retired general surgeon fell while skiing.
He sustained a left closed injury combining a three-part anterior fracture-dislocation of the humeral head and an ipsilateral long spiral displaced humeral shaft fracture (). There were no vascular or neurological complications.
He was referred to our unit after a failed attempt at closed reduction in the local hospital. We performed a computed tomography (CT) scan (). The senior author of this paper (GH) treated both fractures in a single-stage operation, using a long stem humeral hemiarthroplasty combined with screw fixation of the long spiral humeral shaft fracture. The operation was performed in a beach chair position under general anesthesia and interscalene block.
A distally extended deltopectoral approach was used to expose both fractures. At the proximal humerus, the tuberosities with their attached rotator cuff tendons were separated from the anteriorly dislocated head, which was removed. A 1 cm cuff tear at the junction of supra and infraspinatus tendons was found. The intra-articular part of the long head of biceps tendon showed fraying, widening and degenerative changes.
A shoulder hemiarthroplasty with a 200 mm stem in 30° of retroversion was performed. The stem was cementless in the proximal part of humeral shaft and cemented in the distal part. A trial implant introduced from proximal to distal into the two fragments was used to determine the optimal height of the implant. The tension of the trial humeral head implant on the long head of the biceps and the distance between the top of the prosthetic head and the upper border of the pectoralis major tendon [] were also used to optimize the height of the humeral implant.
After removal of the intra-articular part of the long head of the biceps tendon, the final implant was introduced into the proximal humeral fragment using an appropriate 30° retroversion (with reference from the forearm) and cemented into the reduced distal fragment using reduction forceps. The |
Patient: a 55-year-old Japanese female.
None of the factors contributing to lateral compartment knee disease, such as obesity, complications, or psychiatric disorders, were present in the patient. During hyaluronic acid (HA) treatment, although we prescribed strength training to the patient, she did not perform it frequently enough because of severe pain. As the knee pain was caused by tripping while playing tennis, the possibility of trauma cannot be ruled out.
In 2013, due to pain in both knees, she visited our hospital and was diagnosed with OA of the knee.
In December 2017, while playing tennis, the right knee developed a knee collapse. She was examined at the hospital, and an MRI of the right knee was performed. Horizontal dissection of the lateral meniscus and cartilage defect on the lateral condyle of the femur were observed.
Since 2018, injections of hyaluronic acid have been administered every 2 weeks, but joint edema and pain recurrence have been remitted.
The patient had already undergone HA treatment and received multiple steroid joint injections; however, these interventions were not very effective. Moreover, the patient was unwilling to undergo these treatments. The patient was aware that our hospital would start providing regenerative medicine treatments and had been waiting for a year before the start of the treatment. During that period, the patient received HA treatment, which proved ineffective. Therefore, the patient requested ASC treatment in April 2018.
In April 2018, MRI of the right knee was performed. A cartilage defect was found in the external condyle of the femur, and the patient desired ASC transplantation. The range of motion of the right knee is 0–145. Anteroposterior (AP) and lateral radiograph of the right knee are shown in Fig. .
On 28 April 2018, 20 mL ASCs were collected from the abdomen.
On 11 June 2018, the first ASC transplantation was performed on the right knee.
On 2 July 2018, although the effect was experienced after 1 week |
A 35-year-old nulliparous female patient with a previous history of left femoral hernia operation was admitted to our hospital. In her medical history, the patient declared that she had a large painless swelling extending from her left groin to her left leg which grew gradually during one year. No gastrointestinal symptoms were determined. She was initially diagnosed as a femoral hernia and underwent surgery one month ago at another state hospital. Accordingly, she was referred to our clinic because of surgical failure. On physical examination, she had a left groin incision scar. An immobile, painless mass which filled lower quadrants of the abdomen was palpated. The mass was also extended to the one-third upper level of left thigh. Digital examination of the rectum was normal. Vulva was examined macroscopically because the patient was virgin. Subsequently, abdominal ultrasonography (USG), contrast-enhanced abdominal tomography (CT), and magnetic resonance imaging (MRI) were performed for estimating the tumor size, invasion degree of the mass, distant metastasis, and also ruling out other intra-abdominal lesions. A giant intra-abdominal solid mass that is fully filling the pelvis and extending to the left groin was revealed by USG, CT, and MRI (). All adjacent organs and pelvic vessels were depressed by the mass. The origin of the tumor was not well demonstrated due to the huge size. Exploratory laparotomy was planned. A written informed consent including surgical risks was obtained from the patient. Laparotomy was performed through a midline incision that extends to the left thigh. On exploration, a giant, soft, rubbery, and gelatinous appearing mass (like lung tissue) that approximately filled the whole abdomen was noted. The tumor has exerted pressure on the bladder, the left ureter, uterus, and left iliac vein. The bladder and uterus were completely displaced to the right side. The tumor was extending to the left thigh via canal of Nuck. During the dissection, no infiltration into the adjacent organs was detected except a partial invasion into the left external iliac vein. This side was resected and primarily repaired. The external iliac artery was intact. The radix of the tumor was reaching until the posterior of the vagina. The tumor was completely excised by sharp and blunt dissection (). The tumor size was measured as 24 × 12 × 6 cm with a weight of 4.2 kg. On histopathologic examination, the border of the tumor was clear. Morphologically, the tumor was composed of spindled and stellate-shaped cells with ill-defined cytoplasm intermingled with collagen fibers and thin vessels in a myxoid background. The cells had small round hyperchromatic nuclei with small centrally located nucleoli. At the periphery of the lesion, the vessels were thicker due to perivascular hyalinization and medial hypertrophy. The tumor was invading adjacent soft tissue including adipose tissue, muscles, and nerves. The mitotic activity was not observed. Immunohistochemically, the cells show positive staining with vimentin, desmin, estrogen, and progesterone receptor. S100, MUC4, CD34, and SMA were negative in the tumor cells (). According to the histopathological and immunohistochemical findings, the case was interpreted as intra-abdominal aggressive angiomyxoma. The patient recovered uneventfully and was discharged from the hospital on postoperative day 8. The patient displays no evidence of local recurrence for 2 years postoperatively. |
A 64-year-old man with gross swelling in the anterior mandibular gingiva for 1 month after lower incisal teeth extraction was referred to us for a closer evaluation. Oral examination revealed a firm mass measuring 2.6 × 2.1 cm in size arising from the extraction site (Fig. ). The surface of the mass lesion showed erosion at the site equivalent to the wounds after tooth extraction. There was no hemorrhage or paralysis in the mandibular region, and the condition was painless.\nFor the past medical history, the patient underwent low anterior resection of a rectal malignancy diagnosed as moderately differentiated adenocarcinoma 7 years previously. There was no evidence of regional lymph node and distant metastases. Three years after the primary surgery, the patient showed bilateral lung metastases. Thus, the middle lobe of the right lung and the lower lobe of the left lung were partly resected. Four years later, multiple lung metastases and metastases to the vertebral bodies of the VI–VIII vertebrae were observed. The patient received 60 Gy of irradiation to control the pain from the lesion involving the vertebra.\nComputed tomography (CT) scan of the head and neck showed a solid mass and bony resorption in the anterior alveolar ridge of the mandible (Fig. ). There was no lymphadenopathy. Magnetic resonance imaging (MRI) revealed a heterogeneous signal on a T1-weighted image after gadolinium administration and an intense signal on a diffusion-weighted image (Fig. ).\nFor the laboratory examination results, the serum carcinoembryonic antigen and cancer antigen 19-9 levels were 947.6 ng/ml and 1059.2 U/ml, respectively. Pathological examination by incisional biopsy of the gingival mass lesion revealed a moderately differentiated adenocarcinoma. The tumor was composed of proliferating columnar to polygonal epithelial cells with moderate atypia that showed a papillary tubular pattern (Fig. ). Immunohistological analysis demonstrated that the adenocarcinoma cells were positive for cytokeratin 20 (CK20) and negative for cytokeratin 7 (CK7) and positive for caudal type homeobox transcription factor 2 (CDX2) (Fig. ). The biopsy findings from the mandibular mass lesion were consistent with those from the resected rectal carcinoma 7 years previously.\nThe tumor had grown gradually and an ulcer was formed on the surface, making mastication difficult. The patient received palliative radiotherapy for the mandibular mass lesion. However, once the tumor showed a tendency to decrease in size, pneumonia developed and the patient’s cachexia deteriorated. Thus, the radiotherapy was discontinued, but the patient unfortunately died 2 months postradiotherapy.\nOral metastatic tumors are uncommon and comprise approximately 1 % of malignant oral neoplasms []. Most cases were previously diagnosed in reference to a primary neoplasm and were treated accordingly. Therefore, the primary site is usually assumed based on the past clinical history. However, 23 % of oral metastases were shown to be the first sign of the metastatic process []. In the present case, the origin of the metastatic lesion was clarified based on the past history of rectal adenocarcinoma resection and the subsequent lung metastases. The most common primary site in women is the breast followed by the female genital tract, kidney, and colon-rectum. In men, the most common primary site is the lung followed by the kidney, liver, and prostate [].\nIn the oral site where metastatic tumors arise, most tumor lesions are observed in the jawbones, and only 16 % are found in the soft tissues such as the gingiva []. The metastatic rate in the posterior body of the mandible is higher than that in the symphyseal region []. The gingivae (55 %) followed by the tongue (30 %) are the most common soft tissue sites affected by metastatic malignancy []. In the present case, the metastatic lesion has been presumed to develop in the gingival tissue of the symphysis. This lesion was an exophytic growing mass, and the radiological appearance of the mandibular bone invasion was not demonstrated apparently. Likewise, some case reports have shown that the metastatic site was the gingiva for the primary lesion of colonic and rectal adenocarcinomas [–].\nAdenocarcinoma of the colon and rectum commonly spreads to the regional lymph nodes, liver, and lungs, but less commonly to the peritoneum, bone, adrenal glands, brain, kidney, thyroid, pancreas, ovaries, and skin. Clausen and Poulsen proposed the following three criteria for metastatic oral tumor: firstly, the metastatic tumor is pathologically similar to the primary tumor; secondly, the oral tumor is considered to be a metastasis clinically and pathologically; and thirdly, the oral tumor is atypical compared with common oral primary tumors []. The most common primary tumor arising from the oral mucosa is squamous cell carcinoma. Therefore, there may be a need to differentiate metastatic adenocarcinoma from adenocarcinoma derived from the salivary gland, although the frequency of occurrence is very low. Three clinical courses may be considered to underlie the metastasis of colonic adenocarcinoma to the oral cavity as follows: (1) direct metastasis with identification of the primary tumor, (2) secondary metastasis derived from metastasis in another site after treatment of the primary tumor, and (3) occult metastasis without identification of the primary tumor. The present case follows the second clinical course in which the secondary metastasis in the jawbone was derived from multiple lung metastatic lesions. The primary rectal tumor has already been resected completely. The present case conformed to Clausen’s criteria.\nHistopathologically, approximately 70 % of the metastatic lesion in the oral region is reportedly adenocarcinoma, followed with much less cases by clear cell carcinoma from the kidney and squamous cell carcinoma from the lungs []. Also in the present case, the hematoxylin and eosin-stained section showed features of adenocarcinoma arising from the rectum. Furthermore, the histological diagnosis was supported by the immunohistochemical analysis. The metastatic tumor cells demonstrated a CK20-positive and a CK7-negative phenotype. In the evaluation of gastrointestinal tract carcinomas, the great majority of well-differentiated or moderately differentiated large intestinal adenocarcinomas reportedly showed a CK7-negative/CK20-positive phenotype. Adenocarcinomas of the upper gastrointestinal tract were also reported to be positive for both CK7 and CK20 in 78 % of cases []. Thus, an assessment of the CK7 and CK20 phenotype may help in determining the primary site of a metastatic tumor []. In addition to the CK7 and CK20 immunoprofiles, the tumor cells showed CDX2 immunoreactivity. CDX2 is a sensitive and specific maker for adenocarcinoma with a colorectal origin []. CDX2 expression has also been shown in a subset of adenocarcinomas arising from the colon, rectum, stomach, esophagus, and ovary []. Accordingly, CK7, CK20, and CDX2 may be useful for the diagnosis of metastatic tumors of gastrointestinal origin.\nIn the case of oral metastatic tumors, they usually have a poor prognosis because often they have already spread to other sites. Therefore, the appropriate palliative treatment has to be carefully selected. If the tumor is widely disseminated, palliative radiotherapy is recommended []. However, when possible, surgical resection may be recommended mostly for metastatic lesions in the soft oral tissue []. In the present case, as the oral metastatic lesion was rapidly growing with accompanying multiple lung metastases, resection was not possible under general anesthesia. Accordingly, we performed palliative radiotherapy for the mandibular mass. Alternatively, chemotherapy with the FOLFIRI regimen (5-FU, leucovorin, irinotecan) is usually performed for advanced metastatic colorectal carcinoma []. Although the IRIS regimen (irinotecan, S-1) plus bevacizumab (monoclonal antibody targeted against vascular endothelial growth factor) was planned when the lung metastasis occurred to play the role of another second-line chemotherapeutic regimen, the patient showed no response to the chemotherapy.\nPatients with distant metastasis of colorectal adenocarcinoma usually have a poor prognosis. In particular, if a secondary metastatic oral tumor is identified, the disease state may be commonly progressive and the prognosis is extremely poor. In cases involving metastasis to the oral cavity, the mean survival period from the time of mass appearance to the time of death of a patient has been reported to be about 7 months []. Regarding metastasis to the gingiva, some cases have been documented showing that the duration of survival from the indication of gingival mass development was only within 1 year [, , ]. The present case also showed a short survival period of 4 months. |
A 50-year-old male presented with complaints of chronic, intermittent abdominal pain. The patient had a 20-year history of mild-to-moderate amount of alcohol consumption. There was no history of jaundice, fever or weight loss. His laboratory tests revealed no significant abnormal findings. Serum amylase and lipase, and tumour markers [CA 19-9, carcinoembryonic antigen (CEA)] were within normal limits. The patient was subjected to a CT examination. On unenhanced CT image, a poorly defined soft tissue mass was seen in the pancreaticoduodenal (PD) groove with a hypodense cystic lesion within the mass (). On post-contrast study, the lesion showed minimal enhancement in the portal venous phase ( and ), but delayed imaging at 2–3 min showed mild persistent enhancement of the lesion compared with the pancreatic parenchyma that was consistent with scar tissue () and a non-enhancing cystic lesion within the lesion. The lesion showed poorly defined fat planes with the adjacent second part of the duodenum on its right side and pancreatic head on the left side. Mild thickening of the wall of the second part of the duodenum adjacent to the lesion with variable luminal narrowing was noted. The common bile and pancreatic ducts appeared grossly normal. The pancreatic body and tail were normal. In order to clearly delineate the ductal system and the periampullary region, and to know the extension of the lesion, the patient was also subjected to an MRI examination. Axial two-dimensional fast imaging employing steady-state acquisition () sequences showed soft tissue signal intensity lesion in the PD groove with a cystic lesion within the lesion and the aforementioned CT scan findings. MR cholangiopancreatography sequence () revealed smooth and regular tapering of the pancreatic and common bile ducts. The gallbladder was distended and the cystic duct was normal. Incidentally, a few simple cysts (Bosniak 1) were noted in both the kidneys. The patient was advised further surgical intervention but he refused and was managed with conservative treatment. At present, the patient is asymptomatic. |
A 79-year-old male was admitted to the hospital unit with the chief complaint of worsening cough and abdominal pain. He was seen in the emergency room three days before the admission with the chief complaint of wheezing and non-productive cough where he was diagnosed with bronchitis and sent home with levofloxacin 500 mg by mouth daily for seven days and albuterol hydrofluoroalkane (HFA) inhaler as needed. The patient had a significant past medical history of dementia, seizures, cerebral vascular accident, pulmonary fibrosis, and chronic kidney disease with a creatinine clearance (CrCL) of 36 mL/min on day 1 of their hospital admission. The patient’s family reports no tobacco and alcohol use. The patient returns to the emergency room due to a lack of symptomatic improvement as well as a new complaint of abdominal pain, fever, and altered mental status per family members. Upon admission, the patient appeared jaundiced with right upper quadrant pain, and all hepatic enzymes were elevated with total bilirubin three times more than the ULN, alkaline phosphatase two times more than the ULN, AST 14 times more than the ULN, and ALT six times more than the ULN (Table ).\nAn ultrasound of the abdomen was performed and showed a distended gallbladder with no gallstones and a common bile duct diameter of 5 mm. Upon admission, the patient presented with acute chronic kidney injury, with slightly elevated blood urea nitrogen (BUN), and mild tachycardia of 106 beats per minute (all other vitals normal). Of note, medications before admission that may have potentially led to the abnormalities in the hepatic laboratory work are levofloxacin and rosuvastatin (Table ). The patient was diagnosed with drug-induced cholestatic hepatitis due to levofloxacin after performing a hepatobiliary iminodiacetic acid (HIDA) scan and autoimmune hepatitis panel to rule out other causes. All hepatic enzymes peaked between day 8 and day 9 of hospital stay and improved thereafter in the remainder of the hospital admission. The patient’s renal function also improved throughout the hospital stay. The patient was discharged home on day 9 with instructions for outpatient follow-up. |
A 30 year old nulliparous Nigerian woman of the Igbo tribe presented for antenatal care at 24 weeks gestational age. She had two visits to the hospital before she presented to the hospital as an emergency. After a review by the obstetrician, she was admitted to the antenatal ward and a consult sent to the neurologist for a review.\nThe patient gave a two year history of blurring of vision, followed a month later by generalized headache that was worse on bending. The headache had intensified since becoming pregnant. Of recent there had been associated vomiting. There was also a history of menstrual irregularities, urinary frequency and protrusion of the right eye. She did not report any weakness in the limbs or trauma to the head or eye. She had visited an ophthalmologist where she was treated on outpatient basis.\nPhysical examination revealed a young woman in painful distress, conscious and well oriented. She was not pale, icteric or febrile to touch. Blood pressure on admission was 120/80 mmHg and pulse rate was 76 beats per minute, regular and of good volume.\nExamination of the central nervous system revealed proptosis of the left eye and a blind right eye. There was temporal visual loss with reduced acuity in the left eye. Fundoscopy showed established optic atrophy in the right eye with early optic atrophy changes in the left eye. Other cranial nerves were intact with no sign of meningeal irritation. There were no asymmetries in the limbs. The possibility of an intracranial space occupying lesion was entertained.\nRelevant investigations were ordered. A computerized tomography (CT) scan of the brain showed a large pituitary tumour (>10 mm) with pressure effects, occluding the anterior horn of the left lateral ventricle. The other ventricles were dilated.\nThe results of other investigations were as follows - serum prolactin 250 ng/ml (6.0-24), serum T3 2.4 ng/ml (0.6-1.6), serum cortisol 310 ng/ml (50-230) and fasting blood sugar 69 mg/dl (65-110). Abdominopelivic ultrasound scan revealed a live singleton fetus at 33 weeks with cephalic presentation and anterior placenta. The fetal heart rate was 130/minute.\nA diagnosis of pituitary macroadenoma with mass effect was made.\nThe symptoms gradually regressed with good clinical improvement. After sixteen day of admission, the patient went into premature labor at 34 weeks and five days. After a review by the obstetricians, she was booked for emergency caesarean section and the anesthetists were informed.\nBecause the CT scan showed evidence of raised intracranial pressure, general anesthesia with the relaxant technique was used with sodium thiopentone, non-depolarizing muscle relaxant, opioid analgesics and oxygen/air. Sodium thiopentone was used for maintenance of anesthesia in intermittent bolus doses as that would prevent further rise in intracranial pressure and the possible risk of bleeding if the available volatile agent, halothane was used. Anesthesia by the corresponding author was uneventful and the patient recovered satisfactorily. She was taken to the intensive care unit for postoperative care and close monitoring.\nShe recovered full consciousness in ICU. On the second postoperative day, she was resumed on oral bromocriptine with the following postoperative drugs; ampiclox, metronidazole, pethidine and promethazine. The following day, she had complained of restlessness before she was discharged to the ward on the third postoperative day by 2 pm in fairly satisfactory condition. Later that day at about 11:30 pm, the duty doctors were called to see the patient on account of sudden and sustained rise in blood pressure. On examination she was unconscious and afebrile. The blood pressure was 210/110 mmHg and the pulse rate was 150 beats per minute.\nA diagnosis of accelerated hypertension with encephalopathy was made and the following drugs prescribed; intravenous bolus dose of hydralazine 5 mg stat, then 40 mg in a litre of 5% dextrose in water to run at ten drops per minute with quarter hourly monitoring of blood pressure. About 15 minutes later the patient started gasping and went into cardiac arrest. Attempts at resuscitation failed. An autopsy was not done. |
A 28-year-old female, who practiced athletics, came to our institution with a history of chronic severe anterior left knee pain. Pain onset was secondary to a direct traumatism of the knee from playing football one year earlier, increasing in intensity throughout that year until it became so intense that the patient visited our office for the first time (Visual Analogue Scale 8). She had great difficulties in driving her car because of the pain caused upon engaging the clutch, going downstairs, wearing high heels, and sitting with the bent knee for a long period of time (“movie sign”). The psychological evaluation that we routinely perform on our patients with AKP did not indicate anxiety, depression, kinesiophobia, or catastrophizing []. The physical therapy program (patellar taping, muscle training, and flexibility exercises) performed in our institution [] was unsuccessful in improving her symptoms. This pain forced her to abandon the sports activities but she kept going to the gym. At this moment there was no pain in the left hip.\nTen months later, she came back to our office due to severe hip pain with no history of traumatism to justify it. The hip pain was so significant that it not only forced her to leave the gym but also made significant limitations in her regular daily activities. Moreover, she continued to suffer from knee pain. The Kujala Knee Score was 22 and the Nonarthritic Hip Score was 28.75. Preoperative pain intensity on the Visual Analogue Scale was 8 in both knee and hip. During physical examination of the hip there was a positive impingement test and a positive decompression test. A Dunn radiograph view showed an alpha angle of 58°. It is the angle between the line from the centre of the femoral head through the middle of the femoral neck and the line through the point where the contour of the femoral head-neck junction exceeds the radius of the femoral head. An angle >55° is considered indicative of Cam impingement []. The study by arthro-MRI of the left hip showed a Cam FAI and a detachment of the anterior labrum.\nFor documentation purposes prior to hip surgery, she was evaluated using kinetic (gait analysis and hip rotation moment) and kinematic (rotating hip excursion) analyses during gait and stair ascent as the latter activity was the one that brought about a major limitation in her daily life. A pathway with two extensometric force plates on its surface was used to carry out the gait analysis. The subject was asked to walk at a high cadence rate because the faster the subject walks, the more evident the functional impairment becomes. The subject was required to walk at the same cadence before and after surgery. Before the data were collected, the subject walked on the pathway several times until she was able to walk with a natural and constant gait. A portable two-step wooden staircase and two independent dynamometric platforms, placed as indicated in , were used to perform the kinetic analysis during the stair ascent test. An eight-camera computer-aided video motion analysis system and reflective passive markers that determined the spatial position of the segments of the lower limb were used to carry out the kinematic analysis (). All of the markers were placed on the lateral aspect of the leg to allow for a correct visualization by the cameras (). The kinetic and kinematic parameters were analyzed using the NedRodilla/IBV software (Instituto de Biomecánica de Valencia, Valencia, Spain). Preoperative gait analysis showed an altered gait pattern (). Preoperative kinematic analysis showed a gait () and stair ascent () pattern with external rotation of the involved hip. Moreover, hip external rotation torque of the involved hip increased significantly during stair ascent ().\nDuring arthroscopy we confirmed the impingement mechanism with the hip at 90° of flexion and maximum internal rotation. With external femoral rotation we avoid the impingement and, in theory, the hip pain. We performed a femoral neck osteoplasty and reattachment of the labrum. After hip surgery, no specific physiotherapy treatment for the AKP was performed. At 6 months after surgery, the patient had virtually no discomfort in the hip, and knee pain had completely disappeared.\nAt 7 months kinetic and kinematic analyses were performed to evaluate the effects of hip surgery on the preoperative biomechanical parameters. They showed a normal gait pattern () and a symmetric pattern between both hips (Figures , , and ).\nAt final follow-up (26 months) the patient was completely asymptomatic; both hip and knee and activities that previously could not be done or had been done with much difficulty like walking at a high cadence rate, going up or down stairs, squatting, making turns with the hip or using a car with clutch were now done without any problem. Moreover, she had begun running without any limitation. A Dunn radiograph view showed an alpha angle of 32°. The postoperative Kujala Knee Score was 91 and the postoperative Nonarthritic Hip Score was 97.50. Postoperative pain intensity on Visual Analogue Scale was 1 for the knee and 0 for the hip. |
A 36-year-old woman with gravida 2 Para 1 Living 1 with previous caesarean section at 29 weeks four days of gestation was referred with diffuse pain abdomen and giddiness. The pain was diffuse and present for the past 20 days which was partially relieved by symptomatic treatment by local doctors, and she also received antibiotics suspecting urinary tract infection. However she presented then with history of giddiness and one episode of vomiting with no history of diarrhoea and was referred. She was married for 10 years. Her first pregnancy was three years back when she underwent caesarean section for placenta previa. She continued to have episodes of pain abdomen in the postnatal and interpregnancy period for which she received symptomatic treatment by local doctor. She was pale on examination. Her vital signs including temperature were normal. There was no guarding or rigidity except mild tenderness on abdominal examination. The uterus was corresponding to 28-week gravid uterus size and was showing occasional contractions but no scar tenderness. Foetus was in breech presentation having regular heart rate. Her investigations showed mild anaemia with haemoglobin of 8.7 g% and neutrophilic leukocytosis (WBC 20900/c mm). Obstetric ultrasound showed single live intrauterine foetus corresponding to 29- to 30-week gestation. Suspecting chorioamnionitis the tocolysis was not administered. She went into spontaneous preterm labour. She was posted for emergency caesarean in view of previous caesarean with breech presentation under spinal anaesthesia with the coverage of antibiotics. On opening the abdomen, multiple pockets of pus were noted in the peritoneal cavity, and the coils of intestine and omentum were found adherent to the fundus and anterior upper surface of the body of the uterus. Lower segment caesarean section was done, and live male baby weighing 1.37 kg was extracted as breech. Then the general anaesthesia was induced, and the exploration was done by extending the incision. The adhesion between loops of intestine and uterus was released. Loculated pus was drained from subhepatic and subphrenic spaces. No bowel perforation was noted even after thorough exploration. The right salphinx and ovary looked congested and unhealthy covered all over by pus. The left tube and ovary were normal. The right salpingo-oophorectomy and appendicectomy were done. Peritoneal lavage was given, and the abdomen was closed in layers. Patient was discharged on 14th postoperative day in healthy condition. Histopathological examination of fallopian tube showed areas of haemorrhage () and lymphoplasmacytic inflammatory infiltrate (), and that of the ovary showed chronic inflammatory infiltrate () suggestive of pelvic inflammatory disease. Section from appendix showed features of only lymphoid hyperplasia. Aerobic organisms were not grown in the culture obtained from the pus from the peritoneal cavity. She had come for follow-up later with postnatal period uneventful. |
A male child aged 13 years, 8 months, a student of the eighth grade, hailing from a Hindu extended family of middle socio-economic status and an urban background, presented to our center with the complaint that he had been walking in his sleep for the past three years. About a month prior to the onset of these symptoms, the patient had suffered a generalized tonic-clonic seizure. Computed tomography (CT) and magnetic resonance imaging (MRI) scans and EEG done at that time had been normal. He received Carbamazepine 300 mg/day and Phenobarbitone 50 mg/day for one week. Medications were stopped when investigations were found to be normal. The seizure did not recur. About the same time, the patient lost his grandfather to whom he was much attached.\nThe episodes of walking in his sleep would usually occur in the first four hours of sleep in the night but had never occurred in the day. During these episodes, the patient would walk about the room or recite lessons learned in the day. Each such episode would last for up to half an hour and any attempt made to communicate with him during this period would be unsuccessful. The patient had no recollection of the episode on waking up. Over three years, the frequency of episodes had gradually increased to about thrice or four times per week. Over the same period, the patient had begun performing poorly in science and social studies. He would experience frequent and severe headaches (not suggestive of migraine) that would interfere with his studies.\nAt the time of consultation, scholastic difficulties had also worsened with the patient having failed in the 8th grade. He was under considerable pressure from his parents to improve academically. They were worried that there was “something wrong with his brain.” The patient had been born preterm (at ≈ 33 weeks of gestation) and had a low birth weight. Motor and language milestones had developed normally. There was a family history of mental retardation in the elder sister and of seizure disorder in mother. There was no family history of somnambulism. Physical examination was normal and a mental status examination was unremarkable. IQ was 84 at initial assessment.\nA diagnosis of somnambulism (F51.3 as per the ICD-10 criteria)[] was made. Sleep-deprived EEG and a noncontrast CT head were done, which were normal. The parents were educated about the patient's illness, reassured, advised to reduce their pressure on the patient and be supportive. In addition, he was advised to follow a consistent sleep schedule, avoid sleep deprivation and was prescribed 1 mg lorazepam at bedtime. Over the next two months, the somnambulism episodes stopped completely and lorazepam was reduced to ½ mg for the next one month and then stopped. Over the next six months, he improved scholastically with support from his parents and additional coaching with his studies. His headaches stopped occurring. He was followed up and was found symptom-free one year later. |
A 25-year-old gravida 1 para 0 woman at 35.6 weeks of pregnancy who weighed 57 kilograms was admitted to our hospital because of irregular uterine contractions. The patient had been buried for 48 hours in the ruins after an earthquake. She had undergone more than 30 surgical procedures within the previous 6 years. Her legs and abdomen were severely injured in the earthquake. She underwent left, total leg and right below-knee amputations, left hip resection due to clostridial necrotizing fasciitis, transverse colostomy, cystic and vulvar reconstructions, and colostomy reversal surgery approximately 2 years before becoming pregnant. In addition, she also suffered from spinal shock after the accident. Her sensory and motor function below the level of T10 did not recover until 8 months later. In addition, the patient had progressed to a chronic stage in which her reflex activity was regained. This stage was characterized by disuse atrophy, flexor spasms, and exaggerated reflexes.[ To bear the weight of her body, she had to sit, lie down, or lie on her side. As a result, the uneven distribution of the stress caused compensatory changes in her spine, leading to severe scoliosis.\nThis patient had 2 episodes of congestive heart failure during her previous surgical interventions that required hospitalization in an intensive care unit (ICU). When she was admitted to our hospital, the fetal heart rate and movement were monitored closely. Dexamethasone was used to promote fetal lung maturation. At 36.4 weeks of gestation, her uterine contractions became more frequent, and preterm delivery was inevitable. Spontaneous vaginal delivery was not an option because of the patient's incomplete pelvis structure due to the previous left hip resection and extensive keloid tissue over the perineal region (Fig. ). A cesarean delivery was planned after multidisciplinary consultation and meetings with the patient.\nGeneral anesthesia was planned due to the patient's traumatic stress experience. Preoperatively, we ruled out deep venous thrombosis using Doppler sonography. The patient's right internal jugular vein was cannulated preoperatively due to difficult intravenous access. The patient inhaled oxygen in the operating room in the semidecubitus position. In preparation for a potentially prolonged operation, arterial access was also established according to the standard American Society of Anesthesiology monitoring guidelines. We used the central venous pressure (CVP) and pleth variability index (PVI) to guide fluid management. The bispectral index (BIS) and continuous total hemoglobin were also measured. The patient's blood pressure was 105/63 mm Hg, her heart rate was 102 beats/min, her oxygen saturation was 99% when breathing oxygen (>4 L/min), and her CVP was 6 cm H2O. After intravenous hydration with 300 ml of lactated Ringer solution (approximately 10 ml/min), she was positioned in the supine position with left uterine displacement to minimize aortocaval compression.\nAfter sterile preparation, general anesthesia was induced through rapid sequence induction with ketamine, propofol, and succinylcholine, following adequate preoxygenation. A surgical incision was made immediately after successful tracheal intubation. To deliver the fetus as quickly as possible, a high transverse abdominal incision and a low transverse segmental uterine incision were used by the obstetric team to avoid surgical scars and peritoneal adhesions. A male infant weighing 2940 g was delivered in 3 minutes. Apgar scores were estimated to be 10 at 1 minute and 10 at 5 minutes. Anesthesia was maintained with a reduced sevoflurane concentration and sufentanil. Warm blankets were used during surgery, and parts of the patient's limbs were protected. The patient was stable during surgery with no significant blood loss. The patient's intraoperative systolic blood pressure was 110 to 130 mm Hg, her heart rate was 100 to 110 beats/min, her BIS was 45 to 65, and her CVP was 5 to 8 cm H2O. The duration of surgery and anesthesia were 34 minutes and 1 hour and 42 minutes, respectively. Intraoperatively, the estimated blood loss was approximately 500 ml, 800 ml of lactated Ringer solution was administered during surgery, and 200 ml of clear urine was collected. The patient was extubated after surgery and was then transferred to the ICU. At 42-days of follow up, she exhibited no signs of any postoperative complications. |
A 54 year old female presented with a history of a swelling in her right buttock of 6 years duration. Her main complaint was difficulty in defecation when sitting due to a large lump in the perineum (Figure ). She also had features of obstructed defecation syndrome such as excessive straining with unsuccessful attempts to evacuate, prolonged episodes in the toilet, rectal pain, rectal digitation and laxative dependency. Obstructed defecation symptoms were not relieved by regular use of laxatives. She had no obstructive urinary symptoms. She had not undergone any major gynecological procedures.\nShe was a diagnosed patient with multiple neurofibromatosis type 1 since the age of 17 years and had undergone excision of neurofibromas adjacent to right knee joint and over the right buttock 7 years back. She did not have a family history of neurofibromatosis. She did not give a past history of hypertension or other comorbidities. On examination, she had multiple neurofibromas all over the body and one plexiform neurofibroma over left knee area. There was a non reducible lump of 25× 20 cm size over the right buttock. It had an expansile cough impulse and was non tender on palpation. Digital rectal examination was normal. Therefore, a clinical diagnosis of a secondary perineal hernia was made.\nContrast enhanced computed tomography showed a large poorly enhancing mass in the region of right ischiorectal fossa suggestive of herniation of a large neuropathic bladder (Figure ) and rectum through right ischiorectal fossa. Her US scan of the abdomen revealed mild right sided hydronephrosis. She underwent sigmoidoscopy which was normal up to the proximal sigmoid colon. Barium enema (Figure ) showed herniation of the rectum through a defect in the pelvic floor.\nThe patient was planned for a hernia repair by a combined surgery with participation of colorectal, urological and plastic surgical teams. The patient was positioned on Lloyd Davies position and the repair of her hernia was done using an abdominal approach with a lower mid line incision. There was a large hernia sac extending in to right buttock area which contained a large neuropathic urinary bladder (Figure ). A defect was noticed in the levator ani posteriorly on the right side, through which the urinary bladder and a portion of rectum had herniated. Openings of the ureters were not demonstrated and the right ureter was traced up to pelvic brim and stenting done. Cystectomy and reduction cystoplasty was followed by suprapubic catheterization (Figure ). Hernial orifice was repaired with a prolene mesh. She was discharged six weeks following surgery. Currently she is on regular clinic follow up and intermittent urethral catheterization training. |
71-year old male was admitted to emergency department due to a chest pain that was aggravated by moving or breathing. Patient also had unexplained weight loss of 22 kg in the last 3 months. Medical history included arterial hypertension, diabetes and chronic kidney disease. Laboratory data showed normocytic anemia, elevated inflammatory parameters, elevated alkaline phosphatase and creatinine. Chest X-ray did not show any abnormalities. Initially, pulmonary embolisms were suspected, but chest computer tomography angiography (CTA) did not show any abnormalities in the lungs. Abdominal ultrasound examination found already known adrenal adenoma with no other abnormalities. As attending physician was suspicious of malignant disease patient was hospitalized. During hospitalization 18F-fluorodeoxyglucose PET/CT imaging was done which revealed disseminated predominantly osteoblastic metastatic lesions in thoracic () and lumbar spine (), iliac bones (), ribs, humerus and clavicles. However, primary tumor was not identified initially. For further characterization magnetic resonance imaging (MRI) was planned, but unfortunately it was contraindicated due to more than 20 years old osteosynthetic material present in the lumbar vertebra. A CT guided biopsy of small osteoblastic lesion in the iliac crest was ordered. Unfortunately, biopsy was inconclusive, since it showed only a fatty bone marrow without any malignant cells. Finally, patient underwent an open bone biopsy of large osteoblastic lesion in the eleventh thoracic vertebra. Microscopic evaluation of the open biopsy showed clear cell RCC with sarcomatoid differentiation ().\nAfterwards patient was presented to medical oncologist. Control CT scan confirmed a small carcinoma in the right kidney () with diffuse bone metastases, which were predominantly osteoblastic. Additionally, numerous new tiny lung metastases were found leaving no suspicion that primary tumor was not in the lungs. His prostate specific antigen was 0.3 ng/ml and therefore it was very unlikely that osteoblastic metastases were from prostate cancer. At presentation patient had several poor-prognosis risk factors (WHO performance status 2–3, anemia and time from initial diagnosis to the start of treatment less than 1 year), which indicated short life expectancy. He was offered treatment with mammalian target of rapamycic (mTOR) inhibitor temsirolimus. Unfortunately, despite treatment with temsirolimus patient gradually deteriorated and after two months of treatment CT scan showed progression of disease in his lungs. Few weeks later patient died. |
A 27-year-old male was referred to our department in September 2017 with a chief complaint of a six-month progressive trismus and jaw pain. His medical history was unremarkable, and there was no report of recent trauma or infection. Clinical assessment showed limited mouth opening of 25 mm and pain affecting the right side of the TMJ area. There was no associated clicking or deviation on mouth opening.\nAn orthopantomograph did not reveal any significant abnormality of the jaw, and non-contrast computed tomography (CT) showed a well-defined round mass in the right infratemporal fossa with no cranial or TMJ bony extensions []. Magnetic resonance imaging (MRI) revealed a defined round soft tissue mass measuring 3.2 × 3.1 × 2.8 cm, medial to right TMJ head with minimal extension into the soft tissue component of the TMJ []. Both CT and MRI excluded the cranial extension and vascular nature of the lesion but highlighted close proximity to the internal carotid and internal maxillary arteries.\nBased on the clinical findings and imaging modalities, a differential diagnosis of neurofibroma, trigeminal schwannoma, and giant cell tumor was proposed. As the lesion was located at a relatively inaccessible position and being close to critical anatomical structures, the preoperative diagnostic biopsy was neither feasible nor advisable. Therefore, the patient underwent total surgical excision of the lesion under general anesthesia via trans-oral anterior lateral mandibulotomy approach for direct access to the infratemporal fossa. The approach involved a midline lip split that was extended to the submandibular neck crease. The mandibular symphysis was then exposed, marked, and fixed with two mini bone plates before osteotomy. Subsequently, the mandible was laterally rotated, the lingual and inferior alveolar nerves were identified and protected, and the lateral pterygoid muscle was excised to closely approach the lesion, which was then visualized via endoscope and freed from all attachments ensuring total and complete excision. The maxillary artery branches were circulating the mass, and identified and clipped endoscopically [].\nThe histopathology result showed fibrohistiocytic cells with hemosiderophages, foamy macrophages and osteoclast-type multinucleated giant cells on a background of fibrocollagenous tissue with chondroid islands and osteoid formation. The cells appeared to form a lining giving a partly cystic appearance. There were large areas of coagulated necrosis, cholesterol clefts, hemorrhage, and scattered dystrophic calcifications []. The histopathological features were consistent with chondroid TGCT, a rare subset of localized TGCT that was completely excised.\nAt 18-months post-operative review, the patient showed remarkable recovery with improvement in mouth opening to 35 mm and resolution of the associated jaw pain. In addition, the 18-month post-operative MRI showed no evidence of recurrence []. |
An 11-year-old boy presented with complaints of pain and swelling over the right forearm since 4 months. Examination revealed a 10 cm × 5 cm bony hard mass arising from the diaphysis of the ulna. Elbow and wrist range of movements were normal, pronation and supination were restricted due to pain, no distal neurovascular deficiency was noted. The plain radiograph of the forearm in two perpendicular planes revealed a permeative destructive lesion with a wide zone of transition involving the middle and lower third ulna with periosteal reaction and cortical breach []. Magnetic resonance imaging (MRI) revealed the involvement of almost the entire ulna except for the proximal part sparing the olecranon and articular surface (T1-weighted images). It was associated with a large soft tissue component with the displacement of ulnar vessels (T2-weighted images) [ and ].\nThe clinico-radiological diagnosis of Ewings sarcoma was confirmed histopathologically with core needle biopsy. The patient was staged with computed tomography of the chest, a bone scan and multiple-site bone marrow aspiration, which did not reveal metastasis. The patient was evaluated in a multidisciplinary clinic and was started on multi-agent chemotherapy. He was reassessed after induction chemotherapy with plain radiography and an MRI of the forearm for planning local treatment []. The MRI revealed a substantial decrease in the soft tissue component of the disease. Local treatment options (limb salvage surgery with complex reconstruction vs definitive radiotherapy) were discussed with the patient and attendants, who opted for surgical treatment.\nA limb salvage surgical procedure was planned with wide excision of the ulna except the proximal 2 cm, which includes partial articular surface as this was uninvolved by the disease. This ensured a narrow 1 cm tumor-free margin proximally. Reconstruction was planned with medialization of the radius with its proximal articular surface to this retained fragment creating a one-bone forearm. Detailed preoperative surgical planning was done with appropriate drawings [].\nThe patient was operated in the supine position with a tourniquet. A dorsolateral incision was taken. The needle biopsy scar and the tract were excised along with the tumor. The ulnar neurovascular bundle was identified and protected. The planned site of osteotomy was identified at the base of the coronoid process. An oblique osteotomy was done at this level to preserve the olecranon process and its articular cartilage along with the attachment of the triceps tendon [–]. The osteotomy was done obliquely through the elbow joint at the level of the radial head. Distally, the ulna was dislocated and gradually released from the interosseous membrane, leaving a layer of uninvolved muscle on the ulna, as the oncological margin. Proximal radius was released from the tendinous attachments and mobilised medially. The radial head was partially denuded of its cartilage using a burr, leaving cartilage only on the volar side. Osteosynthesis was done between the radius and the ulna with the help of 3.5 mm cortical screw, directed from the olecranon into the radius. Tension band wiring was done to further secure the fixation []. The forearm was fixed in a neutral position. The elbow was immobilized in the above elbow slab for 4 weeks []. Postoperative period was uneventful. Elbow range of motion was initiated after 4 weeks. The final histopathology report confirmed Ewing sarcoma of the ulna with free margins and 95% tumor necrosis. Adjuvant radiotherapy was given in view of the large disease volume at presentation. The patient also completed adjuvant chemotherapy as per hospital protocol.\nTwelve months after the index surgery, the patient sustained a traumatic fracture of the shaft the radius, which was treated with closed reduction and fixation with a Kirschner wire. The patient underwent implant removal after 3 years of surgery, in view of prominence of the implant over the elbow. The patient was last reviewed at 5 years post index surgery with plain radiography []. The patient is disease-free. He has 5 cm shortening of his forearm, 10° of fixed flexion deformity at the elbow, with a further range of movement up to 130° []. The patient is able to do most of the activities of daily living with the operated limb. He functionally fares well with a Musculoskeletal Tumor Society Score of 27 out of 30. |
A 73-year-old female was admitted to our clinic with chest distress and palpitations. The physical examination revealed no positive findings. Electrocardiograph (EEG) and dynamic EEG (DCG) showed arrhythmias, including paroxysmal atrial fibrillation, paroxysmal supraventricular tachycardia, atrial premature beats, and ventricular premature beats. A cardiac B-mode ultrasound showed mild aortic valvular regurgitation and left ventricular diastolic dysfunction. Coronary artery CT found stenosis of the left anterior descending artery (50%). Laboratory findings, including blood chemistry and myocardial enzymes, were normal. The patient was prescribed 100 mg aspirin once a day for 2 months by another center. We decided to continue this existing treatment and add metoprolol 47.5 mg/day for her symptoms. Before our treatment, no examination for sense of smell or taste was performed, and the patient did not report any abnormalities in her ability to smell or taste.\nAfter 2 weeks of metoprolol therapy, the patient reported decreased chest distress and palpitations. She reduced her metoprolol dose to 23.75 mg/day without reporting to the clinic her dose alteration. At the third week of metoprolol treatment, the patient noticed a smell disorder, reporting that she could not perceive the same smells as her relatives. And this disorder continued to worsen until complete anosmia. However, she continued this dosage and did not report to the clinic her new symptoms. During this period of time, the patient denied having exposure to chemicals, using other drugs, or experiencing a traumatic nose injury. Approximately 3 months after starting metoprolol, the patient returned to our clinic with the compliant of an olfactory disorder. No abnormalities were found during the endoscopic nasal examination, with normal color. No gland or turbinate hypertrophy was found. No obstruction or excess secretion was noted in the nasal passages, and the olfactory epithelium showed no signs of congestion or inflammation. It was determined that the olfactory dysfunction was an adverse effect of metoprolol. Considering her better initial symptoms and repeated DCG result, the metoprolol was tapered. The patient recovered from the olfactory dysfunction 3 weeks later, as determined by her ability to once again perceive the smell of soap. By the second month after discharging metoprolol, the patient's ability to recognize smells was returning back to baseline (Fig. ). Also, in the follow-up appointment, she reported no complaints of smell or taste anymore.\nNevertheless, the patient complained that her palpitations were getting worse following discontinuation of metoprolol. Dynamic electrocardiogram presented premature atrial beats and increasing paroxysmal atrial fibrillation. Therefore, the patient was given amiodarone 400 mg/day for 1 week to treat her arrhythmias, and then was tapered to 200 mg/day. However, after using amiodarone for approximately 2 weeks, the patient was not able to distinguish the tastes of bitter and spicy. Considering the potential side effects of amiodarone, we asked her to abandon the drug and have a radiofrequency ablation. Thus, the patient regained her ability to differentiate tastes 2 weeks following amiodarone discontinuation (Fig. ).\nThe authors obtained written consent from the patient to describe her illness and publish this case report. Ethics committee approval is not included, as it is commonly accepted that case reports do not require such approval. In our work, we did not use patient data that would allow identifying her. The patient agreed to the diagnostic tests and treatments used to manage her medical conditions. |
A 56-year-old woman with history of recurrent corneal ulcers of the right eye was referred to an academic center for further workup and treatment. The patient had a history of recurrent right corneal erosions starting 2 years prior with minor trauma to her right eye from eyelash plucking. She did not have findings of epithelial basement membrane dystrophy in either eye. She first developed a corneal ulcer one year prior to presentation that was cultured with no growth on bacterial, fungal, or acanthamoeba cultures. It was treated with topical moxifloxacin and eventually healed with complete re-epithelization and resolution of the infiltrate. She continued using a bandage contact lens due to recurrent erosions and severe eye pain. This bandage contact lens was exchanged at least monthly and she remained on prophylactic topical tobramycin drops twice a day. A corneal ulcer recurred 3 months later and was treated again with topical moxifloxacin with eventual re-epithelization and resolution of the infiltrate. This ulcer was not cultured. Her vision at this point was 20/40 with a central stromal scar. She continued using a bandage contact lens and remained on topical moxifloxacin four times a day.\nTwo months later, she developed another corneal ulcer, now with deep stromal neovascularization and hypopyon. Due to the provider's concern for endophthalmitis, this was treated with vitreous tap and injection of intravitreal vancomycin and ceftazidime in addition to frequent topical fortified vancomycin and tobramycin drops. The vitreous sample yielded a negative fungal polymerase chain reaction (PCR) and bacterial culture. With continued topical antibiotic therapy, the hypopyon resolved and the infiltrate eventually consolidated into a scar.\nUnfortunately, the hypopyon recurred twice in the next four months with worsening of the stromal infiltrate and development of an endothelial plaque. The hypopyon was treated each time with vitreous tap and injection of intravitreal vancomycin and ceftazidime and re-initiation of fortified vancomycin and tobramycin drops. Voriconazole drops were also prescribed due to concern for chronic fungal infection. Vitreous samples continued to be negative for bacterial culture and fungal PCR. Each period of intense treatment led to subsequent resolution of hypopyon and active infiltrate. Between episodes of active infection, she was continued on a bandage contact lens and topical moxifloxacin four times daily. Her vision declined to 20/400 due to dense stromal scarring.\nAt this time, she presented to our center for consideration of corneal biopsy with concern for an indolent fungal or acanthamoeba infection. She was noted to have a dense stromal scar with deep neovascularization, neovascularization of the iris, and posterior synechiae. She had no epithelial defect or signs of active infiltrate and her anterior chamber was quiet. It was felt that neovascularization and scar were likely the result of chronic inflammation caused by chronic recurrent ulcers. Given the recurrent nature of the keratitis despite topical antibiotics, there was consideration of possible herpetic etiology and she was started on prophylactic acyclovir. A corneal transplant was recommended, but the patient was now uninsured and did not have means to pursue surgical intervention. She opted to continue on a chronic bandage contact lens and moxifloxacin four times daily.\nShe returned 2 months later with worsening pain and irritation, now with hand motion vision. She was found to have an active central infiltrate with large epithelial deficit, 50 % focal thinning, dense neovascularization of the deep stroma, and hypopyon. Scrapings of the ulcer were plated for bacterial and fungal culture; additional scrapings were sent to the University of Washington Molecular Diagnostics Laboratory for bacterial, fungal, and viral PCR. She was started on fortified vancomycin and tobramycin drops.\nBacterial identification of the corneal scrapings was completed using broad-range bacterial 16S rRNA gene primers. The 16s rRNA gene was partially sequenced and the sequence was matched to Leptotrichia species in the Basic Local Alignment Search Tool (BLAST, NCBI) database. This method of bacterial detection by PCR is clinically available at select laboratories, including the University of Washington Molecular Diagnostics Laboratory. Fungal and acanthamoeba cultures, as well as fungal and viral PCR were negative. Bacterial cultures grew two colonies of coagulase negative staphylococcus, which was thought to be a contaminant. The bandage contact lens was discontinued and she was transitioned to fortified tobramycin and cefazolin drops with continued improvement of the ulcer and resolution of the hypopyon. The visual acuity at this time was hand motion.\nLeptotrichia species are anaerobic Gram-negative rods that are constituents of normal oral flora. When this was conveyed to the patient, she admitted that she regularly licked her finger to wet her lower eyelid when she felt that her contact lens was irritating. Given chronic recurrent infections despite periods of relative inactivity and negative cultures prior to this, it was suspected that her recurrences were related to re-exposure to mouth flora with chronic bandage contact lens use. She was strongly encouraged to discontinue this habit and stopped her bandage contact lens use. The patient did not have any recurrences of infection after 1 year of follow-up. |
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