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A previously healthy six-year-old girl was admitted with fever, dyspnea, abdominal pain, and pain in the right arm and shoulder. Four days before admission she had fallen from a tree while playing. Shortly after admission she was transferred to the ICU because she acutely developed signs of shock, anemia and progressive abdominal pain. Splenic rupture was suspected and confirmed by ultrasound showing sub-capsular spleen hematoma and free intra-abdominal fluid. During the ICU stay she developed an abscess on the right shoulder, for which antibiotic treatment was started. The culture of the aspirate, taken before start of antibiotics, from this abscess was positive for Staphylococcus aureus. After 1 month she was transferred to our center under the suspicion of pericarditis, because of persistent fever and cardiomegaly on the chest X-ray. Echocardiography revealed pericardial effusion, located mostly behind the left ventricular (LV) posterior wall (Additional file ), with a to and fro blood flow through a fistula between the left ventricular lumen and a cavity in the pericardial space, and echogenic densities suggestive for fibrin strands and clots (see Fig. ). Cardiac function was good with mild mitral valve regurgitation. Findings were suggestive for advanced purulent bacterial pericarditis complicated by covered left ventricular perforation (pseudo-aneurysm).\nHigh doses of intravenous cefotaxime and flucloxacillin, already started in the referring hospital, were continued. She developed arthritis of the left knee and right elbow which were both aspirated but with negative cultures. Two weeks after admission her clinical condition did not improve with persistent leukocytosis and high C-reactive protein levels. A pericardial abscess with ongoing bacteremia was suspected and surgical intervention was scheduled.\nA median sternotomy was performed, leaving the pleural space closed. The patient was placed on extracorporeal circulation using standard bicaval cannulation. The operation was performed on a beating heart. On opening of the pericardium multiple small abscesses and adhesions were identified and removed, as were thick vegetations on the left ventricular posterior wall. The fistula in the LV myocardium connecting the LV lumen with an abscess on the posterior-lateral wall of the LV was found and closed with prolene sutures with felt (see Fig. ). The pericardial space was irrigated multiple times with a solution of sodium-chloride and iodine. Cultures of the abscesses were negative. Post-operatively she had a quick recovery without fever episodes. She was discharged from the hospital in good condition 2 weeks after surgery. Antibiotics were continued for almost 4 months because of persistent osteomyelitis of the right upper arm and a septic arthritis of the right elbow. Echocardiograms during follow-up revealed no abnormalities. |
A 43-year-old Asian male was transferred to our hospital after undergoing a drainage procedure for a gluteal abscess at another hospital. He was known to have poorly controlled diabetes, and hyperlipidemia on treatment; he was also a heavy smoker for more than 20 years. The complaints started 3 weeks prior to presentation with fever and gluteal abscess which was drained surgically (). The fever persisted despite receiving a combination of gentamycin and penicillin. Two days later, the patient’s condition deteriorated with the onset of shortness of breath and orthopnea. Two sets of blood culture performed on 6 August 2017 grew CoNS, which was considered a contaminant. Further evaluation via transthoracic echocardiography revealed the presence of large vegetation on the aortic valve with severe regurgitation and moderate size vegetation on mitral and tricuspid valve with moderate regurgitation plus aortic root abscess. He was subsequently transferred to our hospital for cardiac surgery.\nOn arrival, his condition had worsened as evidenced by fever with a temperature of 38.9°C, tachycardia (142 beats/minute), hypotension (96/54 mm Hg), and blood oxygen saturation level of 91%. Laboratory tests revealed a white blood cell count of 14,000/mm3 with 81% neutrophils while kidney profile showed acute renal failure with urea 19.5 mmol/L and creatinine 533 µmol/L. His C-reactive protein level was 200 mg/L.\nHe was admitted to the intensive care unit and parenteral vancomycin was initiated based on the knowledge of a previous culture of CoNS from the referring hospital. The condition of the patient deteriorated further the next day with refractory heart failure and pulmonary edema due to the extensive valvular lesions and insufficiency with worse blood gas values and desaturation (SpO2, 84%). He was intubated and continuous renal replacement therapy was initiated with a good response as demonstrated by the normalization of his blood pressure and blood gases.\nThe microbiologist in our hospital issued the result of the positive blood culture of CoNS, which was identified as S. lugdunensis by using MicroScan Walkaway 96 Plus commercial system. The decision to add cefazolin was based on the antibiogram which showed the isolate to be sensitive to almost all antibiotics tested including oxacillin. A transesophageal echocardiogram confirmed the presence of a large vegetation on the aortic valve with regurgitation and moderate vegetations on the mitral and tricuspid valves with regurgitation and aortic root abscess (Figures ). The general condition worsened with refractory heart failure and pulmonary edema due to the extensive valvular lesions and insufficiency.\nAn emergency open heart surgery was then performed to replace all valves and drain the aortic root abscess. His postoperative clinical course was uneventful with vancomycin and cefazolin as a combination of antibiotics administered over a period of 6 weeks. He was subsequently discharged in a stable condition (). |
A 39 years old male presented to the emergency department with lower urinary tract symptoms and lower abdominal pain. The symptoms began one week ago and had progressively worsened. Due to the unbearable pain, he was brought to the emergency department by his family. He had previously been diagnosed with schizophrenia and was since cared for by his close relatives. He had no previous history of foreign body insertion into the urethra. Family history was noncontributory. The patient had a surgical midline scar resulting from a laparotomy exploration surgery five years ago due to perforated appendicitis. The patient’s careful history revealed that he had inserted a long, sharp metallic nail into his urethra, which he did not report to his caretaker before the onset of abdominal pain. Fortunately, he did not attempt to remove the nail by inserting other foreign bodies.\nPhysical examination showed a bruised lower left abdomen. The nail was not immediately palpable in the proximal urethra. Hence we speculated that it might have passed into the bladder. There were no signs and symptoms of perforated hollow organ or ileus. Laboratory findings revealed microscopic hematuria and pyuria in routine urine analysis. Complete blood count only showed slightly increased leukocytes. Electrolyte profiles and renal function were normal. Urinary bladder USG showed a foreign body in the bladder. Thoraco-abdominal X-ray confirmed that there were no perforated organs. An abdominal CT Scan showed a hyperdense lesion in the urinary bladder. We found a foreign body inside the bladder and advised surgery for its removal. The patient underwent transurethral cystoscopy to extract the foreign body by using forceps biopsy.\nThe extraction procedure was carried on by a urologist, an expert in endourology with ten years of experience. Under general anesthesia, the inserted nail was removed by cystoscopy. A dark-colored, straight, metallic sharp object was observed at the bladder cavity’s left lateral aspect. We also identified hyperemia, erosion, and debris in the bladder wall. Fortunately, the foreign body was not stuck onto the bladder wall. However, small bleeding was found on several sites in the inner bladder mucosa caused by the sharp injury. The nail was successfully extracted using cystoscopy and forceps biopsy. A biopsy of the bladder was done to detect any malignancy in the bladder. The nail was measured for 1.5 mm in diameter and 12 cm long with a sharp-ended shape on both ends (, ).\nThe postoperative period was unremarkable, with good operation outcome and no infection. The anatomic pathologic report from the biopsy of the bladder revealed no malignancy in the bladder. The patient was put on an oral prophylactic antibiotics regimen for three days and was scheduled for outpatient follow-up for both the urology and psychiatric departments. Follow-up evaluation in the urology department one week later and one month after the procedure revealed no voiding problems; there was no history of lower urinary tract symptoms. The uroflowmetry examination showed normal results. Foley catheter was removed fourteen days after the surgery, and the patient had no difficulty urinating. Our study has been reported in line with SCARE 18 []. |
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. |
In June 2011, a 56-year-old male was referred to our department by head and neck surgeon in order to improve his upper denture retention and stability. The patient was diagnosed with a squamous cell carcinoma of the maxillary gingiva (T4N0M0) in May 2005 and underwent an extended left maxillectomy, an anterior and middle cranial base resection, a left ophthalmectomy, and a flap reconstruction using the rectus abdominis muscle were performed. On physical examination, a recessed deformation on the left side of his face could be seen because of the left ophthalmectomy. The function of the left levator palpebrae muscle was eliminated to the level of a slight elevation by using the frontal muscle. A metal plate was anchored to the inferior wall of orbit. The left ethmoid bone, inferior nasal turbinate, the maxilla, alisphenoid, medial and lateral pterygoid muscle were already excised during the mesh titanium plate reconstruction of the anterior wall from the maxillary orbital region. Intraorally, the left maxilla had been excised from the midline, with the rectus abdominis muscle flap sutured directly to the soft palate. The peripheral mucous membrane around the left upper lip was already scarred, without the oral vestibule, and the flap margin had moved along with the surrounding soft tissue. The 70 × 50 mm flap was sagging from its weight and was in contact with the mandibular molars, reducing the volume of the oral cavity unless dentures were worn. The maxilla was removed from the midline to the maxillary tuberosity, while the mandible was removed from the anterior border of the ramus to the coronoid process. Dead space was eliminated because the abdominal rectus muscle was placed from the anterior cranial base to the oral cavity during reconstruction (Fig. ). No expiratory leakage or food reflux was observed, and the rhinopharyngeal closure was maintained. Prior to performing surgery, there was no tumor recurrence or metastasis. The patient had a mouth opening of 43 mm, which we judged operable and then conducted the flap reduction and elevation under general anesthesia in Dec 2008. Informed consent was obtained from the patient’s parents prior to study initiation, and all procedures were performed in accordance with the Declaration of Helsinki.\nSurgical reconstruction was performed as follows:An incision was made from the buccal side of the sutured edge (scar) in the abdominal rectus muscle flap (Fig. ). We can conduct a vestibular extension at the same time by incising this position. The adipose tissue was peeled from the buccal side to slightly beyond the skin flap center while maintaining approximately 5 mm thickness. The adipose tissue was reduced using a radio knife (8 g) (Fig. ). When we reduce fat tissue, we must avoid perforating of the skin. The skin was incised directly above the zygomatic bone, with tissue separation (avoiding exposure of the plate) to enable easy visibility of the zygomatic bone. Subsequently, the subcutaneous tissue was peeled from the zygomatic bone to the oral cavity for tunneling. Three mini QUICKANCHOR® (Depuy Mitek Surgical Products, Inc. Raynham, MA, USA) anchors were placed in the zygomatic bone, and anchor sutures were drawn through the subcutaneous tissue to lift the skin flap. A modeling compound was used to shape the margin of the celluloid splint (Fig. ). The advantage of flap suspension using Mitek anchors is the simple operability, less anchor positioning limitation, and easier length adjustment of the thread for suspension, which lead to easier fixation of soft tissue without slackness as well as clinically sufficient strength for fixation of ligament and tissue. On the other hand, less than 4 mm thickness of the cortical bone for suture anchor fixation causes insufficient fixation, therefore, determining placing position on the bone for fixation is necessary. Consequently, due to the versatility, the position that is considered optimal for stronger fixation and more efficient suspension can be selected as the anchor placing position, while the periosteum, corium, and scar tissue that are thought the most suitable for maintaining the strength can be chosen for the suture thread. Regarding the anchor placing position in this case, we determined 3 positions on the zygomatic bone and sutured flap corium taking into consideration a complete maxillectomy had been completed, which resulted in being able to lift the flap outward and upward.\nPostoperatively, the color of the skin flap was normal without congestion or necrosis. The celluloid splint was removed 10 days after the surgery with no infection or necrosis observed in the skin flap. We can find only fat, scar tissue, not carcinoma in the reduced fat tissure. At 3 months postoperatively, epithelialization and scarring were observed on the border of the skin flap and buccal mucosa, with no wound opening. Next, a denture that was stabilized to the right residual teeth with a clasp made. This prosthesis had two double Akers cast clasps unilaterally to retain the prosthesis by the four remaining molars. The major connector used anteria paratal plate. The patient was quite satisfied to be able to masticate, form an alimentary bolus, and swallow without any teeth falling out. No re-sagging of the skin flap or wound infection was observed at 3 years postoperatively. Patient follow-up will be continued at our department (Fig. ). |
A 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.\nHe was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later which was thought to be at least partially related to subclinical cirrhosis. He was ultimately discharged to inpatient hospice and died shortly thereafter. |
A 21-year-old man was admitted to our clinic with a sudden and progressive headache and binocular diplopia. His symptoms had appeared 2 months before his first visit to the clinic. He had also experienced a similar attack 6 months earlier, but he was in a good general condition. The neurological examination revealed right-sided abducens nerve palsy. A brain computed tomography (CT) scan was acquired, which showed a suspected lesion in the cerebellopontine angle. Brain CT angiography was also performed, which did not reveal any prominent findings. The brain MRI showed an extra-axial pontomedullary lesion with the classic appearance of a CM, that is, a reticulated salt-and-pepper core, surrounded by a halo rim []. With the diagnosis of brain stem CM with a history of multiple hemorrhages, progressive neurological deficit, and pial presentation of the CM, the patient was enlisted for the surgical resection of the lesion.\nThe patient underwent surgery using the suboccipital retrosigmoid approach with intraoperative neuromonitoring. The procedure was performed through general anesthesia as the patient laid in a lateral position, and his head was fixed in a three-pin Mayfield headrest. After opening the dura, a CM was detected, arising from the sixth cranial nerve, with no invasion to the brainstem or the surrounding tissues. Since the lesion could not be separated from the nerve and its integrity was unclear, we resected the CM by cutting the proximal and distal portions (before the Dorello’s canal) of the sixth cranial nerve []. Intraoperative monitoring was used to detect changes in the function of the nervous structure. Motor and somatosensory evoked potentials were normal during the surgery. Direct nerve stimulation of the sixth nerve was also performed during the surgery. The response to stimulation was normal when stimulating distal to the lesion and weak proximal to the lesion.\nThe greater auricular nerve (>3 cm) was harvested as an interposition nerve graft. An anastomosis was performed using a fibrin glue sealant, as end-to-end suture was impossible. One day after surgery, the patient showed complete sixth nerve palsy. He was discharged on the 4th postoperative day, without any neurological deficit, except for the right abducens nerve palsy. In the 5-month follow-up visit, he showed complete recovery of the cranial deficit and diplopia. The histopathological examination of the lesion demonstrated typical characteristics of a CM []. To determine the origin of the lesion, immunohistochemistry staining for the S100 marker was carried out, and the results showed the intraneural origin of the lesion []. The follow-up imaging was normal after 2 years, and the patient was symptom free during this period. |
An 8-year-old girl suffered from a painless swelling in the left submandibular area that had been progressively enlarging over the previous four months. There was no history of local trauma, surgery or infections on the left side of her face or neck. Her medical and family histories were also unremarkable. Physical examination revealed a soft, mobile, well-circumscribed superficial mass 3 cm in diameter in the left submandibular area. There was no swelling in the floor of the mouth, and the oral mucosa was unremarkable. Computed tomography revealed that a 2.6 cm, cone-shaped, high-density mass with internal microcalcifications was located in the left submandibular gland along the lateral surfaces of the hyoglossus muscle and genioglossus muscle. The mass extended from the anterior aspect of the submandibular gland deep into the mylohyoid, suggesting an ectopic thyroid gland or mucocele likely arising in the deep portion of the submandibular gland (). During the surgical excision, the mass was identified in the surrounding connective tissue of the deep portion of the submandibular gland and was completely excised from the left submandibular gland via an external cervical approach. The gross specimen measured 4×3.5×3 cm and consisted of a unilocular cystic mass that contained grayish brown mucoid material (). The cyst was serially sectioned and entirely embedded for microscopic examination. Microscopic serial sections of the cystic mass demonstrated structures similar to a large bowel loop. The inner cystic space was lined by colonic mucosa with parallel crypts composed of columnar absorptive cells and goblet cells, and lymphoid follicles were sometimes scattered in lamina propria-like stroma (). The cystic surface was composed of colonic mucosa and separated by vague submucosa and muscle layers by the muscularis mucosa (). The submucosal layer showed loosely cohesive collagen bundles and capillary vessels. The muscle layers consisted of bundles of smooth muscles mixed with mature adipose tissue. The distinction of circular and longitudinal smooth muscle bundles was not prominent in the muscle layers. Some parts of the cyst were completely denuded and were composed of inflamed granulation tissue, inflammatory cells and foamy histiocyte aggregate. The cystic wall did not include salivary gland tissue.\nWe characterized the cellular lineage of the cystic lining cells by immunostaining with a colonic lineage marker (CDX-2) and a small intestinal marker (CD10). The antibodies used were CDX-2 (1:100, CDX2-88, Biogenex, San Ramon, CA, USA) and CD10 (1:100, 56C6, Novocastra, Newcastle, UK), and the results of the immunohistochemical study are illustrated in . The mucosal epithelia of the present case were positive for CDX-2. However, CD10 was negative in the mucosal epithelium. The final pathologic diagnosis was a heterotopic intestinal cyst occurring in the submandibular gland, and the immunohistochemical results also supported the diagnosis of a heterotopic intestinal lineage. The patient was discharged from the hospital without any complications, and no recurrence was seen during the one-year follow-up period. |
A 67-year-old male fell accidentally down from an agricultural vehicle a protruding part of which crashed into his right eye. He experienced massive bleeding with a 3- to 5-min period of unconsciousness as the immediate consequence of the trauma. Eight hours later, the patient was brought to the emergency unit of the ophthalmology hospital. On physical examination, the left eye had a normal appearance with a normal range of motion and 17/20 visual acuity, while the right orbit was empty and filled in with a lot of clots. Considering these findings, the primary diagnosis of orbital destruction was made, following which the orbit was irrigated and the upper eyelid repaired. Throughout the 7 days of hospitalization as well as for a further 7 days of partial bed rest at home, the patient complained of severe headache, especially prominent in the area corresponding to the frontoparietal lobe.\nAs a work-up for headache, an initial computed tomography (CT) scan was performed which demonstrated hyperdense foci of the right frontoparietal lobe, typical signs of a right orbital anterior wall fracture implying right globe destruction. Then, a brain MRI with intravenous contrast was done. The MRI study revealed the intact right globe; its related optical nerve possessed normal diameter and signal also. The globe had only herniated through the bony defect of the right orbit roof into the floor of the anterior fossa and caused hematoma and edema in the right frontal lobe, surrounding the displaced globe [Fig. –].\nConsequently, diagnostic and interventional surgery was carried out to save the intact globe cosmetically and functionally.[] Orbital exploration was performed under general anesthesia. The eyelids were opened using Desmarres retractors, and a wide opening in the fracture in the roof of the orbit and frontal bone was discovered. The orbit was examined to confirm its normal integrity. Blunt dissection was performed until the whole eyeball was clearly visible. A squint hook was passed under the insertion of the inferior rectus muscle, and the globe was gently restored to its normal anatomical location using a blunt dissector inserted into the hole. The normal attachments of the all extraocular muscles were checked one by one, passing a squint hook under each scleral insertion. Serendipitously, the four rectus muscles and inferior oblique tendon were still intact, whereas the superior oblique muscle body was partially lacerated. The globe returned into its normal anatomic site and then the hole was considered to be repaired in a way to place the separated bony parts in association with each other.\nThe patient, after 2 days, was discharged and asked to get back for out-patient visit 1 week later. However, the patient was poorly cooperative and came to follow-up visit with 1-week delay. Patient's headache came back and on eye movement examination, extraocular movements were restricted in all directions; blepharoptosis was present, without enophthalmosis. The patient complained double vision (diplopia) when the affected eyelid was elevated manually, despite 8/20 visual acuity and reactive pupil on his right eye exam. Patient's ocular motility evaluation revealed 12 prism diopter hypertropia in the primary position, in the affected eye. A temporary glass was prescribed and a follow-up visit was scheduled for reexamination and possible surgical correction for blepharoptosis and ocular realignment. In addition, the patient was advised for rehabilitation and repeat MRI examination. However, the patient unfortunately never referred again for further clinical follow-up. |
A 45-year-old female was referred to the oral and maxillofacial department of Zacamil's national hospital; the chief complaint was a right trigeminal neuralgia that could not be managed by conservative treatment. It all began 3 years before when the right maxillary first molar was extracted. Four days after the extraction her dentist diagnosed a dry socket, which was treated with an intra-alveolar dressing consisting of zinc-oxide eugenol paste; this medication was placed directly into the alveolus without any other transport vehicle. The patient experienced relief of pain and never went back with her dentist so paste remained inside the alveolus (this information was obtained directly from the medical files of the dentist that treated the patient).\nSeveral weeks later, the patient presented a right maxillary pain. She visited different dentists to find the cure to her pain, and during a period of two years third molar, second molar, first premolar, and second premolar of the right maxillary side were extracted. Hemifacial pain persisted, and the patient was referred to the neurologist who confused by the symptoms treated the patient as a trigeminal neuralgia. Carbamazepine was prescribed for about a year without pain relief; after this the neurologist sent the patient to our department.\nThe chief complaint was an intermittent right hemifacial pain, which was described as an ache with periods of intense shooting pain. A visual analog scale was used to measure it during the intermittent periods finding a severe pain. Physical examination revealed no trigger zones and clinical absence of teeth 1, 2, 3, 4, and 5.\nPanoramic, oclusal, and periapical X-rays were taken. A right maxillary foreign body was found in the position of a nonhealed alveolar bone of the maxillary first molar; the image was in close proximity to maxillary sinus (Figures and ). Due to the signs and symptoms of the patient, the foreign body was removed and curettage of the affected area was done; the findings during surgery were: a nonhealed alveolus, granulation tissue, free bone fragments, and a white solid foreign body that was in direct contact with maxillary sinus (). All tissues were sent to the pathologist who reported a well-vascularized fibrous connective tissue, chronic inflammatory infiltrate, multinucleated giant cells and necrotic bone surrounded by bacterial forms. The final diagnosis was a chronic osteomyelitis with zones of foreign body reaction. Antibiotics and nonsteroidal anti-inflamatory drugs were used the week after the surgery. The rest of the postoperative care was managed in a conventional manner without any further complications. Postoperative X-rays showed adequate healing and complete removal of the foreign body (Figures and ).\nAfter one week of surgery the patient experienced relief of pain. Visual analog scale was used during several months revealing no pain after foreign body was removed. Patient has been followed up for six months without any facial pain during this time. |
A 43-year-old Greek male builder admitted to the Accident and Emergency Department of the Hospital due to fall from a height of about 2.5 m. The patient complained of severe right ankle pain and inability to bear any weight on his extremity. In clinical examination the ankle was substantially swollen and ecchymotic, while the talonavicular and medial subtalar joints were very tender and painful to palpation. However, no neurovascular or tendon disturbances were identified. Both oblique and anteroposterior radiographs showed medial displacement of the midfoot without any evidence of bone fracture. ( and ).\nUnder general anesthesia, the subtalar dislocation was successfully reduced with manual pressure on the head of the talus and traction, plantar flexion and pronation of the forefoot. The knee was kept flexed throughout the relocation process for eliminating the tension of the soleus muscle. Afterwards, the quality of the reduction and the stability of the subtalar joint were evaluated under fluoroscopy. As no signs of anteroposterior or mediolateral instability were recognized, the ankle was immobilized in a short leg non-weight-bearing cast for 6 weeks. A post-reduction compute tomography (CT) scan was also performed to confirm the anatomic reduction of the subtalar joint dislocation and reveal any potential fractures. The CT scan showed a nondisplaced fracture of the talus body, an osteochondral fracture of the head of the talus and a nondisplaced navicular fracture (). Due to the benign character of all fractures, no surgical treatment was decided.\nAfter cast removal, an intensive foot and ankle physiotherapy program was commenced for restoring the foot and ankle mobility and preventing stiffness. The patient was limited to partial weight bearing for another 2 weeks and after that time he progressed to weight bearing as tolerated.\nAt 3 year follow up examination, the patient performed well in terms of foot and ankle range of motion. No signs of instability were identified. The good clinical result was also illustrated from the AOFAS [], ankle hind foot scale, as a total score of 90 out of 100 points was achieved. Although, the patient returned to his prior to injury occupation, he complained occasionally for mild pain. The latter was attributed to the development of sclerotic changes in the body of the talus and post-traumatic osteoarthritis in subtalar and ankle joints (). |
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. |
In September 2016, an 81-year-old woman presented with a suspect skin lesion on the ventral side of her left forearm. The patient had no prior history of skin cancer, but had received radiation treatment for a birthmark or haemangioma at the same location at the age of 4 years. Unfortunately no medical records of the patient's radium treatment could be found. She had always had a reddish pigmentation left at the spot (Fig. ), but she had recently developed an ulcer in the area that would not heal. Upon examination, there was a 10 × 15 mm superficial skin lesion with an ulcer on the skin of the ventral side of the left forearm. The element was excised with a 5-mm margin and sent to pathological examination. The pathology report showed a mixed tumour with sarcoma and carcinoma component, resulting in the diagnosis of sarcomatoid carcinoma (Fig. ). According to the pathologist the tumour fell under the classification of pleomorphic undifferentiated sarcoma. The case was discussed with the sarcoma team, which suggested re-excision with a 3-cm margin and postoperative radiotherapy. Furthermore, the patient underwent a PET-CT scan that showed a malignant suspicious process in the right liver lobe, thickening of the colon ascendens wall, and several enlarged lymph nodes over and under the diaphragm and the left inguinal area. A biopsy of the liver showed metastasis from adenocarcinoma with the colon as the possible origin. Furthermore, an enlarged lymph node from the left inguinal area was extirpated and the pathology report revealed chronic lymphatic leukaemia. Biopsies taken from the colon through colonoscopy showed adenocarcinoma with metastasis to the liver. The patient underwent surgery and chemotherapy, and her latest PET-CT scans from September 2017 showed complete remission of her cancer. Additionally, her chronic lymphatic leukaemia was in a chronic stage and she did not have to receive treatment for it. The patient is alive and is still followed up for her cancer diseases. |
A 70-year-old man presented to his local emergency department the day after sustaining a fall from a standing height. He complained of back pain but experienced no lower extremity numbness, weakness, or sciatica. On examination he was neurologically intact and ambulated without aids.\nPlain film xrays showed a 3 column fracture at L1-L2 and ankylosis of the spine compatible with ankylosing spondylitis Figs. (-). Further investigation with a CT scan showed that the fracture was an AO type C1 extension injury (Fig. ).\nAlthough surgery was discussed as a treatment option, the patient was not keen on operative stabilization of his fracture. In addition to the patient’s wishes, we also took into consideration his age and comorbidities of emphasema and peripheral vascular disease in deciding on nonoperative treatment. Therefore, he was instructed to wear a Jewett back brace while standing or walking. The patient was further instructed to avoid exercises and heavy or repetitive use of his back. His treatment plan was to monitor his progression, both clinically and with xrays, at 5 weeks, 3 months, 6 months, 9 months and 13 months.\nWhen the patient presented over time at follow-up clinics, he noted a steady continuous improvement in his back pain and his ability to function. At 3 months he was independent in activities of daily living, and had switched from his back brace to using a lumbosacral corset. At 6 months he was increasing his mobilization and was able to resume playing darts. At 9 months he reported exercising at the gym 3 times per week. At this time he also reported performing his activities of daily living with ease.\nAt the final follow-up visit which occurred at 13 months, the patient had discontinued the use of his brace. He had increased his activity and reported experiencing only minor and transient back pain after using a shovel. He had no signs or symptoms of neurologic dysfunction. At this time his x-rays showed callous formation anteriorly and laterally between the L1 and L2 vertebral bodies Figs. ( and ), mature bridging bone across the middle and posterior columns at L1 and L2 on the lateral view Figs. ( and ). There was no change in the sagittal or coronal alignments (Figs. & ). |
We present the case of a 30-year-old Nigerian male who was brought to the Surgical Emergency Department of the Lagos State University Teaching Hospital Ikeja 22 hours after he had inserted a constricting ring over his penis. He had developed a painful penile shaft swelling distal to the ring with suprapubic pain and swelling secondary to acute urinary retention. There was associated urethral bleeding.\nThere had been failed attempts at removing the ring by self and the resulting severe pain drew the attention of his relatives who brought him to the emergency room.\nHe had a history of a psychiatric illness and the patient claimed he was under a spell and had heard a voice that instructed him to insert a ring over his penis. He denied using the ring to sustain erection and claimed it was his first time of inserting a ring over his penis.\nThe patient had a history of deterioration in personal and general performance with underachievement dating back to 7 years prior to presentation when he voluntarily dropped out of the university and had done nothing tangible thereafter.\nTwo weeks prior to presentation, the patient's relatives had noticed some unusual behavior in him characterized by talking to self and rubbing salt over his body and the patient claimed he was being chased by unseen people.\nHe had a history of alcohol, cigarette, and cannabis abuse for about 15 years.\nOn examination, he was in acute urinary retention with a tender suprapubic distention up to the level of the umbilicus.\nThere was a thick constricting ring at the root of his penis. There was a markedly swollen oedematous penis distal to the ring with marked reduction in sensation over the penis and glans ().\nWe made a diagnosis of Constrictive Penile Injury (Bhat Grade III) with acute urinary retention [].\nHe had a suprapubic cystostomy done to relieve the acute urinary retention as a urethral catheterization was impossible.\nAttempts were made to remove the constricting ring by the use of aspiration, application of cold compress, and lubrication initially and later by the use of the string method.\nFollowing failed attempts at removing the device with these different manipulations and unsuccessful attempt at cutting with the manual saws available in the hospital coupled with the fact that the patient appeared to have imminent penile gangrene, a decision was made to call the fire service for a power driven saw.\nThe ring was successfully removed by cutting it at two different points () with a power driven arc saw () under conscious sedation at the emergency room.\nThermal injury was prevented by intermittent cooling with ice packs and injury to underlying tissue was prevented by insinuating a pair of artery forceps between the penis and the ring ().\nDressing of the resulting penile skin ulceration was done and the plastic surgery team was invited for possible additional wound care.\nThe patient was also reviewed by the psychiatric team who made a diagnosis of schizophrenia and commenced the patient on haloperidol. He was to be followed up on an outpatient basis in the psychiatry clinic.\nThe patient reported normal nocturnal erections while on admission. Further evaluation of the suspected urethral injury with urethrogram and a urethroscopy was planned but this was declined by the patient who opted to retain his suprapubic catheter.\nThe patient also declined any additional wound care by the plastic surgery team and the wound was healing satisfactorily by secondary intention as at 2 weeks after the initial presentation ().\nHe subsequently defaulted from care. |
The forensic pathologist was called to examine a death of a 37-year-old woman, found death in the morning, without evident signs of violence; no information was provided about the previous evening. This study was in accordance with the 1964 Declaration of Helsinki or the institution’s ethical standards, subject to informed consent obtained from relatives.\nThe young woman was previously healthy and of normal weight. All available court files were analyzed. The woman was in did not smoke, and did not drink alcohol. The general practitioner was consulted, too, and reported that her blood pressure was normal, and she was not taking any medications, and she never suffered from migraines in the past. The previous evening, she had spent some time with one of her friends. During the evening she suffered a sudden headache, nausea and unstoppable vomiting. Because of the onset of such symptoms, she returned home earlier than intended and lay on her bed to rest for the night; she apparently died during the night. No other symptoms were previously reported she was found death by her son during the next morning. Emergency medical doctors confirmed death status and reached law enforcement authorities in the context of a sudden unexpected death at domicile. The local prosecutor called the forensic pathologist to investigate the crime scene and to perform an autopsy to exclude any murder intention from others.\nThe dead body was located on the third floor of a condominium. The apartment was in order and clean. The body was still lying on the bed with blankets partially removed. On the night table, located at the right of the bed, the investigators found a roll of paper. A plastic tray was lying on the floor near the bed containing some dried brownish liquid. Under the head, the pillow and the sheet were stained with dried red liquid. Red and white liquid came out from her mouth.\nThe woman wore a t-shirt, hoodie and trousers. The upper clothes were torn apart frontally, due to cardiac resuscitation efforts. The body temperature was 38.8 °C, while the ambient temperature was 18.7 °C. Lividity was fixed, consistent with her body position. Rigor mortis was in the process of formation. Only minor scars and tattoos were found on her body, initially excluding any violence suffered during her last days. The post-mortem interval (PMI) was estimated between 4 and 8 h before the cadaveric inspection.\nAfter the approval of the public prosecutor to carry out this examination, the corpe was transported to the CT room next to the autopsy room, and was subjected to a CT investigation. The analysis of the CT images was conducted by specialist forensic radiologists. The corpse was placed inside two sterile and waterproof bags to avoid contamination of the equipment. Scans were performed in the supine position from head to toe. Post-mortem imaging was performed using a helical 16-slice CT scanner (Philips Ct Brillance 16, Catania, Italy) The time interval between death and PMCT was about 48 h, PMCT showed multiple signs of intracerebral hemorrhage, originating from the cerebellum and basal ganglia ().\nIn the chest region, some zones of grater opacity mostly of ground glass type, confined in dependent regions (), explainable as normal distribution of blood and air volume after death []. No fractures were identified on total body PMCT ().\nAutopsy was performed about 48 h after death: external examination was unremarkable.\nThe examination of the head and neck was performed through a posterior approach, this cut allowed to respect cervical medulla, pons, cerebellum and brain integrity (). Vertebral arteries were extracted and preserved along with the carotids and the circle of Willis. A section of the optic nerves was performed at the chiasm. The section continued dissecting the tentorium, preserving the brain and cerebellum. The brain had herniated signs to the opposite side of the bleeding. During the autopsy, the larynx and trachea were open, and there was blood and mucus inside. Autopsy was completed by dissecting the remaining anatomical regions after a thoracic-abdominal section, followed by organs extraction taking care to preserve anatomical relations as much as possible. All organ samples were preserved in formaldehyde and stained in Hematoxylin Eosin for histological analysis. All cephalic, thoracic and abdominal tissues were then examinated.\nPMCT findings were confirmed: a massive area of hemorrhagic suffusion was identified after dissecting the cerebellum, mainly in the anterior inferior cerebellar artery perfusion area. Moreover, on the medial side of the right cerebellar hemisphere, a protrusion region, with a range of less than 2 cm, was identified. The exact affected part of the anterior inferior cerebellar artery was not identified. An intense hemorrhagic infiltrate in the subarachnoid space was observed. Both neurological and vascular structures were examined during autopsy and after formalin fixing. After coronal section, the brain was regular in size and displayed small diffuse cerebral hemorrhages of the right frontal and parietal lobe. The right side of the brain stem showed the same lesions ().\nThe heart was 12 × 10.5 × 5 cm and weighed 350 g. The lungs were of regular shape and volume, measuring 23 × 16 × 3.5 the left and 23 × 16 × 6 the right. The left lung weighed 950 g and the right one 750 g, a small white foam protruding from the lung parenchyma. Other organs showed only an intense vascular congestion.\nA toxicological analysis was performed and excluded substances of abuse in the liquids and organs of the cadavers.\nMicroscopy with hematoxylin-eosin staining was carried out and in the brain cortex samples, it was possible to identify a suffusion of erythrocytes in the sub-arachnoid region. In cerebellum samples it was possible to identify a massive suffusion of erythrocytes and other blood elements along the margin of the structures. Most arterial and venous vessels were crumpled with a wavy endothelium. Vascular structures near the cerebellum vermis showed evidence of an arterio-venous malformation, with several intertwine vessels of variable diameter, surrounded by hemorrhagic evidences. In some regions, the hemorrhagic suffusion also affected the cerebellum parenchyma. A Masson’s trichrome stain was performed, which confirmed the AVM. (). The rest of the samples (heart, lungs, liver, kidneys, spleen) were not significant, however. They did show intense vascular congestion.\nThe cause of death was due to a massive intracerebral hemorrhage caused by a ruptured AVM located in the choroid plexus of the fourth ventricle. The compressive action caused by the cerebral hypertension due to the hemorrhage caused an impairment of vital functions. The symptoms she suffered the previous evening, along with PMCT, autopsy and histological findings, support this diagnosis. |
The patient was a 54-year-old Italian Caucasian female. She was a non-smoker. She was evaluated in our hospital for recent onset of pain and tenderness in the left breast. She referred swelling of the breast, but denied nipple discharge. Her past medical history was not significant. Her family history was not significant for breast cancer; she denied oral contraceptives use in the past and she give birth to one child. Her most recent Pap smear had been negative for any squamous lesion. Physical examination revealed erythema, hyperaemia and tenderness to touch of the left breast. A palpable well circumscribed and firm mass measuring about 40 mm was present in the left inferior lateral quadrant. The right breast examination was normal. There was no evidence of lymphadenopathy on physical examination, including the axillary and supraclavicular regions.\nShe underwent an ultrasound examination of the left breast, which revealed a defined 29 mm mass with a thick rind and reduced central echogenicity, consistent with a cystic space. Mammography showed a round, high-density mass with almost regular but partially irregular margins, measuring approximately 30 mm.\nFine needle aspiration cytology revealed an infiltrative poorly differentiated squamous cell carcinoma.\nTotal body CT scan, bone scan, laboratory data (blood count, serum electrolytes, liver function tests, creatinine, prothrombin and partial thromboplastin time), tumors markers, including the levels of serum carcinoembryonic antigen, carbohydrate 15-3 and squamous cell carcinoma antigen were within normal range.\nThe patient underwent a wide local excision of the left breast with ipsilateral axillary lymph nodes dissection. Gross examination revealed a 4.7 cm tumor with central cystic space located in the center to lower outer quadrant of the left breast. There were no component of obvious invasive ductal carcinoma or other features of metaplastic carcinoma for example spindle cells, or osseous or cartilaginous metaplasia. It revealed large squamous cells with keratinizing eosinophilic glassy (Figure ). The lesion tends to be differentiated sufficiently to form keratohyaline granules. The central cystic space contain keratin and necrotic debris (Figure ). Vascular or neural invasion was not identified. There was no involvement of the skin or skin adenexae of the breast or the nipple. The uninvolved mammary parenchyma contained fibrocystic changes. Seventeen axillary lymph nodes were dissected and they were negative for metastatic disease. Immunohistochemical evaluation was negative for estrogen receptor (ER), progesterone receptor (PgR) and Her2/neu overexpression and positive for EGFR. Ki-67 proliferation index was unfavourably high at 60%.\nThe patient received an adjuvant therapy based on 5-Fluouracil 600 mg/mq day 1 and Cisplatin (CDDP) 25 mg/mq days 1, 2, 3 every 3 weeks for six cycles. Afterwards patient refuse radiation therapy to the residual left breast.\nTwenty-eight months after surgery the patient was asymptomatic and disease free. |
A 73-year-old white man presented to our emergency department with a 3-day history of left lower extremity swelling and acute-onset shortness of breath. On evaluation, he was tachycardic with a pulse of 113, hypertensive with a systolic blood pressure of 130-170 mmHg, and demonstrated poor oxygen saturation of 81% on room air. He was supported with continuous positive airway pressure (CPAP) and supplemental oxygen while a computed tomography angiogram (CTA) was obtained, which revealed a saddle PE (Fig. ).\nTissue plasminogen activator (tPA) was administered and he was started on a heparin infusion and admitted to our intensive care unit (ICU) for management. He remained on the heparin infusion for 3 days, during which he continuously improved and was eventually weaned to 3 L oxygen via nasal cannula. On hospital day 2, he was transferred to intermediate level of care. Per hematology recommendations, he would have to be on indefinite anticoagulation due to the massive PE he had sustained, the source of which was a left lower extremity popliteal deep vein thrombosis (DVT). The plan was to transition him from the heparin infusion to enoxaparin twice per day with hematology follow-up in 1 month.\nOn the day of discharge, however, he had sudden onset of right leg numbness and weakness below the level of his hip. He had previously been working with physical therapy and had been able to walk 200 feet with the assistance of a walker during each session. A physical examination revealed decreased sensation to light touch, 2/5 strength in right hip flexion and right knee extension and flexion, and loss of right patellar reflex. Left leg physical examination was normal at that time.\nAn emergent head computed tomography (CT) scan was ordered due to concern for a possible stroke, and neurology was consulted. The head CT was negative for infarction or hemorrhage. Neurology was concerned for spinal cord infarction versus hematoma and recommended emergent magnetic resonance imaging (MRI) of his thoracic and lumbar spine. The MRI revealed a left psoas hematoma (Fig. ). A CT of his pelvis performed the same day also showed a right psoas and iliacus hematoma. Due to these findings, hematology recommended discontinuing enoxaparin and reverting to a low intensity heparin infusion, as well as placement of an inferior vena cava (IVC) filter. The following day his left leg began exhibiting the same symptoms as his right leg. There was concern regarding the risk of progressive and irreversible nerve damage due to compression if the hematomas were not promptly drained. IR was consulted and advised that if the drainage were to occur while our patient was on anticoagulation, the risk of rebleeding into the retroperitoneum would be high and potentially nullify any benefit from drainage. Our patient would also be at risk of hemodynamic instability if the current hematomas were acting as tamponades against further bleeding. An additional complicating factor was the risk of further thrombosis due to the presenting saddle PE. Hematology was consulted for recommendations on pausing anticoagulation, but they were hesitant to offer a timeframe as there was no established safe period to enable this type of procedure to take place. Eventually, a window period of pausing the heparin infusion for 3 hours pre-procedure and up to 6 hours post-procedure was decided upon in the event that our patient agreed to have the drainage performed.\nThroughout this sequence of events, our patient and his wife were aware of the plans and considerations on how to proceed. They were informed of the recommendations and concerns made by neurology, hematology, and IR, as well as the risks and benefits of intervention versus non-intervention.\nAfter speaking with his wife, our patient decided to undergo the procedure. The low intensity heparin infusion was stopped 3 hours beforehand and the IR team then performed drainage of the right retroperitoneal hematoma, placing two pigtail catheters in our patient’s right flank (Fig. ). In total, the hematoma was drained of 215 milliliters of blood, 10 milliliters of which were drained during the procedure itself. The left psoas hematoma was not found to be amenable to drainage.\nOur patient tolerated the procedure well, and the heparin infusion was restarted 6 hours after it was completed. A repeat neurological examination demonstrated improved lower extremity strength bilaterally as well as the return of sensation to light touch. Hip flexion improved to 3/5 bilaterally, and knee flexion and extension improved to 4/5 bilaterally. Deep tendon reflexes remained absent. Four days later, the pigtail catheters were removed. His recovery was complicated by anemia requiring blood transfusions totaling 4 units of packed red blood cells (PRBC). Other sources of potential bleeding were evaluated and not found. A repeat CT on hospital day 10 (Fig. ) showed a stable right-sided hematoma, and our patient did not experience any further neurologic deficits. He was transitioned again from the heparin infusion to enoxaparin after 3 more days. His hemoglobin and hematocrit remained stable. During this time, he worked with physical therapy, who recommended discharge to a skilled nursing facility where his strength began to improve somewhat. Follow-up was scheduled with neurology and hematology. On hospital day 18, he was safely discharged. |
A 6-year-old boy presented to our hospital with a hard neck mass. He did not complain of pain or discomfort in the neck. His parents stated that the mass was observed immediately after he was born and it had grown gradually with age, especially in the past 2 years. He had never been treated before for the mass. He had no history of trauma or persistent fever. His mother's pregnancy and delivery history were normal and the boy exhibited normal growth and development at 6 years of age, with no relevant family history. Physical examination revealed a hard, immobile mass posterior to the cervical spine (Fig. ). There was no swelling or tenderness of the mass. The mass was oval, measuring 3 × 1 cm. The skin temperature was normal and the skin was not attached to the mass. There was no sign of local compression of nerves, arteries, or veins. The patient had full cervical range of motion and the mass was more evident with flexion. No masses were detected elsewhere in his body. His neurological examination was unremarkable. No pain was evoked during the physical examination. All laboratory findings were normal.\nPlain radiographs (Fig. ) showed an anomalous bone attached to the left side of the C5 (the fifth cervical) vertebra. Magnetic resonance imaging of the cervical spine showed a normal spinal cord and intervertebral discs (Fig. ). It also revealed a well-circumscribed cortical bone within the dorsal cervical muscles (Fig. ). Two- and 3-dimensional computed tomography revealed a finger-like bone with a pseudoarticulation attached to the hypoplastic spinous process of the left side of the C5 vertebra (Figs. and ). The anomalous bone had an obvious cortex and medulla osseous structure (Fig. ).\nThe patient was diagnosed with a “cervical digit.” Because of its gradually increasing size and esthetic complaints, the patient underwent surgical excision of the anomalous bone trough a posterior midline approach. Intraoperatively, the bony mass was found to have a pseudoarticulation with the spinous process of C5. No obvious structure was found to connect the bony mass to the surrounding soft tissue. The bone was removed together with the pseudoarticulation and part of the hyperplastic spinous process of C5 (Fig. ). Histological examination showed that the specimen consisted of normal bone and cartilage. The postoperative course was uneventful and the boy returned to a normal life. At the 2-year follow-up, he was symptom free and there was no recurrence. This study was approved by the ethics committee of The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University and the informed consent was obtained from the patient. |
Mrs A is a 43 year old female with a diagnosis of schizoaffective disorder. She was transferred to the National Psychosis Unit, a tertiary referral in-patient service which specialises in the management of treatment resistant psychotic illness. On admission she presented as dishevelled, agitated, thought disordered and labile in mood. She expressed grandiose and paranoid delusions, 3rd person auditory hallucinations and visual hallucinations of large wild cats. Negative features included apathy and withdrawal. Mrs A had little insight into her illness. These symptoms had persisted largely unchanged despite in-patient management and compliance with antipsychotic and mood stabilising medications for the previous 6 months. These visual experiences were evident during the day in clear daylight and consciousness, but worse at night when she was alone in her bedroom; on admission, she would choose to sleep in the corridor so as to avoid these creatures- and had been doing so for over 6 months.\nMrs A first became unwell with features of a schizoaffective disorder at the age of 19. Following treatment and discharge there was a period of relative stability over the next 20 years during which she was under the care of her local community mental health team (CMHT). At the age of 40, Mrs A was again admitted following a breakdown in her ability to function in the community due to deterioration in her mental state. Various treatment strategies were utilised during this period, including clozapine, following failure of combinations of other atypical antipsychotics and mood stabilisers. She had responded well to a combination of clozapine, aripiprazole and escitalopram in terms of a reduction in persecutory delusions and auditory hallucinations, however her visual hallucinations remained vivid. These had then taken greater prominence in Mrs A's mental state and this subsequently led to more subjective distress. Socially she was quite isolative and did not maintain any relations with family or friends Her presentation was not thought to be related to non compliance, drug and alcohol misuse or psychosocial stressors. Physical Investigations were unremarkable. MRI and EEG were reported as normal and blood indices including thyroid function tests, copper, caeruloplasmin and autoantibody screens were negative.\nMrs A's PANSS score on admission was 79 (p30, n15, g34) and MMSE was 30/30. The pharmacological management plan was to commence and maintain semi-sodium valproate within therapeutic plasma levels, reduce and discontinue her clonazepam and to restabilise on clozapine therapy. Following 4 months of this therapy with clozapine at a dose of 450 mg per day and in combination with psychological and occupational therapy, Mrs A's mental state stabilised with marked improvement in her delusions and auditory hallucinations, stable mood and better function. Her PANSS rating improved to a total score of 52 (p14, n13, g 25). Despite these improvements on clozapine, Mrs A continued to experience vivid visual hallucinations of tigers and lions.\nA decision was made by the multidisciplinary team to begin an AChEI, Rivastigmine to target visual hallucination symptoms. Rivastigmine patches at 4.6 mg/24 hrs was initiated. No changes were made to all other psychotropic medications. PANSS rating scales and MMSE scores were done on two occasions following the addition of rivastigmine patches to therapy. In addition a tailored visual hallucination rating scale was developed, adapted from the Psychotic Symptom Rating Scales for auditory hallucinations (PSYRATS) []. This consisted of 3 items measuring frequency, vividness and distress associated with the hallucinations. Items were scored 0-4 (frequency and distress) or 0-3 (vividness), and were clinician-rated. Ratings were taken daily by the primary or allocated nurse in the two weeks prior to treatment with rivastigmine and during treatment.\nMrs A continued to show an improvement in her functioning, demonstrated by the fact she now slept consistently in her own bedroom at night, was independent in her self-care, and started to participate in community outings and OT activities. Mrs A's level of occupational and psychological therapy input remained stable throughout the introduction of rivastigmine patches, and focused on reducing the distress and interference with daily activities associated with the visual hallucinations. No further medication changes were made to her pharmacological therapy. Mrs A suffered no untoward side effects from the rivastigmine patches. Two weeks following the addition of rivastigmine patches her PANSS total score was 45 (P 13, N 10, GP 22) and this improvement was maintained as her PANSS total score at 7 weeks was 43 (P 11, N 10, GP 22). Over the baseline assessment period, Mrs A continued to report distressing visual hallucinations throughout the day. After the rivastigmine treatment was initiated, after 3 weeks of treatment, reporting of visual hallucinations was decreased to once a day on average, and the level of distress was significantly reduced. This one appearance a day was usually reported as seeing a lion or tiger in her bedroom when she woke up in the middle of the night. Slowly, even this report became much more ambiguous; the animals were more unclear at night and she had more difficulty making them out. Subjectively, Mrs. A reported that she thought the patches were helpful and she was seeing the animals less frequently than before. She was discharged from hospital and at 6 month follow up was living independently quite successfully, with support from her locality mental health team, and remaining free from visual hallucinations and continuing her rivastigmine. |
A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast (Fig. a). We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved (Fig. b). Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space (Fig. ). At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.\nThe surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen (Fig. ). The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion (Fig. a). Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) (Fig. b). After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery. |
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 10-year-old male patient presented with a painless mass in the right temporomandibular region. The swelling was evident since one month and it was hard and sensitive to palpation. The patient was able to open widely; the mandible could move in all axes without any limitation. The lesion caused facial asymmetry. There was no paresthesia in the area innervated by the right mandibular nerve or by the right facial nerve. The boy did not have any previous trauma in the swollen region [Figure ].\nA posterior-anterior radiography of the skull was obtained revealing a radiolucent region in the condyle of the right mandible [Figure ]. A three-dimensional CT reconstruction showed the presence of a radiolucent and multilocular lesion in the condyle region. It was possible to appreciate that the lesion had totally replaced the mandibular right condyle and part of the mandibular ascending ramus. The lesion substituted the bone marrow of these anatomical structures and the cortical bone was substantially expanded and perforated. The condyle was so ballooned that it was evident through extra oral examination. Part of the coronoid process was affected by the infiltrative osteolytic process [Figures , and ]. The magnetic resonant imaging (MRI) demonstrated a high-signal intensity within the lesion itself and a low-signal at the periphery [Figure ]. The clinical presentation and the radiographic appearance of this lesion could have been associated to osteosarcoma, ameloblastma, myxoma or central giant cell granulomas therefore the decision for surgical excision was taken. The operation was performed under general anaesthesia. A preauricular incision was performed to identify the ATM joint capsule and thereafter the condyle. This structure appeared deformed and increased. The mandibular cortex overlying the cyst was noted to be thin and actually translucent in some places. Upon removal of the outer cortex of bone, thick greenish fluid was encountered, immediately followed by brisk hemorrhage which was difficult to control. Afterwards a low condylectomy was performed. The lesion underwent a complete surgical excision [Figures , ]. The final histological diagnosis was aneurysmal bone cyst described as an expanding osteolytic lesion containing blood-filled spaces of variable size, separated by connective tissue constituted by bone trabeculae or osteoid tissue and many osteoclastic giant cells.\nPatient's occlusion did not change after surgery however it was evident that the mandible shifted on the right side during opening [Figure ]. The patient underwent throw physiotherapy and functional treatments with Bionator. This device helped the boy to have a good occlusion during his growth. The patient came monthly to our orthodontic department for functional exercises and to upgrade the Bionator. |
An 80-year-old man was admitted to our hospital for the treatment of a rectal tumor found incidentally by rectal examination. The tumor, about 3 cm in diameter, was located on the right side of the lower rectum 3 cm above the anal verge. The pathological analysis of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) indicated that the rectal cancer invaded into the muscularis propria without distant metastases and that lateral pelvic lymph node (LPLN) was not enlarged with a maximum long-axis diameter <3 mm. The most important problem was that the patient had a huge benign prostatic hypertrophy, the size of which was 85 × 80 × 70 mm (Fig. a–c). To achieve complete TME with negative CRM, a hybrid transabdominal-transanal approach for ISR was conducted.\nFirst, vascular division and mobilization of the left colon were performed laparoscopically. The transabdominal approach was continued until the anterior dissection of the rectum became difficult due to a huge prostatic hypertrophy. Next, the circumferential rectal incision and subsequent intersphincteric dissection were performed under direct vision to enable attachment of a single port device (GelPoint Mini; Applied Medical). After closure of the anal orifice, the GelPoint Mini was placed to start the transanal approach. Posterior side of the rectum was first dissected until the transanal approach was connected to the dissection layer made by the transabdominal approach. The dissection procedure was extended to the lateral side. Bilateral pelvic splanchnic nerves were identified at the 5 and 7 o’clock positions. At the anterior side, the proper dissection layer cannot be easily identified because of the perineal body and the enlarged prostate. Once the dissection plane between the rectum and the prostate could be identified, it was relatively easy to continue along the same plane. The assistance provided by the laparoscopic approach was useful to determine the appropriate dissection line in the transanal approach. |
A male patient aged 65 and in good health conditions required a complete rehabilitation of the jaw. As it can be observed in the orthopantomography (), he was completely edentulous and used two conventional removable prosthesis. It was decided to rehabilitate his lower jaw with Nobel Trefoil system surgical protocol.\nAfter locoregional anesthesia into the vestibular and lingual mucosa of the mandible, a crestal incision connecting the two first molar regions was performed, and the alveolar ridge was exposed. The lingual flap was then sutured with a 2/0 silk suture in order to facilitate surgical proceedings and improve visibility.\nOnce the vestibular and the lingual mucosa had been protected with retractors, the surgeon regularized the alveolar ridge with an osteotomy drill. The aim of this step is to obtain a flat surface and an adequate thickness on the ridge for the application of the surgical guides and the following implant insertion ().\nWith a pilot drill, the surgeon performed a guide bore in the center of the mandible and verified the correct orientation in occlusion with a parallelism pin. After that, the first surgical guide was positioned and fixed with a pin in the cavity previously drilled. The same guide has two other bores where the two distal implants will be placed. In these positions with the pilot drill, two new guide perforations were performed and used to fix the surgical guide. The first pin was thence removed and with the help of metal bushings of increasing diameter (from 3.00 mm to 5.00) mounted in the center bore on the guide the operator prepared the first implant site and inserted the fixture (Nobel Trefoil Implant 5.00 × 13 mm, Nobel Biocare, Zurich, Switzerland) ().\nThe surgical guide was removed and a new one was initially fixed on the implant. This second guide differs from the first because of the presence of two further bores next to the central one which is used to lock the guide and prevent it from rotating. Once this guide was completely locked even with appropriate pins in the cavities described, the bores in correspondence of the distal implants were, therefore, free and ready for the site preparation. A surgical template with metal bushings on its ends, different from that used for the first implant, was applied on the surgical guide and used to prepare the distal implants sites ().\nWhen the insertion of the distal fixtures (Nobel Trefoil Implant 5.00 × 13 mm, Nobel Biocare, Zurich, Switzerland) was completed even, the second guide was removed, and the prefabricated titanium bar was screwed onto the implants to check its fitting ().\nNext, the bar was substituted with the healing caps so that the surgeon could suture the flap around them with 4/0 resorbable thread ().\nAs a last step, the transfers were placed on the implants and splinted together with composite in order to give the technician the right position of the fixture to build the prosthesis on the titanium bar ().\nAbout four hours after the surgery, the prosthesis was screwed on the implants and functionalized in occlusion ().\nThe patient underwent a follow-up program and orthopantomographies were taken at six, eighteen, and thirty months after the surgery (). The fixtures and the prosthesis appeared in good health both clinically and radiographically during the last control visit. |
A 60-year-old female with no significant past medical history presented with primary hyperparathyroidism. She was asymptomatic with slightly elevated serum calcium and parathyroid hormone (PTH) levels. The sestamibi scan did not show any uptake, while the computed tomographic scan (CT) of the neck showed an incidental right paraesophageal air-filled diverticulum with multiple thin septations (). During surgery, three and a half parathyroid glands were explored and resected resulting in the drop of blood PTH level, confirming the diagnosis of parathyroid hyperplasia. In addition, a cystic structure densely adherent to the trachea was found in the right tracheoesophageal groove. Blunt dissection was performed around this mass without difficulty, though tissue planes between the mass and the trachea could not be readily separated. Sharp dissection was then performed to complete the resection off the tracheal wall over the small surface area to which it seemed attached. There did not appear to be any apparent lesion left attached to the trachea and there was no tracheal injury or entry point noted at this time. The specimen was sent for intraoperative assessment, which revealed several lumina/cystic spaces lined by ciliated columnar epithelium with mild lymphocytic infiltrate and salivary-type glands in the adjacent fibrous tissue. Given the absence of apparent tracheal entry point, no formal repair of the trachea was undertaken, though the patient was monitored postoperatively for any signs of tracheal communication. In the absence of detailed clinical information, based on these histologic findings, a tracheal diverticulum, laryngocele, or bronchogenic cyst was favored. Lymphoepithelial cyst and branchial cleft cyst were also considered in the differential diagnosis.\nThe specimen submitted for pathologic examination consisted of a 2.4 × 1.5 × 0.8 cm tan brown multiloculated/cystic structure with some attached adipose tissue. The cyst wall measured 0.1 cm in thickness. An opening of 0.2 cm in diameter was noted on one aspect of the lesion ().\nHistologic examination of the entire lesion confirmed the presence of cystic spaces lined by respiratory-type ciliated columnar epithelium, minor salivary gland tissue, and lymphoid aggregates (Figures and ). Given the morphologic, imaging, and operative findings, the diagnosis of tracheal diverticulum was rendered. Branchial cleft cyst and bronchogenic cyst were also considered in the differential diagnosis but were not favored for reasons mentioned in the discussion. |
A 57-year-old man was admitted on March 2006 to our hospital referring acute pain when accidentally injured by a plastic object at head. He mentioned a palpable, soft, immovable and tender mass at the left temporal bone. His left orbit was also painful. He had already used analgesic and anti-inflammatory drugs. No fever, elevated regional temperature nor lymphadenopathy was recorded. The physical and neurological examination had no pathological signs. He did not present numbness, weakness or remarkable tendon reflexes and muscular tone. The mobility of the head was normal. The vision and hearing was not affected.\nThe patient had a height of 1.78 m and weighted 80 kgrs. He belongs to Arabic nation (born in Lebanon) but he has the Greek ethnicity living in Greece the last 40 years. 31 years ago psoriasic arthritis was diagnosed with the joint of the left elbow mainly affected. He received no therapy for the disease. 10 years ago he presented acute myocardial infarction and undertook bypass. Since then he received drug therapy for hypertension. The patient smoked 2 packs of cigarettes since the age of 25 and consumed 1-2 glasses of alcohol per day. No family history of tumors is known.\nBlood examination revealed no pathological findings, neither elevation of leukocytes nor of erythrocyte sedimentation rate. Heart ultrasound revealed no present pathology.\nA first attempt to excise the lesion failed as there was an erosion of the temporal bone. Material for histological examination was extracted and we found a domination of histiocytes. No malignancy was suspected. We continued with radiological depiction of the skull.\nPlain radiographs demonstrated a large oval-shaped osteolytic area in the left temporal bone [figure ]. Its borders were regular and no bone formation was noted. Its size was about 2 cm. CT verified a lytic lesion at the left temporal bone of the skull [figure ]. The estimated size was 1.8 × 1.6 cm. The borders were sharp and periosteal reaction was obvious. The meninges were almost exposed to environment and that is the reason why a moderate injury led to intense pain. No fluid was present. Scintigraphy with Tc-99m demonstrated a non absorbent focus in the left temporal bone [figure ]. Left elbow was also depicted as highly absorbent because of the psoriatic arthritis. No secondary or multiple foci were enhanced.\nA radical excision of the lesion on health borders of 2 cm was performed. The tumor was gelatinous and brownish without hematomas. It was perforating the whole diploe and part of the external meninga. We excised a piece of a diameter of 5 cm including the lesion and used a periosteal transplant to bridge the gap. No cranioplasty was done at first time. The patient received vancomycin and cefoxitime for two days. Material was sent for histological examination which showed many Langerhans cells, eosinophils, neutrophils and lymphocytes. No fibroblasts or giant cells were found. The S-100, CD1a and Langering proteins were positive. There were necrotic elements too. Diagnosis of eosinophilic granuloma of the skull was set. The patient was administered five cycles of low-dose post-surgical radiotherapy were administered.\nCarnioplasty with a heterologous transplant (Porex) was performed eight months later. The aesthetic result was excellent and there were no complications. On March 2008, a new CT of the brain depicted no further lesion and the aesthetical result was excellent. |
A 41-year-old Japanese male presented impairment of consciousness by wide QRS tachycardia (Fig. a). Although his systolic blood pressure has been kept around 60–70 mmHg during the tachycardia, his conscious level was moderately impaired to E1V2M4 in the Glasgow Coma Scale. At his arrival at a hospital, he was immediately sedated and intubated by emergency physicians who assessed his condition as a cardiogenic shock. The tachycardia self-terminated soon after the administration of the sedative. He had a history of a surgical closure of an ASD at 20 years old. After that surgery ~ 20 years earlier, his QRS interval had gradually increased to 198 ms, and in the 2 years prior to his presentation at our hospital, right bundle brunch block morphology became evident (Fig. b). Because the QRS axis of the tachycardia matched that of sinus rhythm, we suspected supraventricular tachycardia (SVT). After the initial assessment, we decided to observe his condition overnight in an intensive care unit under the sedated and intubated condition.\nIn the intensive care unit, his sinus bradycardia seriously worsened during that night while he was under sedation, and he developed polymorphic ventricular tachycardia (VT) followed by ventricular fibrillation (Fig. ) which required a cardioversion. As a marked sinus bradycardia continued, transcutaneous ventricular pacing was initiated, which increased his heart rate and successfully suppressed the recurrence of ventricular tachycardia. We considered that this arrhythmia was not identical with that observed in the initial event where the QRS morphology was stable and the blood pressure was kept above 60 mmHg. During these arrhythmic events, no prolonged QTc interval was recorded.\nIn an electrophysiological study, programmed electrical stimulation (PES) from the right ventricle easily induced polymorphic ventricular tachycardia that sustained and degradated to ventricular fibrillation. Sustained monomorphic VT was never induced during the study. The patient’s SVT was identified as right atrial incisional tachycardia circulating around the scar in the right atrium (Fig. ). The post-pacing interval at the upper end of the scar matched the tachycardia cycle length (Fig. a, b, left panel). At this site, radiofrequency catheter ablation successfully terminated the tachycardia (Fig. b, right).\nTo prevent sudden death by further attacks of ventricular fibrillation, the patient underwent implantable cardioverter-defibrillator (ICD) implantation. His bradycardia was treated by the pace-making therapy afforded by the ICD. Under an 80-bpm DDD-pacing condition, his heart beat was fully paced, and the polymorphic ventricular tachycardia was successfully suppressed. During 18 months’ follow-up, he has never experienced further arrhythmic events and there were no adverse events related to interventions he received. He returned to work as before, and is satisfied with the treatment results he received.\nThe patient’s severe sinus bradycardia, progressive QRS widening, high voltage amplitude of R’ wave in the right precordial leads, and recurrent ventricular arrhythmias indicated that the patient had cardiac sodium channelopathy like PCCD and Brugada syndrome. We then performed genetic screening for inherited arrhythmias by targeted gene sequencing. The genetic analysis revealed a heterozygous SCN5A c.4037–4038 del TC, p. L1346HfsX38 variant (Fig. ). The 2-bp deletion in exon 23 of SCN5A induced the truncation of mRNA, leading to nonsense-mediated mRNA decay (NMD), and thereby decreasing the expression level of the cardiac sodium channel Nav1.5. The same variant was also detected in the genomic DNA from the patient’s asymptomatic mother. Her ECG manifested only mild QRS widening with 130 ms QRS interval and slight sinus bradycardia (HR 50-56 bpm). This variant had not been reported in large genomic databases such as gnomAD () and TOGOVAR ().\nIn the American College of Medical Genetics and Genomics (ACMG) guideline, this variant is classified as “likely pathogenic” with one PVS1 (null variant) and one PM2 (not observed in population databases).\nWe diagnosed this patient as having a PCCD and polymorphic ventricular tachycardia due to the SCN5A loss-of-function variant. Postoperative SVT with wide QRS morphology was a by-standing comorbidity related to the history of cardiac surgery which could miss lead the diagnosis. |
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 45-year-old Hispanic female presented to our community hospital with sudden onset of expressive aphasia, dysarthria and right upper extremity weakness. This patient was last known well one hour prior to arrival. Head computed tomography (CT) demonstrated a subacute hypodensity in the left cerebellum. Perfusion CT imaging demonstrated a deficit on mean transit time concerning for watershed type stroke versus a distal left middle cerebral artery occlusion.\nThe patient has a past medical history of hyperlipidemia and chronic anemia status post gastric bypass surgery several years prior to presentation. She denied alcohol, tobacco, or illicit drug use. She denied family history of stroke, heart conditions, or coagulopathies. Her home medications included atorvastatin 40 mg PO daily and cyanocobalamin 1000 mcg PO daily.\nOn the first day of admission, the patient underwent emergent neurointervention with cerebral angiogram and mechanical thrombectomy of the left middle cerebral artery secondary to significant findings on CT cerebral perfusion imaging. Following intervention, the patient was globally aphasic with gross right upper and lower extremity weakness but able to follow simple commands. Magnetic resonance imaging (MRI) of the brain demonstrated multiple large and small infarcts of the left parietal lobe and left basal ganglia, with an older infarct of the left cerebellum (Figure ). Given the distribution of multiple areas of infarction on MRI, it was suspected that the source of ischemic stroke was thromboembolic in nature.\nTransesophageal echocardiogram demonstrated a positive agitated saline test confirming the presence of a patent foramen ovale. CT angiogram of the chest demonstrated minimal minute filling defects of the right inferior pulmonary arteries consistent with small pulmonary emboli. Doppler ultrasound studies of bilateral upper and lower extremities were negative for thrombus. Hypercoagulable workup including testing for antiphospholipid antibodies, factor V Leiden, protein C, protein S, antithrombin III activity, prothrombin gene mutation, and homocysteine levels were unremarkable. Further investigation into thrombogenic source was warranted and magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) of the pelvis were completed. Three-dimensional (3D) reconstruction of the imaging studies revealed a focal narrowing of the left common iliac vein at the level of crossing of the right common iliac artery (Figure ). To date, the patient had denied symptoms of lower extremity edema or claudication and had never demonstrated physical findings of chronic venous insufficiency. The patient underwent intravascular ultrasound (IVUS) and fluoroscopic-guided iliocaval venography which demonstrated a 52% stenosis of the distal portion of the left common iliac vein at the level of the right common iliac artery compatible with May-Thurner pathology. After discussion and review of the imaging with the patient, she elected to undergo minimally invasive intravascular stenting of the left common iliac vein.\nGiven her history of multiple cerebral infarctions and recent diagnosis of May-Thurner syndrome, the patient was determined to be at risk for recurrent cerebral vascular accident (CVA) and underwent closure of the PFO. Her Risk of Paradoxical Embolism (RoPE) score was calculated to be 7, demonstrating a 72% probability the stroke was due to a pathologic PFO and a 6% chance of recurrent CVA []. The patient received supportive care, daily physical therapy, and speech therapy for the duration of her hospital course. The patient was started on dual antiplatelet therapy and full dose anticoagulation prior to discharge to a rehabilitation facility. With therapy, the patient had improvement of her right hemiplegia and aphasia. |
A 36-year-old Hispanic male presented to the vascular clinic on February 4, 2015, with a history of progressive left lower extremity pain with walking for 1 month. The patient noted a marked decrease in his walking distance over 1 month before his evaluation. At presentation, he was able to ambulate 50–75 feet only before the onset of left calf pain. On January 8, 2015, the patient underwent bilateral varicocelectomy for bilateral varicoceles associated with primary infertility. He admitted to having complications postoperatively, consisting of a large left groin hematoma and left leg pain. The hematoma was treated conservatively with observation and antibiotics. The left groin hematoma resolved 1 week postoperatively, but the left leg pain was increasing, especially with ambulation. He was assured by the operating surgeon that his surgery was successful and that the leg pain was temporary. However, the patient presented to our vascular surgery clinic, seeking a second opinion. His past medical history was unremarkable. He denied any history of tobacco use, hypercholesterolemia, hypertension, diabetes mellitus, or lower extremity trauma. He was without any systemic complaints. At the time of presentation, the patient denied taking any medication. The physical examination was remarkable for normal upper extremity pulses and blood pressures. The lower extremity examination was remarkable for bilateral groin scars, no swelling or hematoma, absent left femoral and pedal pulses, and normal right femoral and pedal pulses. There were no motor or sensory deficits. Ankle-brachial indices were 0.5 on the left and 1.0 on the right. Cardiac and other investigations were normal, although these do not exclude arterial emboli completely. Computerized tomographic (CT) angiogram was requested, and the patient was asked to bring a copy of his previous surgery report. CT angiogram showed complete occlusion of the left common femoral artery up to its bifurcation with normal runoff (). The varicocelectomy surgical report denied any vascular complications apart from minor intraoperative bleeding from the left side controlled by stitches. The patient was informed about the CT angiogram finding and that he needed revascularization of his left leg with the possibility of using a vein graft. On February 7, 2015, through a left groin longitudinal incision, the left common femoral artery was controlled with vessel loops (). Upon dissection, the femoral artery was observed to be completely destroyed, with no anatomical configuration except for fragments of the wall (). At the bifurcation, the profunda and superficial femoral artery were normal with a thrombus at the stump. The incision was extended along the great saphenous vein, which was harvested. A reversed interposition saphenous graft between the left common femoral artery and its bifurcation was performed (). Postoperatively, the patient had palpable pedal pulses. He was discharged on the third postoperative day. In outpatient follow-up, the patient was doing well and ambulating normally. At 6-month follow-up, he had palpable pedal pulses bilaterally and no complaints. The patient provided a written informed consent and the ethical approval was obtained from the Ethical Committee of Dr Sulaiman Al Habib Hospital, Riyadh, Saudi Arabia. |
A 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression and remained clinically stable on off-treatment; however, new tissue was visible surrounding the right renal pelvis and the calices (). The same therapeutic regimens (tamoxifen and docetaxel) were proposed to the patient based on the previous good response; unfortunately, the patient refused any treatment. |
A 44-year-old African American male with end-stage renal disease secondary to focal sclerosing glomerulonephritis underwent sequential renal transplants. He received his first cadaveric renal transplant in 2008, and when that failed, he underwent a second cadaveric renal transplant two years later. Subsequent to transplantation, the recipient of the hepatic allograft developed cerebral melanoma metastases. The donor was not known to have a history of melanoma prior to death. Our patient was notified and further work-up was pursued. He underwent CT of the chest, abdomen, and pelvis, as well as a brain MRI. This demonstrated three indeterminate lesions on the left transplant kidney (), which were subsequently biopsied and demonstrated to be metastatic melanoma. No other foci of disease were demonstrated.\nAt this point, the patient underwent transplant nephrectomies of both kidneys; these took place approximately one year following his original transplant. Final pathology on the left kidney demonstrated 2 foci of metastatic melanoma; one focus was 1.5 cm, and the other was 1.8 cm. Vascular invasion and penetration of the renal capsule were both present. Immunohistochemical staining was performed with S100, HMB45, and MELAN-A, which were all positive. Immunosuppressive medications were tapered and discontinued.\nFour months later, the patient was referred to medical oncology for further follow up. On physical exam, he was found to have a 1 cm firm subcutaneous nodule of the left anterior thigh, concerning for a metastatic deposit. Review of his prior CT scans revealed that imaging did not include this area. Wide local excision of the thigh lesion yielded a 1-cm nodule; pathology was consistent with necrotic melanoma. The lesion was sent for BRAF genomic analysis, which was negative for mutation. A PET/CT and brain MRI were also ordered.\nThe PET scan revealed multiple foci of uptake on skin surfaces, bone, and in the subcutaneous tissues, in the extremities and abdominal wall. A left temporal lobe lesion was also noted; MRI corroborated the impression of a metastatic 3 × 2 cm lesion with corresponding vasogenic edema and mass effect. Following these scans, the patient developed expressive aphasia with word finding difficulties and headaches. Steroids were instituted and emergent neurosurgical evaluation was sought. The patient underwent resection of the left temporal lobe lesion. Pathology was consistent with metastatic melanoma. Postoperatively, he underwent whole-brain radiation with a total of 37.5 Gray in 15 fractions. He regained all of his baseline cognitive ability.\nAfter the completion of whole brain radiation, the patient received a total of four cycles of ipilimumab (3 mg/kg) which he tolerated well. He developed a mild pruritus on treatment, controlled with topical creams. His posttreatment PET-CT scans demonstrated a complete response with no residual metabolically active lesions.\nThe patient is currently 16 months out from his donor nephrectomies, and without evidence of disease. He will continue to undergo surveillance by physical exam and PET-CT every 3-4 months for the next year, and then biannually following this. |
This 65-year-old female presented with the clinical signs of neck pain and subjective systemic spasticity spanning over recent few years. However, the objective finding acquired during the detailed clinical examinations was limited to an intractable cervicalgia provocation only especially during the neck extension without any neurological deficits.\nThe initial dynamic radiographs of the cervical spine revealed the AAD instability phenomenon on neck extension, which was completely reducible during the patient’s self-flexional maneuver, suggesting a flexibility for this condition (). The main background causing this AAD instability was found out to be the inherent existence of an orthotropic type of Os odontoideum, as revealed through the 3-dimensional reconstructed images by the computed tomography (CT). Surprisingly, as concomitantly featured inside the same frame through these CT scans, there were coexistent anomalous features of the inherently fused cervical spine between C2–3 level and inside C3–4 vertebral bodies, respectively. This congenitally fused, bony bridging was most notable along the both anterior and posterior vertebral body margins as well as between the lateral masses and spinous processes across the C2–3 ().\nIn a whole spinal evaluation in order to detect the other feasibly affected levels, she was also compromised with the multilevel butterfly vertebrae formations when traced from the lower cervical down to the thoracic-lumbar junctional levels by the CT work-up process (). Fortunately, none of these butterfly vertebrae infiltrated levels was affected with other pathologic or degenerative spinal conditions mandating another treatment. Also, there was no other congenital syndromes or anomalies involving the systemic organs associated.\nA reduction by posterior screw fixation augmented with allografts on lay over the C1–2 level was schemed and performed to completely resolve the initial intractable discomfort as well as to deter further neurological deterioration for the patient by providing a solid stability at the corresponding unstable level. After this reductive operation, full radiological restoration of the AAD instability as well as the complete resolution of the original cervicalgia was achieved for the patient (). |
An 83-year-old female with bilateral primary TKA performed 17 years prior presented to the clinic. The patient was referred with worsening left knee pain, reported gait instability, and swelling for three months duration. Until this point, she had been completely asymptomatic. She was initially seen and treated by an orthopaedic surgeon from an outside facility with physical therapy, followed by a left knee arthrocentesis to rule out infection. The aspirate demonstrated proteinaceous fluid with few benign inflammatory and epithelial cells and cultures were found to be negative. Due to the increasing pain, gait instability, and discomfort, coupled with lack of relief by the current measures, she was referred to the orthopaedic surgery clinic at our institution for further evaluation.\nAt her initial visit, the patient reported steadily increasing, sharp pain localized to her left knee joint with associated swelling that worsened with ambulation and prolonged standing and lacked improvement with conservative management. Her day-to-day activities were becoming restricted secondary to the pain and she reported occasional falls due to the perceived instability of her knee joint. Physical exam revealed a mild antalgic gait and tenderness over her proximal tibia. An in-house X-ray was notable for an increase in size and number of osteochondral bodies in the left suprapatellar recess with a left joint effusion and “lysis and subsidence of the tibial component and decreased thickness, suggestive of loosening and wear” (Figures -). The patient then underwent a bilateral knee bone scan which confirmed the tentative diagnosis of implant loosening with polyethylene wear and instability. The patient was counseled on her treatment options, including surgical and non-surgical management, and elected to undergo revision surgery of her left knee arthroplasty.\nA classical anterior approach to the knee was made through the patient’s previous scar. A medial parapatellar arthrotomy was performed, after which the knee joint was exposed, revealing extensive osteophytes around the patella (Figure ). The osteophytes were removed and a medial release was performed, allowing for removal of the previous components (Figure ). The femoral component was found to have bone ingrowth, which had encased the patella (Figure ). Visualization of the bone-cement interface intra-operatively proved difficult. Upon gross visual inspection, it appeared that local long-term reaction at bone-cement interface had engulfed the cement and resulted in direct ingrowth of bone to implant. Bone-implant interface tissue was taken for histology examination. Microscopically, the sections examined showed papillary synovial proliferation which is consistent with the patient’s history of long-standing osteoarthritis (Figure ). Multiple foreign body giant cells, which are formed by fused macrophages, are seen in response to polarizable foreign material (Figure ). Orthopaedic implants can cause chronic inflammation and giant cell foreign body response as seen in this case (Figure ).\nAfter component removal, joint preparation was done in standard fashion by membranous tissue removal and minimal freshening of previous bone cuts. Then revision of knee components was performed as per standard technique.\nPostoperative X-rays confirmed excellent placement of a left knee arthroplasty (Figures -). The patient experienced no postoperative complications and was discharged from the hospital on postoperative day 2. She then followed up in the clinic two weeks postoperatively. The patient stated her pain was well controlled and had been working well with physical therapy. X-rays performed at this time reported that the left knee arthroplasty was in expected position with no evidence of hardware failure or loosening (Figures -). She reported that she was pleased with her new prosthesis. |
An 81-year-old Chinese woman was referred to our centre from a private medical centre for further management of intestinal obstruction and pneumonia. She presented with one week history of epigastric discomfort associated with vomiting and abdominal distension. Her bowel habit was mildly altered but there was no history of passing blood per rectally. She denied any loss of weight or appetite. Interestingly she gave a history of eating a large amount of Chinese mushroom a few days prior to her presentation. Medically she was being treated for hypertension and congestive cardiac failure. Her past surgical history consists of a laparotomy performed 26 years ago and a right nephrectomy for renal stone performed 20 years ago. She was however unable to ascertain the reason for the laparotomy.\nOn admission, her vital signs were stable with BP of 200/90 and HR of 100/m. Chest auscultation revealed reduced air entry and crepitation at the right lower lobe. Her abdomen was soft but slightly distended. A mobile vague mass was palpable at the left iliac fossa. Bowel sound was sluggish and per-rectal examination revealed an empty rectum with no palpable mass. Her hernia orifice were normal.\nChest radiograph was done and showed right lower lobe consolidation with evidence of chronic obstructive airway disease and cor pulmonale. Echocardiogram showed evidence of cor pulmonale with no acute ischaemic changes. Her blood investigation results were unremarkable. Blood culture was positive for coagulase negative Staphylococcus. Urine culture and sputum AFB were negative. Her amylase level was normal.\nPrior to admission to our hospital, the patient had a barium meal and follow-through examination and CT scan of the abdomen done at the referring hospital. The barium studies showed proximal small bowel dilatation with an oval intraluminal filling defect seen at the end of the dilated segment which was about 1 foot from the duodeno-jejunal junction. Also present were ‘coil spring’ and ‘claw’ appearance which led to the impression of an intussusception (). It was reported that there was temporary hold up of contrast proximal to this level. Her stomach was of normal configuration and there was adequate gastric emptying. On CT scan of the abdomen, the filling defect seen in the barium study represented a hypodense intraluminal ovoid mass with mottled gas pattern noted within it (). There was no obvious site of attachment to the bowel wall and there was no evidence of whorled appearance which we would expect to see in intussusception. No other intraluminal mass or polyps was found, excluding other causes of obstruction. Bowel distal to the mass was collapsed. The characteristic CT findings immediately alerted us to the diagnosis of a bezoar.\nPathological report of the operative specimen was degenerate vegetable matter with no malignancy and a left paraovarian simple cyst. Post operative period was uneventful, where she was started on nourishing fluid and soft diet. She was discharged 10 days later with Tab Lisinopril 15mg bd, Tab Unasyn 375mg bd and Tab Bisolvent 8mg od. She was found to be well during follow up in surgical clinic one week later. |
In April 2010, a 20-year-old man with a 2-month history of right ankle pain and swelling presented in our hospital. His medical history was otherwise unremarkable. On physical examination, there was a mass with associated tenderness at the posterolateral aspect of the distal tibia. There was 18° restriction of plantar flexion and a 5° restriction of dorsiflexion. Plain radiograph and CT showed lytic lesions on posterolateral aspects of the distal tibia, and it appears as an ovoid lesion located centrally in the epiphysis (Figs. and ). MRI showed that the osteological area expands and its boundaries are unclear. The tumor mass expands beyond the lateral ankle and article surface of the distal tibia and protrudes into the soft tissue, but with the reservation of the fibula (Fig. ). An incisional biopsy revealed aggressive chondroblastoma with an aneurysmal bone cyst. Microscopic fields in the tumor region showed highly cellular tissue, variably differentiated and with discrete granulated to meshy calcification of the matrix and large multinuclear cells present in 20 % of cases. The cyst fields were characterized by blood-filled cavities (Fig. ). The patient also had a bone scan, chest radiograph, and CT of the lungs to determine if there are other metastases.\nPosterolateral incisions were taken according to the site of biopsy and the position of the tumor. During the decomposition, the superficial peroneal nerve was identified and was retracted laterally. The flexor muscle of the thumb was exposed from peroneal muscle gap, and the muscle fibers were cut to the flexor muscle of the thumb, and, the remaining fibula periosteum and some muscle fibers were separated in the fibula. In the separation process, resection of the distal fibular of 12 cm in length should be performed and proximal vascular ligation should be also retained to form a distal pedicel fibula bone flap and peroneal artery including its branch vessels.\nAfter opening the extensor retinaculum, the joint capsule was exposed and meticulous dissection was carried out to preserve a wide protective margin of the tissue. Previous biopsy tracts were incorporated into the incision and completely excised with the specimen. According to the tumor position determined by CT, the posterolateral and central parts of the distal tibia were resected from 1 cm proximal along with the tumor remaining medial part. The soft tissue protruded by the tumor was also wide resected. After the fibula periosteum and the muscle fibers were separated at the fibular head, the fibula head was resected to maintain long enough pedicel and articular cartilage of the talus and medial ankle were eradicated while preparing two holes in the talus head. After distal fibular was folded up into two, the two pedicel graft were inserted between the medullary canal of the tibia and the holes in the talus. Then, a titanium plate between the distal tibia and talus was fixed. Attention should be taken to place the ankle in 50–100 valgus, 100 external rotation, and a neutral dorsiflexion. An autogenous iliac bone graft was also inserted to fill the remaining defect in the tibia and recipient bed of the talus (Fig. ). The patient’s ability to walk depended on radiographic evidence of bony healing. In general, the patient was kept non-weight bearing for 3 months, then progressed to full-weight bearing wearing a walking boot by 3 months, and was allowed to bear without wearing a boot beginning from 6 to 9 months. After that time, the patient was able to walk independently without pain. The patients is now in the third year of follow-up and continues to be free of pain and has had no further complains; plain radiographs show a solid bony union (Fig. ).\nSince chondroblastoma is a benign lesion wholly, curettage and osteoplasty using auto- and homograft are the main method for chondroblastoma in most cases and additional implants may be used if there is mechanical instability. For particularly aggressive tumors, marginal or wide resection is necessary. In exceptional cases, amputation may be necessary when the soft tissue and neurovascular bundle are extensively involved [].\nTumors of the distal tibia are quite rare. For malignant and potential malignant tumors, below-knee amputation had been the standard surgical procedure [] because of the limitation of soft-tissue coverage and satisfactory function of below-knee prosthesis []. Recently, social reasons and improved technique have made limb salvage in the distal tibia increasingly possible []. Among the many options of reconstruction, ankle endoprosthetic is not accepted by most surgeons because of its high rate of complications []. Arthrodesis was preferred, providing excellent stability of the ankle and avoiding problem relating to prosthetic implantation. Arthrodesis with auto-graft is an economical, safe, and effective method without complication of the rejection reaction and non-union, infection, osteolysis, fracture which carried by allograft. Compared with non-vascularized autogenous fibular grafts, vascularized fibula was also superior to non-vascularized grafts with reduced time to union and faster hypertrophy []. Casadei reported good functional and oncological results in 12 patients with malignant bone tumors of the distal tibia, treated by resection and arthrodesis with vascularized free autogenous bone graft []. Bishop et al. also succeed in reconstruction using a vascularized free fibular graft for the treatment of malignant tumors in the distal tibia []. But in their cases, mobility of the donor site and the complicated surgical procedure are a problem. Our retrospective case presents a different method of limb salvage in the treatment of distal tibia tumors. Same as the other methods, wide resection is necessary and the resection needs to include articular surface, ligaments, and the joint capsule. The local extent of the tumor also required resection of the most tibia to an extent that was incompatible with reconstruction of the joint anatomy, so in the case, according to the tumor position, the medial malleolus remained to strengthen the stability. Compared with the Casadei’s technique, we had not used the proximal and middle fibular graft but the distal fibular which can obtain sufficient auto-graft of bone in the same incision. The distal fibular graft can get long enough pedicle after resecting the fibular head and inserted between the tibia canal and talus which can provide an effective foundation of stability after doubling up. After that, autogenous iliac bone grafts were inserted to fill the remaining defect between the tibia and talus. This compound reconstruction in which procedure was simpler than the vascularized one was not the same totally with non-vascularized autogenous fibular grafts and had brought about sound fusion and minimum.\nWe used a plate and a screw as the fixation device in this patient because of enough soft tissue. This procedure was also simpler than intramedullary nailing suggested by Moore’s series for shortage of the soft tissue. In our experience, wide resection and reconstruction with double pedicel fibular graft and ankle arthrodesis is a valuable alternative in limb salvage for aggressive chondroblastoma in the distal tibia. This technique avoids the donor site morbidity of auto-graft used, the talus collapse and bone loss associated with an ankle endoprosthesis. After ankle arthrodesis, our patient had 20° of tibiopedal motion (Fig. ) and no complications of mal-union, pseudarthrosis, loss of internal fixation, post-operative infection, skin necrosis, and chronic edema at 4 years of follow-up. There was no shortening of the lower extremity, and their gait was nearly normal (Additional file ).\nDegenerative arthrosis may develop in the sub-talus joint after ankle arthrodesis []. through there was no evidence of arthrosis in the sub-talus or other joints of the foot in our patient; further longer follow-up clinical effect should take in next step. |
A 64-year-old male patient presented to his primary care physician complaining of a dry cough and recurrent bouts of bronchitis as well as frequent orthostatic dizziness. At the age of 20 years, he had undergone repair of CO-A through a left thoracotomy using an interposition Dacron graft between the left SCA and the mid thoracic aorta. His chest radiograph raised suspicion of AN of the thoracic aorta. Computed tomographic angiogram then confirmed the presence of two large anastomotic PANs at both ends of the graft (\n) as well as an occluded right SCA, stenosis of the left vertebral artery, and bovine origin of the carotid arteries (\n).\nIn view of this complex anatomy, the decision was made to use a hybrid approach to address these findings. In a first stage, a right carotid artery to right SCA bypass was done using a short segment of Goretex graft (\n). Next, using single lung ventilation, a right posterolateral thoracotomy was performed and the chest entered through the fifth intercostal space. With the diaphragm retracted inferiorly, the pericardium, posterior to the phrenic nerve, was gently lifted with a long clamp, thus allowing exposure of the distal most portion of the thoracic aorta, medial to the inferior vena cava (IVC). After heparinization, the aorta was partially clamped and a 22 mm Hemashield graft anastomosed in an end-to-side fashion to an appropriate aortotomy using a continuous suture of 5–0 Prolene (\n). The graft was then brought posteriorly to the IVC and anteriorly to the right hilum, then anastomosed in an end-to-side similar fashion to the partially occluded ascending aorta through a vertical pericardial opening (\n,\n).\nThe immediate postoperative course was uneventful, and 5 days later, the patient was brought to the hybrid operating room for completion angiogram. This confirmed patency of the extra-anatomic graft as well as the presence of a 4 cm proximal left SCA anastomotic PAN with close extension to the left vertebral artery origin, and a 4.5 cm distal anastomotic PAN. EVS of the proximal PAN was done using a 16 × 80 mm covered Medtronic stent deployed across the origin of the left vertebral artery (\n).The distal PAN was excluded using a 26 × 100 mm covered Medtronic stent extending from the level of the coarctation to the insertion of the extra-anatomic bypass graft (\n). Completion angiogram confirmed patency of the latter and occlusion of the left SCA to thoracic aorta graft as well as of both anastomotic PANs (\n). The postoperative course was uneventful and the patient remains asymptomatic 2 years later and will be followed up on a yearly basis. |
A 25-year-old G4P3003 at 7 weeks and 1 day by last menstrual period with a medical history of 3 previously documented low transverse cesarean deliveries and obesity (BMI: 34) presented for management at a county hospital for a missed abortion diagnosed at an outlying rural clinic. The patient reported that this was a planned pregnancy and desired future pregnancies; she denied any spotting, cramping, or passage of any tissue. The formal TVUS report at the outside clinic showed an intrauterine pregnancy with a 27.8 mm mean sac diameter consistent with 8 weeks and no fetal cardiac activity seen; no evidence of a MAP was noted in the report. A repeat bedside TVUS in clinic by a resident physician showed an irregular shaped gestational sac with a crown rump length of 1.5 cm.\nAfter thoroughly counseling the patient on expectant, medical, and surgical management, she elected for medical management. The patient was uninsured and declined surgical management as she did not want to incur the expense of the procedure. The patient received 800 mcg of misoprostol per vagina (PV) in clinic and she was sent home with a prescription to take two additional doses of 800 mcg buccally every 24–48 hours if needed until she noted passage of clots or tissue. She was instructed to return to clinic in one week unless she developed heavy bleeding soaking greater than two pads an hour for two hours or fever greater than 100.4 degrees Fahrenheit []. She followed up one week later and denied spotting, cramping, or passage of tissue. A bedside TVUS by a resident physician showed no change from the week prior. Given that the patient's insurance eligibility status was still pending, the patient declined surgical management due to the potential financial burden and declined expectant management. The patient was counseled that no data supports multiple rounds of medical management but, given her insurance eligibility status and strong desire to not incur surgical fees, she received two more rounds of medical management without resolution of her missed abortion. The patient was then able to acquire insurance approval. She then opted for surgical management. She presented three days later to the ambulatory outpatient surgical center.\nShe was Rh positive with a hemoglobin of 12.7 g/dL. During her procedure, the cervix was dilated followed by insertion of the suction curette; some products of conception were evacuated but the canister filled quickly with bright red blood. Upon removing the curette, she continued to bleed heavily. Methergine was administered intramuscularly which helped decrease the amount of bleeding. The estimated blood loss (EBL) was 1200 cc; two units of packed red blood cells (PRBC) were given and the main operating room (OR) and hospital were notified for her immediate transfer since the ambulatory surgery center was not sufficiently equipped for this level of care. A foley balloon was placed into the uterus and inflated to 60 cc. This was able to tamponade and minimize the bleeding.\nThe patient was transferred to the main hospital by ambulance. A TVUS was performed which showed products of conception versus a 5 cm hematometra. Given that the patient had refractory abdominal pain unrelieved by intravenous morphine and a concern for an expanding hematometra, the patient was taken back to the OR for an exploratory laparotomy. The patient was consented for a possible total abdominal hysterectomy versus evacuation of hematometra. Upon entry into the abdomen, dense abdominal adhesions were noted; there was approximately 200 cc of hemoperitoneum in the rectouterine pouch. It was noted that there was a 7-8 cm portion of the lower uterine segment that displayed placental tissue overlying the uterine serosa by 1 mm. The decision was made to proceed with a hysterectomy. She received 1 unit each of fresh frozen plasma and PRBC intraoperatively. The EBL intraoperatively was 500 cc bringing the total blood loss to 1900 cc. A cystoscopy was performed and bladder involvement was ruled out. The patient met all postoperative milestones and recovered well.\nFinal pathology showed a placenta percreta. Sectioning through the patient's myometrium showed extensive hemorrhage dissecting through the entire myometrial thickness at the level of the lower uterine segment (). Microscopic evaluation showed numerous chorionic villi penetrating through the entire thickness of the myometrial wall and through the uterine serosa which is diagnostic of a placenta percreta []. |
A 72-year-old woman presented to our clinic having nonspecific dyspeptic disturbances and mild pain in the epigastrium. She had no other symptoms and was free from any underlying disease. The patient had a medical history that included thyroidectomy (5 months earlier), tumor excision of her left breast (2 years earlier), and cholecystectomy and appendectomy (both more than 10 years earlier). The patient had an unremarkable family history and was not taking any medications. Other pertinent details from her medical history were that she was allergic to an unknown antibiotic and she did not smoke or drink alcohol. Physical examination revealed mild abdominal tenderness at the epigastrium and left hypochondrium and mild tenderness at her left breast, but no other signs. The patient was completely fit, and her vital signs and laboratory examinations (including tumor marker tests) were all within normal ranges. The patient underwent magnetic resonance imaging (MRI) which revealed a 3 cm, well-demarcated, enhanced mass in the tail of the pancreas (Figures and ).\nShe had no other imaging exams, and she was scheduled for surgery with the suspicion that the tumor was a nonfunctional pancreatic neuroendocrine tumor (NET). Intraoperatively, a well-encapsulated mass was recognized at the tail of the pancreas and distal pancreatectomy without splenectomy was performed by laparotomy. The patient's recovery was complicated by a pancreatic fistula that lasted for ten days and resolved spontaneously with conservative treatment. The patient had no other events, and she was discharged from the hospital on the fifth postoperative day.\nHistological examination demonstrated a solid serous adenoma of the pancreas. Gross examination showed a well-demarcated tumor. Microscopic examination of the neoplasm showed a tumor with well-defined borders with a fibrous capsule () that consisted of clear cells located in solid nests with a few tubules (). The solid nests had round nuclei and were without atypia, mitoses, or necrosis ().\nThe adjacent pancreatic tissue was completely normal, and invasion of the capsule was not discovered in any tumor specimens. Immunohistochemical examination revealed cells positive for each of the following: Cytokeratin-7 (), Cytokeratin-8/Cytokeratin-18 (), neurospecific enolase (NSE) (), and intracytoplasmic periodic acid-Schiff (PAS) (). All cells were negative for vimentin ().\nConsidering all these findings, the tumor was diagnosed as a solid serous adenoma of the pancreas. The patient was followed up one month and six months postoperatively, and we observed that she has recovered completely and remains disease-free. |
A 22-year-old female with morbid obesity and bipolar disorder presented to the emergency room with new onset bilateral nystagmus, and bilateral lower extremity weakness progressing over 4 weeks making her bedbound. Her family also reported mild confusion. There was no known family history of neurological disease, and she had not reported any recent diarrheal illness preceding her symptoms. She was admitted to the hospital with initial diagnosis of possible MS. The patient also had dysuria and urinalysis was consistent with urinary tract infection on admission. She was started on intravenous antibiotics and IV fluid resuscitation for the urinary tract infection.\nWhile on the floors, a detailed history and physical examination was done. The patient had a history of a gastric sleeve surgery 2 months prior and was taking her supplements (including vitamins) as prescribed. Comprehensive neurological examination revealed the evidence of psychomotor slowing with disorientation to time, poor recall and recollection, and short attention span for age. She was also noted to have 4/5 muscle strength proximally, decreased hip flexion and extension with appropriate effort. The range of movements of knee were intact but poorly sustained. Plantar reflexes showed normal flexor response bilaterally. Eye examination showed intact visual fields and no afferent or efferent pupillary defects but was positive for prominent vertical upbeat nystagmus, horizontal gaze evoked nystagmus with torsion bilaterally.\nThe initial differential diagnosis for her neurological symptoms included possible MS. High-dose intravenous steroids were considered but were deferred initially because of the active urinary tract infection. MRI brain showed non-specific T2 FLAIR signals in periventricular, juxta-cortical, and bilateral medial thalamic regions. Cervical and thoracic spine MRI were normal. Lumbar puncture showed no evidence of infection or malignancy. No oligoclonal bands were observed in cerebrospinal fluid making MS unlikely.\nMeanwhile, given her history of recent gastric sleeve surgery, there was concern for vitamin B1 or B12 deficiencies and/or other mineral (Copper) deficiencies - and therefore levels were checked. She was given multiple vitamin supplementations including Vitamin B1 and B12 at admission. Thiamine level returned low at 28 nmol/L (reference range 78–185 nmol/L). She was diagnosed with Wernicke’s encephalopathy and started on high-dose intravenous thiamine (500 mg twice a day). Over her hospital course, both her mentation and gait slowly improved. On discharge to acute rehabilitation, she was ambulating with a rolling walker. At 5-month follow up, she was ambulating without assistance, nystagmus had resolved, but short-term memory impairment persisted. |
A 31-year-old multigravid woman with a history of a prior low transverse cesarean delivery presented to a family planning clinic at 16 weeks gestation for elective termination of pregnancy. Her obstetric history was significant for a prior cesarean section performed six years prior. Her past medical and surgical history was otherwise unremarkable. A transabdominal ultrasound performed on the day of admission confirmed a fetus of 16 week gestation with an anterior placenta. In order to further delineate the relationship between the uterine scar and the placenta, an abdominal MRI was performed. The MRI demonstrated an unclear uterine scar near the placental implantation site. The patient was counseled on risks associated with abnormal placentation and was offered uterine artery embolization, dilation and evacuation and hysterotomy. The patient, however, decided to proceed with induction of labor for termination. The termination of her pregnancy was approved by the ethics committee of Zhejiang Provincial People’s Hospital. A written informed consent was obtained from this patient before the procedure.\nTermination was performed with a loading dose of 50 mg of oral mifepristone (RU486) followed by 25 mg administered every 12 hours until a total of 300 mg had been administered. Following completion of mifepristone, misoprostol was administered at a dose of 200 ug orally every hour. The patient received a total of 1200 ug of misoprostol. She had an unremarkable vaginal delivery with spontaneous delivery of the placenta. Vaginal bleeding was minimal. Four hours after the procedure the patient developed a fever of 38.5°C, but denied further symptoms. The patient’s temperature resolved spontaneously by the next morning without intervention. On post procedure day 1, the patient complained of abdominal distention and dysuria. A urethral catheter was inserted and 800 ml of clear urine was drained. A pelvic ultrasound was performed and demonstrated a 32 x 25 mm abnormal radiodensity at the anterior uterine wall with an unclear boundary at the anterior cervical wall, concerning for retained products of conception versus placenta accreta. Methotrexate was administered. Given the idiopathic urinary retention and abnormal findings on ultrasound, laparoscopic exploration was performed to evaluate for placental growth into in bladder.\nAt the time of diagnostic laparoscopy, no hemoperitoneum was noted; however, there were significant adhesions between the omentum and anterior abdominal wall. Unexpectedly, a uterine rupture at the lower uterine segment was observed when the pelvic organs were restored to their normal anatomy. There was a 1.5 cm length anterior wall uterine rupture along the left portion of the previous scar (Figure ). Moreover, a portion of the placenta was found to be adherent to the uterus at the site of the rupture when the omentum was removed (Figure ). The bladder was firmly adherent to the uterine scar and rupture, and urology was consulted to assist in separating the bladder from the uterus. Dilatation and curettage was performed under direct laparoscopic visualization and the specimens were confirmed to be placenta by postoperative pathology examination (Figure ). An ultrasound was performed to ensure no residual placental tissue was present. The uterine dehiscence was repaired laparoscopically. The entire procedure was performed using minimally invasive techniques. |
A 43 years old female patient was previously submitted to laparoscopic gastric bypass for morbid obesity without co-morbidities. Seven months after the bariatric surgery the patient showed intense episodic epigastric abdominal pain that was aggravated by food ingestion and led to multiple visits to the emergency room.\nOne month after the onset of pain complaints, the patient was offered hospital admission for further evaluation. Physical examination was unremarkable and routine blood assessment of liver and pancreatic functions were normal. The upper endoscopy and esophageal-gastro-jejunal transit were normal; the abdominal CT and MRI were considered normal despite the presence of a mass in the excluded stomach, as it was ascribed to the anatomical rearrangement after the bypass surgery (Figure A). During hospital stay the patient did present any evidence of abdominal pain, complaints or need for analgesia; after formal psychiatric evaluation, a major depression was diagnosed and the patient was started on anti-depressants.\nFive years after gastric bypass, due to ongoing epigastric pain complaints, abdominal CT and MRI were repeated, with subsequent diagnosis of a 4.5 cm of greater diameter subserosal neoplasm in the antrum (Figure B).\nThe patient underwent laparoscopic gastrectomy of the excluded stomach for suspected gastrointestinal stromal tumor (GIST) (Figure A). Gross examination of the specimen revealed a subserosal polypoid mass in the gastric antrum, which corresponded to a 4.5 cm cystic cavity of greater diameter with creamy yellowish thick content, growing in dependency of the gastric muscular layer (Figure B). The histology of the mass showed a flap of gastric wall with antral mucosa and a heterotopic pancreatic cist, while in the adipose tissue of the root of the greater omentum six other yellow and lobulated nodules were identified and dissected. All fragments corresponded histologicaly to pancreatic tissue with normal exocrine and endocrine distribution, as displayed by the immunohistochemistry staining for chromogranin A, insulin and glucagon expressing cells, as well as a low proliferation index as revealed by the Ki-67 staining, which are characteristic of the normal pancreatic tissue (Figure , A-F). After gastrectomy, the patient became asymptomatic and so has remained ever since. |
A 24-year-old healthy woman presented with difficulty breathing and dissatisfaction with her facial appearance. She had a history of childhood trauma resulting in nasal septum deviation and external nasal deformity. Four months after a successful and uneventful septorhinoplasty, she presented to the emergency department with blunt nasal trauma resulting in a septal hematoma, which was drained successfully; the patient was discharged with no adverse sequelae.\nFour months later, the patient sustained nasal trauma again, this time accompanied by clear nasal discharge, raising suspicion of cerebrospinal fluid (CSF) leak. The patient was discharged after managing the nasal injury, as the CT brain showed an intact cribriform plate with no evidence of a CSF leak. Ten days later, she presented at the emergency department with dizziness and an unstable gait. She also had complaints of paresthesia for the past two months, beginning in her right hand and progressing to the right shoulder, arm and leg, associated with some difficulty in the execution of movements in the first and second finger of the right hand. Her right leg was quite stiff with difficulty in walking. On close inquiry, she gave history of pain in the right eye and double vision many months back, which had resolved spontaneously. Examination showed a positive Romberg’s and Lhermitte’s sign, with right-sided sensory impairment.\nMagnetic resonance imaging (MRI) of the brain, cervical and thoracic spine demonstrated demyelinating lesions in the brain and cervical segment of the spinal cord (Figure ). Some of the lesions demonstrated enhancement on post gadolinium administration sequences, suggestive of active demyelinating diseases like MS. A lumbar puncture was performed which demonstrated the presence of oligoclonal bands in the CSF. The diagnosis of MS was confirmed by a neurologist and treatment was initiated.\nThe initial neurological symptoms have largely vanished with only persistent light paresthesia in the right hand. Two years later she has had no new symptoms and continues with the same medication with good tolerance. |
A 52-year-old male patient presented with the chief complaint of pain and swelling in the upper right anterior region for the past 8 months. The patient gave a history of trauma in the same region, after which the swelling had developed and gradually increased in size. The patient was prescribed with analgesic and antibiotic by a local physician, but there was no relief in the symptoms, and hence referred to the institute. Extraoral examination revealed a diffuse swelling of size 4.5 cm × 3.5 cm present on the right side of the face (maxilla), anteroposteriorly 1 cm behind the ala of the nose to the lobe of the ear and superoposteriorly occupying themed region of the face. The swelling had evolved over a period of 8 months. The swelling was firm in consistency and painful, and no local rise of temperature was found [].\nOn intraoral examination, erythematous growth was seen on the right side of the maxilla extending from 14 to 17 [].\nRadiographic examination revealed ill-defined radiolucency and significant bone loss on the right side of the maxilla. Destruction of the lower orbital margin can also be seen. Root resorption of 16 was seen [].\nBased on the clinical examination and radiographic finding, a provisional diagnosis of ameloblastoma was considered. Differential diagnoses of odontogenic keratocyst, primary intraosseous carcinoma and metastatic neoplasm were considered.\nAfter obtaining an informed consent, an incisional biopsy was performed to arrive at a definitive diagnosis.\nMicroscopic examination of hematoxylin and eosin stained histopathological revealed the presence of odontogenic epithelium in various patterns, predominantly in follicular pattern. Sheets like arrangement of the odontogenic epithelial cells were also seen with hyperchromatic nuclei and scanty cytoplasm. Few of the follicles showed stellate reticulum-like cells. There was evidence of increase in cellular atypia and mitotic activity. Connective tissue stroma was fibrocellular [].\nBased on histopathological examination, a diagnosis of AC was established. To further confirm the diagnosis, immunohistochemistry was performed. The sections were stained with CK19 and were found to be positive [].\nThus, histopathology and immunohistochemistry confirmed the diagnosis of AC. |
We describe the case of a 54 year old, non-smoker, Caucasian woman, a computer programmer, who was admitted to the General Hospital in June 2003, following an episode of overdose with Citalopram and alcohol. At the time of her admission, she gave a history of depression and suicidal ideation for six months. She was not known to the local psychiatric service.\nThe patient was discovered by her twin sister soon after the overdose. Initially, she had disclosed to the medical doctor admitting her that she had taken approximately 14 tablets of 20 mgs of Citalopram along with 2 bottles of red wine. However, later on she informed us that she might have taken up to 30 tablets of 20 mgs Citalopram. The actual amount ingested remains unclear.\nSoon after her admission, she complained of painful left eye with blurred vision, and was seen by the Ophthalmologist, who found that our patient had an intra-ocular pressure of 23 mmHg in the right eye and 60 mmHg of mercury in the left eye (Normal IOP-10–20 mm Hg), with left corneal edema, and fixed dilated pupils. She was not hypermetripic and had averaged sized eyes. She was noted to have shallow anterior chambers (central and peripheral depth not available) in both of her eyes. A diagnosis of left angle-closure glaucoma was made and medications were commenced to reduce the elevated IOP. Further investigations including routine blood investigations revealed no abnormalities. Her pulse rate and blood pressure were normal. She had a blood alcohol level of 85 mgs/dl (Less than 10 indicates safe levels and 50–100 indicates toxic levels). Her blood test did not reveal any detectable levels paracetamol or salicylates.\nWith regard to her background history, there was previous episode of overdose with paracetamol tablets in 1978. There was no history suggestive of physical illness, and specifically, no history of previous eye problems. There was no family history of eye related conditions. In December 2002, her general practitioner had diagnosed her to be suffering from depression with harmful misuse of alcohol, and commenced her on Citalopram 20 mgs daily. Later, she informed us that she had not taken any of this prescribed medication prior to her overdose and had only been taking Estrogens, given for hormone replacement (Prempak-C).\nApproximately 48 hours after the overdose, on examination of her eyes, she was found to have left subhyaloid and retinal hemorrhages. After 72 hours, the visual acuity in the right eye was 6/9 and hand movements in the left eye. The intraocular pressures were reasonably controlled and she had bilateral Yag laser iridotomies. Subsequently, she was discharged to the local psychiatric unit as she continued to express suicidal thoughts and was low in mood. Apart from receiving treatment for her eye problems at the general hospital, she was commenced on a reducing regime of chlordiazepoxide for her alcohol dependence. On discharge from the general hospital, she was advised to continue on Timolol, pilocarpine and dexamethasone eye drops for further 14 days.\nShe remained free of anti-depressants and her mood improved gradually in the absence of alcohol. After 14 days, her visual acuity was noted to be 6/18 in the left eye, which improved to 6/12 on pinhole. Her ocular condition was noted to be stable. Her ocular pressures were 14 mmHg in the right eye and 15 mmHg in the left eye, but still had retinal hemorrhages on the left eye, with a clearing vitreous hemorrhage.\nShe was followed-up by the Ophthalmologists and discharged from the psychiatric hospital after 4 weeks with further community support.\nIn August 2004, her right eye visual acuity was noted to be 6/9, which improved to 6/6 with pinhole and her left eye vision was 6/24, which did not improve with pinhole. She had a left afferent papillary deficit. The pre-retinal and retinal hemorrhages had cleared, but she still had some residual vitreous hemorrhage. Her right eye Intra-ocular pressure was 18 mmHg and left was 19 mmHg without any treatment. She is reviewed by the local eye clinic every six months. |
In 2009, a 25 year old man was referred to the Department of Conservative Dentistry at Gangnam Severance Dental Hospital for evaluation and further treatment because of an apical pathosis on a lower left first molar. Nonsurgical endodontic treatment was performed on the tooth by the referring dentist because of apical radiolucency on the tooth 5 years previously (in 2005), and the patient was informed that the size of the apical radiolucency had increased. The patient could not recall the initial root canal treatment and did not experience any discomfort.\nA panoramic radiograph obtained during the first visit to our institution showed a large, radiolucent area around a mesial root of tooth #36 (). Root canal fillings were found, and a metallic obstruction in one canal was noticed (). A clinical examination showed no remarkable findings, including tooth mobility, sensitivity to percussion, or swelling. We informed the patient of a large periapical radiolucency and that the possible treatment options were nonsurgical retreatment, surgical treatment, or extraction. In addition, because of the size of the lesion, computed tomography (CT) was suggested to evaluate the proximity of the lesion to the mandibular canal. However, because the patient was asymptomatic, he did not want to perform further radiographic examinations and active treatment. The patient was recommended to undergo a routine check-up before a final decision. However, the patient did not come for a follow-up without any notice.\nFive years later, the patient came back because of cold sensitivity in the lower left molars. He felt moderate cold sensitivity during outdoor activity a week before this visit, and the sensitivity disappeared thereafter. He recalled his appointment scheduled in 2009 and decided to return for a check-up. A large cystic lesion involving the left lower premolar and molars was found in a panoramic radiograph (). Tooth #36 was negative for percussion and showed a normal range of mobility and periodontal probing. All adjacent teeth were asymptomatic and vital.\nAn oral surgeon at the Department of Oral Maxillofacial Surgery was consulted for surgical intervention. CT (Somatom Sensation 64, Siemens, Munich, Germany, 120 kVp, 90 mA) was performed to evaluate the size and location of the lesion. A large lesion was observed, in which the cortical bone was thinned and slightly expanded to the buccal and lingual sides (). Radiopaque particles were noticed inside the large radiolucent lumen, located approximately below the mesial root apex of tooth #36 (). The preliminary diagnosis of the lesion was a keratocystic odontogenic tumor (KCOT) in the left mandibular area. Possible differential diagnoses were calcifying odontogenic tumor, calcifying odontogenic cyst, apical periodontal cyst, and radicular cyst.\nSurgical enucleation of the lesion under general anesthesia was planned, and basic tests required for surgical and general anesthetic procedures were performed. The patient was informed of possible numbness because of the proximity of the lesion to the inferior alveolar nerve, and he was also informed of the necessity of root canal treatment in the lower left first and second premolars and second molars if any signs of vitality loss were detected.\nUnder general anesthesia, cyst enucleation was performed with crevicular and vertical incisions between the lower left canine and the second molar. After the mucoperiosteal flap was elevated, the buccal cortical bone was detached by creating a window and maintained in sterile saline during the surgical procedure (). The lesion was enucleated after the mental foramen was protected. Beige-colored turbid thick fluid filled the inside of the lumen (). The cystic membrane was thin and torn easily from the bony cavity (). A 3 mm diameter calcific mass with hard and rough texture was found inside the lumen (). Small, yellowish, cheese-like particles were attached to the cystic membrane. An endodontic file was extruded from the mesiobuccal canal of the lower left first molar (). Apical root resection of both roots was performed under a microscope in the operating room. Apical leakage was noticed on both roots (), and the root canals were retroprepped and filled with ProRoot MTA (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA) under a dental microscope (). The cystic lesion was sent to the Department of Oral Pathology at the College of Dentistry of Yonsei University for histopathological examination and diagnosed as an inflammatory radicular cyst (). The calcific mass was diagnosed as protein material with multifocal calcification, and it was suspected that canal filling material or intracanal medicament may have extruded into the apical lesion. After the surgical procedure, the patient did not have any obvious postoperative complications, with the exception of moderate swelling and slight pain for 3 - 4 days (). The patient returned for a one-month check-up and did not report any discomfort after the surgery. A 3 month check-up was scheduled. |
A 48-year-old Sindhi woman, from a middle class household of Karachi, Pakistan, presented to our clinic with sudden onset of loss of consciousness followed by severe headache and nausea. There was no history of trauma, fever, fits or blurring of vision. Her past medical history did not reveal any comorbid medical conditions and she had not had any similar episodes in the past.\nOn examination she was drowsy. She had a pulse of 90 beats per minute, her blood pressure was 165/90 mmHg and her temperature was 37.5°C. Her Glasgow Coma Scale was 14 out of 15. Both her pupils were equal and reactive to light. A fundoscopic examination was within normal limits. She had mild neck rigidity but no other signs of meningeal irritation. There were no other neurological deficits. She was clinically diagnosed with a subarachnoid hemorrhage with Hunt and Hess grade 2.\nHer baseline hematological work-up was normal except for a raised total leukocyte count of 16,000 cells/microliter. A computerized tomography scan showed diffuse hemorrhage in her subarachnoid spaces with a small area of focal hyperdensity in the prepontine area, raising suspicion of an aneurysm of the basilar artery (Figure ).\nDigital subtraction angiography showed a normal origin of the common carotid and vertebral arteries; however, both ICAs were hypoplastic from 1 cm to 2 cm above the carotid bifurcation. The vessels ended in her cranial cavity after feeding her ophthalmic arteries. Her anterior and middle cerebral arteries could not be visualized on the angiograms (Figures , and ); however, her external carotid arteries and their branches were normal. A selective angiogram of her vertebral arteries showed collaterals to her anterior and middle cerebral arteries on both sides through enlarged posterior communicating arteries. A fusiform aneurysm of the right posterior communicating artery was also noted at its basilar end (Figures , and ).\nSubsequent management via microsurgical techniques was proposed to our patient. However, considering the absence of major symptoms and the increased risk of surgery, she refused any therapeutic procedure. Unfortunately, our patient died of a rebleed six weeks after her initial presentation. |
A 70 years old woman presented to our local Accident & Emergency (A&E) Department after a low energy fall in a domestic environment at night time. Past medical history included only hypertension.\nThe patient was provided with the routine triage and A&E evaluation. Plain radiographs were performed at presentation, showing a left 4 parts proximal humeral fracture with an anterior subcoracoid dislocation of the humeral head (). Cervical and Chest X-Rays were negative for fracture. Therefore the patient was referred to our Trauma & Orthopaedic Department for the management of the injury and was admitted under our care. However it must be highlighted that the patient was referred to our Department with a delay compared to the recommended standard management algorithm. We thought this was due to a mixture of multifactorial issues (transports, personnel shortage, night time, initial evaluation and clinical stabilization).\nClinical examination revealed intense localized pain, with no signs of active bleeding nor presence of significant bruising or haematomas. The range of motion (ROM) of the shoulder was obviously very limited. An abnormal shoulder profile was also noted. The distal neurology (both sensitive and motor) was found intact on examination. The hand was warm and pink with a capillary refill less than 2 s. However the radial pulse was absent at this point.\nVital parameters, neurocognitive status, respiratory and abdominal examination were all normal.\nHer initial Hemoglobin was 12,4 g/dl and the other laboratory results were within the normal range.\nGiven this scenario, it was decided to attempt close reduction straight after admission. The procedure was performed under sedation and anaesthetist assistance. However complete joint congruency was not achieved (). As the distal pulse was still absent, the patient was referred and urgently assessed by the vascular team. The clinical evaluation, an Ecocolordoppler was performed showing an interruption of the vascular supply of the radial and ulnar artery.\nAt this point the patient was taken urgently to the Radiology Department for an angiography. This revealed a total occlusion of the subclavian arterial circulation in proximity of the junction between subclavian and axillary artery () After these results the procedure was converted from endovascular to open vascular surgery, with the aim to reinstitute adequate blood flow and save the upper limb. A medial graft from the saphenous vein was taken at the level of the proximal third of the thigh; a 20 cm graft was obtained. A subclavicular and sovracubital approach was performed and the harvested saphenous graft bypassed in correspondence of the two incisions. At the end of the procedure good revascularization was radiologically confirmed and the distal pulse reappeared. Hb dropped to 9,9 g/dl during the first post-op hours and no transfusion was necessary.\nOn day 2 post-op the patient was discharged with the left arm in a sling. In order to prevent the bypass failure and with multidisciplinary consensus, the orthopaedic surgical intervention had to be postponed by 2 weeks.\nSince the fracture pattern, the age and the risk for avascular necrosis, a reverse shoulder prosthesis was found to be indicated to treat this case. It was performed under general anesthesia, in beach chair position, and with an old fashioned deltopectoral approach. The cephalic vein protected and lateralized, the head found posteriorly dislocated and 180° rotated, the head removed, the tuberosities identified and tagged. After glenoid reaming, the small R Metal-Back (Lima Corporate, Villanova San Donato del Friuli, Italy) and a 36 mm eccentric glenosphere with 2 screws implanted. The humeral canal was progressively prepared, and a size 18 press-fit finned stem with metaphyseal engagement system implanted.\nThe stability of the implant and ROMs were tested under total muscular relaxation of the patient. A polyethylene standard reverse liner was chosen. The tuberosities were reinserted, the wound closed in layers.\nA post-op X-ray showed good position of the components without signs of loosening. A sling was worn 24/7 for two weeks and encouragement to actively move from day 1 post-op the ipsilateral elbow, wrist and fingers was given. Passive mobilization of the shoulder was started at 2 post-op weeks, whilst active mobilization in elevation, extrarotation and abduction was allowed from the 4th week. A follow up X-ray was scheduled at 1, 3 and 6 months, together with clinical evaluation (provided also 12 and 18 months post-op).\nThe patient revealed a quite significant level of joint stiffness in the first three post-op months, but exhibited improvements over the next months. In fact the Quick Dash score is 22.0 point and ROM 110° in active elevation and 100° in active abduction 18 months after surgery, so that the patient could achieve satisfactory execution of the daily activities ().\nThe X-ray at last follow up showed good position of prosthesis and no signs for instability, loosening or infection at 6 month follow-up ().\nThe patient was also followed up by the vascular team and the upper arm exhibited good vascularization in the early post-op period, and no sequelae were identified. |
A 10-year-old girl attended with her father after she was referred to Paediatric Dentistry Clinic for diagnosis and treatment. The main chief complaint was the discoloured front teeth. Furthermore, bullying at school was occurring due to her teeth appearance. In addition, general teeth sensitivity was affecting the upper central incisor, especially during brushing and temperature change. A detailed dental and medical history was obtained from the child as well as the parents. Dental family history revealed that the relatives did not suffer from similar dental conditions. However, the patient was born prematurely at 8 weeks, and she was in an incubator for the first 8 weeks of birth. This was followed by a good recovery leading to not requiring any medication or hospitalisation during her first few years after her birth. Upon intraoral examination, we noted a mixed dentition stage, with partially erupted teeth, and caries-free primary and permanent teeth (except for the mobile upper right first primary molar). Regarding the occlusion, we noted a class II division one incisor relationship, skeletal class II relation with increased vertical proportion, midline shift to the left side, and an 8 mm anterior open bite, and the child was occluding solely on the left first permanent molar. The hypoplastic phenotype was affecting the enamel of both dentitions (more prominent in permanent dentition) with demarcated yellowish-brown discolouration at the incisal third of lower incisors, upper central incisors, first molars, and primary teeth. The features obtained from both clinical and radiographic examination were consistent with a possible diagnosis of hypoplastic AI (Figures –). A dental panoramic tomogram (DPT) taken showed all permanent teeth and hypoplastic defects affecting the teeth, including the unerupted second molars ().\nThe treatment planning was based on preserving the remaining tooth structure until the patient can reach the age when she can receive a definitive treatment, keeping in mind the need to relieve the symptoms including sensitivity, improve the occlusion, and aesthetic demands. Following discussion with the child and parents, it was agreed to use a noninvasive approach with no tooth structure removal. The treatment plan was divided into a prevention, restorative, and maintenance phase. In the prevention phase, enforcement of oral hygiene instructions was done at every visit. Sodium fluoride varnish 22,600 ppm (Duraphat, Colgate, USA) was applied to reduce dental sensitivity for three consecutive weeks to reduce teeth sensitivity, protect and prevent remaining structures from future loss, and, at the same time, to avoid caries development [, ].\nDuring the planning visit, orthodontic consultation was obtained. Due to the skeletal open bite tendency of the patient combined with class II and the increased vertical proportion, the orthodontic treatment may include skeletal anchorage device or orthognathic surgery. It was recommended to delay the orthodontic treatment and reevaluate the case after one year, so a referral to Orthodontic department for periodic follow-up until treatment is initiated was done.\nRestorative treatment was done for the permanent incisors and first molars. A direct composite veneer was performed to the upper and lower incisors: following the manufacturer's instruction, an adhesive system was applied (Optibond Solo plus, single component, Kerr Co., CA, USA). The enamel shade was applied in the cervical region, and shade A2 and shade A1 were used to the middle and cervical thirds (GRADIA® Anterior, GC corporation, USA) Finishing and polishing procedures of the restorations were performed using sequential Sof-Lex discs (3M ESPE, Seefeld, Germany). Regarding the first molars, the upper right and lower left were affected more by posteruptive breakdown when compared to the other two molars. As a result, a preformed metal crown (stainless steel crowns; 3MTM ESPETM, St Paul, MN, USA) was done and cemented using glass ionomer cement (Aquacem®; Dentsply, Milford, DE, USA). The other two molars were restored by composite, as the remaining enamel was sufficient to perform a retentive filling (Figures and ).\nFollow-up was done for 15 months. The treatment showed a maintained tooth structure, good oral hygiene, and eruption of premolars (). |
The patient, an otherwise healthy 26-year-old man, had presented to his family physician with persistent, uncomfortable varices along his lower abdomen and bilateral scrotum. He described the symptoms as heaviness, swelling, and burning in these regions. These symptoms were exacerbated by large bowel movements or exercise and persisted for ∼30 minutes after a heavy cardiovascular routine. He had had these symptoms for his entire life; however, they had worsened when he increased his athletic extracurricular activities at the age of 13 years. On physical examination, he was a slender man of athletic build. He had pronounced varicosities in both groins and over his pubic tubercle. The scrotal and penile examination demonstrated pronounced engorgement of his testicular veins within the scrotum. His lower extremities did not demonstrate any evidence of venous insufficiency. The arterial examination findings were unremarkable. The abdominal examination did not demonstrate findings concerning for central abdominal masses. The primary care physician initially suspected that his inguinal enlargement was possibly an abdominal hernia. This tentative diagnosis was explored using duplex ultrasound, which excluded the presence of an inguinal or femoral hernia. However, the duplex ultrasound findings revealed enlarged superficial veins along the length of the suprapubic abdominal region (). These findings prompted magnetic resonance venography (MRV) with gadolinium contrast of the pelvis to evaluate retroperitoneal causes of atypical venous anatomy. MRV displayed tortuous dilated structures within the subcutaneous fat of the inferior ventral abdominal wall above the pubic symphysis compatible with venous varices (). These structures communicated bilaterally with the common femoral veins through large tributaries in the saphenofemoral junctions. Some of the findings were in keeping with common iliac vein occlusion; however, the findings were ultimately indeterminant. No other retroperitoneal anomalies were identified. Based on these findings, his family physician referred him to vascular surgery for further evaluation and consideration of treatment of his symptomatic varices.\nBecause of the strong clinical suspicion of a central cause of occlusion, outpatient computed tomography venogram (CTV) of the abdomen and pelvis was ordered. The CTV showed the absence of the right common iliac vein. Although small in caliber, the right internal and external iliac veins were present. Prominent internal iliac vein collateral vessels (right to the left) were present in the presacral space, which caused varices to develop in the pelvic, scrotal, and penile venous network. The CTV further revealed that the venous collateral vessels in the lower abdominal wall overlying the pubic symphysis had originated from the right saphenofemoral junction, draining into the left saphenofemoral junction (). The left internal iliac and external iliac veins were present and slightly engorged. The left common iliac vein and inferior vena cava were patent, without unusual features. No evidence was found of other relevant abdominal pathology or anomaly.\nThe patient was educated regarding his aberrant anatomy and instructed to forbid ligation or injection of his suprapubic varices, given this important collateral network. He was also instructed to notify surgeons planning future pelvic or urologic surgery of his large pelvic venous collateral vessels. For symptom relief, we recommended a pantyhose height, 20- to 30-mm Hg graduated compression garment. Should the patient progress to debilitating chronic venous insufficiency, suprapubic skin necrosis, or infertility, we are prepared to proceed with iliocaval bypass. Nonetheless, this would be a significant endeavor and the current clinical findings do not warrant major surgery. No clinical follow-up was arranged; however, the patient was given our office contact information and educated regarding the signs and symptoms that would warrant consideration of surgical intervention. |
A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast (Fig. a). We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved (Fig. b). Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space (Fig. ). At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.\nThe surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen (Fig. ). The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion (Fig. a). Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) (Fig. b). After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery. |
A 52 year-old female patient suffering from neurofibromatosis type 1 (NF1) complained about chest discomfort and dyspnea at rest. On past history, she underwent total thyroidectomy for nodular hyperplasia, and mass excision with skin flap operation for a huge sacral ulcerative neurofibroma. The plain chest X-ray showed a well-defined, huge cystic mass and compression of the right whole lung (Fig. ), and magnetic resonance imaging (MRI) revealed 14 x 11.5 x 11 cm, and 9.2 x 9.1 X 8.6 cm double cystic masses connected with T4-5 and T5-6 neural foramens in the right posterior mediastinum (Fig. ). We decided to do a surgical resection due to a symptomatic huge mediastinal mass. However, because this case had compression symptoms by a huge neurosurgical lesion, which could result in neurological problems or difficult manipulations during thoracic surgery, we performed a neurosurgical collaborative management. As for a preliminary treatment, the patient underwent the CP shunt procedure under general anesthesia by a neurosurgeon. A percutaneous catheter was inserted into the meningocele by transthoracic puncture with a needle at the T3-4 level under the fluoroscopy guidance, and a peritoneal catheter was placed through a limited abdominal incision. At postoperative 12 days, the CP shunt revision was performed due to accidental break of a cystic catheter. But the symptoms continued and the size of cystic mass and the amount of newly developed pleural effusion did not change significantly. We expected initial CP shunt would to perform functions to the patient, however, it was not sufficiently effective due to the thick wall of meningocele. Thus, surgical correction was decided and thoracotomy was the only choice since meningocele was extremely large to fill hemithorax. The CP shunt catheter was preoperatively removed at operative room, and then posterolateral thoracotomy was performed through the 5th intercostal space in the left down decubitus position. Two large meningoceles were compressing the whole lung out to collapse. After a dissection was conducted on the meningoceles including mediastinal pleura and a root of meningocele connected with neural foramen, and we suctioned spinal fluid (Fig. ). We checked the exposed spinal cord, and performed primly primary closure on the adjacent mediastinal pleura and some remaining meningocele walls without fluid leakage (Fig. ). The sealed area of the cystic wall was reinforced with an absorbable cellulose mesh and fibrin glue. CSF drainage with lumbar puncture was also performed to lower post-operative cerebrospinal pressure and to prevent spinal fluid leakage. The patient recovered immediately, and her symptoms of dyspnea improved after the surgery. Although CSF pressure was checked to be normal, there was CSF leakage in patient. Therefore we had kept lumbar drainage system for 5 to 7 days, 5 ~ 10 cc per hours. At postoperative 8 months, plain chest X-ray, CT and MRI revealed marked regression of the intrathoracic meningoceles and full expansion of the lung (Fig. ). There were no signs of spinal fluid leakage. |
A 71-year-old male patient was transferred to our department due to soft tissue defect in the left lower leg and infected Achilles tendinitis. The patient underwent incision and drainage of both lower legs with necrotizing fasciitis, at another hospital two months ago. Continuous wound care was performed; however, the left leg open Achilles tendinitis and soft tissue defects were not resolved.\nPhysical examination revealed a 12 × 5 cm wound with exposed Achilles tendon over the posteromedial aspect of lower one-third of the leg (Fig. ). His wound culture grew methicillin-resistant Staphylococcus aureus (MRSA).\nWe performed an operation with the patient placed in the supine position. All infection associated with necrotic Achilles tendon in the proximal muscle tissue was excised (Fig. ). After debridement, the patient had a 16 cm tendon defect from the muscle with the ankle joint in neutral position. He had 2 cm of the distal tendon attached to the calcaneus. We extended the skin incision to the outside of the zone of injury in the anterior aspect of the ankle, dissected anterior tibial artery and vena comitantes to perform vascular anastomosis out of injury zone. We made a template with surgical glove, which included the vascularized fascia lata for the reconstruction of Achilles tendon (Fig. ). We used the already manufactured template on the ipsilateral thigh, centering the flap over the perforator and drew the flap larger than the recipient site (Fig. ). A 14 × 7 cm ALF flap with a large piece of fascia lata (bilaterally, approximately 2 cm extra fascia is taken) was harvested (Fig. ). The donor defect was closed primarily over a silicon drain. For the reconstruction of tendon, the fascia lata was repaired first using multiple figure-eight sutures and modified Becker method[ with 4–0 prolene sutures at the separated end-to-end of the Achilles tendon. An end-to-end microvascular anastomosis was performed between the anterior tibial vessels and the flap pedicle vessels using 9–0 sutures microscopically after inserting the flap into the defect (Fig. ).\nPostoperatively, the ankle and leg were wrapped in a bulky dressing and immobilized with an above-knee splint and the flap was monitored intensively for 7 days. Anticoagulation therapy with prostaglandin E1 (10 μg/day) and heparin (5000 units/day) were administered for 1 week and aspirin 100 mg once a day for 4 weeks after the surgery. The flap survived completely without complications. Passive and active exercise of the ankle joint was started at 6 weeks after surgery. Subsequently, the patient underwent a graduated rehabilitation program, from a non-weight bearing exercise to partial-weight bearing exercise. Twelve weeks after the surgery, the patient was permitted full-weight bearing with gait training.\nAt 12 months of follow-up, the patient was able to resume full daily activities, felt a little discomfort at the donor site after more than 2 h of hiking, but was able to walk without pain and without the need for support, also was able to squat, showed an ankle range of motion of 15° dorsiflexion and 45° plantar flexion, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 (Fig. ). |
A 14-year-old male had an extensive flame burn in the right side of neck, face, and scalp, anterior chest, and right upper limb at the age of 2 years.\nNo past medical or surgical history. No known drug history, no family history of any genetic disorder, patient and both parents are non-smokers.\nHe received multiple skin grafting procedures and an amputation of the right hand. The burn to his scalp was treated with a burr hole to the outer cortex to allow granulation tissue to cover the scalp, and then the wound was skin grafted.\nThe patient chronically continued to have unstable skin over the scalp and kept developing recurrent ulceration. On 29 March 2012, the patient was admitted throw the clinic due to his chronic condition of recurrent open wounds for many years.\nA plan was set for the removal of the unstable ulcer and scarred skin of the scalp and coverage with an omental free flap and split thickness skin graft ().\nUnder general anesthesia with endotracheal intubation, the patient was in supine position, with draping of the head circumflex, face, abdomen, and left thigh down to the knee.\nThe General Surgery team was consulted for laparoscopically harvesting the omental flap and was performed by Dr I.Anwar based on the left gastroepiploic artery. The right superficial temporal artery was identified to be the recipient vessel ().\nThe ENT team did a right neck exploration to explore the neck vessels as a backup in case the right superficial temporal artery was not suitable.\nThe free omental flap based on the left gastroepiploic artery was anastomosed to the right superficial temporal artery. The micro procedure of omental free flap was performed by DR F.Hashem, Plastic surgeon.\nThe patient was given heparin 2000 U intraoperatively. The flap was viable with bleeding with a positive Doppler signal.\nAfter establishing flap revascularization, all the excising unstable scarred and ulcerated skin covering the scalp was resected, and the underlying irregular skull was smoothed down using a flat burr. The omental flap then covered the scalp, and a split-thickness skin graft from the thigh was placed over the omental flap ().\nThe patient was monitored postoperatively in intensive care unit. Post-operative care for microsurgery and wound care for skin graft over omental flap.\nThe hospital course was uneventful. The patient was kept on IV anticoagulants (dextran and heparin) for 5 days.\nThe patient tolerated the procedure well. No wound complications were reported during his two years follow-up (). Re-Exploration nor revision of the surgery were needed |
An 18-day-old full-term Saudi girl who had an unremarkable prenatal and family history (as obtained from the parents) and who was born via normal spontaneous vaginal delivery with a birth weight of 2.5 kg was admitted to a provincial hospital with cardiogenic shock. High BP was diagnosed, and she was treated as a case of cardiomyopathy and was discharged home after 10 days on propranolol and captopril. Without a medical report from the previous hospital, her parents brought her to our pediatric emergency room at the age of 45 days with lethargy and poor oral intake. She looked malnourished and hypoactive. Her weight was 2.4 kg. She had a high systolic BP of 114 to 178 mmHg (normal values for this age and weight are from 70 to 80 mmHg) and a diastolic BP of 57 to 82 mmHg (normal values for this age and weight are from 30 to 40 mmHg).\nShe was admitted to the pediatric intensive care unit and required daily doses of 1.8 mg of hydralazine, 9 mg of propranolol, and 12 mg of captopril to keep her systolic BP in the range of 85 to 142 mmHg and her diastolic BP in the range of 43 to 75 mmHg. Laboratory studies showed the following: a white blood cell count of 32.8 × 109 cells/L, a hemoglobin level of 102 g/L, a platelet count of 804 × 109 cells/L, erythrocyte sedimentation rate of 2 mm/hour, normal renal and liver profile results, normal urine analysis results, a serum renin level of 625 nmol/L, a serum cortisol level of 526 nmol/L, and a growth hormone level of 58 μg/L. An echocardiogram showed severe non-obstructive hypertrophy of both ventricles and normal cardiac function. A Doppler ultrasound of her renal arteries revealed severe bilateral renal artery stenosis with a peak systolic velocity of 250 cm/second and a resistive index of 0.89. A computed tomography (CT) angiography revealed multiple arterial stenoses involving both renal arteries near the ostium (Figure ), the superior mesenteric artery (Figure ), the celiac artery, the hepatic artery, and both femoral arteries.\nOur patient was stabilized on daily doses of 6 mg of hydralazine and 9 mg of propranolol to keep her systolic BP in the range of 97 to 114 mmHg and her diastolic BP in the range of 39 to 54 mmHg. She was discharged home on these medications with a plan to undergo percutaneous transluminal angioplasty (PTA) of the stenosed arteries when she reached a weight of 5 kg. Two weeks after discharge, she presented to our pediatric emergency room with sepsis and greenish vomiting, rectal bleeding, and pneumoperitoneum. A laparotomy revealed bowel necrosis involving her ileum, cecum, and ascending colon. Her necrosed bowel was resected, and a jejunostomy with a mucus fistula at her transverse colon was created. The multidisciplinary team treating her included a pediatric surgeon, a pediatric intensivist, a pediatric nephrologist, a pediatric gastroenterologist, a pediatric geneticist, a pediatric rheumatologist, a pediatric radiologist, and an interventional radiologist. She stayed in hospital for about eight months. The results of a genetic analysis were normal, and metabolic disorders were ruled out. A skin biopsy was normal. The short bowel syndrome was managed successfully. The stoma was closed with a small bowel-to-transverse colon anastomosis. When she reached a weight of 5 kg, two attempts to perform PTA failed because of the very small caliber of her femoral arteries. During this eight-month period, all efforts were directed at keeping her systolic BP between 115 and 150 mmHg to prevent a further episode of bowel hypoperfusion. Later, she was discharged on full oral feeding and 2 mg of hydralazine orally every eight hours and 3 mg of propranolol orally every eight hours as needed if her systolic BP exceeded 150 mmHg.\nAt present, she is two years old and has normal cardiac, liver, and renal functions. She is on full oral feeding, and her weight is 11.5 kg. She has not required anti-hypertensive medications for the last six months. A recent CT angiography revealed increased narrowing of both renal arteries, her superior mesenteric artery, her celiac artery, and her hepatic artery and complete obliteration of her left external iliac and left femoral arteries. However, a good set of collateral vessels was seen during the evaluation (Figure ). |
This is a case of a 37-year-old, right-hand dominant, Malay man who presented to our Emergency Department 6 hours after he had fallen approximately 6 meters from a rambutan tree where his left arm hit the tree trunk on his way down to the ground. Post trauma, he complained of pain and swelling over his left antecubital fossa. There was no wound over his left upper limb. He had no history of trauma to his left upper limb and no significant past medical history. He did not take any medications. He was an army officer and had been an army officer for 16 years. Two years prior to the current accident, he was transferred to the administration unit of the Ministry of Defense. His job scope was mainly office work. He lived with his wife and three children in a small suburban home. He was an active tobacco smoker with a 20 pack year smoking history. Currently he smoked 10–15 cigarettes a day. He did not consume alcohol.\nIn our Emergency Department, his vital signs were stable with blood pressure 132/80, pulse rate 79/minute, and temperature 37 °C. A physical examination of his left upper limb revealed a tender, fluctuant swelling over the left antecubital fossa with slight limitation in his left elbow range of motion due to pain. There was ecchymosis over the lateral aspect of his left elbow joint but his left elbow was not deformed. His left radial pulse was feeble and his left ulnar pulse was not palpable. Capillary refill times of all fingers were more than 2 seconds. Sensation over left upper limb was normal. Doppler signal of brachial artery proximal to cubital fossa was triphasic, radial artery was monophasic, and ulnar artery was absent. Radiographs of his left elbow showed chip fracture over the left lateral epicondyle of the humerus (Figs. and ). Subsequently an urgent computed tomography angiogram of his left upper limb was done which showed a segment of non-opacification of contrast at the distal left brachial artery measuring 3.3 cm with distal reconstitution of the left brachial artery by collaterals just before the bifurcation of the left brachial artery at the left elbow joint (Figs. and ). The computed tomography scan also showed minor fractures of left lateral epicondyle and left radial head (Fig. ). Laboratory investigations (full blood count and renal function test) were all normal.\nHe was seen by general surgery and orthopedics teams. Our hospital did not have vascular expertise; hence, he was referred and transferred to a vascular surgeon in another hospital for surgery. He underwent emergency left brachial artery exploration surgery 15 hours after his fall. On intraoperative examination, his distal left brachial artery was contused. Therefore, a left brachial to brachial artery bypass was done using reversed saphenous vein graft. Intravenously administered antibiotics (cefuroxime 750 mg three times a day) were given before induction and for 3 days postoperatively. Postoperatively, Doppler signals of left radial and ulnar arteries had improved. He did not develop reperfusion syndrome requiring fasciotomy. The vascular repair was successful and he was discharged 4 days after surgery. On discharge, his bilateral radial pulses were symmetrical and strong. Fractures over left lateral epicondyle and left radial head were treated conservatively using a 90 degrees posterior splint for 2 weeks. The plan was to immobilize these fractures for a short duration followed by early range of motion exercises.\nThis patient was followed up in orthopedic and vascular out-patient clinics. Six weeks post trauma, his left elbow was noted to be dislocated in an out-patient clinic (Fig. ). Closed manipulative reduction was attempted but unsuccessful. His left elbow was still subluxed (Fig. ). There was probably soft tissue interposition in the left elbow joint. His left upper limb neurovascular examination was intact. He was counselled for surgery to reduce the elbow joint with vascular team standby. However, he was not keen for surgery at that time. At the last clinic follow-up around 6 months post trauma, his left elbow joint was still subluxed, his left triceps was shortened, and left elbow range of motion was reduced (extension 0 degrees, flexion 45 degrees, and pronation and supination normal). His radial pulses were strong and equal bilaterally. Functionally, he was able to cope with light duties. He used his left shoulder to compensate for the reduced range of motion of his left elbow. However, he was unable to carry weight > 2 kg using his left upper limb. He was still not keen for any surgical intervention to stabilize his elbow joint due to the risk of vascular graft thrombosis and injury. |
MT, a 44 year old Caucasian male with a several year history of psychotic depression, was admitted to hospital for treatment on March 17, 2012. His medical history was significant for chronic headaches, degenerative disc disease in the cervical spine, remote knee arthroscopy, and spontaneous pneumothorax in 1996. None of these medical issues were felt to be contributing to his psychiatric presentation. MT was a smoker, but did not use other drugs or alcohol. Physical examination including screening neurological examination did not reveal any abnormalities. Up until recently, MT was living a fairly functional life. He was married with two children, previously worked in the military, and was working as a security guard until his hospitalisation. He did not appear to have any significant psychiatric difficulties earlier in his life.\nMT’s mood was depressed and he met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for a Major Depressive Episode. He had been depressed since early 2011 and felt it was largely related to the end of his marriage. MT reported that the auditory hallucinations began several months after the onset of depression, and at a time when he was particularly isolated and the depression quite severe. MT reported that he hadn’t had hallucinations prior to the onset of his depression.\nMT’s psychotic symptoms manifested as a single male voice making derogatory comments about him, and telling him to hurt other people. He was also troubled by violent imagery in his mind. He never experienced any somatic delusions or coenesthetic hallucinations. He had previously been tried on risperidone, quetiapine, olanzapine, and haloperidol. During this stay, the patient was started on clozapine (March 20, 2012) and titrated up to 500 mg daily dose prior to discharge. This was the first time the patient had a trial of clozapine. Clozapine is not an approved treatment for psychotic depression, so the treatment was considered an off-label use of the medication. At the time of discharge, the patient was also on quetiapine 50 mg four times daily and quetiapine 200 mg nightly as needed. Aside from excessive salivation and mild constipation, the patient appeared to tolerate the medications well. The patient found this regimen to be effective at controlling his auditory hallucinations and was discharged on April 13, 2012. Depression was managed with venlafaxine XR 225 mg daily.\nMT claims that a few months after discharge he experienced a “burning pain” which awoke him in the middle of the night. He claims it happened once or twice per week and would last for approximately five to 10 minutes, the longest episode lasting approximately 30 minutes. The pain was described as a “head to toe, crippling burning pain” in his “bones” that sometimes caused him to writhe on the cool floor in attempt to achieve some relief. The pain progressively became more frequent and longer in duration, causing MT to discontinue clozapine between the time of August 27 and September 25 of 2012. The patient reports that after the medication was stopped, this pain did not return. The only other medication the patient was on at this time was venlafaxine XR 300 mg daily.\nInterestingly, the patient was diagnosed with a stomach infection during the same time and was prescribed a course of antibiotics. The patient denied any constipation during this time. According to the patient, during this period, he was experiencing frequent bouts of “dry heaving” whenever he would consume any solid food. He stated that no food would come up during these heaving fits, but thick mucus would sometimes be expelled. MT’s blood work from April 25, 2012 to October 18, 2012 often showed elevated leukocytes and neutrophils. His leukocytes went as high as 18.8 × 109/L and neutrophils 14.7 × 109/L on May 30, 2012.\nMT restarted the clozapine shortly after an outpatient appointment with his psychiatrist on September 25, 2012. He started taking clozapine again at 200 mg at bedtime and was titrated back up to his usual dose of 500 mg. During this re-challenge, MT experienced similar pain as he had previously and immediately stopped using clozapine.\nMT tried other antipsychotics which were not effective in controlling his auditory hallucinations and stopped using medications altogether. Eventually, he returned to hospital on April 2, 2013 when he was admitted with worsening intolerable auditory hallucinations.\nDuring this admission MT was rechallenged on clozapine since it was the only medication shown to effectively reduce the auditory hallucinations. Clozapine was initiated at 25 mg at bedtime on April 3, 2013 and titrated up to 400 mg at bedtime on April 22, 2013 when the pain returned. The patient described the pain as the same pain he experienced before, a burning, head to toe sensation that lasted approximately two to three minutes.\nA clozapine level was drawn at on April 23, 2013, but was unremarkable (clozapine =612 nmol/L; norclozapine =544 nmol/L). Other bloodwork from April 23 was also unremarkable (leukocytes =8.6 × 109/L; erythrocytes =5.12 × 1012/L; neutrophils =5.7 × 109/L; lymphocytes =2.1 × 109/L). However, the previous bloodwork on April 15, 2013 showed elevated leukocytes (12.0 × 109) with elevated neutrophils (8.8 × 109). This was an isolated circumstance of increased leukocytes during this admission. MT was also using quetiapine 100 mg every two hours when needed and olanzapine 20 mg daily at the time of the reaction.\nMT’s dose of clozapine was decreased on April 23 to 350 mg at bedtime then increased again to 400 mg at bedtime on April 24 which he was able to tolerate. The bedtime dose was not further increased from 400 mg. The total dose of clozapine was increased to 500 mg, but split with 100 mg given in the morning and 400 mg given at bedtime. MT did not experience any pain on this regimen and was discharged on May 6, 2013 with instructions to increase the clozapine to 200 mg in the morning and 400 mg at bedtime.\nOn June 7, at an outpatient follow-up appointment, MT reported the full body burning pain sensation was once again occurring sporadically on certain nights of the week. He also reported that the symptoms of dry heaving and abdominal pain had returned as well, similar to the symptoms he previously described.\nIt seemed to the treating team that MT’s reaction could be concentration dependent as the reaction always occurs within hours after the patient administering his clozapine dose. This is consistent with the time to maximum concentration of clozapine which is cited as 2.5 hours (1–6 hour range) []. This theory led to his treating team dividing the dose while he was admitted in an attempt to prevent the reaction from occurring. While dividing the dose reduced his pain during his admission, the pain appeared to have worsened since his discharge.\nMT is currently working during the nights and sometimes takes two doses within close proximity to each other due to his work schedule. These times appeared to coincide with the times MT experienced the worst pain. We encouraged MT to keep a log of when he experienced pain to better understand the pattern of occurrence.\nThere are also many documented cases of infections leading to increased serum concentrations of clozapine [-]. MT’s gastric infection could have increased the serum concentration of clozapine at the time, worsening the burning pain. The infection was treated; however, a high neutrophil count persisted throughout his treatment course in 2012. He also had an increased neutrophil count on April 15, 2013, which was just prior to the return of the burning pain during the re-challenge while admitted in hospital. It is possible that there is an association between increased neutrophils and this patient’s “deep, burning, bone pain.” The mechanism behind this reaction is unknown; however, a Naranjo score of 7 (Table ) would suggest that clozapine is probably the cause of this patient’s bone pain. An elevated c-reactive protein (CRP) level in October 2012 (6.3 mg/L) is consistent with an inflammatory process. There are no other CRP levels to compare this to. Further investigations would be beneficial to determine if inflammation could be contributing to the pain response, and what type of inflammation is occurring. There are reports of polyserositis occurring with clozapine [], but MT’s clinical picture was somewhat different given that pain was the only symptom he described. There was no evidence of fever, shortness of breath, or gastrointestinal symptoms, which are symptoms commonly described in serositis.\nThe treating team also considered whether MT’s pain symptoms could be somatic delusions or coenesthetic hallucinations. We felt this was unlikely as MT was frustrated at the possibility of having to discontinue clozapine given that it was the medication that helped him the most. We also observed that no other side effects MT experienced from medication were unusual. MT reported common predictable side effects such as rigidity from risperidone, sedation from olanzapine, and excessive salivation from clozapine. We felt that MT’s reporting of side effects was reliable. The only convincing psychotic symptoms were the auditory hallucinations.\nMT’s most recent out-patient appointment was on August 9, 2013. He reported to still be experiencing the pain, but able to tolerate it. He reported the pain was less intense than what he previously experienced. His log was beneficial as it confirmed that the pain was worse when two doses of 200 mg and 400 mg were taken close together. He is currently using 400 mg at bedtime and 200 mg in the morning. He also eliminated one weekly dose when he transitions from night shifts to day shifts to avoid two doses taken in close proximity, and this appears to have been beneficial. |
A 70-year-old male was referred to our hospital complaining of left flank pain. At physical examination, nothing relevant was observed and laboratory findings were within normal limits. A CT examination of the abdomen and the pelvis was performed with a multidetector scanner, before and after contrast media administration. Portal phase images showed a large amount of solid tissue in the left perirenal space, infiltrating the renal capsule and the main renal vessels; the tissue did not show significant contrast enhancement. Similar findings were detected also in the right perirenal space (). CT images also revealed a partial stenosis of the common bile duct, with intrahepatic bile duct ectasia owing to hypervascular eccentric tissue (). Hence, a diagnostic integration with endoscopic retrograde cholangiopancreatography was performed to exclude an intraductal proliferation. A biopsy was also performed in the left perirenal space; the pathological samples were composed of connective and adipose tissues, revealing the histological features of a DT or abdominal fibromatosis and also showing immunohistochemical markers typical of muscular tissues, such as actine. The tumour was considered unresectable and medical therapy was started with tamoxifen (20 mg die–1); after an episode of thrombophlebitis, the patient asked to suspend tamoxifen and accepted a new therapeutic regimen (docetaxel 75 mg m−2 every 3 weeks); unfortunately, even this treatment was discontinued after only 4 weeks owing to neuropathy. A new CT examination was then performed to assess the results of the treatment. Unexpectedly, on venous phase images, the perirenal tissue showed a remarkable reduction on the left side and had almost disappeared on the right side (). The peribiliary tissue had equally decreased in size and thickness (). The treatment was then discontinued in accordance with the patient’s decision. 1 year later, both the left perirenal and peribiliary tissues demonstrated no progression and remained clinically stable on off-treatment; however, new tissue was visible surrounding the right renal pelvis and the calices (). The same therapeutic regimens (tamoxifen and docetaxel) were proposed to the patient based on the previous good response; unfortunately, the patient refused any treatment. |
A 74-year-old woman with no history of smoking or alcohol abuse developed a verrucous carcinoma of the tongue and right tonsillar pillar in 2015. She underwent radical excision of the lesion and unilateral neck dissection (I-IV), followed by reconstruction with a traditional left RFFF. There were no perioperative complications, the donor-site morbidity was minimal, and no forearm arterial anomalies (e.g., median vessels) were found that would prompt suspicion of contralateral abnormalities. Adjuvant radiation therapy was completed in January 2018. Two years later, a recurrence of the above-mentioned carcinoma in multiple locations (the right labial commissure, cheek mucosa, and vestibular fornix) was noted. After extensive discussions between the patient and treating physicians, the decision was made to perform a transoral excision of the tumor with soft-tissue coverage using a contralateral RFFF. The patient provided written informed consent for the surgical procedure. Blood flow through the radial and ulnar systems of the right side was assessed. A handheld US probe revealed the presence of an aberrant median branch of the forearm, while neither radial nor ulnar-sided vascular insufficiencies were identified using the Allen test, which was subsequently performed. The test allowed us to evaluate the safety of sacrificing the median artery. The lesion was excised with wide margins by head and neck cancer surgeons. Frozen sections were obtained to confirm margin clearance. The defect was therefore large, including the right labial commissure and extending up to the right lower alveolar and buccal mucosa. With a template from the defect and according to the US probe, an unusual forearm free flap was marked over the skin of the distal volar forearm (). The plastic surgery team began the elevation of the free flap at the distal margin, first searching for the previously detected median branch. The aberrant artery was seen running between the palmaris longus and flexor carpi radialis tendons, giving off many tiny perforators to the skin paddle at the level of the mid-forearm, and continued deep into the flexor retinaculum toward the palm. The median vessel was strongly pulsatile (), with a caliber of 0.21 cm. Dissection was therefore carried out in a distal-to-proximal fashion up to the division of the artery from the RA (). It was anomalously accompanied by two superficial venae comitantes that proximally joined into a single venous branch (), which was later opportunely anastomosed. As soon as we decided to harvest the flap from the territory of the median artery, we did not dissect the RA along its entire course. Nevertheless, there were no septal branches communicating from the RA to the distal fasciocutaneous skin island, and its vascularity was provided solely by the aberrant median vessel and its perforators. On the contrary, the vascularization of the skin island was supplied by numerous septal perforators arising directly from the median artery (). After applying vascular clamps to the median vessel and releasing the tourniquet, a second Allen test was intraoperatively performed. As this maneuver resulted in satisfactory perfusion of the whole hand while compressing the median branch, flap elevation on the anomalous vessel was continued. The flap was inset in the intraoral defect, and the donor site was skin-grafted. No functional deficit was noted in the hand, and the healing of the flap and donor area was normal (). |
A 38-year-old female presented with lower abdominal pain for 2 months. The patient had no significant medical or surgical history in the past except for tubal ligation done 5 years back as a measure of family planning. Physical examination was unremarkable with no lymphadenopathy or organomegaly. Urinary cytology showed no malignant cells and culture failed to grow any organisms. Ultrasound scan of the abdomen showed 7 × 4 cm size mass lesion in relation to anterior wall of the bladder. Contrast-enhanced computed tomography abdomen and pelvis showed irregular thick wall enhancing area with internal nonenhancing area in the anterosuperior wall of the bladder with perivesical fat stranding and extension of lesion into the right rectus abdominis muscle suggestive of malignant mass of possibly bladder or urachal origin with multiple enlarged enhancing lymphnodes in pre/paraaortic and iliac regions suggestive of metastasis. A flexible cystoscopy examination revealed 6 × 5 cm mass on the dome of the bladder. Blood counts, lipid profile and other hematological and biochemical investigations were within normal limits. Transurethral resection of the bladder mass was done, and histological examination lesion showed urothelial papilloma. Magnetic resonance imaging abdomen and pelvis of the patient was performed postoperatively which showed approximately 61 × 23 × 43 mm sized enhancing polypoidal mass lesion involving anterosuperior wall of bladder on the right side, the mass appeared hypointense on T1WI and T2WI and showed enhancement on post contrast study, there was focal loss of fat plane of the mass anteriorly suggestive of involvement of perivesical fat with invasion of perivesical fat, bilateral recti and subcutaneous fat present, there was peripheral rim enhancement with central nonenhancing necrotic areas, there was loss of fat plane with uterus and right fallopian tube, multiple enlarged pre/paraaortic, bilateral iliac and inguinal lymph nodes were noted []. Contrast-enhanced computed tomography abdomen + pelvis showed irregular thick wall enhancing area with internal nonenhancing area in anterosuperior wall of bladder with perivesical fat stranding and extension of lesion in the right rectus abdominis muscle []. We performed a partial cystectomy [Figure and ], and histological examination of the mass showed xanthomatous cystitis []. Postoperative period was uneventful, and the patient was discharged. The patient is kept on follow-up for every 3 monthly; however, long-term follow-up is not mandatory as it is a benign condition with no malignant potential. |
An 80-year-old man who had received an acceptable stent implantation (10 mm × 60 mm Fluency stent, Bard Incorporation, Germany) 2 years ago for the treatment of a right subclavian AVM, was admitted to our hospital with complaints of a gradually increasing swelling and pain in his right upper extremity over the past 3 months. The patient denied a history of trauma, infection, and neoplasm. Physical examination showed that his right upper extremity displayed extensive swelling, hyperpigmentation, and subcutaneous palpable varicosities. The motor and sensory functions were normal. Ultrasonography and computed tomographic angiography (CTA) showed that the right subclavian vein was occluded due to compression of the stent in the subclavian artery and there were multiple arteriovenous communications between the right subclavian artery and the adjacent veins (Fig. A and B). A diagnosis of VTOS with recurrent AVM was suspected.\nThe patient was scheduled for endovascular therapy following extensive deliberation. An angiogram of the artery showed that multiple feeding arteries arising from the right subclavian artery formed connections with the adjacent veins, and the subclavian vein emerged in advance (Fig. A). We positioned a 10 mm × 80 mm fluency stent in the subclavian artery to block the feeding arteries and successfully embolized the remaining branches with coils (Fig. B). Next, an angiogram of the vein demonstrated complete occlusion of the right subclavian vein near the previous arterial stent and a mass of enlarged veins (Fig. C). During the procedure, when the balloon was inflated in the subclavian vein, a sharp incisura emerged from the narrowest vein segment (Fig. D). We performed successful dilation three times (lasting 2 minutes each time), followed by the positioning of another 10 mm × 60 mm Fluency stent in the right subclavian vein. The last confirmatory angiogram demonstrated that both the stents as well as the subclavian vessels, were patent and in normal condition, and most of AVM nidus had completely disappeared (Fig. E and F).\nThe patient was provided anticoagulation therapy after the operation, and discharged 3 days later, after significant relief from the symptoms. During the 6-month follow-up, the patient was free of all symptoms and the imaging procedures confirmed an acceptable thrombosis of the AVM with patent stents in the right subclavian artery and vein (Figs. and ). |
A 64-year-old female with a medical history of psoriatic arthritis (not currently on immunosuppressive agents) and type 2 diabetes mellitus presented to an outside community hospital with worsening lower back pain. Three weeks prior to admission, it was noted that the patient had a severe sinus infection and also had a molar implantation around the same time. One week later, she developed pain in her lumbar spine and was prescribed tizanidine and prednisone by her primary care physician with no relief. At the time of presentation to the hospital, she was found to have creatinine of 2.95 (baseline normal renal function) and leukocytosis of 14 (×103) with 57% bands. She was admitted and within hours she acutely decompensated and was intubated for airway protection. A lumbar puncture was attempted unsuccessfully by interventional radiology. MRI of the brain showed restricted diffusion in the supratentorial region consistent with small infarctions or encephalitis. She was started on broad-spectrum antibiotic coverage for meningitis/encephalitis and was transferred to our tertiary care center.\nUpon arrival to our facility, she was febrile and hypotensive. Neurologically, she was unresponsive, but flexion of her neck caused her to wince. Her extremities had good tone and reflexes. She was started on norepinephrine to maintain her mean arterial pressure and continuous venovenous hemodialysis (CVVHD) for fluid overload. A lumbar puncture was performed which showed 3,000,000 RBCs and 722 WBCs (likely a traumatic tap) and cultures were positive for methicillin-resistant Staphylococcus epidermidis—likely a contaminant, as it grew in broth only several days after the initial sample with no organisms on Gram stain. On the following day, we received word that 4 out of 4 bottles of blood cultures from the initial hospital grew Streptococcus pneumoniae that was sensitive to penicillin.\nAfter two days of antibiotic treatment, the decision was made to repeat MRI of the brain and spine as there was no improvement in her condition. FLAIR enhancement showed enhancement of the ventricles and pooling of purulent material into the posterior lateral ventricles, consistent with ventriculitis (). T2 enhancement showed acute infarcts in the periventricular areas, likely from septic emboli (). Spine imaging showed a fluid collection in the left psoas muscle (). Neurosurgery was consulted who recommended medical management only. Interventional radiology performed CT guided drainage of the psoas fluid collection, which produced 10 cc of reddish-brown material consistent with an abscess; subsequently, Gram stain and cultures were negative. A transesophageal echo showed 0.5 × 0.3 cm vegetation on the mitral valve; it was unclear whether this was the source of emboli given its size and unlikely appearance on the echocardiogram.\nA few days later, physical examination revealed a fluid level and debris in the anterior chamber of her right eye. Ophthalmological ultrasound revealed a thickened retina and debris within the vitreous fluid (). She was diagnosed with endogenous bacterial endophthalmitis. A vitreous tap was performed and she was given intravitreal doses of vancomycin, amphotericin, and ceftazidime. Cultures of the vitreous fluid were subsequently negative. Because of the patient's altered mental status, a visual acuity assessment was unable to be performed prior to and following treatment. The gross appearance of the external eye did not seemingly improve in the following days.\nThe patient's fevers, blood pressure, leukocytosis, and kidney function improved over several days—she was weaned off pressors and her renal function returned to normal with adequate urine output. Her mental status, however, seemed to worsen as her extremities became flaccid. All cultures (except for the initial outside hospital blood cultures) remained negative. MRI of the brain and lumbar spine was repeated on day 10. FLAIR enhancement showed improvement in the ventriculitis (); T2 enhancement showed additional infarcts now within the bilateral thalami, basal ganglia, and right parietal lobe (). Lumbar spine showed an increase in size of the fluid collection within the psoas muscle (). Several days later, the patient developed intracranial hemorrhage. The family ultimately opted for comfort care. |
A 53-year old male forester and farmer was admitted with protracted fever up to 39 °C, abdominal pain, diarrhoea without vomiting, productive cough and loss of weight (8 kg, see below).\nThe complaints had started three weeks earlier, with epigastric pain followed by fever and chills, therefore he sought medical attention early in the course of his disease in one of the two existing em departments (one of which is the department of cardiology) of our non-academic tertiary hospital in lower Austria. He was diagnosed with viral gastroenteritis and sent home with supportive measures; follow up with his general practitioner (GP) was suggested.\nAbout two weeks later the complaints had persisted; moreover, he suffered from productive cough and mentioned loss of 8 kg of body weight. Following the advice of his GP, a chest x-ray has been carried out, which was unremarkable. The patient presented again at our hospital, this time at the emergency department of our gastroenterology unit (there is no general emergency department at our hospital at the moment). A detailed history was taken and he was admitted for further investigation and treatment two days later.\nThe patient had an unremarkable medical history apart from a mild Helicobacter-associated gastritis which had been treated a few months before and some previous respiratory infections. He was a non-smoker, with low to moderate alcohol consumption. He denied journeys to foreign countries in the recent past; he had never left Europe but had visited Greece and Croatia, in 2017 and 2016, respectively. When he was asked about his profession, a detailed history of exposure to zoonotic pathogens was carried out. He denied contact with wild animals or slaughter in the last months but reported woodwork in the forest for the last 6 weeks. He was not aware of any tick bites or injuries.\nAt admission, he appeared to be neither septic nor jaundiced; there was no lymphadenopathy or rash. Heart and lungs were clear to auscultation; abdominal examination showed no abnormality apart from hyperactive bowel sounds. Heart rate and blood pressure were within normal limits.\nLaboratory results showed elevated leucocyte count (13/nL), platelet count (560/nL) and C-reactive protein (12 mg/dL). Other remarkable results were as follows: gamma-glutamyl transferase (gamma GT) 108 U/L, bilirubin 1.5 mg/dL, the remaining liver function tests and kidney function tests were within normal limits, as was the procalcitonin. A summary of laboratory test results and cutoff values is presented in the table (see Table ). A chest x-ray showed a discrete pulmonary infiltrate at the right upper lobe, but no hilar enlargement.\nBlood cultures were drawn and serum was sent to a reference laboratory for antibody testing for anaplasmosis, rickettsiosis, babesiosis, Q fever, brucellosis, and tularaemia. Moreover, infection with Rickettsia spp. and Coxiella burnetti was excluded by PCR. Tuberculosis was ruled out by a negative interferon gamma release assay (Quantiferon – QFT PLUS, Qiagen GmbH, Germany). Empiric antibiotic therapy was initiated with intravenous ceftriaxone 2 g bd and oral doxycycline 200 mg qd. The patient recovered quickly, fever, cough and abdominal complaints resolved. During the course, he recognized mild pharyngitis. A control chest x-ray didn’t show any infiltrates.\nSerologic tests for tularemia were performed with an agglutination assay (CCPro, Oberdorla, Germany) and ELISA (Virion/Serion, Würzburg, Germany). The antibody titre was 1:80 in the agglutination assay which was classified as negative and the ELISA was positive for IgG (52,6 U/mL, positive cutoff > 15 U/mL) and IgM (145,3 U/mL, positive cutoff > 15 U/mL). The other serologic tests and blood cultures (after 7 days of cultivation, however) were negative, therefore an infection with Francisella tularensis was suspected. The therapy was switched to oral ciprofloxacin 500 mg bd to complete a 3-week course and the patient was discharged. In order to confirm the infection, serum was sent to the same laboratory 4 weeks later by his GP for a repeated serologic testing. The agglutination assay was positive at the titre of 1:640. The ELISA results changed to 91 U/mL for IgG and 322 U/mL for IgM. |
The patient was a 33-year-old female with a history of cerebral abscess and recurrent olfactory meningioma; she had undergone a posterior fossa craniectomy and C1–C3 laminectomy for a posterior olfactory meningioma and suboccipital pseudomeningocele at another hospital 8 years prior to the current admission at our hospital. She was ventilator-dependent and had repeated episodes of pneumonia, and our department was consulted for tracheostomy creation for long-term respiratory care. Preoperative physical examination and neck computed tomography (CT) revealed an enlarged thyroid gland overlying the trachea, as well as prominent vessels (Fig. ). In addition, the patient was of short stature (140 cm in height), and had a short neck with limited extent of hyperextension. The surgical risks and benefits of a percutaneous versus open tracheostomy were explained to the patient and her family, as were her unique features making her at high risk for a percutaneous tracheostomy. We also discussed our prior experience in performing percutaneous tracheostomies in high risk cases []. After a detailed discussion, she decided to have the percutaneous procedure performed.\nFor the procedure, the patient was placed under heavy sedation, and was put in supine position without neck hyperextension due to the previous C1–C3 laminectomy and fusion. As we are experienced thoracic surgeons, the technical experience and equipment were available if bleeding or other emergencies should occur. Preoperatively, bedside neck sonography was performed for identifying the thyroid, vessels, and appropriate location of the trachea to perform the tracheostomy. Percutaneous tracheostomy was then performed as previously described []. Briefly, a xylocaine injection was administered for local pain control and tracheal depth localization. Then, a 1.5-cm transverse incision through the subcutaneous layer was made about 2 cm above the sternal notch. The endotracheal tube was withdrawn under bronchoscopic guidance to just below the vocal cords so as to illuminate the anterior trachea. External compression using the tip of a mosquito forceps, held in the operator's right hand, was used to confirm the puncture location without any deeper dissection. The trachea was then punctured on the midline between the 2nd and 3rd tracheal rings under bronchoscopic surveillance.\nFollowing bronchoscopic visualization of the puncture site, a guidewire was introduced over the cannula and advanced down the bronchial tree. The cannula was then removed and the percutaneous tracheostomy was performed with the Ciaglia method (Blue Rhino Advanced Percutaneous Tracheostomy Introducer Sets and Trays; Cook Medical Inc., Bloomington, IN). Immediately after tracheostomy tube insertion, a fibrobronchoscope was introduced into the tracheostomy lumen to confirm the position, and for sputum and blood clot aspiration. The operative time was 10 minutes and the blood loss was minimal. The patient tolerated the procedure well. Postoperative CT showed the tracheostomy tube passing through the thyroid gland (Fig. ). The postoperative course was uneventful, and the wound healed well. |
We present a case of a 31 year old female with her medical history. Her family histories were all unremarkable. At the age of 16 she was accidently (at a routine abdominal ultrasound) diagnosed with a right ovarian tumor. The tumor has been removed because of suspected malignant risk. Pathologic examination showed an immature teratoma with glial cells. (Figure a) Six years she was asymptomatic then a left ovarian tumor was found because she accused unspecific pelvic pain which was controlled under usual analgesics. The tumor was evidenced by computed tomography and it was completely removed based on intra-operatory decision. The tumor was yellow, large (7 by 6 cm) with solid and multi-cystic aspects associated with another small tumor of 2 cm at the Douglas level. The intra-operatory pathological exam suggested an ovarian possible malignant Sertoli-Leydig tumor that why the ovary was completely removed. Only two years later the pathological exam was re-analyzed and considered a mature glial cells implanted into the ovary. (Figure b) Six months later the patient accused persistent abdominal pain and discomfort after meals. The computed tomography showed a tumor of 10 by 6 cm at the Douglas level up to the sigmoid with cystic and solid components, with no evidence of lymph nodes, neither hepatic metastasis. She suffered the tumor resection at the level of peritoneum. At that time the diagnosis of peritoneal carcinomatosis was established and she was treated for six months with chemotherapy (bleomycin, etoposide and cisplatin) when she accused again intense abdominal pain and dysuria, associated with mild elevation of the hepatic enzymes. The forth surgical procedure was performed because it was considered a recurrence: exploratory laparotomy with viscerolysis. This time the pathological exam was re-analyzed for all the surgeries and a mature implant of the teratoma was diagnosed in the second procedure as well as the diagnosis of gliomatosis peritonei for the last two procedures was established. (Figure c and d) The immunohistochemistry profile was also performed at this time and it showed positive staining for glial fibrillary acidic protein (GFAP) in each of the four resections (boths ovaries, as well as peritoneal tumor). (Figure ) The stains were also positive for S100 protein. The immunohistochemical method was an indirect bistadial technique performed with a polymer based detection system (EnVision+ Dual Link System-HRP, Dako, Carpinteria, CA). Only the first tumor, from the right ovary, expressed Epithelial membrane antigen (EMA) and Ck34beta E 12. IT contains different types of cells, including the immature glial cells, while the gliomatosis contains only mature glial cells (Table ). Since she was ovarectomized, and the malignant diagnosis was finally excluded she came to our attention to evaluate the estro-progestative therapy. No estrogen or progesterone receptors were positive into the tumors so the therapy was started. She was followed-up for the next seven years. We consider that life follow-up is necessary. In addition, at the age of 23 she was diagnosed with primary hypothyroidism and autoimmune thyroiditis, which is currently in substitution treatment with L-thyroxine (75 μg / day). The risk of recurrence in case of gliomatosis persists also the chance of its malignant transformation is low. Based on the medical history, probably an adequate pathology diagnosis at the moment of the second procedure would have saved the second ovary. Yet, the pathological exam is difficult and the pre-operative computed tomography showed a very large tumor. Also, at that moment the immunohistochemistry was not routinely performed. The long medical history of this case highlights that even in rare situation like this the clinical data and its analyses may improve the clinical practice and eventually the patients care. |
A 62-year-old woman was clinically monitored for primary hyperparathyroidism since 2005. She had a medical history of arterial hypertension and in 2015 she underwent a laparotomic left nephrectomy for hydroureteronephrosis caused by recurrent kidney stones.\nIn March 2017, she had a neck ultrasound showing a nodule with a size of 9 × 5 mm in the lower third of the left thyroid lobe, consistent with left parathyroid. Subsequent T99m single-photon-emission computed tomography (SPECT)/CT scans did not show any uptake of the radioactive tracer at the level of the lower left thyroid gland different from the surrounding glandular tissue. A left parathyroidectomy was scheduled and preoperative laboratory tests showed elevated PTH at 453 pg/ml, low Vitamin D at 25.1 ng/ml, elevated serum calcium of 12.9 mg/dl, slightly reduced level of phosphorus. A neck CT was performed, not showing solid growing mass in the cervical district, in the absence of observable thyroid or parathyroid lesions.\nIntraoperative PTH at the beginning of surgery was 440 pg/ml. The intervention started with a Kocher cervicotomy and cervical exploration at the left lower thyroid lobe. Here, there was a voluminous lesion with adipose appearance and texture. After identification and preservation of recurrent laryngeal nerve, the lesion was completely excised. On macroscopic investigation it was multilobulated, with a size of 7 × 7 cm, containing a little and poorly defined lump consistent with a pathologic parathyroid (). The sample was sent to obtain frozen sections and definitive histological examination. Frozen sections revealed the presence of adipose and connective tissue with tubular epithelial basaloid proliferation made of little cells without significant nuclear atypia, with focal areas of possible oncocytic differentiation. In those sections, the morphological features did not allow to distinguish between a thymic or parathyroid origin of the proliferation. After the excision intraoperative PTH dropped down to 34 pg/ml, supporting the decision not to proceed with bilateral cervical exploration.\nThe final pathology report described that in all sections examined there was a remarkable presence of fatty tissue with inside a cord proliferations of main and oncocytic cells zonally associated with sclerosis phenomena, and of lobular structures consisting of solid, cordal and microfollicular proliferations of parathyroid cells mixed with variable amounts of adipocytes (). Parathyroid cells, positive for CK-pan chromogranin A (80%), are zonally reactive for CD57 (<5%), in the absence of reactivity for calcitonin, synaptophysin and CD56. Ki67 < 2% (focal). Not histologically provable thymic structures. The histological picture and the immunohistochemical profile guided for a diagnosis of parathyroid lipoadenoma.\nThe patient was discharged on the third postoperative day in good general conditions. At discharge the patient’s serum calcium was 9.7 mg/dl and PTH was 12 pg/ml. |
A 19 year old male presented to outpatient department with slow and progressive enlargement of tendinous nodule on the posterior aspect of ankle for last 2 years. The disease had progressively worsened in last 3 months with difficulty in walking. The patient was mentally retarded (intelligence quotient 55). Clinical examination did not reveal nodule or mass anywhere else in the body. The patient's blood lipid profile showed hypercholesterolemia (serum cholesterol level 331.7 mg/dl) while serum uric acid level was normal. There was no history of prolonged medication or antecedent trauma. There was no similar history in any of his siblings. Karyotyping of the patient and his parents was normal.\nThe radiographs of the lower legs and ankles demonstrated bilateral soft tissue shadows on the posterior ankle region []. The masses on both sides extended from the ankle to the lower calf and were located along the expected course of the tendoachilles []. No associated calcification or osseous abnormalities were seen. Magnetic resonance imaging of the brain showed diffuse cerebral and cerebellar atrophy.\nFine needle aspiration cytology showed giant cell rich lesion both side. The patient was taken for bilateral wide local excision of tendoachilles and reconstruction of the tendon with fascia lata graft.\nThe curvilinear lazy S incisions were made on the posterior aspect of the lower calf till tendoachilles insertion in prone position. Tendoachilles exposed which revealed large grayish white rounded mass involving 3/4th of length on the right side and full length of tendoachilles on the left side []. Abnormal tendoachilles tendons were excised almost completely creating a large gap which was not possible to reconstruct by primary repair. The defect in each limb was almost from musculotendinous junction to insertion on calcaneum. The thigh was prepared for fascia harvesting. A 25 cm skin incision was made 6 cm proximal to the lateral femoral condyle at the lateral border of patella, extending towards the anterior border of the greater trochanter. The skin flaps were sharply elevated above the fascia lata and reflected apart. The sheath was outlined 3-4 cm anterior to the lateral intermuscular septum, that is, anterior to the iliotibial tract. The deep fascia of thigh was separated from the underlying muscle. A transverse incision was made through the fascia distally while two tissue forceps were used to hold and fasten the fascia. The fascial sheet of 30 cm × 10 cm was procured and divided into two halves of 30 cm × 5 cm each. Each sheet layered onto itself 4 times with width of one cm and secured by interrupted suture with 4-0 proline. One end of prepared deep fascia was sutured to the cut end of muscles with proline 3-0 then it was tunneled through a drill hole in the calcaneum. During the repair, the foot was kept in equinus to reduce the gap and produce repair under adequate tension []. Other end of fascia graft was sutured back to the muscle end of the gastrocnemius and soleus with proline 3-0. The closure was done in layers. Thompson's test was done prior to dressing to check the integrity of reconstruction. The procedure was repeated in other limb in the same sitting. The excised specimen was sent for histopathological examination.\nGross specimen showed large cylindrical grayish white soft tissue mass that involved the tendoachilles completely on the left side and almost 3/4th of tendon on the right side. Specimen was measuring 12 cm × 3 cm × 3 cm on the right and 13 cm × 4 cm × 4 cm on the left side in craniocaudal, transverse and anteroposterior dimension [].\nMicroscopic examination showed a large number of granuloma composed of giant cells with foamy cytoplasm and lymphocytes in subepithelial tissue. Giant cell were mostly langhans type []. Adjacent tissue was with a smaller number of granuloma.\nPostoperatively, the ankle was immobilized in nonweight bearing plaster at 15° of plantar flexion for first 6 weeks and then in plantigrade cast for another 4 weeks. Stitch removal was done at 3 weeks postop and showed no evidence of wound dehiscence, infection or discharging sinus.\nAfter removal of plaster cast the patient was allowed to begin active physiotherapy. Weight bearing was delayed as this was a bilateral case. After 3 months, patient was allowed to increase weight bearing progressively within the limits of comfort. At 5 months followup the patient was able to walk without crutches. At 1 year followup, range of motion in both ankle joints was 15° of plantar flexion and 10° of dorsiflexion. The patient was able to stand and walk on toes, which he was able to since 6 months postsurgery []. Despite low intelligence quotient, at 1 year followup, the patient was independently mobile without pain with good cosmetic outcome. The functional outcome was satisfactory in all aspect except moderate limitation of sagittal and hindfoot motion with an American Orthopedic Foot and Ankle Society ankle hind foot score of 93/100. |
Patient A was an otherwise healthy 10-year-old girl who participated in competitive figure skating. She experienced insidious onset left knee pain, which was 8/10 in severity and only moderately improved with ibuprofen. Her family initially thought this could be related to skating and waited for it to disappear. However, the pain persisted, and she developed a limping gait. She had no fevers or rash, nor recent illnesses, travel, or tick exposure.\nHer pediatrician referred her to orthopedics, who noted pain out of proportion to exam and ordered imaging. MRI of the left knee showed an intramedullary lesion in the proximal tibial and distal femoral metaphyses surrounded by edema and inflammation (). Due to concern for potential malignancy, she was referred to oncology who ordered a technetium 99m-MDP bone scan and CT-guided biopsy. The bone scan was not consistent with acute osteomyelitis, with only mild radio-tracer uptake in the tibial lesion. Curiously, there was also a region of increased avidity in the posterior second rib. Subsequent tibial biopsy showed an inflammatory process in the marrow space extending to the growth plate. All cultures were negative.\nThe patient was referred to specialists in infectious disease whose differential diagnosis included acute bacterial osteomyelitis vs. CRMO. Due to elevated inflammatory markers, the patient was started on an empiric trial of antibiotics. Over the course of the next few months, her pain decreased, and her inflammatory markers and lesion on MRI imaging improved. The antibiotics were then discontinued after 4 months. Her knee pain remained quiescent for another 7 months but then recurred. Repeat MRI showed exacerbation of the tibial lesion, and repeat biopsy was again negative for growth of organisms. She was subsequently referred to our rheumatology practice for workup of CRMO (1 year after disease onset).\nOn initial visit, she had tenderness to palpation of the lateral proximal tibia. Her range of motion was fully intact, and inflammatory markers were, at this point, normal. WBMRI revealed lesions in eight regions, including her posterior rib (previously seen on bone scan), T9 vertebral body, bilateral sacroiliac joints, bilateral distal femoral metaphyses, and bilateral proximal tibial metaphyses. She was started on indomethacin, which provided some benefit but did not completely eliminate her pain. Methotrexate was added along with a brief course of oral prednisone, since glucocorticoids can help prevent vertebral collapse in the setting of spinal lesions (, ). She developed new bone lesions while on therapy and was switched to adalimumab (TNF-α inhibitor). She is not currently experiencing any of her pain and has returned to figure skating competition. |
The patient is a 56-year-old gentleman who had undergone an emergency coronary artery bypass graft (CABG) due to occluded coronary stents and severe left ventricular (LV) systolic dysfunction. An intraaortic balloon pump (IABP) was placed due to difficulties with weaning off cardiopulmonary bypass. Persistent hemodynamic deterioration with oxygenation issues resulted in the placement of an extracorporeal membrane oxygenation circuit (ECMO) and emergency transfer to our tertiary center.\nAfter 2 weeks of intensive care at our institution and persistent LV systolic dysfunction despite ECMO support, LVAD was electively placed. In a LVAD, the inflow cannula is attached to the apex of the left atrium and the outflow cannula is attached to the ascending aorta. The postoperative period was prolonged and complicated by acute gastrointestinal (GI) bleeding and acute renal failure requiring continuous renal replacement therapy (CRRT). The patient was discharged to a rehabilitation facility with return of normal renal function, regular diet intake, and routine follow-up. However, he was followed up by the GI team for episodes of bleeding due to ischemic enterocolitis. Three months later, he was readmitted for an acute episode of GI bleeding and surgical intervention, i.e., laparoscopic ileo-colectomy was considered necessary to control bleeding and to maintain future anticoagulation requirements for LVAD. In addition, he was scheduled for debridement of a sacral pressure sore in the lateral position at the same time.\nPrior to surgery, in the intensive care unit (ICU), the patient was awake, alert, and spontaneously ventilating without any vasopressor or inotropy. All routine laboratory tests including coagulation tests were within normal limits. Due to ongoing bleeding, the patient was bridged with heparin, which was stopped preoperatively. Review of TEE findings performed during and after LVAD placement revealed severe LV systolic dysfunction and mild right ventricular (RV) dysfunction. The inflow and outflow cannulae of the LVAD were noted to be in good position with low flow velocities and laminar flow on pulse wave and color Doppler interrogation. No mention was made of any other significant findings. The anesthesia team, accompanied by a certified perfusionist, transported the monitored patient to the operating theatre (OT) directly from the ICU. The LVAD was functional on a battery unit while transporting and then placed back on its permanent power source on arrival in the OT.\nStandard American Society of Anesthesiologist (ASA) monitors were placed. The HeartMate II displayed a flow of 5.1 l/min at a speed of 9800 rpm and the SpO2 was 98% on room air with a good pulsatile waveform possibly due to some return of ejection through the native aortic valve. A Doppler ultrasound was used to place the radial arterial catheter due to a weak radial pulse. A preexisting peripherally inserted central access catheter (PICC) was used for induction of anesthesia with etomidate 18 mg, fentanyl 100 mcg, and vecuronium 8 mg. Anaesthesia was maintained with isoflurane, fentanyl, and vecuronium with a fractional inspired oxygen concentration of 50%. Soon after induction, the waveforms on the arterial blood pressure (ABP) and pulse oximetry (SpO2) flattened. The ECG was noted to be in normal sinus rhythm. A TEE probe was placed for evaluation of intraoperative cardiac function. Initialfindings noted weregood systolic function of RV free wall, global severe LV dysfunction, mild mitral regurgitation (MR), mild tricuspid regurgitation (TR), and a continuously closed aortic valve. The inflow and outflow cannulae of the LVAD were unobstructed with low flow velocities on Doppler interrogation. An atrial septal defect (ASD) of approximately 7 mm size with bidirectional shunting was noted immediately after the placement of TEE probe during the laparascopic colectomy. We feel this was either unappreciated earlier or possibly a new finding, which was detected during our TEE exam for the noncardiac surgery. The central venous pressure (CVP) was measured as 10 cmH2O through the PICC catheter. Sinus rhythm was maintained and arterial blood gas analysis revealed pH 7.38, pCO2 39.8 mmHg, pO2 91 mmHg, bicarbonate 24 mEq/l, and SaO2 97% (SpO2 read 82% with no waveform). ABP was noted to read 65 mmHg (MAP). After establishment of pneumoperitoneum at pressures of 15 cm of H2O, laparascopic surgical access ports were placed and the patient was positioned in steep Trendelenburg position for good surgical access. Bilateral breath sounds were auscultated after positioning of the patient. The LVAD speed was maintained at 9800 rpm and the flow measured at 6.1 l/min. The flows subsequently decreased to 4.9 l/min. The TEE now revealed a right to left atrial level shunt and bowing of the intraventricular septum into the LV cavity and there was no opening of the aortic valve. TEE findings were conveyed to the surgeons and the Trendelenburg position was neutralized with reduction in right to left shunt. Enterectomy was completed in approximately 2 h and the patient was then positioned laterally for the sacral wound debridement. The LVAD speed was unchanged and flow in the lateral position was 6.6 l/min. TEEfindingsincluded a significant increase in TR, right to left atrial shunting, and RV distension. The entire procedure took approximately 4.5 h necessitating a fluid input of 2300 ml, with total urine output measured was 350 ml. All TEE findings were noted to return to baseline function (reduced right to left shunt at the atrial level) in supine position before recovery from anesthesia. The neuromuscular blockade was reversed and trachea extubated after the patient awakened in the OT. Patient was transported back with monitoring on a battery power source with a LVAD flow of 6.5 l/min at a speed 9800 rpm. The patient remained hemodynamically stable during the postoperative period with no major clinical issues. The patient recovered well after this surgery and came back for heart transplant a few months later and currently is doing well. |
We report a case of a 67-year-old aboriginal woman who was admitted to the rehabilitation ward. In March 2007, the patient underwent right femoral popliteal artery bypass surgery for occlusive peripheral vascular disease. Four months later, intermittent claudication recurred; she also complained of right leg pain at rest and developed ulceration of the right toes. The patient underwent right trans-tibial amputation in August 2007 because of ischemia and gangrene of the foot. This was followed by left superficial femoral artery stent placement in November 2007. Her ankle brachial pressure index was markedly reduced at 0.11 (normal, 0.95-1.2). Despite previous surgical treatment, her peripheral vascular disease progressed to gangrene of the right foot, thus necessitating the right trans-tibial amputation. The stump healing was initially delayed because of the wound infection, but eventually healed well. Her past medical history included a 61 pack-year smoking history, severe COPD, type 2 diabetes mellitus, hypertension, ischemic heart disease and a myocardial infarction three years ago treated with percutaneous coronary intervention and stent placement. The patient had a supportive husband, lived in a wheelchair-accessible bi-level home and was using a wheelchair for ambulating long distances and was mobilized with a walker for short distances.\nHer physical examination revealed a well-oriented individual with normal vital signs and oxygen saturation at 88% on room air. Her neurological and cardiac examinations were normal. The respiratory examination showed hyperinflation of the thorax, decreased air entry to the lung bases bilaterally and occasional expiratory wheezing. Her residual limb length was 5 cm from the tibial tuberosity and had a 15-degree flexion contracture. The incision line was well healed with an adherent scar. Her left lower extremity showed some atrophic changes: loss of hair with absent dorsalis pedis and posterior tibial pulses were noted. The popliteal pulse was palpable but weak. General strength was graded 4 to 4+ out of a maximum of 5 in both upper and left lower extremities. Laboratory investigations revealed pulmonary function tests showing severe irreversible airflow obstruction with the following findings on pulmonary function tests consistent with severe COPD: forced expiratory volume in 1 second (FEV1) was 0.54 L/s (25% predicted) and forced vital capacity (FVC) of 1.37 L (52% predicted). Arterial blood gases demonstrated compensated hypercapnic respiratory failure (PaCO2 at 54 mmHg) and hypoxemia (PaO2 at 58 mmHg). An echocardiogram showed a normal systolic ejection fraction at 76% with mild diastolic dysfunction.\nIn December 2008, the patient underwent 10 weeks of in-patient rehabilitation. Her severe COPD was optimized with inhaler therapy consisting of bronchodilators and inhaled corticosteroids. Oxygen therapy was utilized during rehabilitation exercises and ambulation, with the goal being to keep percutaneous oxygen saturation above 92% during activities and rehabilitation. Following initial slow progress due to the patient's generalized deconditioning, low endurance and stump contracture, her motivation and endurance gradually improved. She was then able to fully participate in the rehabilitation program. She attended two physiotherapy sessions per day (approximately 60 minutes in length each time). Her pre-prosthetic rehabilitation program included general upper- and lower-extremity strengthening and conditioning exercises. Oxygen supplementation during exercise and ambulation greatly facilitated the rehabilitation. We were able to improve the stump contracture from 15 degrees to 10 degrees, and she was able to hop with the aid of a walker. She was casted for a custom trans-tibial patellar tendon-bearing prosthesis with a 1.5-mm silicone liner (ICEROSS) and sleeve suspension system with a dynamic solid ankle cushion heel (SACH) foot. With further gait training, she was able to ambulate 200 feet with the aid of a walker and was discharged to home.\nAt the time of hospital discharge, kinematic data were collected using the VICON motion analysis system to capture the kinematics of the lower limbs and the spatio-temporal parameters of her gait. The patient walked independently with supplemental oxygen using a two-wheeled walker. It was unknown how much weight bearing occurred through the upper extremities during the level walking trials. Her cadence and velocity were very slow compared to 76- to 87-year-old community-dwelling older adults (Table ), but there was no difference between the left and right step time and step length []. However, the time spent in the right single support of the gait cycle was considerably less than the time spent on the left single support of the gait cycle. At a follow-up visit at six months, the patient had returned to her previous activities. She lived independently, ambulated and performed activities of daily living with the use of her prosthesis. |
A 42-year-old man with schizophrenia experiencing worsening fatigue over 2 weeks was referred to our hospital. He had been drinking approximately 4 liters of distilled spirits per week for a year. The patient lived alone, and consumed only various types of junk food instead of balanced meals or vegetables.\nPhysical examination revealed facial pallor and leg edema bilaterally. His body temperature was 37.2°C, pulse rate was 102 beats/min, blood pressure was 101/64 mm Hg, and respiratory rate was 16 breaths/min. Laboratory tests revealed that his hemoglobin level was 2.8 g/dL; he had macrocytic anemia with hemolysis and pancytopenia (Table ). A peripheral smear revealed that the anemia was megaloblastic. After admission, additional tests showed that his vitamin B12 level was within normal range but that his folic acid level was below the lower limit of normal. Other findings were otherwise normal. He was diagnosed as having folic acid deficiency anemia due to excessive alcohol consumption, and his hemoglobin level improved by administration of folic acid and cessation of alcohol.\nWe inquired why the patient never finished his vegetables during his meals. He responded that he had not felt the need to eat vegetables, although this did not mean that he disliked them. We discussed folic acid deficiency anemia due to excessive alcohol consumption with him, along with the cause of his symptoms, worsening fatigue, and admission. We also listened attentively to his narrative and expressed understanding toward his thoughts. Afterward, he realized that ceasing alcohol consumption and eating vegetables as part of a balanced meal were indispensable for preventing recurrence of folic acid anemia and staying in good health.\nAlthough the patient had been drinking approximately 4 liters of distilled spirits per week, he was not a constant consumer of alcohol and did not show any signs or symptoms of withdrawal after admission to our hospital and cessation of alcohol use. We diagnosed the condition of the patient as pre-alcoholism, a recently proposed disorder. We subsequently discussed the patient's condition with his father, whereupon we discovered that the patient's alcohol abuse was partially caused by his father's purchasing of bottles of distilled spirits for the patient. Furthermore, his father was divorced and had been living with a woman out of wedlock at her house, leaving the patient alone at home. We communicated directly with his primary care doctor regarding public and social support and assistance. We found that the patient had never applied for social support for which he was eligible under the Basic Act for Persons with Disabilities. We advised the patient on how to obtain support from his primary care doctor and other mechanisms. The patient currently continues to eat vegetables and balanced meals, and has avoided alcoholic beverages completely since the two years after his discharge from our hospital. |
A 56-year-old non-smoking male was admitted with repeated cough and massive hemoptysis that had lasted a month. No other complaints or remarkable past medical history, including previous chest injury, were advised. The patient had been diagnosed a month earlier with pulmonary sequestration by chest computed tomography (CT) at another hospital, which indicated that the nutrient vessel was arising from the intercostal arteries. Transcatheter arterial embolization (TAE) had been performed three times at the previous hospital. After the right common femoral artery was accessed for digital angiography, some feeding arteries originating from the fifth and the sixth intercostal arteries were found, which supplied the abnormal lung tissue (Fig a–c). The aberrant arteries were then completely embolized with coils. After seven days, the second coil embolization was required because of continuous hemoptysis. Pre-embolization aortography demonstrated aberrant arterial blood supply from the seventh intercostal artery, and the aberrant artery was completely occluded with coils once again (Fig d,e). The third embolization was performed five days later to block the aberrant arteries as a result of the recurrent hemoptysis. Pre-embolization aortography showed aberrant arterial blood supply from the fourth intercostal artery (Fig f,g). Although TAE was performed three times with platinum micro coils and gel foam before the patient presented to our department, the patient continued to experience hemoptysis measuring approximately 50 mL per day, indicating unsuccessful occlusion of the intercostal arteries.\nWe performed a post-embolization enhanced chest CT scan, which revealed an irregular margin of a pulmonary mass on the left lower lobe with a feeding vessel originating from the intercostal arteries, particularly on the basal segments (Fig ). Some metal micro coils were also observed on the CT scan. The radiological findings indicated pulmonary sequestration. A general left lower lobectomy was performed by video-assisted thoracic surgery (VATS) because of the repeated cough and massive hemoptysis. A mass in the base of the left lung was resected during surgery, and aberrant arteries woven into vascular vines originating from multiple intercostal spaces leading to the abnormal lung tissue were observed (Fig a,b). The aberrant arteries were carefully separated from the surrounding adhesion and then divided using an endothoracic stapling device. Standard thoracoscopic lobectomy was then performed and the tissue was sent for histopathology. The final histopathology report suggested an intrapulmonary sequestration (Fig c,d). The patient was discharged on the fifth postoperative day. After six months of follow-up, the patient completely recovered without any complaint.\nWritten informed consent was obtained from the patient for the publication of this case report and the accompanying images. |
The patient was a 60-year-old man who was the husband of the patient described above. He experienced lumbago on the same morning his wife was hospitalized. Fever and disturbance of consciousness occurred in the evening, and he visited the emergency room at another hospital. He had completed the course of neoadjuvant and adjuvant chemotherapy and radiation for glioblastoma 6 years ago, and was able to carry out his daily activities independently. He had no medical history of pneumonia or a history of pneumococcal vaccination. Although right lumbar pain was observed, the origin of fever was unknown; antimicrobial treatment was initiated with 4.5 g piperazine/tazobactam every 8 h. The results of the blood test taken at hospitalization are shown in Table . Pneumococcus was detected in his blood culture as well, and the regimen was changed to 2 g ABPC every 6 h. There were abnormal findings in the lumbar MRI scan taken on hospital day 2. Nonetheless, the results of the spinal fluid test, head MRI, thoracoabdominal contrast CT, transesophageal echocardiography, did not reveal presence of infection at other sites. Because lumbago persisted, MRI was performed again on hospital day 9; the consequent MRI results revealed purulent spondylitis (Fig. ). The patient was transferred to our hospital on hospital day 9. To normalize white blood cell count, CRP level, and blood sedimentation rate and to improve CT findings, antimicrobial drug treatment was carried out for a total of 9 weeks.\nBoth patients tolerated the antimicrobial treatment well, and recovered completely. A 13-valent pneumococcal conjugate vaccine was administered initially, and a 23-valent pneumococcal polysaccharide vaccine was administered 1 year later in both patients. More than 1 year has elapsed since the completion of treatment, and there has been no recurrence.\nIn the bacterial strain analysis (Table ) performed on the samples from both patients, the capsule serotype was 12F identified by the capsule quelling reaction using rabbit antisera (Statens Serum Institute, Copenhagen, Denmark). Drug sensitivity test was performed using a dry plate Eiken (Eiken Chemical Co., Tokyo, Japan), and was performed in accordance with CLSI M100-S-18 (hemosupplemented Mueller–Hinton broth, 22-h culture). The drug sensitivity in both strains was similar. As the next step, we performed a sequence typing match using the defined genetic sequence of the pneumococci was determined (aroE, gdh, gki, recP, spi, xpt, ddl) according to the method described in /, and it was compared with the sequence information present in the existing databases. Both strains matched completely. |
A 54-year-old woman was referred to our tertiary care Head and Neck Surgery clinic for evaluation of a rapidly enlarging left neck mass. She reported the neck mass had developed over the past four months, caused mild discomfort, and had associated unintentional weight-loss. The patient endorsed a remote 20+ year smoking history but denied any family history of head and neck malignancies. Physical exam during this visit revealed an eight-centimeter nodal conglomerate in the left supraclavicular area and diffusely enlarged thyroid gland with a roughly 5 cm right thyroid mass. She had previously undergone fine needle aspiration (FNA) of the neck mass at an outside facility which demonstrated rare degenerated atypical cells suspicious for malignancy, and a positron emission tomography scan (PET) scan with fluorodeoxyglucose (FDG) avid lesions in the neck and lungs concerning for metastases, which also showed tracheal deviation secondary to mass effect. Inhouse computed tomography (CT) of her neck showed a necrotic mass, while CT angiography of the chest showed lung lesions consistent with her previous imaging (). Repeat FNA cytology of the supraclavicular mass revealed a poorly differentiated carcinoma. These cells were positive for TTF-1 and PAX8 by immunohistochemistry, and the treatment team continued to suspect a thyroid origin. After consultation with the oncology team, the surgery team and the patient elected for surgical resection of the left neck mass for diagnostic purposes, as well as thyroid surgery for palliation, given the mass effect and tracheal deviation. With diagnostic surgery as the next step, additional thyroid lesion workup such as a thyroid ultrasound, or measurement of her serologic thyroglobulin, anti-thyroglobulin, and calcitonin were not taken at this time. The patient then underwent a left neck dissection, and her left thyroid lobe and isthmus were resected. Additionally, the level 4 supraclavicular mass with multiple surrounding firm, enlarged nodes was resected en bloc. The right thyroid lobe and left central neck compartment contents were left in place to minimize surgical morbidity. The left thyroid lobe and supraclavicular mass were sent for pathology.\nThe histological sections showed a dense, monotonous mass of cells with abundant amphophilic cytoplasm and open nuclei that contained coarse chromatin and prominent perinuclear hof. A large fraction of the cells was binucleated (). This was a peculiar finding as these features are consistent with mature plasma cells. There were very few cells with plasmablastic or anaplastic features, and a distinct lack of pleomorphism or prominent nucleoli. The large lymph node that was taken showed the same cellular architecture, with almost complete erasure of the native lymphoid tissue (). These histologic findings on the initial H&E were peculiar and further immunohistochemical stains verified the diagnosis. The lesion was positive for cytokeratin AE1/AE3, TTF-1, and PAX-8 with a markedly increased Ki-67 proliferative index at over 50%, consistent with an aggressive carcinoma of thyroid origin. Medullary thyroid carcinoma can have a similar cellular morphology, however, stains for Calcitonin were negative, which suggests against this entity. A negative p63 stain helped rule out a primary squamous cell carcinoma, while a negative SOX10 stain helped rule out a neuroendocrine or melanocytic origin. The workup for any lymphoid or histiocytic origin turned up negative, as the tumor cells did not stain for CD3, CD20, CD45, CD79a, CD138, or MUM-1. Additionally, there were areas of papillary thyroid carcinoma in both specimens collected (). Further genetic testing found that the lesion contained a BRAF (V600E) mutation. With these findings alongside the patient’s clinical presentation, we were able to conclude that the patient developed an aggressive anaplastic thyroid carcinoma with a plasmacytic morphology from her background papillary thyroid carcinoma. The patient and family elected to undergo palliative radiation therapy and cytotoxic chemotherapy, as well as pursue further molecular profiling and B-RAF inhibitor treatment in the future. |
A 53-year-old male, with worsening chronic back pain but no focal neurology, was referred for a haematology opinion following a magnetic resonance imaging (MRI) scan which showed a large extradural soft tissue mass from T5 to T9 that was displacing the spinal cord, pressing on his descending aorta, and extending through his left intercostal muscles. Biopsy with morphology and immunohistochemical staining of this paraspinal mass confirmed a myeloid sarcoma. Many of the neoplastic cells found on morphology were myeloblasts with eosinophilic cytoplasm, fine chromatin, and prominent nucleoli (left side of ). These expressed mostly CD33 and CD34 immunohistochemistry with some positive for CD117 and myeloperoxidase. There were also clusters of myeloid cells showing monocytic differentiation with ovoid nuclei and abundant pale cytoplasm (right side of ). These expressed CD33, CD4, and CD14 but were negative for CD34. shows full results of the immunohistochemical stains performed with notably positive stains for CD68, CD43, CD34, and scattered TdT and Ki67 positivity [, –].\nThe initial bone marrow biopsy contained approximately 5% nucleated blasts; thus the patient was diagnosed with isolated myeloid sarcoma. This was treated as acute myeloid leukaemia and the patient entered the AML 17 clinical trial following discussion with the trial chief investigator, receiving Daunorubicin and Cytarabine chemotherapy. The AML 17 trial required monitoring with bone marrow response. As the patient had an essentially normal bone marrow, monitoring could not be possible and he was therefore withdrawn after the first course of the treatment.\nA repeat MRI following the first course of chemotherapy showed minimal response, with less than 50% reduction in size of the mass. A baseline positron emission tomography (PET) scan performed at a similar time demonstrated metabolic activity of this paravertebral mass (shown in ). Due to the poor initial response and its proximity to the central nervous system (CNS) empirical intrathecal Cytarabine was added to each course of chemotherapy.\nDuring the second intrathecal chemotherapy administration, cerebrospinal fluid (CSF) taken identified myeloid blasts. The patient was subsequently changed to FLAG-IDA chemotherapy, the gold standard therapy at the time, for high risk leukaemia.\nAn MRI scan following the first course of FLAG-IDA chemotherapy showed a good response with 50% reduction in size of the mass, with subsequent CSF samples showing no signs of further blasts. The intended plan of weekly intrathecal Cytarabine became difficult for the patient to tolerate and was hindered by episodes of neutropenic sepsis. However, as FLAG-IDA chemotherapy contained high dose Cytarabine with more effective CNS penetration the need for intrathecal Cytarabine was reduced. Two further CSF samples following FLAG-IDA chemotherapy showed no blasts and therefore intrathecal therapy was discontinued.\nFollowing three courses of FLAG-IDA chemotherapy a repeat PET scan was performed (shown in ). Although this demonstrated some decrease in volume of the mass, it showed high metabolic activity. As there was no significant change to the mass following four courses of chemotherapy intended to treat acute myeloid leukaemia, palliative radiotherapy was considered to help control local disease. Chemotherapy was to only be reconsidered if disease progression occurred.\nFollowing radiotherapy treatment aimed at the site of the mass (details shown in ) a repeat PET scan showed that the myeloid sarcoma was now metabolically negative (). The PET scan did demonstrate metabolic activity in the lung but was thought to reflect postradiotherapy change rather than metastases. Radiologist advice was also obtained for the cause of myocardial uptake, likely due to poor patient compliance of the six-hour glucose fasting required prior to scan. Blood tests at this point showed no evidence of transformation to acute leukaemia.\nThis patient presented a few months later to hospital with a severe headache. To exclude subarachnoid haemorrhage, a lumbar puncture was performed. CSF fluid identified myeloblasts suggestive of a relapse of myeloid sarcoma in the CNS. Blood samples at this point did not identify progression to acute leukaemia. Craniospinal radiotherapy was therefore given (details shown in ).\nMonths later, the patient presented with symptoms of general decline and was referred for palliative input. Blood films still did not demonstrate any AML transformation although no bone marrow biopsy was performed. After deliberation the patient had a further PET scan, six months after the previous scan (slides shown in ). This PET scan demonstrated a large soft tissue mass infiltrating the epicardium anteriorly, right intercostal space, and the right pectoralis musculature. Further FDG positive disease was found above and below the diaphragm with supraclavicular and retroperitoneal lymphadenopathy and at the level of C4–C6 of the cervical spine. There was also a left para-aortic nodal mass encroaching the left renal hilum and a soft tissue mass encasing the distal abdominal aorta. Further FDG uptake was found in the head of the pancreas, the right lobe of the liver, the right groin, and the medial aspect of the left thigh and was bilaterally infiltrating the pleura fluid. This PET scan described widely disseminated malignancy, confirming massive disease progression. The patient was too unwell for chemotherapy and died shortly later of metastatic myeloid sarcoma. |
Patient 1 was a 28-year-old Caucasian Irish woman in her first pregnancy. She presented to our Emergency Room (ER) in July 2012 with vaginal bleeding. Her last menstrual period (LMP) was 5 weeks and 3 days previously. An ultrasound scan showed an empty uterus and she was referred to our Early Pregnancy Unit for further assessment. A subsequent transvaginal ultrasound showed a left-sided adnexal mass with a background of serial serum beta subunit of human chorionic gonadotropin (beta-HCG) levels that were plateauing (94 to 108IU/L).\nShe initially refused any intervention and discharged herself against medical advice. She stated that she did not want any medical treatment and was advised fully of the risks of declining same, including death or severe maternal morbidity, by senior staff members. Our unit takes the issue of very ill patients self-discharging very seriously, given the obvious potential risks to their lives or well-being. On this occasion, we followed every protocol within the hospital, including having the most senior staff available to meet with her to advise her fully on the gravity of the situation. She was, however, found to be of sound mind and thus we could not force her to stay against her will. She left in the care of her partner and signed a form advising that she was taking her discharge against medical advice. Her general practitioner was also contacted advising them of the situation; her general practitioner assured our team that they would contact her directly themselves to attempt to persuade her to return.\nSubsequently she presented to the ER 6 hours later in a state of collapse with hypotension and tachycardia. Urgent bloods were procured and her haemoglobin level was found to be 90g/L. She was reviewed by senior obstetric and anaesthetic consultants and consented to theatre. She was advised that this could be a life-threatening situation but she refused to accept red blood cell transfusion intraoperatively based on her religious beliefs. She consented to platelets and plasma transfusions. She underwent laparoscopic right-sided salpingectomy. Intraoperatively, a haemoperitoneum of 2 to 3 litres was noted. The use of cell salvage was also implemented to minimise blood loss.\nPostoperatively, her partner advised hospital staff that she was not in a position to consent to platelets or plasma given her religious beliefs. He furthermore produced written directives, which he stated had previously been signed by the patient declining any blood products. The hospital legal team were contacted and advised as follows: “Physicians are not bound by written directives which they have not seen themselves. The initial verbal consent is valid and supercedes the written directive signed even if same is produced by the partner”. She was stable postoperatively and warranted no further intervention. |
The patient was a 23-year-old woman who was otherwise healthy when she was involved in a high-speed motor vehicle crash. Two of the passengers in the other vehicle died at the scene. The patient was intubated at the referral hospital for a persistently low Glasgow Coma Score (GCS) of 8. On subsequent radiographic evaluation, she was noted to have a small subdural hematoma, a moderate amount of hemoperitoneum thought to be related to a possible splenic laceration, an L5 end-plate fracture, a right humeral fracture, a right femur fracture, and an open right patellar fracture. During the transfer via helicopter to a higher level of care, she became hypotensive and was noted to be a transient responder to blood products dictating the need for an emergent trip to the operating room upon arrival at the tertiary care center.\nAn exploratory laparotomy revealed a small bowel mesenteric injury near the terminal ileum, and 30 cm of small bowel was resected and left in discontinuity. A rent in the sigmoid colon was noted, and a 10 cm segment was resected and also left in discontinuity. There was a minor Grade I injury of the spleen. At no point was the duodenum manipulated or a Kocher maneuver performed. The abdomen was left open with an ABThera device in place, an external fixator was placed on the right femur fracture, and a closed reduction and splinting was performed for the right humeral fracture.\nShe was returned to the operating room on POD#2 to reestablish bowel continuity with a small bowel and then sigmoid colon reanastomosis followed by abdominal closure. She was found to have an end-plate fracture of L5; however, this was determined to be stable, hence there was no need for a brace for immobilization. The external fixator was removed and the femur fracture definitively repaired at the time of final laparotomy. The right humeral fracture was internally fixated on POD#10/12.\nThe inferior vena caval filter (DENALI Vena Cava Filter, Bard Peripheral Vascular Inc., Tempe, AZ) was placed on HD#5 as a prophylactic intervention in an individual who would be at high risk for pulmonary embolism given her extensive extremity injuries and multiple trips to the operating room with a known intracranial bleed from trauma. The intermittent use of subcutaneous enoxaparin would place the patient at significant risk of pulmonary embolism.\nHer oral intake was sparse and poorly tolerated with intermittent nausea and vomiting until she demonstrated the need for nasogastric decompression due to voluminous vomiting on POD#12/14. A KUB at that time was unrevealing and demonstrated minimal gas, if any, in the bowel. On POD#16/18 and with an IVC filter dwell time of 16 days, an upper GI study demonstrated an almost complete cut-off of the contrast flow beyond the second to third part of the duodenum (). The obstruction to the flow of oral contrast correlated with the location of the IVC filter in the infrarenal IVC to create a functional obstruction within the duodenum similar to an SMA syndrome. Computerized tomographic scan cross-sectional imaging shows a pinching mechanism between the right-sided IVC filter and the left-sided SMA with the third portion of the duodenum compressed between the two structures (Figures and ). This corresponds to the area of complete occlusion of the third part of the duodenum. A review of the abdominal-pelvic CT scan on the day of admission () failed to show any preexisting evidence for SMA syndrome, and it was ascertained that there was no history of oral intake intolerance prior to the injury. There is some free blood in the abdomen on that original CT scan but no evidence for duodenal hematoma. The IVC filter was removed after a dwell time of 18 days, and clinically, the patient continued to put out a large amount of fluid from the nasogastric tube.\nAn upper endoscopy was performed five days after the IVC filter had been removed, yet the duodenal edema and obstruction persisted (Figures and ) requiring NG tube decompression for another four days. At that point, an upper GI series was repeated () and that demonstrated complete resolution of the previously documented duodenal obstruction. The nasogastric tube was removed, and the patient resumed a diet without further issue. |
A 56-year-old male patient was referred to the oral and maxillofacial surgery department for evaluation of a large painless swelling in his right parotid gland region. Facial asymmetry due to the lesion was noticeable. There was no pain, paresthesia or lymphadenopathy. No pus drainage was evident in extraoral and intraoral examination; the regional skin and the tissue mass were intact. The patient’s past medical history was unremarkable. The patient reported swelling since 3 months ago. The patient underwent computed tomography of the head and neck, which revealed an ill-defined lesion in the right parotid gland that was attached to the superficial skin ().\nAn incisional biopsy was performed and histopathological examination revealed a malignant salivary gland tumor composed of islands and sheets of large epithelial cells with numerous ductal structures and comedo necrosis ().\nSevere pleomorphism and atypical mitotic features were also seen. The most probable diagnosis was high-grade carcinoma most compatible with high-grade SDC. Immunohistochemical staining was performed to confirm the diagnosis. The tumoral cells showed positive staining for CK7 and androgen receptor (AR) ().\nOver 40% of tumoral cells showed positive staining for Ki67. The tumoral cells were negative for S100, estrogen receptor and progesterone receptor. These findings were in favor of high-grade SDC of the parotid gland. Thus, total parotidectomy was carried out followed by adjacent radiotherapy ().\nThe patient had no noticeable complication at the 6-year follow-up; however, in his next follow-up session, an exophytic ulcerated small lesion was detected at the previous surgical site. The entire lesion was surgically excised with 2 mm of safe margin (). Microscopic examination of the lesion revealed the same features as the previous lesion with free surgical margins. Considering the history of total parotidectomy and development of a new skin lesion at the same site 6 years later, we presumed that the new lesion more probably was a delayed metastatic skin lesion. Although the lesion could be a late local recurrence possibly due to implantation or seeding of the tumoral cells during the previous surgical procedure, but local recurrence was expected to happen earlier than 6 years. The patient underwent full body examination to find any other possible distant metastatic lesion. Computed tomography of the head and neck revealed one ill-defied lesion in the brain (). Unfortunately, the patient died 2 weeks after surgical resection of the brain lesion. |
A 72-year-old male presented with a history of pneumothorax that occurred 2 years previously and had experienced chronic cough, expectoration, and shortness of breath for 10 years. He was diagnosed with COPD in 2018 and received regular inhalation treatments of budesonide and terbutaline. The patient was hospitalized with the symptoms described above as well as fever. A CT scan revealed mild hydrothorax and a hydropneumothorax of 70%. Thoracic drainage of 24F was performed, but after 3 days, the air leaks persisted. A CT scan at our hospital revealed multiple pulmonary bullae, as well as reduced and disorganized pulmonary vascular markings. The thoracic surgery department was consulted concerning the poor cardiopulmonary status of the patient associated with his diffuse lung injury and comorbid illness, which could lead to a higher risk of death during or after surgery. Based on our consultations, 60 ml autologous blood pleurodesis was performed on the ninth and 11th days after admission to the hospital, which relieved the patient’s shortness of breath. However, a subsequent CT image revealed a pneumothorax of 20% and bubbles were observed in the water-sealed bottle. Thoracoscopy was performed. Pleural adhesions were observed in the right pleural cavity, several thin-walled bullae with diameters less than 2 cm were observed in the superior lobe, and a larger bulla with a diameter greater than 5 cm was located in the inferior lung lobe. The pleural fluid had not been sent for analysis as no lesions in the parietal pleura were found. The bullae were coagulated using argon ions. All bullae in the right superior lung lobe shrank, and the larger bulla was reduced by approximately 60% after the coagulation. The chest drain was removed 3 days after the procedure; no fever, bleeding or signs of infection and tube blockage were seen. The patient was discharged after an additional 2 days. Follow-up of physical examination and chest radiography had not been taken because he had a long journey to the hospital. At a 10-month follow-up phone interview, no recurrence of pneumothorax was reported. |
A 39-year-old woman was scheduled to undergo split thickness skin grafts as part of a reconstructive program following extensive burns. She was burned in a house fire 2 years previously, when she suffered 93% total body surface area burns, with a burn index of 85. Her history was significant for having undergone 39 reconstructive operations over 2 years. Her neck was reconstructed using a graft from the latissimus dorsi, and both femoral veins were occluded due to multiple accesses and indwelling catheters. A subclavian venous catheter had been inserted once before under ultrasound guidance. Physical exam showed her weight was 49 kg, and her height was 155 cm. Most of her body was covered by hard contracted skin. There were no peripheral veins evident on inspection.\nTo obtain venous access for this operation, we searched for veins using a linear probe ultrasound device (6–15 MHz, SonoSite Edge, FUJIFILM SonoSite, Inc., Washington, USA) on the chest and arm. This revealed accessible veins, including the subclavian and axillary veins on the anterior chest, and the brachial vein of the right arm. An indwelling catheter in the right brachial vein was considered as the first choice to avoid possible complications of using the subclavian or axillary veins such as pneumothorax or hemothorax. The right brachial vein measured 3 mm by ultrasound imaging.\nThe right arm had restricted motion range due to extensive contractures. She was positioned in the right semilateral position to gain easy access to the medial side of the arm by supination and abduction. A pillow was placed behind her back to maintain this position. The skin of the arm was prepped with 1% chlorhexidine alcohol solution and covered with a sterile drape. The ultrasound probe was covered with a sterile plastic probe cover. The indwelling venous catheter was placed using sterile barrier precautions. Local anesthetic (5 mL of 1% lidocaine) was injected, and a 20G catheter-over-the needle (48 mm) was inserted. Ultrasound-guided venous catheterization was performed. To access the brachial vein, we used the short-axis out-of-plane approach to avoid mechanical complications of unanticipated artery or peripheral nerve injuries, and then used the long-axis in-plane approach to penetrate the anterior vein wall and cannulate the vein. After inserting the cannula, a guide wire was placed through the cannula using the modified Seldinger technique. We placed a single lumen polyurethane catheter (3 Fr., SMAC Plus, Nippon Covidien, Japan), a commercially available central venous catheter (there is no commercially available midline catheter in Japan). Successful insertion of the catheter was confirmed with ultrasound imaging (Fig. ). The catheter entered the vein 6 cm from the skin entry site (Fig. ). After placing the catheter, we checked venous flow using color Doppler imaging (Fig. ).\nSurgery was performed the following day with no adverse events. A split-thickness skin graft was harvested from the head, and grafted to the neck. The skin graft became infected several days later and the midline catheter was used for administration of antibiotics. A second skin graft was performed again postadmission day 16 and the catheter removed on postadmission day 24. She was discharged without complications. |
A 70 year old woman with a history of low back pain and discogenic symptoms underwent open discectomy. Over the next year her back pain worsened, and her spine surgeon performed an L4-L5 in situ spinal fusion with posterior iliac crest autograft. She continued to experience progressive and disabling pain and subsequently underwent an L4-S1 fusion via both anterior and posterior approaches. During surgery an injury occurred to her inferior vena cava requiring extensive resuscitation and a sixty day stay in the intensive care unit. Post-operatively, a wound dehiscence and Staphylococcus Aureus infection developed in the posterior incision. Treatment consisted of wound debridement, dressing changes and intravenous antibiotics until wound healing. She subsequently recovered from surgery with low grade back pain but increasing pain in her gluteal region and symphysis pubis region. Six months after her fusion an AP x-ray view of the pelvis was obtained revealing symphysis diastasis with significant rotation of the left hemipelvis (Fig. ). She was referred for treatment of the pelvic ring disruption. Reconstruction of the pelvic ring disruption was approached with double plating of her symphysis pubis with 4.5 mm reconstruction plates (Fig. ). No surgical treatment of the posterior pelvis was undertaken. Two months following ORIF of the pubic symphysis she presented at a community hospital with anterior pelvic pain, wound drainage and fever. Aspiration of the suprapubic region revealed the presence of purulent material. She was transferred to the regional trauma center for further care. At the time of referral she was hemodynamically stable. Pain to palpation in her anterior pubis region and over her left sacroiliac joint was noted. Her white blood cell count was 11.2 × 109/L, and her erythrocyte sedimentation rate was 52 mm/hr. A CT scan and radiographs revealed significant fluid collection in the area the symphysis and a complete dissociation of the left hemipelvis with erosion of the left iliac wing near the site of the posterior crest graft. Indium bone scan was unremarkable with no evidence of active uptake in the posterior pelvic ring.\nInitially, the anterior pelvis was debrided through her previous Pfannensteil incision. Forty milliliters of purulent fluid was evacuated and the plates were removed. Cultures were positive for coagulase-negative Staphylococcus. Based on culture and sensitivity studies intravenous vancomycin therapy was initiated and continued for 3 weeks. The posterior graft site was re-explored, and we found a large posterior iliac crest fracture. There was intra-operative evidence of both a malunion and non-union but no evidence of gross infection. Intraoperative gram stain was negative. The fractured segment was severely osteopenic, could not contribute to the stabilization, and was excised. The sacro-iliac joint was reduced, decorticated and grafted with allograft and demineralized bone matrix. The joint was reduced and compressed with three iliosacral screws between the sacrum and the remaining portion of the posterior ilium. The posterior fixation was supplemented by an anterior external fixator in order to control rotation (Fig. ). Postoperative cultures revealed Staphylococcus Aureus despite the negative intra-operative gram stain. This bacteria was different than the bacteria found in the anterior pelvis but the same organism responsible for the previous spine infection. In view of the positive culture, the intravenous vancomycin was continued for three more weeks prior to conversion to oral rifampin and levofloxacin for a six month treatment course.\nPost-operatively the patient continued to experience posterior pelvic pain and loosening of the iliosacral screws occurred by four weeks. The iliosacral screws were removed and repeat debridement of the non-union site with revision fixation was performed. Revision fixation was performed with the aid of CT guidance secondary to the lack of normal landmarks caused by bone loss (Fig. ). These screws remained in situ for nine months before they also required to be removed due to loosening.\nCurrently, at two year follow up, the patient has minimal pain and is ambulatory with any aids or assistance. Her laboratory data indicates no signs of active infection and are within normal limits. Her radiographs demonstrate a stable fibrous union of the sacro-iliac and pubic symphyseal joints. |
An eight years, ten months old girl was referred to the Orthopedic Clinic of the University of Catania, Italy for the diagnostic work up of her scoliosis. She was the third child of healthy, unrelated Italian parents. At the gestation, the mother was aged 31 and the father 33 years. A sister and a brother aged 4 and 2 years, are healthy and do not show hairy abnormalities at their clinical examination. The mother felt normal fetal movements during gestation and the pregnancy was uneventful. The mother denied having had any infections or having used folic acid, any drugs or alcohol during pregnancy and specifically any topical or systemic drugs which can cause hypertrichosis.\nThe girl was born at 39 weeks gestation by cesarean section with breech presentation. The birth weight was 2700 g, height 49 cm and head circumference 35 cm. The Apgar scores were 8 and 10 at 1 and 5 minutes, respectively. The mother referred to have noticed in the girl a tuft of hair in the thoraco lumbar region a few days after birth and the hairy at the elbow level at the age of 3-4 years. The scoliosis was noticed at the age of 8 years during a scholastic medical checkup.\nAt the physical examination the girl’s general conditions were good, her weight was 24 kg (25rd centile) and height was 138 cm (50rd centile). During the examination for the scoliosis a tuft of hairs was seen in the thoraco lumbar area (). At the same time abnormal hairiness was noticed at the elbow from mid humerus to mid forearm bilaterally (). The hairs were thin, lanuginose and fair colored and reached the length of 12-20 centimeters. A thoraco lumbar right convex scoliosis was present. The big toes were large () with recurrent drug resistant infections in the left big toe. Scholastic performance was good. Routine blood and urine analysis and full metabolic and endocrinologic screening yielded normal results. Abdominal ultrasound was also normal. Histological studies of hair taken from affected areas yielded no anomalies with most of the hair follicles in the anagen phase. No abnormalities were noticed at the brain-MRI. Spine MRI disclosed a wide dilation of the ependymal channel from Th1 to medullar cone with segmentary syringomyelic cavitation at the level Th1-Th4 and at the Th12-Ll lumbar level with liquoral signal (-). Normal the intersomatic spaces. Feet X-Ray showed large big toes with absence of bone lesions. The karyotype of the patient was normal (46, XX). |
A 52-year-old woman presented in our neurosurgical emergency ward with severe headache accompanied by nonspecific radiating neck pain. The headache persisted for 3 days, and due to an exacerbation, the patient was admitted to the hospital.\nMedical history revealed that the patient fell in the last few weeks due to a known right-sided hemiplegia. The physical examination did not show any sign of external injury like abrasions, hematomas, etc. The neurological physical examination showed an oriented but aphasic patient with a preexisting high-grade right-sided hemiparesis (3/5). The aforementioned hemiparesis resulted from an earlier (around 1976) hemorrhage of an AVM on the left hemisphere with accompanied intraventricular bleeding. The pupils were equal in size, reactive to light, and there was no relative afferent pupil defect. Moreover, an exophthalmus of the left eye was revealed as well as a known strabismus divergens and a facial nerve paresis on the right side. Furthermore, signs of meningeal irritation in form of a stiff and painful neck were detected. A brain computed tomography (CT) imaging was conducted to investigate any intracranial pathology responsible for the headache symptoms as well as the hemiparesis. The results of the CT imaging were similar to those of 10 years ago, detecting no pathological findings. Thus, we proceeded with a cervical spine CT scan due to the accompanied cervical symptoms. The latter revealed an unstable fracture through the base of the dens, type II based on the Anderson and d’Alonzo classification []. There was no evidence of a spinal hematoma. Moreover, an extended osteolysis was revealed with reactive sclerosis of denses and axis’ endplate and margins, as shown in and . The dens fracture was evaluated as a pathologic fracture. The fall incident could not explain the expanded osteolysis. Our assumption, based on the conducted imaging processes, is that the fracture was caused by a large AVM, which extended from the right side of the axis till the basis of the dens. The AVM also spread into the surrounding soft tissue.\nDuring the hospitalization period, the neurological status of the patient remained unchanged, with persistent mobility difficulties. Taking into consideration the giant craniocervical AVM, the osteolysis of dens coupled with the decreased general condition of the patient, as well as her wish to avoid any kind of treatment, a conservative approach was chosen. The conservative treatment involved the adjustment of analgesics, a stiff neck collar for at least 6 weeks and regular application of physiotherapy. |
A 12-year-old girl presented with a history of frontal headaches for several weeks after suffering minor head trauma. The initial CT scan without contrast showed no evidence of intracranial bleeding. Because of persistent headaches, however, as well as nausea and vomiting, she underwent another CT scan less than a month later that showed a 6.2 × 3.5 cm right fronto-temporal mass with associated edema and a midline shift. Magnetic resonance imaging (MRI) of the brain with and without intravenous gadolinium was then performed and demonstrated a 5.5 × 2.2 × 5.1 cm, apparently extra-axial mass, largely within the right Sylvian fissure (A). The interface of the brain was lobulated and irregular, raising the possibility of the invasion of the brain and subarachnoid space, but no definite intraparenchymal component was recognized. There was vasogenic edema in the subcortical white matter and a 5-mm midline shift towards the left side. Based on imaging, it was felt that the tumor was likely to be a hemangiopericytoma. Physical examination was notable for an intact neurological examination.\nThe patient underwent a right-sided craniotomy after a successful partial embolization of the tumor the day prior (B). A significant portion of the mass was visualized, deep to middle cerebral artery branches shown by intraoperative ultrasound to be coursing through the mass and providing blood supply to the temporal and frontal lobes. The attempted dissection of the tumor off the pial surface also led to devascularization of the underlying brain as the tumor had parasitized the pial vasculature. Therefore, further dissection following superficial excisional biopsy of the mass was not performed for safety reasons. A dural graft was placed. Because of significant brain swelling, the bone flap was not immediately replaced. The temporalis muscle was closed in apposition to the dural graft. Postoperative MR imaging showed that the resection of the anterior and superior aspects of the mass had been accomplished, although the majority of the mass remained (C). Microscopic examination revealed a cellular neoplasm with clear or eosinophilic cytoplasm in sheets, small nests and pseudopapillary formations associated with small foci of necrosis (A). There were rare mitotic figures. Thin connective tissue bands with blood vessels containing endothelial hyperplasia were frequent. Immunostaining revealed vimentin in all of the tumor cells and scattered tumor cells positive for bcl-2, p53, desmin and factor XIIIa. CD99 and CD34 were negative. The mitotic labeling index using Ki-67 staining was approximately 10%. The initial pathologic diagnosis was hemangiopericytoma.\nPostoperatively, the patient remained neurologically intact. One month after her initial surgery, however, the patient developed a rapidly worsening mental status that progressed to coma. Imaging studies showed a hemorrhage within and an interval growth of the tumor (A). The patient underwent an emergent craniotomy with the evacuation of the hemorrhage and near total resection of the residual tumor (B). Although the patient experienced a complete recovery from a cognitive standpoint, she did have a severe left-sided hemiparesis. Two months after the emergent surgery, she underwent another craniotomy for the resection of the recurrent tumor and replacement of her bone flap in preparation for radiation therapy. At that time the tumor was noted to be densely adherent to the overlying dura and temporalis muscle, from which all gross tumor was removed. The resected tumor revealed a few minute areas of infiltration into superficial cortex with no bulk tumor identified within the brain. However, areas of dural infiltration and some infiltration of the temporalis muscle were identified.\nSecond opinions on the pathologic diagnosis with additional immunohistochemical staining revealed that all of the tumor cells were positive for glial fibrillary acidic protein (GFAP). A diagnosis of high-grade glioma was made. Findings of astrocytic tumor cells, vascular endothelial hyperplasia and focal necrosis, along with accumulating imaging and intraoperative information, led to the conclusion that the tumor was a glioblastoma multiforme (GBM) that might have initially expanded in the subarachnoid space rather than subcortically. Further studies included immunostaining for nestin with all tumor cells being positive and for synaptophysin showing focally positive tumor cells from all three resections with slightly increased staining in the second tumor sample and larger foci of stained cells in the last resection (B,D). E-cadherin was negative in the initial tumor biopsy, while there was focal membrane staining in the tumor from the third craniotomy. The patient was treated with external beam radiation therapy 60 Gy with concomitant temozolomide at a dose of 75 mg/m2/day during radiation. Over the course of radiation therapy, she remained clinically stable.\nTwo weeks after the completion of radiation therapy, the patient developed painless bilateral cervical adenopathy with several firm, immobile, right posterior cervical lymph nodes approximately 2 cm in the greatest diameter. One week later, the patient developed midline back pain primarily in the lumbar area and also pancytopenia. An MRI demonstrated the bilateral cervical adenopathy, as well as lytic vertebral lesions of the cervical, thoracic and lumbar spine with multifocal bone marrow involvement (A). A mass deep to the right sternocleidomastoid muscle was excised. Microscopically, there was an infiltrated lymph node along one edge, and the mass consisted of sheets of poorly-differentiated metastatic tumor cells positive for GFAP and rarely for synaptophysin. A right iliac crest bone marrow biopsy was performed, and it showed 60% infiltration with GFAP-positive and nestin-positive tumor cells, while synaptophysin was focally positive ().\nSince the tumor had progressed with extracranial metastases on temozolomide, the patient was started on treatment with vincristine, dactinomycin and cyclophosphamide, as well as external radiation therapy to the lower spine and hip. Because of the unusual course of the disease, a metastatic tumor of the neck was tested for molecular alterations, using a CLIA certified targeted resequencing panel of “actionable” genes using hybrid-capture and next-generation sequencing approaches [,]. Briefly, formalin-fixed, paraffin embedded tumor specimens were sent to have targeted sequencing performed on 236 genes and 47 introns of 19 genes that are involved in fusions. The alterations found in this tumor were the BRAFV600E mutation, CDKN2A loss and PTPRD S1845fs*2. Allele frequencies for BRAF and PTPRD were 64% for BRAF, with a read depth of 2,838; 70% for PRPRD at a read depth of 1,504. The tumor purity was estimated at 60% computationally.\nThis pattern of mutations has been reported in high-grade pediatric gliomas and supported this diagnosis. The presence of a BRAF V600E mutation suggested additional therapeutic options. Following the discussion of this case at the Rutgers Cancer Institute of New Jersey Molecular Tumor Board, vemurafenib (960 mg BID), an oral BRAF inhibitor, was added to her treatment regimen. She developed a macular rash on the extremities five days after starting vemurafenib, while both back pain and pancytopenia improved and the cervical adenopathy regressed. An MRI of the spine also showed partial regression of the bone marrow disease (B). After four weeks of this treatment, she developed worsening back and hip pain, and the size of the cervical adenopathy increased. Her chemotherapy regimen was changed to carboplatin, which did not result in a sustained response. Comfort care was pursued, and the patient subsequently died of her disease, 11 months after symptoms began and 10 months after the initial craniotomy. No autopsy was performed. |
The patient was a 35-year-old female who presented to clinic for evaluation of abdominal pain compatible with symptomatic cholelithiasis. She described intermittent, cramping, right upper quadrant pain starting six months prior to presentation. The pain usually lasted up to one hour and was exacerbated by eating. She denied fevers, chills, nausea, vomiting, jaundice, and changes in the color of her stool and urine. Her past medical history was relevant for morbid obesity (BMI of 42), diabetes mellitus, hypertension, and irritable bowel syndrome. She had undergone recent colonoscopy but had no prior abdominal surgeries. On social history she endorsed occasional alcohol use but denied tobacco and illicit substance consumption. Her physical examination was only remarkable for obesity. Her right upper quadrant was non-tender to palpation and she had no palpable organomegaly, hernia, or mass. The patient had undergone laboratory work up which included a complete blood count, comprehensive metabolic panel, and liver function tests all of which were within normal limits. An abdominal ultrasound did not demonstrate a well-delineated gallbladder. There was increased echogenicity on the proximal edge of the gallbladder fossa compatible with a Wall Echo Shadow (WES) sign suggestive of either large calcified or multiple small calcified gallstones in the gallbladder (). No sonographic Murphy’s sign was elicited and the common bile duct measured 4 mm.\nTaking into consideration the patient’s characteristics (obese female of childbearing age), along with the history of intermittent right upper quadrant pain, and the US findings, the decision was made to take the patient to the operating room for a laparoscopic cholecystectomy in the setting of presumed symptomatic cholelithiasis. Upon entry into the abdominal cavity using standard laparoscopic technique, the gallbladder was not appreciated. The right lobe of the liver was elevated but the gallbladder was not visualized (). Additional dissection was performed in order to clear the liver plate but still no gallbladder was seen (). No surgical clips or signs of prior surgery in the right upper quadrant were identified. Close inspection of both lobes of the liver as well as the falciform ligament was performed but no aberrant location of the gallbladder was identified. At this point the procedure was terminated. A magnetic resonance cholangiopancreatography (MRCP) was performed to evaluate the patient’s anatomy in an outpatient setting that confirmed the absence of the gallbladder (). The patient was discharged home and recovered as expected. She continues to experience intermittent right upper quadrant pain similar to that which she experienced prior to surgery. |
A 59-year-old man with a past medical history of nonischemic cardiomyopathy who initially underwent OHT in 1994 (biatrial anastomosis) was referred for pacemaker lead revision. His posttransplant course had been complicated by transplant vasculopathy, and he ultimately required a second heart transplant in 2002 (bicaval anastomosis). He also developed ESRD and underwent deceased donor kidney transplantation in 2004. He developed ehrlichiosis in 2011 in addition to cryptococcal pneumonia and histoplasmosis requiring chronic treatment with antifungals. In 2013, he had syncope leading to a subarachnoid hemorrhage and was diagnosed with sinus node dysfunction in the setting of intermittent sinus bradycardia to less than 20 beats per minute. He underwent dual chamber pacemaker placement in 2013 (Medtronic ADDRL1) with a Medtronic 5076 lead in the ventricular position and a Medtronic 5592 lead placed in the right atrial appendage after an active fixation lead was deemed to be unstable.\nHe was admitted for volume overload three years later, and pacemaker interrogation revealed undersensing on the atrial channel due to a gradual P wave amplitude decrease from 4.7 mV at implant to ~0.4 mV, leading to asynchronous ventricular pacing and failure to recognize atrial arrhythmias. No change in lead position was detectable on chest X-ray. An atrial lead addition was planned. However, the left subclavian vein was occluded. He underwent extraction of the atrial lead to obtain venous access. A 12 French Spectranetics SLS II laser sheath was advanced over the lead, and minimal application of laser energy was used to free adhesions. Countertraction using a snare was also employed from the femoral vein. The lead was removed, and subclavian access was retained. A Medtronic 3830 lead was implanted in the right atrium. The patient tolerated the procedure well, and he had no complications within the next 30 days. However, he was admitted with cryptogenic encephalopathy two months later which was thought to be at least partially related to subclinical cirrhosis. He was ultimately discharged to inpatient hospice and died shortly thereafter. |
In May 2006, a 25-year-old man, who had sustained a complete left brachial plexus injury with cervical root avulsion and subclavian artery lesion in a motorcycle accident, came to our attention. An exposed distal humeral shaft fracture at the level of the elbow with median and ulnar nerve transection was also identified.\nThe patient was treated in an emergency department with humeral fracture stabilization (Synthes locking compression plate; Synthes, West Chester, PA, USA) and revascularization of the left arm. In July 2006 he underwent surgery of the brachial plexus lesion, with nerve transfers of the distal spinal accessory to axillary nerve and the phrenic to musculocutaneous nerve. Unfortunately he did not show any sign of recovery of the motor function in the left upper limb, and in August 2008 a functional transfer of a gracilis free flap to brachial biceps and a wrist arthrodesis were performed. Over the last 6 years the patient has undergone surgery 3 times and has followed a rehabilitation program.\nFrom the outset, the patient has been treated by searching for symmetry in orthostatic posture. The Global Postural Rehabilitation technique has been used thus far in the course of rehabilitation. Three times per week the patient sustains passive mobilization of each upper limb joint to maintain articular suppleness and prevent stiffness. During the session, the physiotherapist also administers sensitive stimulation to maintain afferent channels.\nAt all times the patient wears splints to place the distal extremity in an intrinsic position for correct articular and muscle length. The whole upper limb is supported by a sling. Postural control, splinting, mobilization, and sensibility rehabilitation have all been included in the rehabilitation program.\nSince 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb in both radial (dorsal) and median (volar) regions.\nFrom the outset until December 2010, NP was successfully controlled with pregabalin, 600 mg/day, and duloxetine, 75 mg/day. On rare occasions severe pain was controlled with oxycodone and paracetamol, but with adverse side effects. Ultimately satisfactory pain relief was obtained with morphine, 60 mg/day.\nIn January 2011, the NP gradually worsened and became localized in the ulnar side of the hand and the volar thumb. Because of the severe NP, the patient was unable to wear a splint on his forearm and hand. He had continuous pain ranging from 3 to 9 on the Visual Analog Scale (VAS). The pain worsened when the patient was tired and after a busy and active day and was relieved by rest. Night rest was disturbed. As a result of pain worsening, we decided to perform PRF treatment. |
A 35-year-old male patient presented with abdominal and lower extremity swellings. He stated that abdominal swelling started 15 days ago and then he observed an increase in the swelling. Meanwhile, six days before admission, he noticed swelling in both legs. He also complained of jaundice, dyspnea on exertion, loss of appetite and malaise. Abdominal ultrasound was performed and revealed severe ascites, splenomegaly and a hypoecho mass in the right liver lobe with extension to midline. On physical examination, the patient was conscious and a generalized icterus was seen. Abdominal distention, bilateral decreased breath sounds in basilar lung regions and pitting edema of both lower extremities were detected but the remainder of examination was normal.\nOn evaluation, ascitic fluid analysis revealed the high serum-ascites albumin gradient (SAAG) fluid and triphasic abdominal computed tomography (CT) confirmed a large mass in the right liver lobe with changes in inferior vena cava (IVC) and hepatic veins suggestive of tumor extension or thrombosis (, ). Doppler ultrasound of hepatic and portal veins showed no thrombosis.\nFor further evaluation of generalized edema and cardiac function, transthoracic echocardiography was done and showed a large mass 40*40 millimeters in the right atrium and small pericardial effusion. Laboratory tests were remarkable for abnormal liver function test in hepatocellular pattern and prolonged prothrombin time (PT) in association with hypochrome microcytic anemia ().\nFemoral vein catheterization was done to try biopsy of IVC mass, femoral vein catheterization was done to perform IVC mass biopsy but tortuous course of IVC made it impossible. Due to the location of hepatic mass, transjugular or percutaneous liver biopsy was not possible. So, CT-guided biopsy from IVC mass was performed. Pathologic examination and immunohistochemistry study revealed high grade leiomyosarcoma (, , ).\nThe patient received chemotherapy regimen including gemcitabine and docetaxel under diagnosis of metastatic leiomyosarcoma. Due to tumor extension, patient was not a suitable candidate for surgery or radiotherapy; so, chemotherapy continued. He then developed hepatic encephalopathy and liver failure during hospitalization and unfortunately passed away. First degree relative of patient had given a written consent for publishing information. |
A 73-year-old male with a past medical history of type 2 diabetes mellitus, hypertension, and stage III chronic kidney disease was vacationing in Mexico when he and his four family members became ill with nausea, vomiting, and diarrhoea several hours after ingesting grilled and raw barracuda fish. Over the following 2 days, they began experiencing a constellation of peculiar neurological symptoms including the sensation of a metallic taste in their mouth, tingling and burning in the extremities, as well as a feeling of intense heat when touching cool objects and an ice cold sensation with warm objects. They presented to a nearby hospital in Mexico where our patient was initially admitted due to an acute kidney injury and uncontrolled blood sugars. On presentation he had a blood pressure of 80/60 mmHg, heart rate of 58, and temperature of 36.3°C. His cardiovascular exam was notable for absence of jugular venous distention, a slow but regular heart rate, normal heart and breath sounds, and no lower extremity oedema. He had a normal neurological and musculoskeletal evaluation. An electrocardiogram (ECG) was then performed () which revealed sinus bradycardia with a heart rate of 29 and no atrioventricular delays or block. He had no electrolyte derangements at the time of his bradycardia. He became intermittently lightheaded with pre-syncopal symptoms and also reported shortness of breath. He received intravenous (IV) mannitol therapy, followed by IV atropine for his symptomatic bradycardia. A dopamine drip was initiated for ongoing bradycardia and hypotension. His daily home medications notable for pravastatin 20 mg, metformin ER 1000 mg, losartan 12.5 mg, and aspirin 81 mg were initially held. Two days later, he was air lifted back to the USA and admitted to the cardiac intensive care unit for monitoring. At that time no further cardiac studies were pursued including cardiac enzymes or echocardiogram. No head imaging was performed. During his hospitalization, he had an episode of hypotension with a blood pressure of 83/46 mmHg, which improved to 110/55 mmHg with fluid resuscitation. He otherwise remained free of pre-syncopal episodes and did not require further chronotropic agents. By the time of discharge, the patient noted some ongoing peripheral neuropathy and altered heat and cold sensation. However, his heart rate had improved, now ranging from 40 to 50 b.p.m. at rest, and augmenting to 60 with exertion. He was discharged with an ambulatory monitor. At follow-up 1 month after his discharge, it was noted that his heart rate had increased to 77 b.p.m. at rest () and he had remained free of pre-syncopal symptoms or shortness of breath. |
A 39-year-old Hispanic woman was referred to our hospital due to the sudden appearance of a painful, mobile, fixed mass of about 5 cm in diameter in the internal upper quadrant of her right breast. The lesion was classified as a breast cyst, and a puncture of it was performed. Hyaline fluid was aspirated from the mass, with a subsequent decrease in its size. After two months, in the next follow-up, the growth reappeared. Therefore, the mass was surgically resected. The resected lesion was sent to the pathology department and a diagnosis of chronic granulomatous mastitis and fat necrosis was made.\nThree months after the surgery, the patient presented again for an evaluation due to the presence of a keloid scar of about 5 cm. When the breast was examined a 2 cm nodule located under the scar was palpated. The mass had well-defined borders and was not fixed to superficial or deep tissue (). A breast ultrasound was performed, and it showed a cystic tumor of 2.33 cm, with well-defined borders and mixed echodensity. Due to the result of the ultrasound, the growth was described as a recurrent, complicated right breast skin cyst.\nThe patient underwent surgery in order to remove the tumorous growth. The lump was excised with amplified margins of 2 cm. The macroscopic appearance of the tumor was of a pale yellow, firm, solid, lobulated, poorly defined mass, of 2.8 cm in length and 2.5 in width, covered by mature adipose tissue (). Microscopically, the tumor was described as a mixed tissue tumor, consisting of solid and cystic areas. The solid part of the neoplastic lesion was formed by squamous cells disposed as cordons, exhibiting peripheral palisades, with the presence of abrupt keratinization of the outer layers and focal calcifications. The cystic part presented a wall showing stratified squamous epithelium, multiple pleomorphic mitotic cells, and intraluminal keratin deposits (Figures and ). In some areas of the adjacent stroma, the pathologist observed squamous epithelial cell nests, with desmoplastic reaction and lymphocytic proliferation (). The immunohistochemistry report was as follows: CD34 negative in the neoplastic cells, positive cytokeratin AE1/AE3, and positive p53 in 40% of the tumor. Finally, the diagnosis of MPTT was made, and the patient has been followed up since the diagnosis without any signs that the neoplasia has relapsed. |
A 65-year-old female was diagnosed with limited systemic sclerosis 11 years previously after presenting with Raynaud's phenomenon complicated by digital necrosis resulting in amputation of the tip of her left third finger and interstitial lung disease. Her SSc had been managed with various disease-modifying agents, but each had to be discontinued due to intolerance. She was maintained on chronic low-dose prednisone. Her first encounter with our facility was when she presented to vascular surgery with chronic venous insufficiency and a nonhealing venous ulcer on the medial aspect of her left lower leg which had developed in October 2016. At the time, her functional status had declined from being fully functional to being confined to a wheelchair or a walker due to the discomfort from her leg ulcer and exertional dyspnea. She had debridement of the wound and radiofrequency ablation of her left saphenous vein and developed hypotension following the procedure requiring ICU admission. During workup for the hypotension, she had an echocardiogram which showed a left ventricular ejection fraction (LVEF) of 30-35%, a severely dilated right ventricle (RV) with moderately reduced function as measured by a tricuspid annular plane systolic excursion (TAPSE) of 1.1 cm and an estimated right ventricular systolic pressure of 66 mmHg. A noncontrast CT scan of her chest showed mild interstitial lung disease. She subsequently had a right heart catheterization which showed a pulmonary artery pressure of 91/37 mmHg with a mean of 55, a transpulmonary gradient of 47 mmHg, a pulmonary capillary wedge pressure of 8 mmHg, and a pulmonary vascular resistance of 18.1 Woods units. Her cardiac output was 2.6 L/min and cardiac index was 1.8 L/min/m2. She had a normal ventilation perfusion scan. She was diagnosed with PAH with a World Health Organization (WHO) functional class of IV. A repeat echocardiogram prior to the initiation PAH therapy showed a LVEF of 55-60%. The patient refused parenteral prostanoids. She was treated with sildenafil and macitentan and inhaled treprostinil with improvement of her WHO functional class to class III.\nShe began treatment of her left lower extremity wound at our wound care center in April 2017. At her initial evaluation, her wound measured 10 cm long, 5.3 cm wide, and 0.3 cm deep with an area of 41.626 cm2 and a volume of 12.488 cm3. It was described as a full-thickness wound without exposed structures, with well-defined borders, a large amount of serosanguineous exudate and with medium amount of granulation tissue (). Initial treatment was with nonadherent Silvercel as the primary dressing and Kerlix with ABD pad applied as the secondary dressing. After 2 months, the primary dressing was changed to the bioengineered skin substitute Apligraf and Mepitel One. Three months later, it was switched to Adaptic. The maximum reduction in wound area achieved with these modalities was 78.1% reduction after 7 months of treatment. The patient was thought to have exhausted her options at this point. After a thorough search of the literature, consulting with the patient's pulmonologist and cardiologist, and detailed discussion with the patient outlining the potential risks involved and possible benefits, a joint decision was made to attempt HBO2T which started in November 2017. Her most recent echocardiogram had been obtained 4 months prior, and it showed an LVEF of 61%, grade 1 diastolic dysfunction, a moderately dilated RV with mildly reduced function, TAPSE 1.6 cm, and an estimated RVSP of 72 mmHg. The patient received 30 treatments between 11/13/2017 and 12/19/2017 in a monoplace chamber at 2 ATA with 90 minutes of oxygen with no air breaks. Duration of each treatment ranged from 106 to 110 minutes. No immediate adverse events were noted during any of the treatment sessions, and she did not experience any worsening of her exercise tolerance. After completion of HBO2T, wound care continued with Apligraf, Adaptic, and Xeroform. Complete wound closure was achieved by April 2018 (). She had 3 wound debridements during her treatment at the wound care center, 2 while receiving HBO2T. At follow-up, her functional status has improved to WHO class II, echocardiogram showed a LVEF of 65-70%, mild left atrial enlargement, grade II diastolic dysfunction, mild right atrial enlargement, and a mildly to moderately dilated right ventricle with normal function measured by a TAPSE of 1.9 cm. She had started exercising on a stationary bicycle and worked 5-7 hours per day. Prior to HBO2T, significant nocturnal wound pain interfered with her sleep. After wound closure, her pain resolved and quality of life vastly improved. The patient continues to do well. At her most recent follow-up in October 2019, her functional status remains at WHO class II, serum brain natriuretic peptide level was 45 pg/mL, and her echocardiogram showed a normal-sized RV with normal function and an RVSP of 33.9 mmHg. |
A 64-year-old man with a known liver cancer diagnosed 6 months ago, was presented to our clinic with severe pain in the lower thoracic region, deteriorating at night without any neurological deficit. He was neurologically intact. His medical history revealed a stable coronary heart disease. Histologically, the tumor was characterized as a hepatocellular carcinoma with moderate growth complicated with a treatable lung metastasis during the investigation after hospitalization. According to the classification of Tomita et al. [], the patient with 6 points in the scoring system, was an eligible candidate for a palliative surgery, aiming at short-term local control. Preoperatively his VAS score was 8 and his Oswestry low back pain disability questionnaire 84%.\nThe plain x-rays and the MR image show the malignant fracture at T12 level with moderate posterior bulging into spinal canal (Fig ). An additional secondary deposit is shown in the T11 vertebral body. RFA and BKP of the lesion was performed. The radiofrequency electrode was introduced two times into the body and one time in the left isthmus area of the Th12 vertebrae. The volume of the injected PMMA cement during BKP was 4 ml (Fig ). The placement of the PMMA is performed very carefully after 10 min of preparation and under continued fluoroscopic image in order to avoid the symptomatic extravasation. Increase of 8% and 11% were measured respectively for the anterior and middle vertebral wall. RFA only was performed in the T11 vertebrae and the surgical treatment was completed with the laminectomy of the T12 vertebra in order to avoid the challenging anterior approach and reconstruction in an already aggravated patient.\nImmediately post-operatively, the VAS score was 4 and the need for painkillers was drastically reduced. No complications related to the procedure were observed. The VAS and the ODI at the 3-months follow-up were 2 and 52% respectively. The patient died 6 months after treatment from complications related to portal hypertension, being neurogically intact. |
A 47-year-old female was admitted with a complaint of a large palpable mass in the left breast. This mass had gradually grown over 6 months. There were no associated symptoms of pain, nipple discharge or history of trauma.\nPhysical examination revealed an over 8 cm sized large subareolar lesion of the left breast which appeared to be a firm, well-described mass, attached to the skin.\nThe patient subsequently underwent several studies for diagnosis. Abnormal laboratory findings were not observed with a normal range of complete blood count and C-reactive protein. Mammography showed a round, dense, smoothly outlined mass measuring 7 × 6 cm (). Breast sonography showed a solid, hypoechoic with heterogeneous internal echoes and well demarcated border ().\nPhysical and imaging examination indicated a benign nature. Therefore, we presumed a large fibroadenoma or phyllodes tumor, or benign features of a malignant lesion such as mucinous carcinoma due to the overly large size.\nA fine needle aspiration biopsy was done and a thick yellowish viscid material with offensive odor was aspirated during the biopsy thus confirming the cystic nature of the lesion. However, we could not get adequate biopsy material due to too its thick nature and the mass was still palpable. The giant size and breast location of the palpable mass was causing the patient's discomfort, and the mass size had grown gradually over the past month. Moreover, there was clinical concern for possible underlying malignancy due to the overly large sized mass, and the mass had a potential risk of malignant transformation. We therefore decided to perform a total mass excision.\nThe histology of the specimens showed a cyst lined by mature stratified squamous epithelium filled with laminated keratin along with a cholesterol cleft surrounded by a giant cell and histiocytes suggesting a microruptured cyst ().\nBased on these data, we established the diagnosis as a micro-ruptured epidermal inclusion cyst in the breast.\nAt the follow-up examination 8 months postoperatively, the patient was asymptomatic and there was no local recurrence of the lesion.\nIn summary, we encountered a rare case of a giant-sized epidermal inclusion cyst of the breast that initially mimicked a large fibroadenoma or phyllodes tumor. |
The patient, a 30-year-old Tibetan man, was treated in the Lhasa Hospital for right tibiofibular fracture December 2012 (Fig. ). After the swelling subsided, he underwent right tibia fracture intramedullary internal fixation. Two weeks after the operation, the patient was able to walk with double crutches without load, and was able to walk without crutches and with some load 3 months after the operation. However, the patient complained of pain in his right lower extremity, especially when moving downhill or down stairs, and experienced a limping gait and obvious tenderness at the fracture end. Three years after originally presenting at Lhasa Hospital, the patient was experiencing persistent pain in the right lower extremity, and his daily activities were severely affected. Thus, he was re-diagnosed with nonunion of the right tibial fracture after internal fixation (Fig. ). The main causes of the nonunion of the fracture were considered to be the excessively thin intramedullary nails and unstable fixation of the fracture. The operation was repeated with replacement of the crude intramedullary nails and grafting of iliac bone (Fig. ). Three months after the operation, the tibial fracture had failed to heal, and further surgical treatment was performed. The proximal locking screw of the intramedullary nail was removed with an expectation to eliminate the stress shielding effect and to promote fracture healing by increasing the microdynamic force while retaining the static interlocking nail. Five months after the operation, the patient abandoned the crutches and was able to walk with a heavy load. Nevertheless, 2 years after the operation, active pain of the right leg persisted with some tenderness around the fracture, especially when moving downhill or down stairs. August 2018 the patient was admitted to our hospital. Physical examination revealed that two old incision healing scars, approximately 2 cm in length, were present at the proximal and distal ends of the right tibia. The middle section showed a scar from an approximately 10-cm incision; pigmentation was found around the incision and tenderness was experienced around the fracture. Imaging results revealed a nonunion of the right tibial fracture, and the admission diagnosis was nonunion of the right tibial fracture after surgery (Fig. ).\nTwo days after admission, “right tibial locking intramedullary nail removal, open reduction and porous tantalum metal plate fixation” was performed. After removal of intramedullary nails during the operation, nonunion of the tibial fracture was corrected and osteoporosis of the fracture end. Osteosclerosis of the fracture was observed, and the sclerotic bones as well as part of the hyperplastic epiphysis were removed; the marrow was reamed at the fracture to keep the medullary cavity open. The resected osteophytes were implanted into the fracture, followed by fixation with a porous tantalum plate.\nAfter the operation, the affected limbs were fixed with plaster. Ankle joint activity training was initiated on the first day after the operation, and knee joint activity training began 2 weeks after the operation. The patient was able to walk with double crutches without load 4 weeks after the operation and could perform normal activities 12 weeks after the operation without pain in the right limb. However, slight tenderness was still experienced around the fracture. Five months after the surgery, the right tibial fracture had healed, based on imaging examination, and the tenderness around the fracture had disappeared; the patient was able to work normally (Fig. ). |
This is a case of a 37-year-old, right-hand dominant, Malay man who presented to our Emergency Department 6 hours after he had fallen approximately 6 meters from a rambutan tree where his left arm hit the tree trunk on his way down to the ground. Post trauma, he complained of pain and swelling over his left antecubital fossa. There was no wound over his left upper limb. He had no history of trauma to his left upper limb and no significant past medical history. He did not take any medications. He was an army officer and had been an army officer for 16 years. Two years prior to the current accident, he was transferred to the administration unit of the Ministry of Defense. His job scope was mainly office work. He lived with his wife and three children in a small suburban home. He was an active tobacco smoker with a 20 pack year smoking history. Currently he smoked 10–15 cigarettes a day. He did not consume alcohol.\nIn our Emergency Department, his vital signs were stable with blood pressure 132/80, pulse rate 79/minute, and temperature 37 °C. A physical examination of his left upper limb revealed a tender, fluctuant swelling over the left antecubital fossa with slight limitation in his left elbow range of motion due to pain. There was ecchymosis over the lateral aspect of his left elbow joint but his left elbow was not deformed. His left radial pulse was feeble and his left ulnar pulse was not palpable. Capillary refill times of all fingers were more than 2 seconds. Sensation over left upper limb was normal. Doppler signal of brachial artery proximal to cubital fossa was triphasic, radial artery was monophasic, and ulnar artery was absent. Radiographs of his left elbow showed chip fracture over the left lateral epicondyle of the humerus (Figs. and ). Subsequently an urgent computed tomography angiogram of his left upper limb was done which showed a segment of non-opacification of contrast at the distal left brachial artery measuring 3.3 cm with distal reconstitution of the left brachial artery by collaterals just before the bifurcation of the left brachial artery at the left elbow joint (Figs. and ). The computed tomography scan also showed minor fractures of left lateral epicondyle and left radial head (Fig. ). Laboratory investigations (full blood count and renal function test) were all normal.\nHe was seen by general surgery and orthopedics teams. Our hospital did not have vascular expertise; hence, he was referred and transferred to a vascular surgeon in another hospital for surgery. He underwent emergency left brachial artery exploration surgery 15 hours after his fall. On intraoperative examination, his distal left brachial artery was contused. Therefore, a left brachial to brachial artery bypass was done using reversed saphenous vein graft. Intravenously administered antibiotics (cefuroxime 750 mg three times a day) were given before induction and for 3 days postoperatively. Postoperatively, Doppler signals of left radial and ulnar arteries had improved. He did not develop reperfusion syndrome requiring fasciotomy. The vascular repair was successful and he was discharged 4 days after surgery. On discharge, his bilateral radial pulses were symmetrical and strong. Fractures over left lateral epicondyle and left radial head were treated conservatively using a 90 degrees posterior splint for 2 weeks. The plan was to immobilize these fractures for a short duration followed by early range of motion exercises.\nThis patient was followed up in orthopedic and vascular out-patient clinics. Six weeks post trauma, his left elbow was noted to be dislocated in an out-patient clinic (Fig. ). Closed manipulative reduction was attempted but unsuccessful. His left elbow was still subluxed (Fig. ). There was probably soft tissue interposition in the left elbow joint. His left upper limb neurovascular examination was intact. He was counselled for surgery to reduce the elbow joint with vascular team standby. However, he was not keen for surgery at that time. At the last clinic follow-up around 6 months post trauma, his left elbow joint was still subluxed, his left triceps was shortened, and left elbow range of motion was reduced (extension 0 degrees, flexion 45 degrees, and pronation and supination normal). His radial pulses were strong and equal bilaterally. Functionally, he was able to cope with light duties. He used his left shoulder to compensate for the reduced range of motion of his left elbow. However, he was unable to carry weight > 2 kg using his left upper limb. He was still not keen for any surgical intervention to stabilize his elbow joint due to the risk of vascular graft thrombosis and injury. |
A 10-year-old male child patient reported at the Department of Oral Medicine and Radiology with a chief complaint of swelling on the anterior part of the tongue since 3–4 months. The swelling was small in size and progressed gradually over the time to reach the present size. The patient has no history of pain; however, discomfort was present. This was associated with difficulty in speech and mastication as the swelling increased in size of the cyst. The past medical and dental history was not significant. General physical examination and extraoral examination were unremarkable. Intraoral examination revealed a well-circumscribed, round, firm, non-tender, cystic swelling of about 2.5 × 2.5 cm in size, with a smooth surface (). Overlying mucosa looked normal. Swelling was embedded in the right side of the dorsum surface of the anterior tongue involving the lateral border and extending up to the ventral surface ( and ). There was no discharge from the swelling. The swelling was asymptomatic. Based on the history and clinical appearance of the lesion, a provisional diagnosis of the dermoid cyst was hypothesized. Differential diagnosis of the lesion included epidermoid cyst and lymphoepithelial cyst. The investigations included complete hemogram and intraoral periapical radiograph and ultrasonography. Routine hematological investigation values were found to be within normal limits. No calcification was detected on an intraoral periapical radiograph (). The ultrasonic scan of the lesion revealed a thin-walled anechoic cystic lesion measuring 13 × 10 × 9 mm in the submucosal plane of anterior one-third of the tongue on the right superior aspect. The lesion did not show internal vascularity; however, there was a mural nodule measuring 5.6 × 3.1 mm which demonstrates faint vascularity (). Complete surgical excision of the cyst was done and the mass was sent for histopathological examination (). Histopathology confirmed the diagnosis of an epidermoid cyst by the presence of the stratified squamous epithelial tissue covering the cyst cavity, with laminas of parakeratin on the surface (). The postsurgical period was completely successful. The patient was followed-up for the next 6 months, and no recurrence of the lesion was observed. |
A 28-year-old woman had a history of sudden onset of syncope diagnosed as paroxysmal ventricular tachycardia. She underwent electric ablation and placement of an ICD in her left shoulder. She had poor wound healing at a 5-month follow-up visit and she was admitted to the hospital on December 1, 2008 for management of a pocket infection. Exposure of the ICD generator and pacing lead were found on February 26, 2009, and the generator was removed, leaving the pacing lead in place. She had episodic pyrexia beginning in May 2009 and her blood cultures grew MRSA (isolate st01, positive in one of two sets blood cultures collected). ICD device-related endocarditis was highly suspected. Intravenous antibiotics with vancomycin 1 g every 12 hours for 14 days followed by oral linezolid 600 mg every 12 hours for another 14 days were prescribed for her endocarditis, but the blood cultures still grew MRSA (isolate st02, positive in one of two sets blood cultures collected). A thoracotomy was planned to remove the pacing lead. However, because of three episodes of broken peripheral venous catheter tips left in the vessels, generator displacement requiring surgical intervention, and emotional fragility, the surgical intervention was postponed due to the high possibility of postoperative wound infection and further osteomyelitis. Daptomycin at a dosage of 6 mg/kg daily was prescribed for its effective biofilm penetration ability and rapid bacteriocidal efficacy, and the subsequent blood culture (one set collected) yielded negative finding. A total 65 days of treatment were completed and the patient was discharged on October 24, 2009.\nUnfortunately, spiking fever and chills occurred 1 day after discharge and the blood cultures grew MRSA again (isolates st03, positive in one of two blood cultures collected). During antibiotic treatment with intravenous tigecycline (100-mg loading dose and 50 mg every 12 hours for 14 days), one of two sets of blood cultures grew MRSA (isolate st04). Teicoplanin 400 mg every 12 hours for another 14 days was given, but another one of two sets of blood cultures grew MRSA (isolate st05). Intravenous daptomycin was prescribed at a dosage of up to 9 mg/kg daily in combination with intravenous fosfomycin 6 g every 6 hours starting December 16, 2009, due to the persistence of MRSA bacteremia with the ICD device in place. The patient's fever subsided after these treatments and the next three sets of blood cultures were negative 1 week after the start of daptomycin-fosfomycin combination therapy. However, transesophageal echocardiography revealed vegetations growing on the pacing lead, and a scan for osteomyelitis showed increased uptake of the radiotracer in the left proximal clavicle. Moreover, the daptomycin Etest (AB Biodisk, Solna, Sweden) of MRSA isolate st05 indicated that it was nonsusceptible to daptomycin, with a minimal inhibitory concentration (MIC) ranging from 1.5 to 2 mg/L. After discussion among the surgeons and infectious disease specialists, a thoracotomy was performed on December 22, 2009 for removal of the pacing lead due to the previous persistence of S. aureus bacteremia; high-dose daptomycin 12 mg/kg intravenously daily was also started. A vegetation measuring 1.3 × 0.6 × 0.1 cm was found on the pacing lead, but the Gram stain showed no microbes. Tissue culture of the vegetation found on the pacing lead grew MRSA (isolate st06), as did as the tip of the pacing lead (isolate st07).\nBecause the osteomyelitis scan was positive, combination therapy with daptomycin 12 mg/kg intravenously daily and fosfomycin 6 g intravenously every 6 hours was administered for total of 56 days. The patient had no further pyretic episodes following hospitalization. A follow-up osteomyelitis scan on March 8, 2010 was negative, and follow-up transthoracic echocardiography showed no vegetation. The patient's symptoms were attributed to endocarditis; she remained symptom free during 12 months of follow-up. |
A 38-year-old female patient referred to the Department of Oral and Maxillofacial Surgery with a complaint of swelling at the right lower side of the angulus mandibula. Intraoral examination showed an expansion of buccal cortical plate and a palpable soft swelling over the residual alveolar ridge bone in the second and third molars region of lower mandible (). Medically, the patient condition was fit and well, without any previously known allergic reaction, and she was not taking any medication. Orthopantomography revealed that there was bilateral impaction of the lower second and third molars in each side of the angulus region of the mandible. In each side of the mandible, the impacted teeth (the second and third molars) had their occlusal surfaces contacting each other in a single follicular space ().\nThe stipulated treatment plan was the surgical removal of the kissing molars. Before the surgery a complete survey was performed, including blood tests. Results of the tests did not reveal any medical problem and/or risk condition. The surgical operation was performed under regional and infiltration anesthesia blocking the inferior alveolar, buccal, and lingual nerves. The patient was medicated preoperatively with 40 mg prednisolone for controlling the postoperative complications. The kissing molars were approached with the help of a vestibular incision. After the vestibular incision, mucoperiosteal flap was removed. Then, osteotomy was performed to expose the impacted kissing molars. The next step of the surgery was the sectioning of the third molar with surgical burs to minimize the quantity of bone removal and facilitate the extraction. After removal of the third molar, second molar was removed by the same approach. Following removal of kissing molars, the socket was rinsed with saline solution and residual follicular tissue was removed (Figures and ). Finally, the operational region was sutured by interrupted stitches using 3/0 silk suture. After 3 months from the first operation, the same surgical intervention procedure was performed to the other side of the mandible (Figures and ). Following the surgical operations, for controlling postoperative pain and infection, 1000 mg amoxicillin and 550 mg naproxen sodium were prescribed to the patient for a week. Swelling decreased gradually in the follow-up period after surgery. The sutures were removed seven days after the operations. The patient was kept on a soft diet for about two months. After that, recovery period was uneventful (Figures and ). |
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. |
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