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A 40-year-old right hand dominant female patient presented to the Out Patient Department with pain in the right hand due to a fall on the out stretched hand. Swelling present on radial half of the wrist and lower forearm ( & ). She had pain over the radial side of the wrist, tenderness over the trapezium and base of first metacarpal with no tenderness in the anatomical snuff box with no crepitus or abnormal bony movements. Movements of her thumb was only restricted in the terminal range, palmar flexion and radial deviation were painful and her neuro-vascular status was intact.\nInvestigations: A plain radiograph of the left hand revealed a incomplete fracture trapezium similar to Walker Type-1 but is incomplete with intact 1st CMC Joint ( & ). CT scan confirmed the coronal split fracture of the trapezium with a major volar fragment and a dorsal fragment without articular involvement ()\nTreatment: The patient refused operative intervention. A Cock up back slab was given for 5 days in emergency room to relieve pain and swelling. Fracture was treated conservatively. Under general anaesthesia, a below elbow plaster cast was done for 8 weeks, later converted to synthetic cast at 4th week due to patient’s discomfort with the regular cast.\nOutcome and follow-up: Physiotherapy initiated at 8 weeks. She resumed normal activities assisted with a planned physiotherapy regimen at end of 8 weeks. At 3 month and 6 month follow-up the patient reported good functional outcome. At 6 months, she had a painless and complete range of motion of the left thumb (Figs , & ) and wrist, compared to the uninjured side. The follow-up radiographs showed normal articular relationship of the trapezium with the base of first metacarpal and scaphoid. The fracture healed with no complications (Figs & ). Though we did not formally score his function, she reported satisfactory return to all her normal activities of daily living including writing, dressing and lifting. Her grip strength was normal. |
A healthy 36 years old woman who had pregnancy complicated by placenta previa and placenta accreta was referred to our hospital. She had a history of twice caesarean section which one of them was due to placenta previa. In ultrasonographic examination the internal cervical os was covered completely by placenta. In addition the sonographic examination of placenta revealed multiple hipoechoic spaces (lacunae), turbulent internal flow and thinnig of the myometrium []. These findings were interpreted in favor of total placenta previa and abnormal placental invasion.\nThe patient was scheduled for an elective Caesarean section at 38 weeks. The patient was informed the type of operation and possible complications which is related with procedure. Preoperatively hemoglobin was calculated as 10.2 g/dl. All the coagulation profiles were found within normal range. Against the risk of bleeding and disseminated intravascular coagulation, four unit erythrocyte, eight unit platelet and eight unit plasma suspensions were prepared.\nIn the operating room the abdomen was penetrated by vertical incision. For the uterus high vertical incision was preferred instead of uterus Kehr incision in order to avoid bleeding of placenta. Subsequent to the removal of fetus; we waited 15 minutes to see normal placental seperation.At the end of this time normal separation could not be seen. Gentle traction was applied to remove the placenta but it could not be extracted from the uterine wall.\nBy this step preoperational diagnosis of placental invasion anomaly was confirmed surgically. Retaining the placenta within the uterus, retroperiton was dissected in order to visualize the retroperitoneal vessels. External iliac and internal iliac artery was observed in the retroperitoneal area. Bilateral hypogastric artery ligation was done at 5 cm distal of arteria iliaca communis bifurcation. Following the ligation, placenta was removed from uterine cavity by strong traction. Minimal placental tissues were cut with metzenbaum.\nThe myometrium was invaded by the placental tissue. The uterine serosa was intact. These findings confirmed the diagnosis of placenta increta. Bleeding in the cervical region was observed and a Bakri balloon was placed into the uterine cavity. The uterine incision was separately sutured before filling balloon with saline solution. The tube was inflated with 500cc of hot saline solution. Bakri balloon stopped the small bleedings from the placental bed. Uterine vertical incision were closed by using interrupted absorbable sutures and continuous monoflament delayed absorbable suture was used to close the fascia. The skin of the abdomen was closed separately with non-absorbable sutures. The patient was not observed to have an extra bleeding.\nAfter 24 hours from the operation, 200cc of the tube was taken out and bleeding control on the patient showed no bleeding. After 26 hours, the remaining amount of 300cc was also taken out and the tube was displaced from the patient. Antibiotics were administered at duration of balloon usage to reduce the risk of iatrogenic infection caused by contamination of the uterine environment by the balloon from the vaginal environment.\nThe hematocrit level of the patient was measured 30.2 before the operation and 26.8 after the operation. First 24 hours from the operation the distended uterus can cause discomfort and pelvic pain. In this period 50 mg Pethidin (Aldolan, Liba) was administered every 6 hours and Diclofenac (Diclomec, Abdi Ibrahim) sodium was applied two times. At 48 hours after the operation, the patient had no additional bleeding.\nTransvaginally ultrasonography showed no placental residual mass in the uterus. Therefor we did not perform methotrexate therapy. The patient was discharged on the 3rd postoperative day. Patient was examined every 7 days sonographically in the puerperium period. In this period no complication was seen. Her beta human chorionic gonadotropin (-hCG) level was 5mUI/mL in the 40th postpartum day. |
A 78-year-old male was referred to our colorectal department with a more than 1-year history of perianal irritation and pain. He complained that these symptoms troubled him almost every day and worsened during defecation. He thought they decreased his quality of his life significantly, though he could endure the mild symptoms. There was no evidence of perirectal bleeding. He was diagnosed as suffering from hemorrhoids by the community physicians and was treated with a topical cream named compound carraghenates cream, 0.5 g, three times a day. However, there were no improvement. He had no weight loss or any other gastrointestinal symptoms. He had no family history of colon cancer or other malignancy. He had had type II diabetes for 15 years, glucose levels being controlled by metformin tablets. He had had hypertension (stage 2) for 3 years. His blood pressure was in the normal range by take one tablet of Norvasc per day. Physical examination showed pale plaque-like lesions involving two sides and the posterior zone of the perianal skin, measuring 1 × 3 cm, with no evidence of erythema or anabrosis. Digital rectal examination of the anus and rectum revealed a 1.0 × 1.2 cm tumor located in the posterior anorectal region in close proximity to the perianal lesion. The tumor was hard with tenderness and good mobility. There was no evidence of inguinal lymphadenopathy.\nIn the preoperative setting, a colonoscopy was done and showed slight inflammation of the rectum. A CT scan of his chest, abdomen and pelvis was unremarkable. Endoanal ultrasound showed evidence of a tumor within the anal canal without invasion of the surrounding anal sphincter musculature. Biopsy of the tumor and perianal skin under local anesthesia was performed. Histological examination of the specimen was suggestive of a malignant tumor of epidermal origin, possibly representing carcinoma of the sweat gland.\nAs the patient had refused abdominoperineal resection and the tumor might be syringocarcinoma, wide local excision and reconstruction with transposition flap was performed. However, histological examination of the resected specimen revealed a poorly differentiated anorectal adenocarcinoma and PPD (fig. ). The margins of both lesions were clear of malignancy. Immunohistochemical stains were positive for CK7, but negative for GCDFP-15, CK20, CDX2 and MUC2 in the Paget's cells. CK7, CK20, CDX2 and MUC2, but not GCDFP-15, were present in cells of the invasive anorectal adenocarcinoma (fig. ). We strongly advised the patient to receive abdominoperineal resection or chemoradiotherapy. However, he declined further treatment and was discharged 2 weeks after the operation. A 6-month follow-up showed no recurrence of Paget's disease or of the adenocarcinoma. |
A 25-year-old female patient sought medical attention complaining of a three-month history of weight loss, intermittent fever, nonproductive cough, thoracic pain, abdominal pain and increased abdominal girth, nausea and vomiting. She presented syncope on the day she was admitted in the hospital. Symptoms had begun two weeks after her third deliver. Her past obstetrics history comprised three gestations without pre natal care all of them were uneventful. She denied any other comorbidity, allergy, smoking, alcoholism, prior blood transfusion or similar cases in her family. She lived in a Brazil’s northeastern state that is well known for high prevalence of schistosomiasis. Physical examination demonstrated tachycardia with pulse rate of 100 beats per minute, blood pressure of 90 × 60 mmHg, tachypnea with 25 respiratory movements per minute, temperature 37 °C, oxygen saturation of 96% at room air. Cardiac and pulmonary examinations were unremarkable while the abdominal exam showed signals of small ascites. Gynecological examination ruled out any abnormality and the transvaginal ultrasound was normal except for a presence of a small myoma. The initial laboratory tests are shown in .\nThe multi detector computed tomography (CT) of thorax and abdomen are shown in -.\nThe patient progressed, on the day after admission, with worsening of the abdominal pain, nausea and vomiting and respiratory distress. Besides the stability of hemodynamic parameters, the cutaneous perfusion got worse and serum lactate level rose.\nshows the liver enzymes and prothrombine time evolution. She was referred to the Intensive Care Unit because of her clinical instability and respiratory insufficiency, where she presented cardiac arrest after vomiting and probable aspiration of gastric content.\nSerologies for HIV and Hepatitis virus B and C were negative.\nAn autopsy was performed.\nThe abdominal and thoracic cavities were opened, revealing a mild serous ascites and bowel distension. The visceral peritoneum showed a whitish diffuse thickening throughout the gastrointestinal tract from the stomach to the colon. ().\nThe longitudinal sectioning of the small and large intestines showed some swollen and slightly congested patchy areas of the mucous membrane. The microscopic examination evidenced the presence of uncountable, embryonated and occasionally calcified eggs of Schistosoma mansoni within the wall (most prominent in the submucosal layer) and serosa of the gastrointestinal tract. Granulomatous reaction with eosinophilic infiltration surrounded the eggs. These granulomas, of miliary distribution, showed necrotic-exudative and productive patterns, but few of them showed an advanced fibrotic stage. There were also observed numerous viable and dead worms in the lumen of veins, especially in the subserosal layer and occasionally in the submucosa ( and ). On the distal submucosal layer of the esophagus it was found embryonated eggs. No evidence of esophageal varicose veins was depicted.\nThe liver weighted 1547.0 g (reference value: 1100.0-1450.0 g). On sectioning it showed a winy appearance with thickening of the larger portal tracts, featuring the Symmers fibrosis. Multiple whitish granules scattered randomly in the parenchyma were present, more evident in the left lobe ().\nMicroscopically, there were fibrous expansion of portal spaces in the pipe-stem pattern fibrosis with granulomatous reaction, at different stages of immunomodulation with eosinophilic infiltration, surrounding embryonated and occasionally calcified eggs in the conjunctive stroma or portal vessels, as well as in the hepatic lobule. In the hepatic lobule there were also extensive areas of sinusoidal congestion and hepatocyte necrosis, especially in zones 3 and 2, with areas of microvesicular steatosis ().\nThe pancreas weighted 193.0 g (reference value = 60.0-135.0 g) and presented a whitish thickening of the anterior surface. On sectioning it showed the usual lobulated parenchyma. On microscopy, it was observed countless embryonated eggs entrapped in the pancreatic parenchyma, some of them surrounded by granulomatous reaction exhibiting a necrotic-exudative pattern with eosinophil ( and ).\nThe spleen weighted 170.0 g (reference value = 112.0 g); the capsule was smooth and the parenchyma was homogeneous and winy, on sectioning. The microscopy showed white pulp reactive hyperplasia and red pulp congestion with no evidence of congestive spleen sclerosis ( and ).\nIn the thoracic cavity effusions were not observed. Both lungs were enlarged, right lung weighted 610.0 g and left lung weighted 498.0 g (reference value RL = 360.0-57.0 g and LL = 325.0-480.0 g) and showed countless whitish nodules measuring up to 0.2 cm scattered throughout the lung parenchyma and pleural surface. In the left upper pulmonary lobe there was a cavitated lesion measuring 3.0 cm. In the base of the right lung, a grayish triangular area of firm consistency was detected resembling a pulmonary infarction ().\nThe microscopic examination showed a necrotic-exudative granulomatous reaction with eosinophil surrounding embryonated eggs of S. mansoni within peribronchial artery branches and adjacent alveolar parenchyma. There were still observed the presence of numerous viable and dead worms within the vascular lumen, sometimes eliciting necrotic-exudative granulomatous reaction, eosinophilia, and ischemic necrosis of the adjacent parenchyma. It was also identified a dead worm within a segmental bronchus accompanied by the similar histologic feature of the acute Loeffler’s syndrome. On the wall of the left upper lobe cavity lesion it was identified the presence of countless embryonated eggs ().\nLymphadenomegaly was found in the mesenteric, peripancreatic, along the curvature of the stomach, pulmonary hilum and peritracheal lymph node chains. Many of these lymph nodes entrapped schistosome eggs surrounded by granulomatous reaction.\nNo other significant gross or microscopic findings were detected. |
A 45-year-old man who complained of severe abdominal pain located around the umbilicus with a palpable mass in the left upper abdominal quadrant presented to our clinic. At admission, the patient had stable vital signs, his laboratory findings were normal and he did not report any recent weight loss. Due to his abdominal discomfort and the palpable abdominal mass, an abdominal computed tomography (CT) was performed. The abdominal contrast-enhanced CT demonstrated a well-demarcated 25-cm tumor in the left hemiabdomen. The tumor was encapsulated in dense fibrosis and displaced surrounding jejunal loops to the midline (fig. ). A large fat component and areas of soft tissue attenuation in the posterior and lateral part of the tumor suggested a diagnosis of liposarcoma, although a differential diagnosis of SM was also considered. Calcification in the tumor area was absent.\nConsidering the tumor size, unusual site of origin and other imaging features, the multidisciplinary tumor board decided to perform a surgical exploration and tumor removal. The left half of the greater omentum was infiltrated by the tumor along with 20 cm of the jejunum. The partial resection of the greater omentum and resection of the affected jejunal segment was performed and the tumor was excised completely. The intraoperative frozen sections failed to discriminate between the tumor-like mesenteritis and liposarcoma or other mesenchymal tumors. The microscopic frozen sections showed mesenchymal proliferation only and the malignant potential could not be estimated. Gross examination of the specimen showed a well-circumscribed and mostly pseudoencapsulated tumor with a soft to rubbery consistency. On the cut surface there was a grey-yellowish solid mass showing irregularly septated lobular architecture of fat tissue with foci of pseudocysts partly filled with hemorrhagic fluid and small scarring areas. The paraffin sections showed extensive fat necrosis, and variably expressed fibroinflammatory reactions with clusters of mononuclear inflammatory cells and lipid-laden macrophages suggestive of mesenteric lipodystrophy (fig. ). The final pathological diagnosis was consistent with type 2 (pseudotumor) SM with a dominant ‘mesenteric lipodystrophy' type of lesion, supposed to be an early stage of the disease. The postoperative course was uneventful and no recurrence of the SM was observed 24 months following surgery. |
This 46-year-old Caucasian female with a past medical history significant for Charcot-Marie-Tooth disease, degenerative arthritis and scoliosis was evaluated for lumbar pain progressively worsening for the last 3 years in her left hip and buttock with radicular symptoms radiating to her left anterior thigh. Her other pertinent history includes a hysterectomy, a left hip replacement, two knee surgeries and an appendectomy in the distant past. Neurological examination demonstrated no focal neurological deficits, but was notable for pain in a left L4 and L5 distribution.\nA review of imaging studies of the lumbar spine with and without contrast showed a variable enhancing lesion with what appears to be some fluid levels in a multilobulated lesion of the left L4 neural foramen that was read by the radiologist as a hemangioma or possible nerve sheath tumor (). She has had imaging studies as recently as 3 years ago which she reported did not show any abnormality in the lumbar spine.\nA midline lumbar incision was utilized and intraoperative x-rays were used to confirm the L4-L5 level. Exposure of the intertransverse membrane at the L4-5 level was completed and a left L4-5 hemilaminectomy and removal of the ligamentum flavum was completed. The exiting L4 nerve root was subsequently identified underneath the pars.\nFurther exposure distally with partial removal of lateral wall of the superior facet joint of L5 was completed to allow visualization of the entire length of the nerve at the L4 level. The nerve appeared to be swollen and enlarged, and appeared to have some fatty components infiltrating within some of the nerve rootlets. Differential dissection around the nerve revealed that there was a soft tissue mass ventrally and extending up to the neural foramen.\nLongitudinal incision was made in the nerve. Upon opening the nerve, there was no clear evidence of distinctive intraaxial tumor and there were abnormal appearing nerve fascicles with fatty material in the fascicles. No tumor was identified within the nerve frozen section. The nerve was debulked of all visible tumor, circumferentially, with gentle mobilization. The wound was then assured for hemostasis and irrigated copiously with antibiotic irrigation and self-retaining retractors were removed. At the end of the procedure, the patient was rolled onto the hospital bed, awakened, extubated, and transferred to the recovery room in stable condition.\nPostoperatively, the patient reported that she had pain at the incision and intermittent radiation to her left gluteal area, however, she denied any radiation to her left lower extremity. The patient had an uneventful recovery and was discharged home on the 3rd postoperative day. The postoperative MR image revealed resection of the nerve root sheath mass (). She continues to be asymptomatic on follow-up at 18 months.\nSections showed bland-appearing endometrial glands with associated endometrial stroma with mild early secretory change and adjacent dense fibrous stroma (). Focally, there are clusters of hemosiderin-laden macrophages, consistent with remote hemorrhage, however, no apparent cytological atypia is identified. |
A 25 year-old female patient sought the emergency department complaining of dyspnea and cough for several months aggravated in the last three days when she began to present purulent sputum with bloody traces and daily fever of 38 °C. She had been presenting progressive dyspnea, orthopnea, increased abdominal volume and edema of lower limbs for the last three years. She started looking for medical care one year after the initial symptoms when a cardiopathy was diagnosed and a heart surgery indicated at her local State of origin, but not performed due to the delay in scheduling. The patient lived in the interior of a northeastern state of Brazil far from a tertiary hospital. She denied any morbidity or physical limitation during childhood and adolescence. Her obstetrical history included three pregnancies and the symptoms began during the last gestation. On admission the patient was agitated, confused, presenting dyspnea, tachycardia, cyanosis, and was emaciated. Vital signs were: respiratory rate = 27 bpm, pulse rate = 120 bpm, blood pressure = 96 × 60 mmHg, temperature = 35.5 °C, oximetry = 65%. The pulmonary auscultation revealed the presence of rales in the left base, the precordium examination showed systolic thrill on the left sternal border. The cardiac sounds were rhythmic with loud S2, S3 present and a marked murmur was audible on the tricuspid area. The abdominal examination showed hepatomegaly and percussion was dull on the Traube’s space. Lower limb edema was present. Laboratory tests are shown in and the electrocardiogram in . The patient was initially treated with oxygen by Venturi mask followed by endotracheal intubation and mechanical ventilation, ceftriaxone and clarithromycin were prescribed considering the possibility of pneumonia. The hemodynamic instability was treated with saline volume expansion followed by intravenous vasoactive drugs. Despite the adopted treatment the patient died on the second day of hospitalization. An echocardiogram performed on admission with the patient on sitting position showed: aorta = 28 mm, left atrium = 30 mm, ventricular septum = 8 mm, posterior wall = 7 mm, left ventricle ejection fraction = 60%. There was also significant increase in the size of the right atrium and ventricle, hypokinetic right ventricle, mitral valve degeneration with prolapse and mild regurgitation, tricuspid valve reflux with important right ventricle-right atrium pressure gradient = 140 mmHg. The blood sample collected at admission showed growth of Streptococcus pneumoniae.\nThe autopsy findings showed an emaciated woman with signs of growth impairment, mild cyanosis and lower limb edema.\nThe heart was enlarged, weighed 702 g (normal range, 248-431 g), and showed usual atrial arrangement, with concordant atrioventricular and ventriculo-arterial connections. There was massive enlargement of the right-sided cardiac chambers, with severe dilation and hypertrophy of the right ventricle.\nExamining the right atrial septal surface we detected a huge ASD located in the area of the oval fossa (secundum atrial septal defect). There was also an additional interatrial communication situated postero-inferiorly, close to the opening of the inferior caval vein into the right atrium, and where the right pulmonary veins were connected ( and ). These veins retained, partially, their connection to the postero-inferior wall of the left atrium.\nThe left atrium was small, receiving also the two left pulmonary veins, which were far from the sinus venosus defect. The mitral valve showed moderate thickening of the leaflets, mainly the anterior one, besides fusion of the postero-medial comissure and thick chordae. The left ventricle was normal in size.\nA schematic view of the heart with the anomalous connection of the right pulmonary veins and with a secundum atrial septal defect is exemplified in .\nThe right and left lungs weighed 935 and 850 g respectively (normal range, 360-570 and 325-480 g). The microscopic examination revealed diffuse infiltration of neutrophils filling the alveolar spaces accompanied by hemorrhagic and edematous areas with considerable destruction of alveolar septa () configuring the histological picture of bronchopneumonia; and thickening of the fibromuscular layer of the pre and intra-acinar peripheral pulmonary arteries () representing chronic pulmonary hypertension.\nThe liver weighed 1560 g (normal range 1330-2100 g) and showed chronic passive congestion compatible with right sided heart failure, and peri-central hemorrhagic foci due to septicemia and shock.\nSystemic findings of sepsis and shock were also observed in other organs as acute reactive splenitis, renal tubular acute necrosis and hemorrhagic foci of cortical adrenal glands.\nThe gross and microscopic examinations of the other organs were unremarkable. |
A 72-year-old male attorney presented to the hospital complaining of worsening headache, neck pain and difficulty with speaking. His prior medical history was significant for hypertension, dyslipidemia and well-controlled type 2 diabetes mellitus. In the patient’s words:\nI would hope that you would report my complaints preceding August 6, 2016, diagnosis relating to stiffness and pain in my neck, headache, and pain in primarily my right shoulder. This began, as best I remember, about a year and a half prior to the diagnosis. These complaints were pronounced when I saw you, as I recall, in May 2016. They appear to be similar or the same as I have experienced since the diagnosis. While these are rather common ailments for a person my age and do not generally suggest a malignant tumor, it seems to me that my complaints might lead a medical provider to consider the possibility of a type of Sarcoma, including Chordoma, possibly leading to an early diagnosis. For a few weeks prior to August 6, I woke earlier than desired on a regular basis. On August 4, I realized that I had been unable to move my tongue all the way to the left in my mouth since the day before. On August 5, that continued and I felt a slight tremor in my tongue. I remembered the symptoms my wife had taught me based on her experience as a social worker at a rehabilitation hospital, I thought that it might indicate a stroke.\nExamination showed a concerned but well-appearing septuagenarian, who was neither febrile nor hypertensive. He was alert, had no word finding or understanding difficulties and had a normal gait. His tongue had mild right sided atrophy without fasciculation and deviated to the right on extrusion. He had difficulty enunciating his labials and was unable to perform lingual gymnastics without slurring his words. Apart from a mild length dependent diabetic polyneuropathy affecting predominantly vibration, the rest of a detailed neurological examination was normal.\nOur initial diagnosis was a medial medullary syndrome although he had no contralateral posterior column findings and the acute neck pain we misattributed to a vertebral dissection. MRI showed no restricted diffusion in his medulla but did show a clival mass invading his right hypoglossal canal (See Fig. ). Subsequent neurosurgical debulking of his tumor confirmed chordoma. |
A 46-year-old woman of unknown ethnic origin presented to her primary doctor with a one-month history of a painless left breast lump without associated nipple discharge that was noticed by the doctor on examination. She was otherwise healthy with no other relevant history. Physical examination revealed a large, non-tender, freely movable mass in the left breast and multiple enlarged lymph nodes in the left axilla. Our patient reported no systemic B symptoms such as fever or weight loss. A biopsy of her left breast mass revealed a DLBC lymphoma. Our patient was then referred for staging with F-18 FDG PET/CT that was acquired from base of skull to upper thigh with the CT being low-dose and unenhanced. The PET/CT scan revealed a 8 × 10 cm hyperdense and intensely FDG-avid mass occupying almost the entire left breast with maximum standard uptake value (SUV) of 21 (Figure ). In addition, several left axillary lymph nodes measuring up to 5 cm in size and several left sub-centimeter internal mammary lymph nodes showed intense FDG avidity (Figure ), with SUV values of 33 and 3.3. However, PET/CT findings were suggestive a breast carcinoma rather than a lymphoma, based on the location and distribution of the lesion. Because of the rarity of breast lymphoma, it would be unusual to consider metastatic breast lymphoma in the differential diagnosis of breast tumors. As a result, it would have been impossible to distinguish breast lymphoma from breast carcinoma through PET/CT. An incidental finding of intense FDG uptake in the uterine cervix, SUV of 8, led to the subsequent pathologic diagnosis of a previously unsuspected squamous cell carcinoma (Figure ). The lesion appeared to involve the proximal third of the vagina and the corpus uterine, but a tumor extension to the parametrial soft tissue was not noticed.\nOur patient underwent chemotherapy for NHL of the breast and cervical cancer as well as afterloading brachytherapy to the uterine cervix. A repeat FDG PET/CT three months after completion of therapy showed resolved FDG avidity of all previously described lesions (Figures , , ). |
Patient 2 was a 41-year-old woman who presented with left flank pain. Her medical history was unremarkable. White blood cells were detected in the urine. Empirical antibiotics were started. A CT scan of abdomen and pelvis showed the presence of left mild hydronephrosis and renal calculi was measured at 2.2 cm. The patient was diagnosed with renal calculi and mild hydronephrosis. A PCNL procedure protocol was planned. A ureteral catheter was inserted into the left ureter retrogradely. The target calix was the middle posterior calix. The puncture site of the target calyceal fornix was localized under fluoroscopy monitoring using contrast agent injected through ureteral catheter, producing a RP. Clear urine was seen on withdrawal of the stylet. During an injection of contrast agent in her left collecting system through the puncture needle, we were able to visualize her left renal vein filled with contrast agent (Fig. ). We could also identify that the location of the puncture needle tip was not optimal. The puncture needle tip was near the calyceal infundibulum. The puncture needle was pulled out. A puncture tract passing through the middle posterior caliceal fornix was performed simultaneously and the renal calculi was removed uneventfully. The operative steps were as same as patient 1.\nAmong our two patients, we saw the renal vein filled with contrast agent during PCNL and identified the location of the puncture needle tip was not optimal. The puncture needle tip was located outside the collecting system near the calyceal infundibulum in the two patients. The visualization of renal vein branches during antegrade pyelography and bloody fluid drips confirmed the puncture needle tips located in a vein vessel or injured a vessel. The following procedures were not carried out. The original operation PCNL was performed successfully by another puncture tract in the two patients. They were discharged uneventfully with the stones cleaned by simultaneous PCNL.\nSix articles relevant to the vein injury during PCN or PCNL were selected [, –]. The data of the six articles were summarized in Table . As noted in Table , the vein injury in patient undergoing PCN occurred in the initial stage of the operation. The guidewire or catheter perforated and migrated into the vein directly. In patient undergoing PCNL, the vein injury occurred either in the initial stage due to the dilator tearing motion or during the operation due to the fragmentation energy. |
A 50-year-old male with a past medical history of nephrolithiasis and gout and a history of significant cigarette smoking presented to his family medicine physician with six months of progressively worsening right foot pain with associated redness and swelling (Figure ). The patient was also experiencing burning, numbness, and tingling in his right lower extremity. After ruling out more benign causes, his family physician directed him to the local hospital for a workup of more insidious etiologies.\nIn the emergency department, the patient had an ankle-brachial index of 1.13 which was falsely elevated secondary to hardening of the arteries at the ankle. Moreover, a lower extremity arterial study revealed a digit pressure of 0 mmHg, suggesting critical pedal digit occlusive disease. The patient underwent a right lower extremity angiogram that showed significant chronic occlusion of the anterior tibial artery and attempts to recanalize were unsuccessful (Video ). Vessels below the distal third of the leg were not present with the exception of a few collaterals to the foot. Since there was no flow to the foot and the occlusion was present for at least six months, vascular surgery concluded that this patient would not be amenable to endovascular nor open surgical interventions.\nFollowing an unsuccessful revascularization, therapy shifted to hyperbaric oxygen and medical management with aspirin, atorvastatin, cilostazol, and gabapentin. The patient was also counseled about the consequences of smoking and received nicotine patches to assist with cessation. Other cardiovascular risk factors were not present. The patient was not diabetic and had a hemoglobin A1C of 5.9. Moreover, he had no history of hypertension and was normotensive throughout his admission. After failing to respond to this treatment, the patient was told that he would need a below-the-knee amputation. The patient refused and decided to explore other options including seeking a second opinion and researching online supplements.\nAfter exhausting other options and treatments, the patient heard from a friend about leech therapy. Hoping to avoid amputation, the patient decided to self-treat by purchasing leeches online and placing four leeches on his foot twice daily until satiated for five days each week (Figure ).\nAfter six months, the patient presented to his family physician with improved foot pain with no numbness, burning nor tingling. The patient was not taking any medications or supplements other than completing his weekly leech therapy. On exam, the patient’s right foot was warm, dry with palpable pulses, and no cyanosis, erythema, or edema was present. The patient’s foot was remarkable for skin scars where the patient had placed the leeches (Figure ) |
A 50-year-old female patient presented with hematuria, massive weight loss (45 kg), asthenia and right lumbar pain 7 months prior to the consult. Previous blood work-up revealed anemia and previous CT and ultrasound revealed a solid injury of 10 cm on the right kidney and a mass in the right flank (). The patient denied previous family history of neoplasia and previous diseases, although she confirmed smoking habits.\nPhysical exam revealed a palpable mass with roughly 10 cm at the right hypochondrium and another palpable mass situated at the dorsal surface of the left lumbar region with roughly 5 cm. The patient had regular and stable vital signs.\nRoutine admission blood work-up confirmed anemia, and a contrasted CT scan revealed a solid mass on the right kidney (12 cm) and a solid mass situated on the muscle plane of the abdominal wall muscles (7 cm). The patient was promptly submitted to a right total nephrectomy, retroperitoneal lymphadenectomy, right total adrenalectomy and a cavotomy with the purpose of removing the caval thrombus.\nThe tumor and the excised kidney () were submitted to a histopathological analysis, which confirmed renal cell carcinoma of clear cell type with sarcomatoid cell type component (). The histologic grade of the tumor was 4 and the tumor was associated with neoplastic thrombus in the inferior vena cava (pT3b).\nThe surgery was uneventful and since the patient made a good recovery from the procedure, she was subsequently discharged from the hospital. One month later, the patient returned to the hospital for a tumor resection of the abdominal wall, which raised suspicion of metastasis.\nAfter resection, the tumor was sent to histopathological analysis, which revealed a neoplasia with myxoid component and a predominance of fusiform cells (). The immunohistochemical profile was unspecific, with characteristics of low grade fibromyxoid sarcoma.\nSince the surgery was successful and there were no complications during post-op, the patient was discharged and subsequently monitored during routine check-ups. |
A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.\nThe baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment. |
A 65-year-old male presented with a three month history of progressive left hip pain. His past medical history was noteworthy for a non-ischemic cardiomyopathy for which he underwent a heart transplant ten years prior to presentation. He had a history of osteoarthritis for which he had undergone bilateral hip replacements complicated by a left prosthetic hip infection with Cutibacterium acnes. His past history was also positive for rheumatoid arthritis, hypertension, and type 2 diabetes.\nThe first stage of his left hip revision after his first episode of prosthetic joint infection with C. acnes occurred pre-heart transplantation and he was treated with 6 weeks of vancomycin following hardware explantation. His second-stage hip revision occurred over a year later, following his heart transplant. His post-transplant course was otherwise uncomplicated, without any episodes of graft dysfunction, rejection, or infectious complications over the previous nine years. He was maintained on tacrolimus and mycophenolate mofetil since his transplant without recent corticosteroid exposure.\nWith regard to his present symptoms, along with the pain, he noted occasional night sweats. He reported receiving 2 hip injections for the pain (one into his hip joint and another into his trochanteric bursa, both on his left side) by his outpatient orthopedic doctor about 2 weeks prior to presentation that provided temporary relief. Sterile precautions were reportedly observed during in-clinic procedures. Following the injections, the patient noticed a progressive fluctuant area swelling of his left lateral thigh and hip. Aspiration of that area 4 days prior by his outpatient orthopedist yielded purulent-appearing fluid that was Gram stain negative for organisms, with no growth seen either on aerobic or anaerobic cultures. Three days prior to admission, he underwent hip arthrocentesis that showed cloudy fluid with 65,000 white blood cells per microliter and a differential of 95% polymorphonuclear neutrophils. Gram stain was negative, and no crystals were seen. Culture of the synovial fluid was later finalized as no growth. However, prosthetic joint infection was suspected and so the patient was admitted for surgery.\nThe patient was an active dog breeder (Yorkies, Maltese, and Morkies), with over 10 dogs at home at any one time, and had recently participated in the birth of several puppies. There was no history of illicit or injection drug use. He also noted being scratched on his legs by the dogs in the past, but could not recall any recent scratches or bites recently.\nOn admission, he was well appearing and comfortable at rest. All vital signs were normal and he was afebrile. He noted mild pain with passive and active movement of his left hip, however, he was able to ambulate. Oropharyngeal exam was unremarkable with good dentition. His bilateral shins had evidence of previously-healed scratches. On the lateral aspect of his thigh was a tender egg-sized swollen area of fluctuance and erythema, without increased warmth or obvious drainage or sinus tract.\nLaboratory evaluation was notable for a peripheral white blood cell count of 6300 per microliter. Erythrocyte sedimentation rate and C-reactive protein levels were 63 mm/hour and 5.4 mg/dL, respectively. Hip X-ray did not show loosening or disruption of his prosthesis. He did not receive any antibiotics prior to surgery. Two sets of pre-operative blood cultures were drawn and finalized as no growth. Medications at the time of presentation included methotrexate (2.5 mg daily), mycophenolate mofetil (250 mg twice daily), and tacrolimus (1 mg twice daily). His diabetes mellitus was well-controlled with dietary changes and his most recent hemoglobin A1c measurement was 6.2%.\nThe area of the suspected abscess the lateral thigh was incised and drained. The proximal prosthetic body, femoral head, and acetabular liner were all removed, the joint was irrigated and debrided, and hardware was replaced in a one-stage fashion. Vancomycin and tobramycin-containing beads were placed. Intraoperatively, frank purulence within the joint was not observed. Five separate tissue specimens were sent for bacterial, fungal, and mycobacterial culture. Post-operatively, vancomycin and ceftriaxone were begun empirically pending further culture data.\nApproximately 2-3 mm of each tissue submitted was embedded whole in fungal media. The remaining tissue from each site was ground in 1 mL Tryptic Soy Broth. Mycobacterial, fungal, and bacterial growth media were inoculated with ground tissue suspension. Gram, Acid Fast, and Calcofluor White stains were prepared from touch preps of intact tissue and ground tissue suspensions. All stains of tissue were negative for organisms. Bacterial cultures were incubated at 35 °C in a 5–10% CO2 incubator for aerobic cultures and in the BD BBL GasPak anaerobic pouch for anaerobic cultures. After four days of incubation, tissue cultures collected from the left hip (one of 5 total submitted) grew small, translucent, spreading colonies from the anaerobic blood agar incubated under anaerobic conditions. Gram stain of the colonies demonstrated spiral-shaped gram-negative rods (Fig. ). Matrix-assisted laser desorption time of flight (MALDI-TOF) mass spectrometry yielded and identification of Anaerobiospirillum succiniciproducens, which is currently unclaimed in the bioMerieux Vitek-MS database. Therefore, 16 s ribosomal RNA gene sequencing was performed, with the best matches using NCBI Blast Nucleotide Sequence Database to Anaerobiospirillum succiniciproduces and Anaerobiospirillum species with > 99% query coverage and identity. Ultimately, the laboratory report was released as “most closely resembles Anaerobiospirillum species; Identified by DNA sequencing.” 16S sequencing was not performed on any other samples including blood.\nMycophenolate was held temporarily in the setting of infection. Following identification of the organism, vancomycin was discontinued and ceftriaxone (2 g daily) was continued to complete 6 weeks total of antibiotic therapy. He tolerated treatment well to date, without evidence of recurrent infection.\nSaliva and perirectal anaerobic cultures of two of the patient’s dogs (both Maltese) were performed using flocked swabs submitted in anaerobic agar gel transport media, and cultured on standard anaerobic media. No organisms resembling Anaerobiospirillum spp. were isolated.\nFollow up 2 months later was unremarkable for relapse of infection, after completion of intravenous antibiotics,. |
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. |
A 73-year-old man was initially referred to the memory clinic in December 2013 with a history of gradual deterioration of short-term memory and increased dependence on family over an approximate 18-month period. This was with a background of stable multiple sclerosis with no other medical history of note. He was functioning well owing to a supportive family and positive routine activities undertaken mostly with his wife and had a strong academic background which could have contributed to masking of cognitive defects. He was given a diagnosis of a mild cognitive impairment based on impaired short-term memory, as evidenced by clinical evaluation and formal cognitive testing. He scored 80/100 on the Addenbrooke's Cognitive Examination III; most points were lost in the memory parts (where he scored 10/26) and less so in the fluency part (scoring 10/14) of the test. He was referred to neuropsychology, for brain imaging and was to be seen back in the clinic in 6 months' time. There were no treatable cardiovascular risk factors at this point; however, the patient was counselled on exercise and diet as well as basic activities to promote cognitive training in keeping with present guidance. The patient and his wife were informed it was difficult to give prognosis and although evidence is varied, a person with amnesic (memory loss) mild cognitive impairment would be at around 1 in 5 risk of being diagnosed with dementia at a later stage. From this presentation and clinical evaluation, it was thought that an Alzheimer's dementia was the most likely future diagnosis.\nThe patient then travelled by plane from Scotland to Australia, which involved a short connecting flight to London. On descent from the air to Australia, he experienced an episode of agitation and bizarre, nihilistic delusions about Nazis taking over the plane. After landing, he was admitted to a large, well-known teaching hospital in Australia. He continued to exhibit challenging behaviours such as agitation, wandering and resistance to attempts at basic care from nursing staff. The patient required assistance with feeding and one-to-one nursing care for the majority of the in-patient stay.\nThe patient's medical investigations included a positron emission tomography (PET) scan, magnetic resonance imaging (MRI) brain scan, lumbar puncture, electrocardiogram (ECG), chest X-ray, urinalysis, basic blood tests and whole-body computed tomography (CT) over the course of admission without an obvious cause being found for such a dramatic decline and previously unseen behaviours. Of note, any cerebrovascular accident, pneumocephalus, acute kidney injury, external and middle-ear disease and sepsis were ruled out on admission. It was noted that there were no particular risk factors in terms of family history, smoking, hypertension, dyslipidaemia and diabetes which could have increased the risk of most of the proposed diagnoses. Basic observations, including oxygen saturations, were largely unremarkable throughout his admission. He was reviewed by both the neurology and neuropsychiatric teams who came to a joint conclusion that he was experiencing a delirium and previously undiagnosed Alzheimer's dementia.\nHe was treated with antipsychotics and given a short trial of intravenous steroid given the history of multiple sclerosis (although not indicated by way of imaging) without any improvement in clinical state.\nThe patient stabilised enough for repatriation to the UK with a nurse escort after approximately 4 months of in-patient care. At this stage he showed significant deterioration in executive functioning from baseline assessment, limited capacity for new learning, confabulation and required assistance with all personal needs. On descent of the aircraft the patient again deteriorated, with disorientation, agitation and paranoid features once again predominant. Admission to hospital and further investigations gave us no obvious clues to an ongoing acute event. Brain imaging in both Australia and the UK remained unchanged with CT showing generalised atrophy and MRI revealing a minor degree of small vessel disease and smaller than expected hippocampal volume, and suggested Alzheimer's as the only radiological explanation for the presentation.\nThe episode has had a significant effect on the patient's level of functioning and a sizable knock-on effect on his family. He is now a patient in a National Health Service (NHS) long-term care facility requiring assistance with all basic activities of daily living and without much by way of coherent or meaningful conversation. He continues to be managed with antipsychotic medications and benzodiazepines which allow him to be settled on the ward and nursing staff to assist with his needs. It is difficult to ascertain whether there has been any further deterioration in the patient's disease process, however, there has not been any improvement seen. His family continue to harbour feelings of guilt at the original decision to fly to Australia without consultation with medical staff and disappointment at being unable to care for the patient in their home.\nMy overall aim for writing this case is for the reader to acknowledge the case of a patient with a likely dementia who has had a stark and accelerated decline in function as a result of a change in environment and residual delirium after going on two long-haul flights. Pinpointing the precise mechanism for the delirium continues to be a challenge owing to the number of medical staff involved and the difficulties with communication between continents. Prolonged hypoxia or changes in cabin pressure would seem to be the most obvious causative factors for the delirium given the collateral history, with particular focus on symptoms becoming pronounced on descent. However, this is without any firm scientific basis and is not backed up by anything discovered on clinical examination or investigation. |
A 60-year-old Caucasian female was reported with a history of heavy smoking (30 packet year), 20 years of medically treated hypertension, partial thyroidectomy and familial history of osteoporosis (in the mother). The patient suffered 6 months earlier from an insignificant trauma. The patient was admitted to the hospital for a dysfunctional left lower limb characterized by pain in the left knee with difficulty walking and standing. The complaint developed to pain in the left hip worsening on movement, not responding to analgesics, radiating to the medial surface of the left lower limb down to the toes, accompanied by a limping gait and crackles in hip and knee joints. On exam, her left limb was 2 cm shorter than the right with a swelling of the posterior lateral surface of the right hip.\nPelvic X-ray showed decreased bone density, a complete absence of the left femoral head, articulation of the left femoral neck with the iliac bone, regions of osteolysis in the right upper and lower divisions of the pubis and left sacroiliac articulation leading to the upward displacement of the right half of the pelvis accompanied by a small avulsion fracture on the anterior lower border of the twelfth thoracic vertebra (); then, CT and MRI revealed the complete absence of the left femoral head with cystic heterogeneous soft tissue in its place, and focal soft osteolytic tissue in the right upper and lower divisions of the pubis and in the right sacroiliac articulation ( and ); thus, radiological findings suggested degenerative changes.\nLaboratory tests () showed a decrease in vitamin D and Ca+2, and DEXA revealed a decreased bone density (T-score = −3), and the Z-score to be estimated <−2 [based on NHANES database] []. The patient underwent surgery to exclude malignancy, and the biopsies from the femoral head were as follows: A segment showed highly vascular papillary formation covered by synovial cells with small nuclei and ill-defined boundaries, large clefts and scattered mononuclear inflammatory cell infiltrate. Another segment had soft tissues from a lytic lesion of the femur bone and revealed massive angiomatosis surrounded by fibrous connective tissue and residual lytic bone tissue (). No cellular atypia was noted within the examined specimens. Immune stains showed CD 34 positive proliferating blood vessel cells—Angiomatosis (). Later, a CD68 immunestain was negative; by then, the tissue remains were, however, predominantly necrotic. Other immunestains mentioned in literature (among others: TRAcP, Podoplanin and D2–40) as indicators of bone resorption and lymphatic-vessel-proliferation were unavailable. In conclusion, the pathologist stated the consistency of the specimen with aggressive osteolytic angiomatosis (GSD). The patient was provided with symptomatic treatment (anti-osteoclastic drugs [bisphosphonates], calcium and Vitamin D) along with walking aid support. The patient was kept under regular follow-up. Later, the pain reduced and the walking function improved. |
A 90-year-old man presented with a palpable mass on his left postauricular region that had been present for three years. The mass was hard, fixed, and recently increased in size. These symptoms were not accompanied by pain, tenderness, local hotness, or recent weight loss. The patient was healthy for his age and had an unremarkable medical history.\nMagnetic resonance imaging revealed a well-enhanced 5 cm solid mass including a cystic component in the left parotid gland. The margin of the mass was partly ill-defined. Neither regional nor distant metastasis was found on positron emission tomography-computed tomography scan. The initial diagnosis from clinical and radiologic evidence was a metastatic lymph node or a malignant tumor of the parotid gland. FNA of the tumor was performed.\nPapanicolaou-stained smears revealed that tumor cells were arranged both in tight clusters and individually dispersed (). The tumor cells had round or oval nuclei with mild atypia. Most of the tumor cells had fine chromatin without prominent nucleoli, but some had inconspicuous small nucleoli (). The cytoplasm was scant in most of the tumor cells, and numerous naked cells were identified (). Some tumor cells had a polygonal shape with dense opaque cytoplasm, which suggested squamoid differentiation even though no obvious keratin material was noted (), and a few had cytoplasmic vacuoles of various sizes (). Cytoplasmic granules were not found. Inflammatory cells, including lymphocytes, neutrophils, and some macrophages were scattered across the background, and characteristically, numerous psammoma bodies were identified throughout the smears. Most psammoma bodies were present in the background and not connected to the tumor cells, but some of them were surrounded by tumor cells (, inset). Necrosis, mucin, and myxoid stromal components were not found in the background, and only one mitotic figure was noted. In view of these cytologic findings, we considered the possibility of either a malignant tumor of the parotid gland or a metastatic tumor of some other organs, most likely the thyroid gland. The possibility of a metastatic thyroid carcinoma could not be excluded because of the presence of many psammoma bodies, which are unusual findings in FNA of salivary glands. No other findings suggesting a specific type of thyroid carcinoma were identified, and no intra-thyroidal lesion was found in radiological examination. Therefore, we diagnosed a low-grade malignancy of the parotid gland and recommended complete excision of the mass.\nWe surgically removed the parotid gland, which measured 8.5 cm×6 cm×5 cm. On a cut section, a tan to gray solid tumor with a cystic area measuring 5.3 cm×4.5 cm×4 cm was seen. It was relatively well demarcated from the surrounding parotid gland but was nonencapsulated. In the cystic area of the tumor, an intracystic papillary-growing pattern was noted (). Microscopically, the tumor was composed of multilocular cystic lumens in the periphery and solid or papillary proliferation of tumor cells with fibrous stroma in the cystic area (). The cystic lumens were lined by two or more bland tumor cells. In the intracystic solid area, the tumor cells were arranged in papillary, cribriform, and solid patterns (). The cystic lumens were filled with pink secretory materials, including some macrophages. The tumor cells had round to oval nuclei with inconspicuous nuclear atypia and eosinophilic or clear cytoplasm. Mitotic figures were very rare (<1/10 high power fields), and necrosis was absent. Cellular pleomorphisms and prominent nucleoli were not observed, but some small nucleoli were present. Neither perineural nor vascular invasion were present, but focal stromal invasion of the tumor cells into the fibrotic stroma was noted. Numerous psammoma bodies were observed in fibrotic stroma and between the tumor cells (). All these microscopic findings in the surgical specimen were similar to the cytologic findings from preoperative FNA. Immunohistochemically, most tumor cells were positive for S-100 protein (). Smooth muscle actin (SMA) () and p63 () were positive only in the periphery of the cystic lumens and the rims of papillary, cribriform, and solid tumor cell nests, which suggests intracystic or intraductal growth. The Ki-67 proliferation index was less than 5%. Thyroid transcription factor-1 (TTF-1) and thyroglobulin were negative. |
A 38-year-old Caucasian female reported to the Graduate Periodontics Clinic at the College of Dentistry, The Ohio State University, for a single tooth extraction and implant therapy. A nonrestorable maxillary right central incisor with external root resorption () was observed at the initial examination and was confirmed by a periapical film. The patient reported a history of trauma around the upper anterior teeth resulting in endodontic treatment of teeth 12, 11, and 21. She reported no significant medical history except an allergy to penicillin. She had no history of smoking and was classified as American Society of Anesthesiologists (ASA) Physical Status Classification System I. A comprehensive periodontal exam revealed no probing depths greater than 3 mm, and the embrasure spaces between the maxillary incisors were completely filled with interdental papilla. Neither tooth mobility nor percussion/palpation pain was detected in teeth 12 to 22. Radiographic examination illustrated external root resorption on the distal aspect of tooth 11 at the CEJ level with no apical radiolucency. After clinical and radiographic preoperative analysis to assess the patient risk profile for immediate implant placement, four treatment options (immediate implant placement, early implant placement with soft tissue healing, early implant placement with partial bone healing, and late implant placement) [] were reviewed with the patient. Immediate implant placement with provisionalization after tooth extraction was recommended, and the patient accepted the treatment plan.\nOne hour before the surgery, the patient was given 600 mg of Clindamycin for surgical prophylaxis to enhance the success rate of the implant []. Under local anesthesia, an intrasulcular incision was placed 360° around tooth 11 using a 15C blade to cut the connective tissue fibers above the bone. An anterior periotome was used to sever the periodontal ligament to facilitate the removal of tooth 11 with minimal damage of the surrounding alveolar bone. The tooth was then removed using extraction forceps with controlled rotational force without flap elevation. Extreme care was taken to avoid fracturing the socket walls, especially the buccal plate, so the gingival and bone architecture would be preserved. The external root resorption was also confirmed on the tooth removed (). The extraction socket was thoroughly debrided using a serrated excavator to remove any granulation tissue and then irrigated with sterile saline before osteotomy. A periodontal probe was used to confirm the integrity of the socket walls and to verify that the distance from the alveolar crest to the gingival margin was less than 3 to 4 mm as recommended for immediate implant placement. A sharp precision drill (Nobel Biocare, Yorba Linda, CA) was used to penetrate the palatal wall of the extraction socket that guided the initial preparation of an osteotomy. The osteotomy was prepared under the guidance of a surgical stent and extended about 3 to 5 mm beyond the root apex to ascertain implant primary stability []. A periapical radiograph was taken with a twist drill to verify the angulation (). An OsseoSpeed 4.0 × 15 mm implant (Astra Tech Dental) was placed immediately into the fresh extraction socket following the rule of restorative-driven 3-dimensional placement [, ], and the implant shoulder was positioned at least 3 mm apical to an imaginary line connecting the cementoenamel junctions of the adjacent teeth [, ] (). The primary stability of the implant was confirmed by achieving a torque resistance of 40 Ncm. Hydrated freeze-dried bone allograft was placed in the gap between the labial bony wall and the implant. A customized screw-retained provisional crown was made so its subgingival contour supported the soft tissue emergence profile and protected the blood clot and graft particles (). The temporary crown was torqued to 25 Ncm and left to heal for 9 months. The occlusion of the provisional crown was adjusted to ensure that it was free from any contact during articulation. The patient was informed that she should not place any pressure on the provisional crown during the healing period. Postoperatively, Clindamycin 300 mg was given four times a day for 7 days and ibuprofen 600 mg every 4 to 6 hours for the control of infection and pain, respectively. Chlorhexidine gluconate 0.12% oral rinses were prescribed twice daily for 2 weeks. The patient was advised to adhere to a soft diet and avoid forces on the anterior teeth.\nThe patient received regular check-ups at 2, 4, and 7 weeks and 3 and 4 months after the implant placement surgery with no tenderness reported or adverse events observed. During the postoperative follow-up appointments, the gingival margin around the implant provisional crown appeared stable and there was functional attachment (). After a 9-month healing period, the provisional crown was replaced by a definitive restoration. The patient was followed for 6.5 years after final crown restoration.\nRecall appointments were made every 6 months after implant loading. At these recall appointments, the implant remained stable and functioned well without any problems. The peri-implant gingiva was pink and healthy with probing depths all within 4 mm without bleeding on probing. In addition, a periapical radiograph was taken every year for the assessment of marginal bone level on the mesial and distal sides of the implant. The radiograph revealed a stable marginal bone level around the implant () compared to the radiograph taken at final crown delivery, without any peri-implant radiolucency noted. An excellent esthetic outcome with patient satisfaction through immediate implant placement and provisionalization was observed during the 6.5-year follow-up period (). |
A 45-year-old male patient not known to have any previous medical illnesses, reported to the surgery outpatient department with a clinical history of severe pain in right lower abdomen, with abdominal distension and constipation since 2 days. The patient was febrile and also had history of nausea and vomiting. On clinical examination, tenderness and guarding were observed at McBurney’s point.\nRoutine blood tests showed leukocytosis and raised erythrocyte sedimentation rate (ESR), while other hematological parameters were within normal limits. Chest X-ray were unremarkable while on plain X-rays abdomen (erect and supine), dilated intestinal loops were seen. Computed tomography (CT) scan revealed scalloping of visceral surface and hyperdense mucinous ascites filling the peritoneal cavity, bowel loops showing external compression by peritoneal implants, appendix was not visualized ().\nEmergency laparotomy was done through a midline incision. Peroperative examination revealed, ruptured cystic mass (appendix) with adherent mucus material, attached to the dilated, tensed and inflamed cecum in the right iliac fossa. The small bowel appeared normal except for the mild dilatation of distal 8 cm of the terminal ileum. Pools of mucin were seen within the peritoneal fat and on the serosal surface of the viscera. No gross abnormality was visualized in the retroperitoneal organs, surgical debulking including appendectomy with partial resection of the attached cecum and extensive removal of gelatinous material was taken up. Subsequently, the peritoneal washing with normal saline was done, but chemotherapy was not given.\nAll the tissues removed along with the gelatinous material were submitted for histopathological examination. Gross examination revealed dilatation of the cecal area, measuring 10 × 9 × 9 cm with very scant amount of mucin in the lumen. The appendix was received as a small tubular structure of 2 × 1 cm attached to a ruptured distorted mass measuring 7 × 6 × 1 cm () with abundant mucin adhered to the mucosal as well as serosal surface. We also received large amount of mucin ().\nOn microscopic examination, normal histomor-phological characteristics of an appendix were disturbed with the loss of lymphoid follicles in the submucosa () and replacement of the normal appendiceal epithelium by mucin-producing columnar glandular epithelium (). Part of appendix showed villous adenoma like dysplastic epithelium, the nuclei of the neoplastic cells were elongated, hyperchromatic and pseudostratified at places (). The muscularis propia was replaced by fibrotic, hyalinized tissue. Lakes of mucin seen dissecting the serosal fibrofatty tissue () and dystrophic calcification was in the acellular mucin pool (). Cecal mucosa showed edema and transmural inflammatory infiltrates. Regional lymph nodes did not show any metastatic deposits. Correlating the clinical, CT, peroperative and histopathological findings, the diagnosis of LAMN neoplasm was reached.\nThe patient was discharged after a week stay in hospital in a satisfactory condition. |
A 40-year-old male was admitted to hospital because of chest discomfort and dyspnea. The patient had been well until 2 weeks before admission, when chest pain, cough, and dyspnea had developed. Two days before admission, he could not lie down because of dyspnea. He went to another hospital and a chest X-ray (CXR) was performed. A CXR revealed a widened mediastinum and he was referred to the emergency department of our hospital.\nOn examination, he appeared dyspneic and presented with orthopnea. His vital signs were normal. He had no peripheral lymphadenopathy. Laboratory tests on admission showed elevated lactate dehydrogenase level of 744 IU/L. The result of arterial blood gas was normal (). A CXR revealed a widened mediastinum and left pleural effusion () and contrast enhanced computed tomography (CT) of the chest showed a mediastinal mass of 12 cm by 7 cm, compressing the trachea (). A CT revealed no lymphadenopathy other than the mediastinal lesion.\nOn hospital day 2, tracheal intubation was performed by an anesthesiologist as the patient was considered to have high risk of suffocation. During the tracheal intubation, the left main bronchus was obstructed completely by a mediastinal tumor and the patient suddenly developed hypoxia. Oxygen was administered through a tracheal tube but the oxygen saturation was approximately 80 percent. ECMO was introduced immediately to recover oxygenation, placing a venous cannula in the right common femoral vein and an arterial cannula in the jugular vein. A CXR after intubation revealed atelectasis of the left lung (). After introducing ECMO, oxygen saturation was maintained at about 98 percent and PaO2 was 96 mmHg (). Percutaneous fine needle biopsy of the mediastinal tumor was performed and the patient was transferred to the intensive care unit. A provisional pathological diagnosis was LBL. On hospital day 3, chemotherapy, comprised of adriamycin, vincristine, cyclophosphamide, and prednisolone (CHOP), was started to debulk the mediastinal lesion.\nAfter chemotherapy was started, the mediastinal mass shrank rapidly and oxygenation gradually improved. He was weaned from ECMO on hospital day 8 and weaned from the mechanical ventilation and was extubated on hospital day 28. He did not have any respiratory sequelae after extubation. The final pathological diagnosis was T-LBL. Chromosomal analysis did not reveal any abnormalities and an FISH of the BCR-ABL was negative. Acute Lymphoblastic Leukemia 202 protocol without imatinib (Japan Adult Leukemia Study Group) [] was started on hospital day 23 followed by subsequent consolidation chemotherapy. A CXR performed on day 71 shows disappearance of atelectasis and shrinkage of the mediastinal tumor (). A contrast enhanced CT of the chest performed on hospital day 87 confirmed partial remission of the tumor (). The patient's sister was confirmed as having full-matching HLA and the patient was referred to another hospital to receive allogeneic hematopoietic transplantation.\nAdverse reactions during clinical courses were febrile neutropenia, acute kidney injury, which did not require renal replacement therapy, and right femoral subcutaneous abscess caused by cannulation for ECMO. He did not develop bleeding or thromboembolism as complications of ECMO. |
We present the case of a 26-year-old male who is referred to the digestive consultation by two episodes of spontaneous paraesophageal abscess in an interval of 2 years.\nIt is a patient with no pathological history of interest that is presented in the Emergency Service for dysphagia for solids of 3 days of evolution that at the same time was suffering stabbing chest pain and fever of up to 38.8 °C in the last 24 h. In the last year the patient had already been in the Emergency Room (ER) twice for chest pain with non-altered complementary tests. The patient denies having any traumatic history or onset of symptomatology after food impaction. The physical examination shows no abnormality on a hemodynamically stable patient. It is performed a blood test showed a C reactive protein (CRP) 190 mg/L (Normal values 0–5 mg/L), and white blood cells 12,000/μL (Normal values 4000–10,000). For that reason it is decided to perform thoracic-abdominal computed tomography (CT), where a collection of 8 × 4 × 5 cm is displayed in the third inferior–posterior of the esophagus compatible with hematoma vs mediastinal abscess (Fig. ).\nThe surgery service is contacted and it is decided to choose the conservative treatment with broad-spectrum antibiotics and absolute diet. During the admission, a echocardiogram with normal results was performed, an esophagogram that does not present alterations and a gastroscopy, where a linear ulcer of 5 mm in distal third of esophagus with biopsy that shows granulation tissue was found.\nThe patient is discharged 7 days after, with the normalization of his analytical and clinical parameters, and showing a correct oral tolerance for later control in consultations.\nAn outpatient USE is requested 3 weeks later, after being discharged, where no paraesophageal collection is displayed. Gastroscopy was repeated where the esophageal ulcer is not visualized and biopsies are taken from the distal and proximal esophagus. In those biopsies, it is noticed an eosinophilic inflammatory infiltration of 40 eosinophils per field.\nThe patient does not attend any control, so no treatment is started.\nOne year later the patient returns to the emergency department with chest pain and dysphagia with same characteristics, and elevation of CRP and white blood cells. Again, a toraco-abdominal CT is performed, objectivizing mediastinal collection in the same location as 1 year before, with a size of 7 × 4 × 4 cm, compatible with abscess, which is retreated in a conservative manner with broad spectrum antibiotics. After 10 days, a CT control confirms resolution of the collection.\nAmbulatory gastroscopy is performed with biopsy-taking by objectivizing an eosinophilic inflammatory infiltrate compatible with eosinophilic esophagitis.\nThe patient denies dysphagia, chest pain, heartburn or any other clinic between episodes of mediastinal abscess.\nIt starts treatment with proton pump inhibitor in double doses during 8 weeks, persisting the eosinophilic inflammatory infiltrate in the biopsies. It is agreed a diet with the patient where two foods will be removed (milk and wheat), obtaining histological remission, and identifying the milk as the cause of the inflammation.\nAfter 2 years of follow-up, the patient maintains milk and derivatives restriction, and has not shown again any episodes of mediastinal abscess. |
Patient B was a 56-year old woman, 18 months after end of treatment for breast cancer, referred for psychological treatment because of cancer-related fatigue. She underwent treatment with curative intent consisting of a partial mastectomy, adjuvant chemotherapy, adjuvant radiotherapy and adjuvant hormonal therapy. At the time of referral patient still received hormonal therapy. At baseline (T0), before intake and start of treatment, patient B had a score of 44 on the subscale fatigue severity of the Checklist Individual Strength (CIS), indicating presence of severe fatigue (see ).\nPatient B completed the first EMA after intake. Patient B completed 68 of the 70 offered assessments. In the fatigue scores of patient B during the first EMA is plotted (E0, blue line). In the scores on the maintaining factors of patient B at E0 are shown. Six variables had a mean successive difference (MSSD) of less than 50. Based on the analyses, three variables Granger caused fatigue. These variables were: social activity, mental activity and physical activity. The three factors were not associated with one of the four optional treatment modules. The factor that predicted fatigue in the most valid VAR models (highest percentage) was social activity (see association in ). Higher scores on the social activity item predicted higher scores on the fatigue item ().\nAs the individual time series analyses showed that no factors associated with one of the optional treatment modules Granger caused fatigue, we used the questionnaires to determine which optional module to assign first. Based on the questionnaires, one optional module was indicated for patient B (see ). This treatment module was helpful thinking. Therefore, this optional treatment module was assigned to patient B ().\nAfter finalizing the three treatment modules, patient B completed the Checklist Individual Strength (CIS) again. Patient scored 21 on the subscale fatigue severity of the Checklist Individual Strength (CIS) (see ), indicating absence of severe fatigue. Patient B also completed the second EMA (62 of the 70 assessments). In the fatigue scores of patient B during the second EMA are plotted (E1, red line). In the scores on the maintaining factors of patient B at E1 are shown. Eight variables showed a mean successive difference (MSSD) of less than 50. Based on the analyses, three factors Granger caused fatigue. These factors were all associated with the mandatory treatment module ‘activity pattern’ (see ). Higher scores on the activity items predicted higher scores on the fatigue item.\nAt T1, patient B showed a score of 21 on the subscale fatigue severity of the Checklist Individual Strength (CIS) (see ), indicating absence of severe fatigue. Therefore, it was advised that CBT could be ended. However, patient B preferred to continue with treatment. Therefore, treatment was continued by repeating the ‘activity pattern’ module (). After repeating this module, treatment was ended. In total, treatment consisted of 15 sessions (face-to-face or online, 1 video session) spread over 25 weeks. After completing treatment, patient B completed the Checklist Individual Strength (CIS) once again. She had a score of 16 on the subscale fatigue severity of the Checklist Individual Strength (CIS) (see ), indicating absence of severe fatigue. |
A 42-year-old man with a left frontal head lump which had been largening progressively during the past 4 months came to our hospital. He also complained of a recent headache. There was no significant medical history including trauma or seizure. Local examination revealed a non-tender soft 5 × 10 cm sized swelling over the left frontal region, fixed to the underlying skull. There was no sign of inflammation or tenderness over the lesion. In general examination, no focal neurological deficit, lymphadenopathy or organomegaly was noted.\nSkull radiographs showed a relatively well-defined soft tissue density over the left frontal bone, without evidence of calcification, or obvious bone erosion or sclerosis (). Noncontrast CT demonstrated a slightly hyper-dense mass emanating from the calvaria extending both intracranially and extracranially with minimal underlying morphological changes in the bone as mild increase in bone thickness (hyperostosis) (). On MRI, T1 and T2-weighted images revealed lesion isointensity to gray matter (). Following gadolinium injection, intense homogeneous enhancement of the lesion and the dural tail beneath was noted (). In addition, another small mass was detected on the more caudal right parietal bone. This mass was completely extracranial and had the same MR signal characteristics. The preoperative impression of meningioma with transcalvarial extension was made. Slight changes in the bone signal in comparison to uninvolved regions were also seen ( and ).\nThe histological examination of the surgical specimen showed lymphoid infiltration of the skull bone and adjacent dura, with tumor cells demonstrating large vesicular nuclei and extremely large reddish nucleoli as well as scattered mitotic figures (). Immunohistochemistry revealed positive staining for CD20 and CD30 and negative staining for ALK (). The resultant diagnosis of diffuse large B-cell lymphoma with anaplastic features was reported. A thorough search in order to find another source of involvement was made. Complete blood cell count, biochemical profiles and viral markers including HIV were unremarkable. The CSF cytology examination was negative for malignant cells. The bone marrow biopsy results were free of tumor. Contrast-enhanced CT (CECT) scan of the chest, abdomen and pelvis were negative for any considerable finding. So, the diagnosis of primary DLBCL of the cranial vault was established. |
A 70-year-old female with advanced chronic renal failure secondary to chronic interstitial nephritis was admitted with left hand pain, paraesthesia and reduced hand function. The symptoms started 24 h after the formation of a left brachiocephalic arteriovenous (AV) fistula as a vascular access for haemodialysis in the near future. The surgeon chose the brachial artery for this AV fistula as the wrist cephalic vein was damaged as a result of previous venous cannulations. The patient's symptoms were of severe neuropathic pain, a cold hand and loss of function. These symptoms could not be controlled with analgesia, amitriptyline and GTN patches.\nExamination revealed a palpable radial pulse, a cold hand, without cyanosis, ulceration, necrosis or gangrene. Hand grip was impaired but it was difficult to assess motor function due to severe pain. She had sensory impairment in the distribution of median, ulnar and radial nerves in the hand. Blood pressure and systematic examination were normal.\nNerve conduction studies (NCSs) showed absent sensory responses from the left median, ulnar and radial nerves. The left median and ulnar motor responses were also significantly attenuated ( and ). This indicates severe axonal degeneration in the sensory and motor branches of these nerves. Ischaemia is a well-recognized cause for such neuropathy and with the clinical history, the diagnosis of IMN was made. Incidentally, NCS also showed evidence of bilateral median nerve neuropathy at the wrists manifested by prolonged distal motor latencies. However, the patient did not express any symptoms of a carpal tunnel syndrome at any point.\nElectromyography (EMG) showed fibrillation potentials and positive sharp waves in the small muscle of the left hand, which indicates active denervation in keeping with an acute nerve lesion.\nShe underwent distal revascularization and an interval ligation (DRIL) procedure to reduce the blood flow in the AV fistula and to improve the distal blood supply. Her symptoms of pain improved immediately.\nWhen the patient was reviewed in the clinic, she did have ongoing neuropathic symptoms with paraesthesia and hypoaesthesia. These symptoms were not as severe as witnessed prior to the DRIL procedure.\nGiven the findings of a bilateral carpal tunnel syndrome on NCS, the patient was reviewed by the orthopaedic team and underwent left carpal tunnel release surgery, 3 months after the DRIL procedure.\nWhen last reviewed (8 months following the DRIL procedure), the patient had regained physical function of her hand. The symptoms of hypoaesthesia and paraesthesia had improved significantly.\nA further NCS was performed 10 months following the DRIL procedure that showed significant improvements in the sizes of the left median and ulnar motor responses ( and ). It was also possible to record small sensory responses from the left radial nerve. EMG showed evidence of chronic partial denervation in the small muscles of the left hand, but there was no evidence of active denervation.\nDoppler ultrasound 1 year after the DRIL procedure showed very satisfactory flow in the brachial artery, widely patent anastomosis and no evidence of stenosis in the draining vein. The radial artery measures 1.2 mm in diameter and the ulnar artery 0.6 mm. |
A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line (). Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve (). The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed (Figs. and 4 ). The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up. |
A 64-year-old female who had undergone PN in 2011 in The First Affiliated Hospital, Zhejiang University, Zhejiang, China for treatment of a tumour in the left kidney was admitted in February 2011 after 20 days of moderate left lower back pain. Imaging revealed two renal masses in the lower pole of the left kidney (). Following appropriate preoperative preparation, open PN was performed and the two masses were resected. The collection system was not opened during the surgery and the wounds were carefully closed with absorbable sutures. The wounds of the kidney were covered with perirenal fat and fibrin glue was used to adhere the fat to the kidney. The wounds were carefully sutured and a temporary drainage tube was placed near the left kidney. Pathological examination of surgical specimens revealed renal angiomyolipoma. The drainage tube was removed on the 5th postoperative day. The patient recovered completely and was discharged on the 7th postoperative day.\nHowever, the patient was re-admitted on the 14th postoperative day due to the discharge of increasingly milky, thin, odourless fluid every day from the unclosed external orifice of the drainage tube. The amount of fluid reached 800 ml on the second day after re-admission. The creatinine concentrations of the fluid and urine were 1847 and 4640 μmol/l, respectively. The result of qualitative analysis of chyle was negative. CT urography () revealed a clear renal collecting system and no significant hydronephrosis. However, contrast remained in the left kidney and upper ureter and leakage in the perirenal space and along the psoas muscle, and was drained out of the body through the drainage tube. Moreover, no contrast agent was observed in the middle and lower ureter. In MR urography images (), there was fluid signal in the perirenal space, particularly inside and below the left kidney. The results of CT and MR urography revealed left urinary fistula. A 5-F ureteral catheter was inserted into the left ureter for retrograde pyelography and elevated ∼20 cm but did not pass to the left renal pelvis. Then reoperation was performed on the 16th postoperative day to explore the left kidney and ureter in order to relieve the obstruction, allow unobstructed drainage and save renal function (). During the reoperation, almost complete occlusion of ureteral stricture was found in the upper ureter 5 cm from the left ureteropelvic junction. The ureter near the stricture was enfolded by fibrin glue and exhibited marked stiffness and adhesion. The lesion of the ureter was resected and the ureter was anastomosed end to end with the routine double-J stent (). Pathological examination of surgical specimens revealed fat fibrous scar tissue hyperplasia with inflammatory cell infiltration. The double-J tube was removed by cystoscopy two months after the second surgery. The patient recovered completely without exudate. |
A 50-year-old male was brought to the emergency department after he jumped from a 5-meter bridge in an attempted suicide and fell on the hard concrete below. Upon admission, the patient was agitated, disoriented, and in intense respiratory distress. Examination revealted that the patient’s airway was clear, but there was a bilateral absence of breath sounds and hyperresonance on percussion. The patient was hemodynamically stable. He was intubated due to respiratory failure. Bilateral chest tubes were inserted based on a high clinical suspicion of pneumothorax. Thereafter, the patient developed a large subcutaneous emphysema, despite the fact that the chest tubes were functioning with his severe air leakage. Past medical history was unremarkable with no previous formal depression diagnosis. A social history check showed daily marijuana and tobacco use.\nThe patient was sent for a head, neck, thorax, abdomen, and pelvis CT scan. The scan revealed giant bullous emphysema on the superior lobes bilaterally, right pneumothorax with a collapsed lung, along with multiple rib fractures, and lung emphysema (, ). A hip dislocation was detected, and closed reduction was performed.\nThe patient was sent to the ICU, where he improved clinically after conservative treatment with continuous negative pressure suction using a 20 cm water column. He was extubated after 48 h, with persistence of the air leakage on both chest tubes.\nOn the day following extubation, he developed hypoxia associated with disorientation and agitation and had to be intubated again. Hypoxia was postulated from pulmonary contusion and ventilator-associated pneumonia worsening his already baseline compromised lung. He developed sepsis, and subsequently acute kidney injury with the need for dialysis.\nDuring the course of 5 days, the patient presented hypoxia and a severe mixed metabolic and respiratory acidosis, despite the use vancomycin and piperacillin/tazobactam. The treatment with bilateral chest tubes associated with continuous negative pressure aspiration did not correct the air leakage, which caused an important lost of tidal volumes on the ventilator. Changes in ventilator parameters (increases in PEEP, tidal volumes, etc.) did not improve his oxygenation or decrease his pCO2. In an effort to expand his lungs and improve his ventilatory function, we decided to perform a bilateral bullectomy.\nAs the patient had poor surgical status, only a right bullectomy was performed 8 days after the trauma. The right side was chosen over the left, because it showed more compression and a larger residual, healthier parenchyma. After surgery, the right side fistula was resolved (). Four days after surgery, the patient developed a right-sided empyema, right lung incarceration, and blood clots in the chest tube (). In order to resolve these issues, videothoracoscopy and decortication of the right lung were performed, which resulted in the resolution of these problems () and improvement in ventilatory parameters with conservative treatment for the left lung. Notwithstanding antibiotic treatment and successful surgical interventions, the patient died on the 25th day of hospitalization due to infectious complications. |
A 78-year old male patient with recent contralateral right below-the-knee amputation initially presented in July 2019 with ischaemic rest pain and dry gangrene involving his left heel and his first and second toes. His comorbidities included type II diabetes, hypertension, previous stroke and hypercholesterolaemia. Duplex ultrasound showed a focal stenotic lesion in the distal SFA and heavily calcific occlusive tibial disease. He was classified as Rutherford category 5 with a Society for Vascular Surgery WIfI “wound, ischemia and foot infection” score of 2–3-0, which meant he was at high risk of major amputation within the year. The patient initially underwent balloon angioplasty of the SFA but angiography revealed poor outflow to the foot with no suitable target for distal angioplasty or bypass (Fig. A). The lower limb multidisciplinary team at our institution reviewed the case and agreed to proceed with pDVA as the only possible treatment apart from major amputation.\nThe patient underwent vein assessment prior to the procedure and this included duplex scan imaging of the superficial and deep venous system of the foot. Good calibre lateral plantar and posterior tibial veins are necessary for a successful outcome while the presence of DVT contraindicates the procedure. The arterial inflow was assessed in detail on the previous conventional angiograms and the crossing point was determined to be in the proximal posterior tibial artery. The peroneal artery was avoided as a potential ‘crossing’ artery since it supplied the ischemic foot with useful collaterals. Active foot infection, significant cardiac history were excluded and life-expectancy and functional status were also considered before listing the patient for intervention.\nThe pDVA procedure was performed in August 2019 as the first use of the LimFlow System in the United Kingdom. Under ultrasound guidance, arterial access was performed antegrade in the left CFA and venous access was performed in the lateral plantar vein. Using the LimFlow arterial and venous catheters, an arterial-venous communication was created at the level of the proximal posterior tibial artery into a posterior tibial vein. The target posterior tibial and lateral plantar veins were then treated with the LimFlow antegrade (push) valvulotome to render the valves incompetent which was confirmed with balloon dilatation. Finally, the LimFlow self-expanding PTFE-covered stents were deployed in the posterior tibial vein distally from the ankle level to the crossing location where a conical stentgraft was deployed to secure the fistula and optimise flow transition from the artery into the vein. The completed pDVA circuit successfully established blood-flow to the foot (Fig. B) and post-procedure ultrasound demonstrated a satisfactory volume flow of 250 cc/min in the arterialised lateral plantar vein. The case took just under three hours from the time of initial access until final access site closure.\nThe procedure was technically successful with no perioperative complications. The patient experienced an almost complete resolution of ischaemic rest pain after the procedure and did not experience any adverse events in the first 60 days. He was discharged home at day 18 post-procedure to the care of the community diabetic foot and district nursing teams to oversee his foot wound care. Ten weeks after his index procedure, the patient presented to the emergency department with diabetic foot sepsis most likely due to a combination of superimposed infection of the existing necrotic tissue and ischaemia. He underwent first, second and third toe amputation and foot debridement for sepsis control. During his admission to hospital, the patient also had a duplex ultrasound to monitor flow into the affected area, his third surveillance scan as part of a defined follow up protocol to closely monitor and optimise blood flow as necessary. Consequently, angioplasty was performed at the same sitting as surgical debridement to treat the narrowing of the inflow and outflow tracts of the stent grafts at the level of the origin of the posterior tibial artery as well as in the lateral plantar vein. No signs of in-stent stenosis were observed at the time of inflow and outflow treatment. Further surveillance duplex imaging at 3 months revealed a reduction of flow in the stent due to narrowing in the lateral plantar vein. Although there had been no clinical deterioration, further intervention was performed with the implantation of a Supera stent into the lateral plantar vein distal to the LimFlow stent in order to enhance the flow in the venous arch. This was followed by coil embolisation of collateral veinsin order to focalise blood flow to the distal foot. Stealing branches of the great saphenous vein were embolised in the foot in order to encourage flow in the deep venous system and consequently improve healing. At 4 months, the patient underwent a final maintenance angioplasty where the outflow pedal venous arch was treated with balloon angioplasty to further aid circulation to the area of the toe amputation (Fig. ). The heel ulcer and minor amputation wounds showed continued improvement post-pDVA with tissue granulation after debridement at 2 months and complete epithelialisation by 12 months (Fig. ). Ischaemic rest pain resolved almost completely after the index procedure and the patient did not report any pain by 6 months and onward. Due to bone protrusion from the wound, a completion transmetatarsal amputation was performed at 13 months. Most recent Images of the foot (Fig. ) obtained 18 months post index procedure, showing complete wound healing and preservation of the foot. |
A 62-year-old woman, G1P1, was referred to a gynecological doctor for a large “vaginal mass”. She did not have abnormal vaginal bleeding but found one vaginal mass by herself 1 month ago. Her age at the beginning of menopause was 52 years old. Her medical and surgical histories were both negative. On gynecological examination, we found that the mass was non-mobile and was 5 × 5 cm2 in size, with a location of approximately 3 cm from the vaginal orifice and closely attached to the vaginal wall. On rectal examination, we found that the mass located on the anterior of the rectal wall was approximately 3 cm from the anal verge. The pelvis MR scan and transvaginal ultrasound results showed a tumor, 5 cm in diameter, was mostly located in the space of the rectovaginal septum, with large portion protruding into the vaginal wall but only a small portion protruding into the rectal wall. Its boundary is clear (Fig. a, b). Colonoscopy revealed that the root of the tumor was located on the rectal dentate line (Fig. c). The origin of the tumor was uncertain. Based on these examinations, the gastrointestinal doctor and us co-evaluated that if we selected a transvaginal resection, we could intactly excised the tumor with less possible complications such as fecal incontinence or anal sphincter dysfunction due to its special location. The patient refused to radical anal resection for its anal complications. Therefore, we chose transvaginal resection as a better alternative. Under general anesthesia, the patient was placed in a lithotomy position. Epinephrine, diluted at 1:40,000, was injected into the vaginal submucosa for resection. We incised the vaginal mucosa and separated the surrounding tissue until we reached the submucosa, keeping the tumor capsule intact. After exposing the tumor, we confirmed that it was located in the rectovaginal septum and partially encapsulated by the rectal muscle (Fig. a). We mobilized the tumor from the capsule and resected the intact tumor. The defect of rectal muscle was very small but kept the rectal mucosa intact. We vertically stitched the vaginal layers and horizontally stitched the muscular layer of the rectum (Fig. b). The postsurgery biopsy showed spindle-shaped cells were moderate differentiation and regular arrangement with clear margin by pathological examination (Fig. a, b). The results of histological examination showed that the tumor was positive for CD117, Dog-1, and CD34 (Fig. c, e). These findings suggest a moderate-risk rectal GIST that required follow-up. The patient recovered quickly. She had not suffered any anal dysfunction nor postoperative vaginal-rectal fistula. She refused to undergo enlarged resection but received imatinib treatment after surgery. She remained tumor-free for 2 years after surgery. She was lost for follow-up thereafter. |
A 65-year-old male was admitted to the emergency department with acute shortness of breath and chest discomfort. The symptoms were gradually progressive over the past few days. He had an episode of acute upper respiratory infection in the past week and was on decongestants for symptoms of cold and congestion. The patient tested negative for influenza A and B. He had a significant medical history of mitral valve prolapse, benign prostatic hyperplasia, and hernia repair. He had no significant history of smoking, alcohol or drug abuse. Upon examination, the patient’s vitals were within normal limits. The patient was not overweight and had a bodyweight of 72 kg. The jugular venous pressure was normal. The heart rate was regular and in normal sinus rhythm. A soft ejection systolic heart murmur was present. The breath sounds were present and were equal on both sides of the chest.\nThe lab results were significant for brain natriuretic peptide (BNP) levels elevated up to 407 pg/ml (normal up to 100 pg/ml), normocytic normochromic anemia, leukocytosis with increased neutrophils, and mild thrombocytopenia consistent with bacterial pneumonia. However, blood cultures were negative, likely due to empiric antibiotic treatment. The BNP levels returned to normal after the valve replacement.\nThe electrocardiogram (ECG) showed normal sinus rhythm with premature atrial contractions, prolonged QT interval, and ST depression followed by subsequent elevation in the lateral leads. No arrhythmias were present. The chest X-ray showed bilateral interstitial infiltrates. The computed tomographic angiogram (CTA) of the chest showed diffuse bilateral airspace opacities, consistent with multifocal pneumonia (Figure ). Small bilateral pleural effusions were present.\nNo aortic aneurysm was seen. Pulmonary embolism was ruled out. There was borderline pulmonary artery enlargement reflecting a degree of pulmonary artery hypertension. A potential right renal parapelvic cyst was identified. The patient was admitted for treatment and further testing. The treatment for bilateral pneumonia was started with oxygen through high flow nasal cannula and antibiotics including ceftriaxone and azithromycin. The patient was started on heparin to provide prophylaxis for deep vein thrombosis.\nIn light of his previous significant history of mitral valve prolapse, a transthoracic echocardiogram (TTE) was performed that showed a normal-sized left ventricle with concentric mild left ventricular hypertrophy as well as mild right ventricular and moderate right atrial dilatation. The left ventricular ejection fraction was found to be normal (0.6-0.65). He had grade III diastolic dysfunction with a restrictive pattern, consistent with markedly increased left atrial pressure. No left atrial mass or thrombus was visualized. There was mild mitral valve thickening with a flail posterior mitral leaflet. There were no vegetations on the mitral valve. No rupture of chordae tendineae was noted. The mitral regurgitant jet was anteriorly directed consistent with posterior leaflet pathology. There was severe mitral valve regurgitation as well as mild tricuspid and aortic valve regurgitation. There was no pericardial effusion. However, severe pulmonary hypertension was noted; the coronary angiography revealed normal coronary arteries with right coronary artery dominant circulation in the heart. The aortic root was normal in size.\nThe patient’s medications during hospitalization included aspirin, famotidine, furosemide, and acetaminophen. The mitral valve replacement was done. The post-procedure echocardiography confirmed the bioprosthetic valve in place. No valvular or para-valvular regurgitation was seen. The left ventricular function was normal. The patient had normal sinus rhythm post-procedure upon ECG. The patient recovered and was discharged in good condition on postoperative day seven without any complications.\nThe native mitral valve was received in the pathology department for histopathological examination. The macroscopic examination of the valve showed two valvular cusps measuring 3.0 x 2.0 x 0.1 cm each along with multiple separate pieces measuring 0.3 x 0.2 x 0.2 cm, which included chordae tendineae measuring 2.5 x 2.0 cm. The surface of the cusps showed yellow nodules with focal calcifications. No other gross abnormalities were noted. The microscopic examination revealed aggregates of mature adipocytes in the spongiosa layer of the valve, replacing the collagen and elastic fibers (Figures -).\nThere was no extension of adipocytes to the valve annulus. Calcific atherosclerosis was seen, but there were no foamy macrophages or vegetations. The immunohistochemical stain for S-100 was positive and showed adipocytes (Figure ). |
A 71 year old female was referred for investigation of a presacral mass found incidentally during a staging CT (figure ) and MRI (figure ) of a recently diagnosed rectal carcinoma. The mass was located anterior to S4 and S5 in the presacral space. She was completely asymptomatic of this mass. Except for the recently diagnosed rectal carcinoma and hypertension, she had no other medical issues.\nHer CT scan revealed a suggestion of an ill-defined presacral mass, reported as possible oedema. The subsequent staging MRI clarified a 3.3 × 1.9 × 2.3 cm presacral mass at the level of S4/S5. Evidence of bony erosion could not be seen.\nInitially, differential diagnoses for this mass included chordoma, schwannoma and plasmacytoma. The mass was further investigated with a whole body thallium study and a CT-guided biopsy (figure ). The thallium study revealed no evidence of a thallium avid tumour in the sacrum or elsewhere. The biopsy revealed fat and haematopoietic tissue, consistent with a diagnosis of extramedullary haematopoiesis (figure and ). The occurrence of EH in the presacral area is an extremely rare finding with only 17 reported cases in the literature.\nThis remarkable diagnosis was further investigated with the help of a haematologist. A full history found no personal or family history of bleeding disorders or anaemia. Full blood examination and liver function tests revealed no abnormality. A bone marrow biopsy was taken which revealed mildly hypercellular marrow, showing a mild increase in trilineage haemopoiesis. This was likely to be reactive. A cytogenetics study was organized to differentiate reactive marrow from early myelodysplasia. No cytogenetic abnormality was detected.\nThe case was discussed at a multi-disciplinary meeting and a decision was made that this mass was benign in nature. No further investigations or treatment was deemed necessary. The patient subsequently underwent an uncomplicated resection of her rectal carcinoma. This is only the second case reported in the literature of a prescaral site of extramedullary haematopoiesis with no obvious underlying cause. |
A 55-year-old female reported to the Department of Oral and Maxillofacial Surgery, with complaints of swelling in the right mandibular angle since 1 year and pus discharge in the same region since 2 months. History revealed that the patient had mild swelling with respect to the right mandibular angle since 6 years which underwent a sudden increase in size since a year. No history of fever, paresthesia, and numbness of the lower lip was reported. The past medical history revealed chronic obstructive pulmonary disease in the patient.\nAn extraoral examination revealed facial asymmetry due to the presence of diffuse swelling and draining sinus with respect to the inferior border of the right mandibular angle. Swelling was firm to hard with no tenderness. An intraoral examination revealed buccal and lingual cortical expansion with third molar. A hard mass was palpable beneath the buccal mucosa and also on the lingual mucosa with respect to the mandibular angle. Provisional diagnosis of cementoblastoma, cement-ossifying fibroma, and complex odontoma was made.\nA panoramic radiograph revealed a dense radiopaque mass surrounded by a well-defined radiolucent band with respect to the mandibular angle. The outline of the roots of the third molar was obliterated and the radiopaque mass seemed to be attached to the roots of third molar [Figures –].\nA CT examination of the mandible revealed a large expansile radiopaque mass measuring 2×2 cm in size.\nThe patient was treated for the COPD first by the physician and simultaneously the patient was put on antibiotics to eradicate the infection from the lesion. After the patient was medically fit, the lesion was surgically excised along with the tooth and the sinus lining was excised. The specimen was submitted for the histological examination. A postsurgical panorogram was obtained.\nHistopathologically, the tumor consisted of a calcified mass fused with the roots of third molar with a resultant obliteration of the periodontal ligament. The tumor comprised sheets of calcified tissue with multiple reversal lines and prominent cementoblasts and multinucleated cementoclasts. The peripheral columns showed characteristic radiating columns of the cementum perpendicular to the surface of the lesion. The patient did well postoperatively, with no complications or paresthesia. A postoperative radiograph revealed a complete excision. |
A 27-year-old male was admitted to hospital emergency due to 4 h of chest pain in 13 January 2016. In fact, he had suffered from fatigue after activity for more than 10 days and felt chest tightness and chest pain for 4 days before admission. The patient, a taekwondo trainee, had a healthy body, and his family history was unremarkable. Emergency aortic computed tomographic (CT) scan showed a thickened aortic wall, bilateral pleural effusion and pericardial effusion (Figs. a and b). Cardiac colour ultrasound suggested aortic hematoma or dissection (Fig. ). On the basis of the condition and the results of auxiliary examination, the formation of aortic dissection should be considered. The next day, after excluding surgical contraindications, the patient was performed an emergency operation. Cardiac surgeons underwent ascending aortic replacement and aortic arch replacement. They developed postoperative comprehensive treatment measures, including anti-infection, adjustment of cardiac function, nutritional nerve and symptomatic supportive treatment, and the patient recovered well and was discharged after 15 days. The cause of aortic dissection was unclear, although the surgeons extracted arterial tissues and pericardial tissues and sent them for pathological examination. In fact, postoperative pathology of the aortic wall tissue showed aortitis, such as visible necrosis, granulation tissue hyperplasia and a large number of acute and chronic inflammatory cell infiltration (Figs. b, c and d). However, the surgeons and the pathologist at the time did not consider the cause of aortitis or aortic dissection due to GPA because of a lack of understanding of GPA-induced aortitis or aortic dissection. This event is one of the starting points of our study. We want to attract the attention of clinicians. GPA is also a common cause of aortitis and even aortic dissection.\nOn the first day of 2017, the patient was re-examined for aortic CT because of a 6-day fever and right chest pain. He showed a good prognosis in terms of aortic dissection after a review of aortic CT, but we found significantly increasing lesions in his lung, such as flake density increased shadow, less clear boundary, visible cavity and bronchial meteorology (Fig. c). The patient had no renal insufficiency and sinusitis but had eye damage with scleritis. The next day, the patient was readmitted to our hospital. At first, we considered pulmonary infection because of the combination of fever, haemogram, pulmonary shadow and cavitary lesions. Hence, we administered moxifloxacin. After 12 days, we reviewed chest CT again and found that the lung lesions became significantly heavier than before (Fig. d). Moreover, the patient still had intermittent fever, and the infection treatment was ineffective. At the same time, the patient developed conjunctivitis in the left eye and pain in the finger joints. Thus, we started to suspect pulmonary infection. We checked connective tissue disease-related indicators, such as ANCA, anti-nuclear antibody and immune indicators. The proteinase 3 (PR3)-ANCA (c-ANCA) level was 180 IU/mL, and the MPO-ANCA (p-ANCA) level was 10 IU/mL. Rheumatoid factor and anti-O experiments were positive, and anti-nuclear antibody spectrum was negative. We then performed a bronchoscopy, including brush biopsy, bronchoalveolar lavage and transbronchial lung biopsy. The pathological results suggested inflammatory cell infiltration, cellulose exudation and necrosis in clamped lung tissues (Fig. a). However, these pathological changes may be insufficient to diagnose GPA. We therefore carefully re-examined the pathological findings of the patient’s aorta and pericardium one year ago. Surgical biopsies obtained from the aorta and pericardium tissue showed that the epithelioid cells and multinucleated giant cells formed a granuloma (Fig. b), small vasculitis (Fig. c and Additional file : Figure S1 and Additional file : Figure S2) existed in the aorta and cellulose exudation and inflammatory granulation tissue hyperplasia were present in the pericardium (Fig. d).Combining with the two pathological results, clinical manifestations and laboratory tests, we invited a radiologist and a pathologist to perform a multidisciplinary discussion in the initial diagnostic assessment of the patient with suspected GPA. Finally, the diagnosis of GPA was established. Then, immunosuppressive therapy with i.v. steroids (methylprednisolone 40 mg twice daily) and cyclophosphamide 125 mg·day− 1 was initiated. The patient is currently followed up with the above treatment programs. We also adjusted the treatment program according to the patient’s disease progression. At present, the patient recovers well and is in stable condition. |
A 36-year-old male reported with a history of seizures following sexual intercourse. He was married for 15 years and had normal sexual interactions till about 5 years ago. He reported episodes of loss of consciousness and falling on his wife immediately after ejaculation. It was followed by tonic clonic movements in all four limbs as reported by his wife. Each episode lasted a few minutes. He would feel the heaviness in his head and dazed feeling after regaining his consciousness. He did not report feeling any discomfort during foreplay and the initial part of sex. This continued after every act of sexual intercourse and ejaculation leading to a gradual reduction in the frequency of sexual intercourses. It led to marital strain and feeling of frustration and helplessness in the patient. These seizures were seen exclusively after sexual intercourse initially, and 3 years later he reported experiencing 5–6 episodes during which he dropped objects held in hand, was unresponsive and slumped to the ground, each lasting few seconds. It happened at different times of the day and was not associated with the sexual interaction. His neurological examination did not reveal any significant finding. There was no history of any head trauma in the past. He never consumed alcohol or any other substance of abuse, and he was not taking any other medication other than antiepileptic.\nInterictal electroencephalograms done during earlier consultations at different places were normal. Computed tomography scan and magnetic resonance imaging (T-3) testing of the brain revealed no structural abnormality. His blood examination findings were normal. At various places, he was treated with phenytoin sodium and clobazam with no change in frequency of the seizures. We added sodium valproate and levetiracetam and gradually increased the dosage of both the drugs to 1000 mg/day, He responded well and seizures were under controlled totally. Three months after initiation of treatment patient reported great relief as seizures were controlled and his marital relationship improved. |
A 78-year-old female presented with a 1-month history of colicky abdominal pain, abdominal distension, vomiting, and unintentional weight loss. Her past medical history included ischemic heart disease on clopidogrel and previous history of deep vein thrombosis. She recently returned a positive stool occult blood test, awaiting colonoscopy. Her past surgical history included a hysterectomy, cholecystectomy, appendectomy and notably, a right lobular Stage IIB, Grade 2 lobular breast cancer. She had a wide local excision and sentinel lymph node excision with 1/3 biopsied lymph nodes positive. Despite her positive lymph node, she was deemed lower risk lobular type, and her treatment included adjuvant radiotherapy for 6 weeks and hormonal therapy letrozole, which was discontinued after 7 months due to arthralgia severely impacting her quality of life. Tamoxifen was deemed unsuitable due to associated risk of thromboembolism and her previous history of deep vein thrombosis. She continued regular outpatient surveillance and was in remission, confirmed by a normal breast ultrasound and mammogram a year prior to presentation.\nAn Abdominal Computed Tomography (CT) in the Emergency Department at the time of presentation demonstrated concentric wall thickening and narrowing of the distal transverse colon with dilatation of the proximal transverse colon and ascending colon, concerning for a neoplastic lesion (Figures and ). Her CEA level was elevated at 5.8. Subsequent investigation with a colonoscopy revealed a circumferential lesion in the proximal descending colon, not typical in appearance for an adenocarcinoma. It was difficult to negotiate past the tumor and biopsies were taken. The histopathology demonstrated features of sessile serrated adenoma with some reactive changes, however, no evidence of dysplasia or malignancy. A semi-urgent laparotomy with curative intent was performed in view of her progressive abdominal pain and distension and found the offending, thickened segment to involve the distal transverse colon and splenic flexure. An extended right hemicolectomy was performed, and her surgery was routine. The histopathology comprised of a circumferential, firm, ill-defined partially ulcerated lesion in the transverse colon measuring 25 × 20 mm and measuring 370 mm to the proximal margin, 110 mm to the distal margin. The lesion appeared to invade through the muscularis propria into the pericolic fat by 5 mm and measures 1 mm to the closest serosal surface. Multiple lymph nodes were identified in the mesentery ranging from 2-20 mm in maximal diameter. This was demonstrated to be a metastatic, grade 2 lobular carcinoma deposit. Lymphovascular invasion was present and three separate extranodal deposits of metastatic lobular carcinoma were seen in the mesenteric tissue. The immunohistochemistry demonstrated ER and PR positive status, HER2 FISH negative and a Ki-67 of 18% in keeping with the previous lobular breast carcinoma histopathology.\nShe recovered well postoperatively, requiring a short period of rehabilitation. She was recommenced on letrozole to reduce the risk of further recurrence and associated issues including ascites and pleural effusion. She was not a candidate for chemotherapy given her frailty. A CT pan scan and bone scan did not demonstrate any other evidence of metastatic disease. Prior to further follow-up and a planned PET scan in a tertiary center. Unfortunately, prior to further follow-up, she passed away, 2 months postoperatively with increasing anorexia and fatigue. |
A four-year-old Arab-Egyptian boy was brought by parents to pediatric clinic seeking prosthetic replacement of multiple missing teeth. The patient was elder of two siblings from a consanguineous marriage. History revealed the patient was born at full term through normal delivery and both parents and the younger brother were healthy.\nPast medical history showed previous hospital admission at the age of two years and ten months for emergency intervention to treat chronic osteomyelitis and periostitis that resulted in swollen right foot above the talus. The condition at that time was diagnosed as septic arthritis and acute osteomyelitis. The condition in the right foot recovered well albeit with some scarring. At age three, patient's right little toe got hurt while playing for which he obviously never complained, which later got infected leading to necroses and ultimate amputation (). At this stage he was diagnosed as suffering from congenital insensitivity to pain without signs of anhidrosis. The pediatric neurologist confirmed his poor attention and concentration span and a pediatric orthopedic surgeon diagnosed his right foot condition as “charcot arthropathy.” He sleeps well at night and sweat profusely particularly when the room is warm.\nThe parents noticed that the patient is suffering from some chewing difficulties due to premature tooth loss but without swallowing difficulty and this was the main reason that had brought them to seek dental treatment. General examination showed a fully alert patient with hyperactive behavior and short attention span. The patient's height and weight was appropriate for his age with normal gait and posture. There was an extensive damage to index finger of the right hand due to biting and chewing (Figures , , and ).\nClinical oral examination demonstrated scars on tip of the tongue and around vermillion border of the lower lip suggesting self-inflicting injuries probably due to pain insensitivity. The tongue was of normal size and color but bald and depapillated. Intraoral hard-tissue examination demonstrates no carious lesion. There was an open wound in the left mandibular quadrant with exposed alveolar bone due to a very recent self-extraction of two deciduous molar teeth (74, 75), according to the history. Distal to the wound, there was premature exposure of mesiobuccal cusp tips of the left mandibular first permanent molar. In addition, severely resorbed maxillary and mandibular alveolar ridges were evident clinically and radiographically. The orthopantomogram (OPG) examination of the jaw bones showed normal jaw anatomy and bone density (). The crowns of permanent teeth development are consistent with the physiological and chronological age of the patient. However, both mandibular permanent second premolars are absent.\nIt was noted that piercing the buccal gingiva with a sharp dental probe during oral examination did not elicit any physical reaction from the child.\nBased on the available pediatric, orthopedic, and neurological records, a diagnosis of oral self-mutilation secondary to congenital insensitivity to pain was established. |
A 67-year-old man presented with low back pain, sciatica, and weakness of the lower limbs for 2 years. His back and leg pain exacerbated after standing or walking and relieved by lying supine with the knees and hips flexed. Overall, his pain was tolerable. He can walk well, though he felt his legs were weaker than usual. He sought treatment at a local hospital, and magnetic resonance (MR) imaging revealed a herniation disc at L3/4 level. Two months ago, however, his back pain worsened considerably and he started to have intermittent claudication. His symptoms failed to respond to conservative treatments, and his walking distance decreased to approximately 100 m. He was referred to us for further treatment. His bowel and bladder functions were normal since he was sick.\nOn physical examination, there was mild tenderness on L3-5 spinous processes. While straight leg raising test was negative, femoral stretch test was positive at both sides. Neurological examinations revealed decreased muscle power for the right quadriceps femoris and left tibialis anterior (Manual Muscle Test grade IV). His knee and ankle reflexes at the right leg disappeared, and sensation at the medial side of his left calf diminished. Pathological reflexes were negative at both legs. Lumbar spine MR imaging revealed an intradural lesion (14 × 8 mm2) at the left side of the dural sac and a herniated disc of moderate size at the right lateral recess of the L3/4 spinal canal (Figs. and ).\nThe patient underwent laminectomy and intrathecal tumor resection. Intraoperatively, the lesion was found to be encapsulated and stuck to a nerve root. After tumor removal, discectomy and posterior lumbar intervertebral fusion were performed. Histological studies revealed a herniated disc and a schwannoma. At the 6-month postoperative follow-up, the patient did not have back and leg pain. Neurological deficits at the extremities fully recovered, and he returned to normal life.\nThe current case highlights a rare situation that symptomatic disc herniation and spinal tumor present simultaneously in a spinal segment. To our knowledge, there are only four similar cases of lumbar disc herniation coexisting with intradural tumor reported in English literatures [–]. Albert et al. reported a case of L4/5 disc herniation presented together with a neurinoma at the L5 nerve root in a 52-year-old man []. The clinical manifestations revealed typical signs of L5 root compression from the herniated disc, and the tumor was an accidental finding on myelography. Liu et al. reported a 51-year-old man with L2/3 disc herniation coexisting with a schwannoma causing cauda equina syndrome []. The patient had suffered from low back pain for 3 years and was diagnosed with L2/3 lumbar disc herniation. To begin with, his back pain was relieved by conservative treatment but deteriorated progressively till cauda equina syndrome occurred. Bhatia et al. reported a paraganglioma coexisting with L5/S1 disc herniation in a 33-year-old man []. The clinical presentation was left sciatica associated with paresthesia in the left S1 dermatome. In 2014, Baek et al. described another case of intradural schwannoma coexisting with lumbar disc herniation at L4/5 disc level in a 71-year-old woman who suffered from lower back pain and L5 radiculopathy []. Intrathecal tumor resection and discectomy were performed using a posterior approach in these cases. In our case, right leg radiculopathy resulted from L4 nerve root compression due to L3/4 disc herniation. Some other symptoms, such as claudication and leg weakness, may be the results of both pathologies. We used a single operation to address both conditions, as did others [–].\nSpinal schwannoma is a benign nerve sheath tumor, which comprises approximately 15 % of all spinal tumors []. The vast majority of schwannomas was located at the intradural space and occasionally presented as extradural or a dumbbell-shaped lesion []. Intradural schwannoma may produce symptoms similar to those of disc herniation, such as back pain and neurological deficits []. On MR images, schwannoma typically presents as an isolated and encapsulated mass, as hypointense or isointense on T1W images and hyperintense on T2W images []. Contrast MR imaging may reveal a well-delineated enhanced mass and, thus, is useful for differential schwannoma from disc degeneration []. In the present case, gadolinium contrast MR images revealed two heterogeneous signal masses at the same level, with one at the right extradural space and another at the left intradural space. As a result, the establishment of diagnosis was relatively easy.\nIn general, posterior epidural migration of a herniated lumbar disc fragment, a rare situation of disc herniation, should also be included in the differential diagnosis for extradural and intradural tumors [–]. Extradural disc fragment presents signals similar to those of a disc on both T1-weighted and T2-weighted MR sagittal images []. Moreover, disc fragment may demonstrate peripheral enhancement on contrast MR images [, ]. Even rarer, calcified disc sequestration may mimic an intradural spinal tumor and had MR findings similar to that of schwannoma []. Occasionally, a histological study is the only way to verify the diagnosis.\nWhen clinical symptoms cannot be fully explained by an identified pathology, the coexistence of another spinal pathology should be considered. It is easy to establish the diagnoses when a spinal tumor and a herniated disc present in the same spinal region, as both pathologies are displayed on a MR study. It is noteworthy, however, that spinal tumor and lumbar disc herniation may present at different spinal regions and a single MR study may not be able to reveal both. Knafa reported a patient who presented rapidly progressive spinal cord compression following discectomy []. Her symptoms temporally restored but soon developed progressing paralysis in her right leg. Retrospective MR revealed an extramedullary tumor at T1/2 level. Another scholar reported a similar case of misdiagnosed thoracic tumor with neurological deficits deteriorated after decompression surgery for lumbar spinal stenosis []. Symptoms of upper neuron compression in patients who suffer from lumbar degenerative disorders, therefore, should be carefully examined to exclude possible concomitant pathology in the thoracic or cervical regions. |
We present the case of a 72-year-old African American male who was brought in by family members to the psychiatric emergency department for new-onset auditory hallucinations that became increasingly worse. In the four months leading to the patient's presentation to the hospital, he had increasingly frequent and intense hallucinations as well as paranoid beliefs that usually occurred when he was driving. He believed people driving in other cars and pedestrians were trying to harm him. He began hearing congruent persecutory hallucinations while driving the car and made dangerous and strange driving maneuvers. These episodes of paranoia occurred in 15-20-minute intervals, lasted for a few minutes, and were accompanied by hallucinations. He was admitted to the inpatient psychiatric unit as he posed a danger to himself and others while in his state of psychosis.\nThe patient had a prior medical history that included hypertension and chronic kidney disease. He denied any past or current use of alcohol or other illicit substances. He had a prior psychiatric history in which he reported paranoid delusions since the age of 15. His paranoid beliefs centered around people in his family and arbitrary strangers he met who he believed were plotting to hurt him. The patient was on haloperidol 10 mg PO daily that managed his paranoid beliefs throughout his adult life. He worked successfully as paralegal, raised a family, and retired from work without any significant psychiatric episodes.\nUpon mental status examination, he exhibited significant psychomotor retardation; however, his gait was steady. His affect was blunted. His thought content was notable for paranoid beliefs. A cognitive assessment utilizing the Montreal Cognitive Assessment (MoCA) screening tool revealed a score of 20/30 while a MMSE revealed a score of 21/30 consistent with moderate cognitive impairment. Physical examination was within normal limits; however, he demonstrated decreased muscle strength ⅗ in both the right upper and lower extremities, along with absent reflexes in both the right biceps and triceps muscles. The results of laboratory and imaging findings were unremarkable as shown in Tables and and .\nBrain imaging is demonstrated in .\nAn image of an MRI of the brain of the patient is shown in . The MRI was compared with a prior CT scan two years before and indicates new pathology of a likely stroke involving the parietal cortex, insular cortex, and subcortical striatal structures and white matter/lacunar changes. There is no significant pathology of the hippocampus, cerebellum, occipital cortex, thalamus, or frontal corticosteroids. No acute cerebral cortical infarct or intracranial hemorrhage was present. Collateral information from medical records indicated a prior presentation in the emergency room for transient ischemic attack four and a half months prior to his presentation, and two weeks before the worsening of psychotic symptoms. He was managed with aspirin 81 mg and an outpatient follow-up. lists the MRI findings of the brain regions of interest.\nDue to extrapyramidal symptoms, haloperidol was discontinued and sensitivity studies by gene therapy were performed for medications that could be started. The treatment plan included cognitive behavioral therapy with cognitive restructuring, supportive therapy, motor vehicle safety plan, and olanzapine 10 mg PO as needed. The patient showed significant improvement with psychological interventions and was discharged home with weekly outpatient cognitive behavioral therapy sessions. |
We present a case of a 56-year-old male with medical history of hypertension and hyperlipidemia who was found on the floor by his spouse unresponsive and not breathing in the early hours of the morning. The last-known–well was the night prior. There was no clear estimate of duration of events. Upon arrival of Emergency medical services, patient was found to be in pulseless electrical activity (PEA). Patient achieved return to spontaneous circulation (ROSC) 15 minutes after initiation of advanced cardiac life support (ACLS) protocol. Patient received 3 doses of Epinephrine, 2 doses of Bicarbonate and 1 dose of Calcium. EKG done immediately post ROSC showed ST elevations in inferior and lateral leads. Patient was brought to the hospital as a STEMI arrest. A detailed analysis if the EKG revealed helmet sign in leads aVL and II, also ST segment elevation was noted in V1, V2, V3 and ST segment depression was noted in V5 and V6. Bedside echocardiogram obtained showed no wall motion abnormalities and repeat EKG including with right sided leads revealed no ST segment elevation with no accompanying pathologic Q waves or T-wave inversion. Troponin was negative at the time of initial evaluation but trended up gradually during hospitalization. Laboratory results were also notable for creatinine of 3.07 and CPK 457 in addition to mildly elevated White blood cell count and elevated aspartate aminotransferase, alanine aminotransferase, and lactate most likely as a result of tissue hypoperfusion due to the cardiac arrest. CT scan angiography of the chest was negative for pulmonary embolism. A head CT without contrast showed diffuse anoxic brain injury. Patient was started on hypothermia protocol. Official Echocardiography obtained later the same day of presentation showed an increase in right ventricle size in the upper limit of normal and a reduced right ventricular ejection fraction. Estimated peak pulmonary artery pressure was 35 – 45 mm hg. Left ventricular ejection fraction was estimated to be between 45% – 55% with no regional wall motion abnormalities. Mild concentric hypertrophy was also noted in the left ventricle. Doppler parameters were consistent with abnormal ventricular relaxation and no valvular abnormalities were noted. Patient remained intubated with continuous vasopressor support. Upon family request, patient was terminally extubated two days into hospital stay and expired shortly after. |
A 28-year-old recently married lady with 8 years history of type I diabetes mellitus had presented to a local hospital with a one-day history of sudden onset generalized abdominal pain which was persistent and worsening over time. On examination, she had low blood pressure and low urine output. Despite fluid resuscitation, she required inotropic support to maintain blood pressure. Her abdomen was mildly tender to palpation with no significant guarding. She had no previous history of abdominal pain. An initial ultrasound scan of the abdomen revealed multiple pancreatic calcifications with mild to moderate ascites. She had high CRP (C-reactive protein) levels (258 mg/L), but her amylase level was <30 IU/L. Despite resuscitation, she developed acute kidney injury. She became oxygen-dependent and was developing features of respiratory failure as well. The patient was transferred to our unit for intensive care and further surgical management.\nWith continued resuscitation, her renal functions improved. But she was continued to be oxygen-dependent and required inotropic support. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a pancreatic fluid collection (PFC) at the tail of the pancreas with gas formation within and severe peripancreatic fat standing and oedema, which was suggestive of an infected PFC in association with acute focal pancreatitis involving the pancreatic tail region (). CECT also showed a moderate amount of free fluid in the abdomen with a pelvic fluid collection. Ultrasound-guided aspiration of pelvic collection revealed purulent fluid. Clinical picture and CECT findings were in favour of free peritoneal rupture of an infected PFC.\nAs she required control of sepsis within the peritoneal cavity as well as drainage of the infected PFC, laparoscopic drainage of PFC was planned. She was operated in a supine position. Pneumoperitoneum was achieved with the open Hassen technique. Laparoscopy revealed a moderate amount of purulent free peritoneal fluid with pus discharge from an opening in the gastrocolic omentum. Free peritoneal fluid and pelvic collection were drained. Opening in the gastrocolic omentum was widened to reveal the ruptured PFC (). Cavity of the PFC was entered with blunt dissection, which revealed necrotic debris. Thorough lavage and drainage of the cavity was carried out. All dependent areas of the peritoneal cavity were inspected for residual collections. Following a thorough peritoneal lavage, wide bore tubes were placed into the cavity of the PFC and to the pelvis (). A 32 Fr intercostal tube (IC) was placed into the cavity of the PFC, while a 14 Fr feeding tube was anchored inside it. This improvisation technique of the drainage tube allowed frequent flushing through the inner tube to prevent blockage of the larger drain tube. A single 32 Fr IC tube was placed into the pelvis.\nPeritoneal fluid and necrotic tissue culture were positive for pure growth of coliform species. She had a gradual recovery. All inotropes were omitted on the second day following surgery. She was sent to the ward from the ICU on the 4th postoperative day. Her inflammatory markers normalized. By one week from surgery, she was fully mobilized and was tolerating a normal diet. The drain that was placed into the pelvis was removed on the 4th postoperative day as the drain amount was minimal.\nDrain amylase levels from the drain placed into the cavity of the PFC was 15 U/L on the 3rd postoperative day. Even though output from this drain was minimal since the 4th postoperative day, it was kept until two weeks. She underwent a repeat CECT abdomen after 2 weeks from surgery, which showed resolution of the collection. At two months from surgery, she did not have any pain symptoms. As there was only a mild dilatation of the pancreatic duct and the patient did not have any pain symptoms, no further interventions were planned. She is scheduled for routine clinic visits for long-term follow-up. |
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube insertion. There was granulation tissue visible sprouting through the tract externally (Figure ). The patient had no signs of peritonitis and the abdomen was soft. On flushing the tube with saline, peritubal leakage was noted and there was resistance to flow. Endoscopic examination was performed to visualize the position of the internal bumper. On endoscopy, the internal bumper was not visualized. Only a small dimple was seen in the mucosa of the anterior wall of the stomach (Figure ). The internal bumper appeared to have migrated through the tract and was entirely covered by the gastric mucosa with only a small dimple seen at the site of the tract. An ultrasound of the abdomen was performed which showed that the internal bumper was in the intramuscular plane of the rectus abdominis muscle (Figure ).\nAs the patient’s GCS was still poor with no mature swallowing reflex, we planned to remove the old PEG tube and replace it with a new one for continued enteral feeding. The procedure was performed under general anaesthesia. Under fluoroscopic guidance, a guide wire was passed through the previous PEG tube from outside piercing the gastric wall. Then the old PEG was removed by gentle firm traction and the tract was dilated using dilator passed over the guide wire. The position of the dilator inside the stomach was confirmed by injecting a contrast dye under fluoroscopic visualization. Since the tract was well formed, a 20 Fr balloon replacement gastrostomy tube was inserted from outside and secured (Figure ). Once again the position was confirmed by fluoroscopy and free flow of saline. The patient was started on PEG feeds later on the same day and had no complications. The patient was followed up for a month and was on continuous PEG feeds without any complications. |
A 62-year-old male patient with liver cirrhosis due to HCV infection since 1993 was found to have HCC in 2003 and underwent caudate lobe resection. After surgery, he received antiviral therapy, with a sustained virological response to antiviral therapy by interferon plus ribavirin. Four months after the liver resection the patient was found to have HCC recurrence in the liver, and during the next 3 years, he consequentially received several TAE/TACE procedures for HCC in S2, S4 and S7, percutaneous ethanol injection for HCC in S7 and RFA for HCC in S2, with good clinical and roentgenological outcomes.\nThirty-eight months after the initial finding of HCC, the patient underwent LDLT from his daughter, using a left lobe graft, and his treatment followed the general clinical protocol of the center, including immunosuppressive therapy. A few days before transplantation, the patient's prognostic criteria presented with CTP class C (10 points), a MELD score of 10 points and HCC within the Milan criteria. The tumor marker levels were normal: AFP 1.9 ng/dl and PIVKA II 24 mAU/ml. Histopathological study of the explanted liver showed no evidence of malignancy.\nHowever, with elevation of AFP 19 months after LT, a single nodule of peritoneal tumor in the pelvic cavity was observed under PET/CT. Within 1 month the patient underwent peritoneal tumor resection, and histopathological investigation of the tumor revealed moderately differentiated HCC. After 3 months, the patient was accepted for adjuvant therapy with sorafenib 400 mg, but at the same time, he was observed to have recurrence of the pelvic tumor, with invasion in the rectum, and it was noted that he also had liver recurrence. TACE was performed for both the pelvis and liver tumors, and thereafter the patient was supported with palliative treatment. After about 1 month of this treatment, the patient asked to be discharged so he could go home, where he died within 3 months. Overall, the patient survived 46 months after LT. Maintenance immunosuppressive therapy was under cyclosporine with the trough level of 50–100 ng/μl without any signs of rejection. This case was partly reported in our previous publication []. |
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 50-year-old female presented with complains of painless progressive swelling in right cheek region of two months duration. Examination revealed a 6 × 4 cm bony hard swelling in right zygomatic region near and below lateral canthus of right eye (Figure ) Roentgenogram of the paranasal sinuses showed a lesion arising from right maxilla and right zygoma. Computerized tomographic (CT) scan revealed two separate masses one in right orbit and other infiltrating zygoma and maxilla (Figure ), radiographic picture was suggestive of osteogenic sarcoma or Ewing's sarcoma. A fine needle aspiration was carried out that showed typical polygonal and spindle cells with moderate amount of cytoplasm and vesicular nuclei with nucleoli, many with intracellular pigment; seen singly and clusters, the picture was suggestive of malignant melanoma (Figure ). The ophthalmologic consultation revealed that there was no useful vision in the right eye. A B-scan of the right eye showed an organized mass within the vitreous cavity indicating vitreous haemorrhage (figure ). A detailed clinical examination failed to show any other melanocytic lesion on skin and other mucus membranes.\nWith a provisional diagnosis of melanoma of the maxilla and zygoma with vitreous haemorrhage and no useful vision in right eye a wide excision of the lesion including anterolateral maxillectomy, zygomectomy, and removal of superolateral wall and floor of orbit with en bloc exenteration of the right eyeball was carried out (Figure ). Histopathological examination of the resected eyeball specimen showed a neoplasm in choroid, filling posterior chamber with no extraoccular extensions, composed of sheets, nests and cords of polygonal cells and vesicular nuclei. Prominent nucleoli and eosinophilic cytoplasm containing abundant melanin pigment were noted (figure ). Similar tumours were seen in the extra ocular soft tissue and resected maxilla and zygomatic bones. A final diagnosis of choroidal melanoma metastasizing to maxillofacial bones was made. Differential diagnosis of primary bone melanoma with metastasis to choroids was kept.\nSurgical excision was followed by 40 Gy./15 fractions of radiotherapy to right face using lateral portal. Patient is on regular follow-up two years after surgery and is free of any local or systemic recurrences. |
A 61-year-old gentleman presented for a health maintenance examination. His medical history was significant for diabetes mellitus type 2, hypertension, hyperlipidemia, and IgM monoclonal gammopathy of unknown significance. He reported no symptoms and maintained an active lifestyle by exercising several times per week. Physical exam findings revealed a BP of 139/81 and heart rate of 70 beats per minute with a regular rate and rhythm and no murmurs or gallop. Other systems were unremarkable, including the absence of systemic symptoms. The patient's baseline ECG showed minor abnormalities. In the setting of chronic hypertension and ECG abnormalities, a TTE was obtained and showed normal left ventricular size and function, but incidentally revealed a subaortic membrane in addition to a highly mobile mass arising from the membrane (). Differential diagnosis of the mass included endocardial tumor, thrombus, or endocarditis. Due to the highly mobile nature of the mass, endocardial thrombus was less likely. Additionally, in the absence of clinical evidence of infection, endocarditis was ruled out. The patient was referred to cardiovascular medicine for further investigation of the cardiac mass.\nTEE confirmed the presence of a mobile 9 mm × 3 mm mass on the subaortic membrane within the LVOT suspicious for a PFE () (video ). No Doppler evidence of significant left ventricular outflow tract (LVOT) obstruction was present; however, due to the size, mobility, and location of the mass, cardiothoracic surgery was consulted for surgical removal of the mass.\nIn preparation for surgery, the patient received a preoperative cardiac CTA which showed an insignificant coronary atherosclerotic plaque and confirmed the presence of the mass on a nonobstructive subaortic membrane 11 mm from the aortic valve (Figures and ).\nThe operation was performed through a median sternotomy, and the patient was placed on cardiopulmonary bypass. Inspection of the LVOT revealed a multifaceted mass extending from a partial subaortic membrane, the appearance of which was consistent with a papillary fibroelastoma. The mass was excised and the subaortic membrane was dissected to the muscular portion of the septum (). The specimen was submerged in water revealing the frond-like appearance which can be likened to a sea anemone (). The patient had an uneventful postoperative course.\nHistologically, hematoxylin and eosin (H&E) stain of the specimen revealed branching papillae () which were avascular and rich in collagen (). CD34 stain highlighted the surface composed of a single layer of endothelial cells (). The pathologic examination confirmed the diagnosis of PFE. |
A 25-year-old male was brought to our emergency department following a road traffic accident in July 2018. The patient was intubated in view of poor score on Glasgow Coma Scale (GCS). He was hemodynamically stable. On clinical examination, the patient had bilateral decreased air entry and positive chest compression. There were no abdominal signs. On focused assessment with sonography in trauma (FAST) there was minimal free fluid in the abdomen. Contrast-enhanced computed tomography (CECT) of thorax and abdomen showed bilateral hemopneumothorax and a grade III liver laceration. Initial non-contrast computed tomography (NCCT) of brain showed no intracranial injury but later the patient was declared to have a diffuse axonal injury and was shifted to critical care unit for monitoring. The liver laceration was managed conservatively since the patient was hemodynamically stable. Hemopneumothorax was managed with bilateral intercostal drains. The patient’s GCS was persistently poor. Initially, the patient was started on enteral feeds through nasogastric tube and later a PEG tube placement was planned for the purpose of continuing enteral feeds.\nThe procedure was performed while the patient was on endotracheal tube, and under intravenous (IV) sedation. A 20 Fr PEG tube was placed by the standard ‘Pull’ technique. Second look endoscopy confirmed the position of the internal bumper against the anterior wall of the stomach. Externally the tube was fixed and free flow of saline through the PEG was confirmed. There were no complications during the procedure and the patient was started on enteral feeds through the PEG tube on the same day. The patient was extubated after few days but he was continued on PEG feeds as his GCS was persistently poor.\nAt four weeks after PEG there was peritubal leakage noted during feeds with resistance to the flow of feeds initially, which later progressed to complete the blockage. On examination, there was a slight bulge at the site of PEG tube insertion. There was granulation tissue visible sprouting through the tract externally (Figure ). The patient had no signs of peritonitis and the abdomen was soft. On flushing the tube with saline, peritubal leakage was noted and there was resistance to flow. Endoscopic examination was performed to visualize the position of the internal bumper. On endoscopy, the internal bumper was not visualized. Only a small dimple was seen in the mucosa of the anterior wall of the stomach (Figure ). The internal bumper appeared to have migrated through the tract and was entirely covered by the gastric mucosa with only a small dimple seen at the site of the tract. An ultrasound of the abdomen was performed which showed that the internal bumper was in the intramuscular plane of the rectus abdominis muscle (Figure ).\nAs the patient’s GCS was still poor with no mature swallowing reflex, we planned to remove the old PEG tube and replace it with a new one for continued enteral feeding. The procedure was performed under general anaesthesia. Under fluoroscopic guidance, a guide wire was passed through the previous PEG tube from outside piercing the gastric wall. Then the old PEG was removed by gentle firm traction and the tract was dilated using dilator passed over the guide wire. The position of the dilator inside the stomach was confirmed by injecting a contrast dye under fluoroscopic visualization. Since the tract was well formed, a 20 Fr balloon replacement gastrostomy tube was inserted from outside and secured (Figure ). Once again the position was confirmed by fluoroscopy and free flow of saline. The patient was started on PEG feeds later on the same day and had no complications. The patient was followed up for a month and was on continuous PEG feeds without any complications. |
A 31-year-old woman from Columbia with medical history significant for Gestational Diabetes presented to the labor ward without prior prenatal care. She came to the United States eight months prior to presentation. She received cesarean section for fetal distress and gave birth to a healthy baby. Her medical history was negative for cough, shortness of breath, fever, night sweating or loss of appetite, incarceration or living in institution, and any contact with TB patient or chronically coughing person. She was never diagnosed with active or latent TB. At the time of presentation patient was not actively coughing. Patient did not remember if she received BCG vaccination as a child or not.\nPhysical examination revealed young healthy looking female patient without any cardiopulmonary distress. Examination was negative for lymphadenopathy; chest was symmetrical, resonant to percussion, clear to auscultation bilaterally. Examination of other systems was within normal limits. BCG vaccination scar was not noted on either of the both upper arms.\nThe patient's perioperative chest X-ray () showed a small irregular density in the right middle lung and there was a hazy increased density over the left upper lung, which was suspicious for infiltrates versus fibrotic changes. Lucency was also noted within the left upper lobe, which was suspicious for cavitary change and further evaluation with CT was recommended for possible pulmonary tuberculosis. Noncontrast CT () showed patchy and nodular opacity in the apical posterior segment of the left upper lobe and to a lesser extent in the superior segment of the right lower lobe and right lung base as well as a small axillary node. The differential diagnosis would include mycobacterial infection and pyogenic pneumonia. In light of positive chest X-ray and chest CT scan, TB quantiFERON gold test was requested. All other lab tests including tests for hepatitis B surface antigen, HCV, HIV, work-up for collagen vascular diseases, and sarcoidosis were negative.\nQuantiFERON TB gold test was positive. To address further plan of management following the positive quantiFERON TB test, a multidisciplinary approach, which included pulmonary diseases specialist, infectious diseases specialist, obstetrician, and pediatrician, was undertaken to address the following areas of concern: (1) isolation of baby from mother, (2) isolation of baby from other babies in nursery, (3) initiating LTBI (latent TB infection) treatment in baby, and (4) initiating four-drug TB regimen in the mother. The panel agreed to respiratory isolation, obtaining three sputum samples for AFB smears, bronchoalveolar lavage (BAL) for mother, starting mother on four-drug anti-TB regimen and the baby on LTBI treatment, while keeping the mother and baby together.\nThree induced sputum samples were obtained and were stained for Acid Fast Bacilli (AFB) which did not reveal any Acid Fast Bacilli. Patient initially refused bronchoscopy procedure, but after explaining to her the significance of the procedure, she consented for bronchoscopy. She received bronchoscopy () with biopsy and BAL. Bronchoscopy revealed hyperemic and friable bronchial tree mucosa. BAL was done from both left and right side and biopsy was taken from left upper lobe. Lab data are summarized in . Biopsy from left upper lobe showed predominantly bronchial mucosa with chronic inflammation and fibrosis. Special stain for Acid Fast Bacilli (Fite Stain) and fungi (GMS stain) were negative. Immunostain for CD-68 highlights few macrophages. BAL from right lower lobe was negative for malignancy and no evidence for infectious organisms and showed lympho/histiocytic infiltrate (primarily histiocytes). Left upper lobe BAL was also negative for malignancy and showed lympho/histiocytic infiltrate.\nSputum and BAL sample analysis with Direct AFB probe and AFB culture was positive for AFB. Public health was notified and mother was continued on full course of TB treatment.\nBaby was evaluated by neonatology team, PPD was performed, and it was negative and chest X ray was normal. As per multidisciplinary team plan, baby was started on INH prophylaxis for the possible latent TB infection while awaiting gastric aspirate TB work-up results. Mom and baby are allowed to be together.\nPatient and the baby were closely followed in pulmonary, infectious diseases, and pediatric clinics. Importance of medication compliance and adverse effects of medication were explained to the patient and she clearly understands the instructions. Two months after commencement of the treatment, patient and baby remained compliant with treatment regimen and did not experience any adverse effects of medications. Baby's growth chart was satisfactory. Patient expressed wish to travel back to her home country. We took the opportunity and once again clearly gave her the instructions about the need for regular doctor follow-up of both mother and the baby. Patient has good educational background and she promised to follow our instructions. Sadly, we lost contact with her after she left the USA. We sincerely hope that she followed our instructions and both mother and baby completed treatment and prophylaxis, respectively. |
A 45-year-old female was admitted to the hospital after complaining of an orthostatic headache and cervical pain the day before. The headache occurred whenever the patient was in a sitting or standing position, but not in a supine position. She did not have a history of trauma. She was alert and did not have other neurological symptoms. There were no abnormal findings in the brain MRI.\nThe day after the patient's hospital admission, she had sudden quadriplegia and paraesthesia. The motor grade of her lower extremities was 0, and that of her upper extremities was I. The pain and high temperature on both sides were reduced, and the patient recovered with a motor grade of 3 in her upper and lower extremities. C-spine MRI was taken, and SEDH was suspected because isointensity was observed in the T1-weighted image of the epidural space from C2 to T2 while hyperintensity was observed in the T2-weighted image of the same ().\nAngiography was performed to rule out any vascular abnormality, such as arteriovenous malformation. Its result was normal. An emergency left hemilaminectomy from C4 to T1 was performed to remove the hematoma, and controlled the bleeding. During the operation, engorged epidural veins were observed, and the dura was not damaged during the operation. After the operation, the patient recovered completely from motor and sensory deficits. 6 day after surgery, myelography and computed tomography (CT) were performed due to the CSF leakage in the wound. As a high density was observed from C3 to T3 (), lumbar drainage was performed. During the lumbar puncture, the opening pressure was too low to be measured, and the lumbar drainage was minimal. The patient was treated for two weeks, for stabilization. There was increased epidural fluid collection at C2 to T3 in the spinal CT(). Second operation was thus performed, and there was no leakage at the dorsal part of the dura but there was some leakage at the C5-6 ventral part that was not found at the 1st operation. The dura defect was covered with collagen sponge (Gelfoam) and fat tissue, and sealed with adhesive sealant (Tisseel). The symptoms disappeared, and no CSF leakage was found in the follow-up myelography and spinal CT. The patient was discharged without deficits. |
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 73-yr-old male presented to us with a pulsating abdominal mass. Abdominal computerized tomography (CT) scan showed an abdominal aortic aneurysm having crossed ectopia with fusion anomaly of the kidneys. His past medical history was positive for smoking, hypertension, benign prostatic hypertrophy, and parkinsonism. On physical examination, a pulsating non-tender abdominal mass of about 8 cm in diameter was palpable around the umbilicus. Lower extremity pulses were palpable without evidence of aneurysmal dilatation. Laboratory tests, chest radiography, and electrocardiography were normal. The patient underwent a transfemoral aortogram () to evaluate the renal arterial anatomy. One renal artery from the abdominal aorta for the upper (right) kidney, and two renal arteries from the aneurysm and one renal artery from the left common iliac artery for the lower kidney (crossover left) were seen. One pelvis and one ureter for each kidney were also identified. Operation was conducted. The retroperitoneal cavity was approached transperitoneally. The ureter of the lower (crossover left) kidney crossed the midline at the level of the bifurcation and entered the bladder. To minimize renal ischemic injury, we dissected the lower two renal arteries (one from the aneurysm itself and the other from the left common iliac artery) and anastomosed the lowest renal artery (from the left common iliac artery) to middle renal artery (from the aneurysm itself) in a side-to-end fashion before aneurysm resection. We administered mannitol before the aortic cross clamping. After clamping the abdominal aorta below the level of the right renal artery and bilateral internal and external iliac arteries, the aneurysm was opened and two renal artery orifices were discovered. After the proximal anastomosis of the bifurcated graft, two renal arteries were individually reimplanted and blood flow was resumed to renal arteries. The renal arteries were reperfused within 20 min after the aortic cross clamping. Anastomosis of the two iliac limbs of the bifurcated graft to common iliac arteries was performed without concern of the time. The patient recovered uneventfully and was discharged on postoperative 7th day. Magnetic resonance (MR) angiogram () was taken two weeks after the operation and showed patent renal arteries and well perfused kidneys. |
A 12-year-old female with no prior psychiatric history was brought involuntarily by police for suicidal ideation with a plan after CPS was notified of suspected emotional and physical abuse by her mother. The child reported that her mother found out she hid food under her bed, which resulted in her mother causing physical harm with an electrical cord and a belt to the child's bilateral upper extremities. After this incident, the child took a knife from the kitchen and hid it in her room, with the intent of harming herself and ending her life. CPS found the knife, resulting in her involuntary psychiatric hospitalization. On evaluation, the child also reported that this was not the first time her mother physically abused her. She also stated her mother often called her derogatory names.\nUpon obtaining collateral information from the mother, she admitted to disciplining her daughter. She said she hit her with her bare hand first, but her daughter continued to talk back to her. She then hit her with a belt out of anger. Contrary to the child's statement, the mother claimed it was the first time she hit her daughter with a belt. She also stated that her daughter often verbalized suicidal statements when she did not get her way.\nOn physical examination, the patient appeared as stated age with fair grooming. Multiple cord-shaped and belt-buckle-shaped bruises were found on the child's arms and legs. She was calm and cooperative although mildly guarded. She presented with poor eye contact and some psychomotor retardation. Her speech was slowed and low in volume. She reported feeling sad and fearful with congruent affect. Her thought process was logical and linear. Thought content included fear of her mother and suicidal intent and plan as above. Insight and judgement were fair and congruent with her developmental age.\nThe patient endorsed symptoms consistent with major depressive disorder, including depressed mood for about a month, poor appetite, feelings of guilt regarding the abuse, poor concentration reflected in her poor school grades, insomnia, and suicidal ideation with intent and plan. Differential diagnoses included child physical abuse, child psychological abuse, and other unspecified trauma- and stressor-related disorder. The patient was admitted to the inpatient youth psychiatric unit with a plan to improve the patient's mood and suicidality through both pharmacological and nonpharmacological therapy.\nThe patient was provided with group and individual psychotherapy. Since her mother did not consent to psychopharmacological treatment, no medications were given. Throughout her hospital stay, the child often expressed fear of her mother and pleaded with the hospital staff to not discharge her home. At the end of the investigation, CPS determined that the child was safe to return home. After her mood had improved and she no longer endorsed suicidal ideation, she was discharged home in the custody of her mother. A follow-up appointment with her outpatient psychiatrist was set up upon discharge. The appointment was later rescheduled and resulted in a no-show. |
Patient aged 19 years old, male, university student and resident in central Morocco. He presented for 3 years a painful swelling on the left side a few days after the installation of a dental prosthesis, the patient was put under amoxicillin by his dentist without improvement, the evolution was marked by the appearance of a fistula facing the chin with pus. Faced with no improvement, the dentist referred him to us for further treatment.\nThe patient has been followed for osteopetrosis since childhood with a history of two fractures of the right and left femur following a minor trauma that was treated orthopedically.\nNo notion of similar cases in the family and no notion of consanguinity. No notion of allergy.\nOn admission to hospital, clinical examination revealed the presence of pus in the endobuccal area with chin fistula. The biological examination revealed a hemoglobin level of 12 g/l, the rate of GB 12000/mm. The panoramic X-ray showed persistent dental germs with foci of mandibular osteitis. 5 days later, the surgical intervention was performed by the chief professor of our department who has 16 years of experience, the patient under general anesthesia was given a sequestrectomy with extraction of 3 dental germs and was put under intravenous antibiotic therapy based on amoxicillin - clavulanic acid for 6 days and then relayed orally for 15 days. The pathological examination confirmed the diagnosis of osteomyelitis.\nThe patient was lost to follow-up for 6 months and was then seen at the clinic, where 3 skin fistulas with pus discharge were discovered, and the presence of mandibular bone sequestres visible on endobuccal examination.\nThe patient was depressed due to the continuous pus flow in the fistulas and therefore the absence of dentures (due to the persistence of mandibular osteomyelitis) prevented him from continuing his university studies. After a multidisciplinary team of dentists and psychiatrists, the decision was made to perform a second surgery with antidepressant treatment.\nHe again underwent a sequestrectomy with extraction of 4 teeth with ectopic aspects and curettage of the surrounding bone which appeared to be necrotic, then the 3 skin fistulas were removed and an attempt was made to cover the mandibular bone. The patient was put on ciprofloxacin (1g per day in two doses) intravenously for 5 days and then relayed orally.\nThe patient was seen at points J1, J7, J14 and J28 where two persistent fistulas were observed with denudation on the left side of the mandibular bone, a new bacteriological sample was taken and the patient is still on Ciprofloxacin. |
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. |
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 52-year-old woman presented with a swelling over the outer aspect of her left shoulder and proximal part of her left arm which she had first noticed 2 years ago. The swelling was obstructing the movements of her affected shoulder and was cosmetically unacceptable []. She had no history of trauma or fever. Her appetite was not affected, and there had been no weight loss. The globular swelling was painless and measured approximately 8 inches in diameter. No tenderness or warmth, but some pseudofluctuation was observed, along with restriction of all movements except adduction. No abnormality was detected in central nervous, cardiovascular, respiratory, genitourinary, or gastrointestinal systems. She was postmenopausal with no gynecological problem. Routine preoperative investigations (including liver function and renal function tests) were within the normal limit. Serological investigation for rheumatoid arthritis was negative. Plain roentgenogram revealed a soft tissue swelling only []. There were no areas of calcification.\nOn MRI, multiple nonosseous loose bodies were visualized in the bursa deep to the deltoid muscle. These spread up to the subacromial space as well as the anterior and posterior aspects of the shoulder. These appeared to remain outside the rotator cuff [ and ]. Aspiration returned the nonhemorrhagic synovial fluid with no sign of tuberculosis or other chronic infective pathology.\nThe tumor was exposed through a linear incision over the deltopectoral groove. A large protruding synovial membrane was visible under the deltoid muscle []. The synovial sheath was adherent to the surrounding structures. Innumerable pea-size cartilaginous loose bodies were extruded on an incidental rupture of the sheath []. All the loose bodies were taken out and the whole bursal sheath was removed from below the deltoid and from the subacromial space []. There was no connection of synovial bursa to the joint and all loose bodies remained external to the rotator cuff. A histopathological study revealed the early stages of the development of cartilaginous loose bodies in the synovial lining, suggestive of metaplastic transformation of the synovial tissue [ and ]. Areas below the synovial lining contained a large number of mononuclear cells and a fair number of small blood vessels. This was consistent with chronic inflammation. In the cut-section of the loose body, chondrocytes were visible inside the newly formed cartilage [].\nBy 2 weeks, the wound was well healed and the patient recovered a full range of motion of the affected shoulder. At 1 year follow-up she does not have any recurrence. |
A 54-year-old right hand dominant woman was referred to our services by haematology colleagues with long-standing paraesthesia in her right hand and nerve conduction study-proven severe carpal tunnel syndrome. The patient was taking warfarin (international normalised ratio (INR) 3.2) due to a history of subclavian vein thrombosis in the symptomatic limb. No other relevant medical history was noted. She described symptoms of pain and paraesthesiae along the distribution of the median nerve. The patient was reluctant to consider surgery given her history of thrombosis and requested a trial of steroid injection directly into the carpal tunnel. Direct needle infiltration can involve pain and with the high INR, there was also an associated risk of bleeding. We discussed the use of a blunt-tipped cannula to directly infiltrate the carpal tunnel with steroid and the patient agreed.\nThe median nerve was located by strongly flexing the fingers and thumb (). This manoeuvre allows the median nerve to be identified by rolling it in an ulnar to radial direction. A small blister of local anaesthetic was infiltrated into the volar aspect of the wrist over the proximal wrist crease (; ). A small nick in the skin directly ulnar to the median nerve () allows the cannula to pass underneath the transverse carpal ligament (TCL) and parallel to the nerve and into the carpal tunnel (). The cannula is passed at a 45° angle underneath the TCL and then the angle is further reduced to prevent contact with the median nerve as the cannula is fed distally (). Therefore, blunt piercing of the TCL does not take place but rather the antebrachial fascia of the forearm. Prior to infiltration, the cannula tip should be at its most distal position (). The steroid is slowly infiltrated (10 mg of triamcinolone) into the tunnel and the cannula is withdrawn proximally while infiltrating. The technique is approachable, even with a slight learning curve to it. It can be taught to trainees and most importantly it is comfortable for the patient. The trajectory and length of the cannula is illustrated in . |
A 54-year-old woman with history of migraines presented to ER with worst headaches of life for the past few days. Although she had a history of migraines, this headache differed from her usual migraines. In the ER subarachnoid hemorrhage (SAH) was suspected and a noncontrast head CT was done which was negative for any hemorrhage. As she continued to have severe headache, a lumbar puncture (LP) was done which was negative for xanthochromia, and thus SAH was ruled out. She was sent home with recommendation for over-the-counter analgesics. Following discharge patient continued to experience worsening of headaches associated with nausea, and vomiting. Three days later she presented to the emergency department (ED) with worsening headaches, nausea and hiccups preceding vomiting. Two days later MRI of the brain was done which revealed subdural fluid collections over the bilateral convexities and SAH in the parietal and occipital lobes. There were prominent cortical veins but no obvious CVT. At this point the etiology of the headache was unclear as the head CT during the initial ED visit was negative for any subdural or SAH. Because of venous engorgement, a cerebral venogram was done and was negative for venous sinus thrombosis. A four-vessel angiogram was performed to investigate the cause of SAH which revealed a 1.8 × 1.6 mm right ophthalmic artery aneurysm (). Rupture of this ophthalmic artery aneurysm was presumed to be the cause of SAH and headaches. It was stented and coiled. However, the patient showed no improvement in symptoms over the next few days and a repeat magnetic resonance venogram (MRV) was done which revealed a cortical vein thrombosis on the left side with extension into the superior sagittal sinus. CVT was treated with anticoagulation therapy. The patient's headache, nausea, and vomiting continued. A repeat careful history revealed that she was comfortable lying down and headaches escalated upon standing. These headaches were different from usual migraines in that they were more positional, worse when sitting or standing. Reviewing the initial brain MRI, pachymeningeal enhancement and sagging of the pituitary fossa were noted, and hence SIH was suspected. Anticoagulation was reversed and a blood patch was performed which resulted in complete resolution of headaches, nausea, and vomiting. Follow-up MRI of the brain 3 months later showed complete resolution of the subdural collections, SAH, and CVT (). |
We report here the case of a 63 year-old diabetic woman presenting for diabetic macular edema and cataract. There was no history of previous blunt trauma to the eye. She was on oral hypoglycemic medications for her diabetes. On ophthalmological examination, best-corrected visual acuity was 20/63 in both eyes. The slit lamp examination revealed a bilateral cataract. Intraocular pressure (IOP), measured by Goldmann applanation tonometry was 19 mm Hg in each eye. Discs were healthy and not cupped. There was a severe no proliferative diabetic retinopathy in both eyes. We diagnosed a central diabetic macular edema on her left eye and decided to treat the edema before operating on cataract. A Dexamethasone implant injection was performed on her left eye. The injection technique and execution were unremarkable. The needle was inserted 4 mm away from the limbus in the inferior and temporal quadrant, directly, without scleral path towards the center of the eye. The needle was advanced until the sleeve touches the conjunctiva, and then the implant was injected.\nTwo days after injection, the patient was referred to the department complaining for floaters. On ophthalmological examination, best-corrected visual acuity was 20/63 in the right eye and decreased at 20/125 in the left eye. The slit lamp examination after dilatation revealed the dexamethasone implant confined just behind the posterior capsule (Fig. ). The implant only showed a little mobility and did not exit of this confined localization. Whatever the position of the patient, prone position or seated, the implant was always visible in the pupillary area without slit lamp, and did not change position. Examination of the fundus was unremarkable except for the severe non proliferative diabetic retinopathy. IOP measured by Goldmann was 21 mmHg in the left eye and a preventive combination of timoptol and dorzolamide was prescribed twice a day. The scheduled cataract surgery of the left eye was performed one month after Dexamethasone injection and was unremarkable. There was no acceleration of cataract development, and no evidence of lens traumatism visible during surgery.\nSeven days after surgery, in the left eye, best-corrected visual acuity was 20/32 and IOP at 26 mmHg under treatment. The slit lamp examination after dilatation revealed the absence of dexamethasone implant in the visual axis (Fig. ). |
A 50-year-old woman was admitted to our hospital complaining of severe left lower quadrant pain which began 10 days prior to admission. The patient experienced one episode of hematochezia and a change in stool caliber, both of which first began two months before. The patient also had a history of hypertension and an appendectomy. A physical examination identified tenderness in the right lower quadrant of the abdomen. The laboratory findings, upon initial admission, showed a slight decrease of hemoglobin (11.5 g/dL) and hematocrit (33.1%) level, as well as a marked elevation of the eosinophil count (17.1%). The serum level of the carcinoembryonic antigen (CEA) was within the normal range. An abdominal plain radiography revealed a distension of the bowel loops, which was a sign of ileus. A coronal multiplanar reconstruction image of a CTC demonstrated a concentric and enhancing wall thickening, along with luminal narrowing in the sigmoid colon (), and a low attenuating wall thickening with pericolic infiltration in the ascending colon (). A volume-rendered surface-shaded image of a CTC showed an apple-core shaped, concentric narrowing in the sigmoid colon (). In addition, a segmental fold thickening with a thumbprint-like appearance () was seen in the ascending colon. A virtual endoscopic image of the sigmoid colon revealed a concentric mass (), which led to a narrowing of the colon. An irregular fold thickening and mild luminal narrowing () was also observed via a virtual endoscopic image of the ascending colon. A colonoscopy was performed; however, due to the severe obstruction of the sigmoid colon by the concentric mass, the scope could not traverse the mass and hence, could not attain the ascending colon.\nThe diagnosis of synchronous double primary colon cancers was made preoperatively. The patient underwent total colectomy, and a gross pathologic examination of the resected specimen (), which showed an ulceroinfiltrative mass in the sigmoid colon and another ulcerative mass in the ascending colon. The adjacent folds around the ascending colonic mass were edematous. Histologically, the sigmoid mass was diagnosed as an adenocarcinoma infiltrating the subserosal layer. The ascending colonic wall was heavily infiltrated by eosinophils, in addition to the presence of several parasite worms in the submucosa (). Moreover, diagnostic morphologic characteristics of sections in the intestinal region of the nematode were made (). In addition, a thin external cuticle with no lateral alae and a muscle layer with prominent Y-shaped lateral epidermal cords were observed. The digestive tract of the parasite consisted of a single layer of columnar epithelial cells with no apparent reproductive system. A pathologist confirmed this lesion as anisakiasis. According to the patient's account, she frequently consumed raw marine fish at Japanese restaurants. The final diagnosis of human colonic anisakiasis associated with a carcinoma was based on the morphology of the parasite and the frequent history of raw marine fish consumption. The preoperative findings were not adequate to differentiate between advanced colonic carcinoma and anisakiasis in this case. |
The patient is a 46-year-old male nonsmoker with no other medical problems. Two years prior to his current presentation, the patient was evaluated for right lower quadrant pain. Computed tomography (CT) image showed acute epiploic appendicitis of the cecum and a small fat-containing right inguinal hernia. No further treatment was pursued at that time. He had persistent symptoms, and two years later his primary care provider ordered an ultrasound, which showed a 3 × 3.4 × 3.6 cm complex heterogeneous mass superior to the bladder. Repeat CT scan confirmed a fat-containing right inguinal hernia and a solid mass just below the right inguinal canal, concerning for liposarcoma versus inflammatory process (). The patient underwent mass excision; given prominence of the mass in the retroperitoneum on imaging, the surgeon used a laparoscopic approach and visualized a 4 × 3 cm retroperitoneal mass tracking along the gonadal vessels (). The patient developed severe bradycardia during laparoscopy, and surgery was converted to an open approach. The area of the mass was accessed via a traditional right inguinal hernia incision and by enlarging the internal inguinal ring. The mass lesion was felt to be associated with the intraabdominal portion of the spermatic cord structures and also incorporated a large multilobular cord lipoma. The mass, along with the cord lipoma, was completely excised (). Surgical clips were placed along the resection margin of the retroperitoneal dissection. Intraoperative pathology could not confirm a malignant process so no further resection was undertaken at that time, and a standard Lichtenstein hernia repair was then completed, using polyprolene mesh. After outside consultation, final pathology results revealed an abnormal lobular adipose tissue specimen, measuring 23 × 9 × 3 cm. Within the larger fatty tumor was a well circumscribed firm 4 × 4 × 2.8 cm mass, which contained a high-grade spindle cell malignancy with pleomorphic cells and a high mitotic rate, consistent with dedifferentiated liposarcoma. MDM2 and CDK4 were positive in the well differentiated portions. Complete staging scans subsequently showed no evidence of metastatic disease to the intraabdominal organs or lungs. The deep retroperitoneal margin was positive for tumor cells, and the dedifferentiated portion was closely associated with the intraabdominal spermatic cord, necessitating wider resection margins and right orchiectomy. Three weeks from his index surgery the patient underwent repeat excision of two centimeter circumferential margins on the abdominal wall surrounding the internal inguinal ring, removal of additional retroperitoneal tissue overlying external iliac vessels, and finally a right radical orchiectomy (). The inguinal floor defect was repaired with biologic mesh. Pathology from the second operation revealed a microscopic focus of residual liposarcoma from the excised external iliac tissue, measuring 0.6 mm, 0.5 mm away from the cauterized edge. The remaining orchiectomy specimen and abdominal wall tissue were negative for malignancy. Once recovered from surgery, the patient underwent adjuvant radiation therapy of 25 fractions delivered at 50 Grays (Gy) in addition to a sequential boost of five fractions at 10 Gy. Six month follow-up magnetic resonance imaging (MRI) showed him to be free from disease recurrence. At that time, the patient remained active with biking and kayaking, denying any symptoms suggestive of hernia recurrence. |
The patient was a 16-month-old boy whose parents noticed esotropia and a white pupil in his right eye at 1 year of age. He had visited 3 hospitals before he was finally referred to our hospital. At the first visit, the patient was noted to be esotropic with a deviation of the right eye. Visual acuity was not measurable because the patient was too young. The anterior segment of the right eye was normal by slit-lamp examinations, but a totally detached retina was observed. Because the detached retina was close to the lens, the peripheral retina could not be observed (fig. ). There were no abnormal findings in the left eye. B-mode ultrasonography showed a diffuse, high echo area in the vitreous cavity with no apparent sign of calcification (fig. ). The CT image that had been taken at a previous hospital 1 month earlier showed no evidence of calcification in the right eye (fig. ). The MRI evaluations taken at 1 of the 2 previous hospitals showed high-intensity signals in the T1-weighted images and low-intensity signals in the T2-weighted images in the vitreous body of the right eye. However, high-intensity signals were observed in the T2-weighted images in the same area on the second MRI, which was taken 3 months after the first MRI examination (fig. ). No evidence of a mass was seen in both eyes on the MRIs. He was born full-term without any abnormality. There was no positive family history of any eye diseases, and no systemic abnormality was found.\nSurgery was performed for exudative retinal detachment 2 months after the first visit to our hospital. First, external subretinal fluid (SRF) drainage was performed, and SRF was submitted for a rapid pathological examination, so this was a diagnostic procedure. The examination showed many histiocytes and a small number of epithelial cells but no signs of malignancy. Second, lens-sparing vitrectomy was performed, and the retina was reattached under perfluoro-n-octane. Thus, the fundus, especially the peripheral area, could be seen better, and the clinical characteristics of Coats' disease, including dilated retinal vessels, numerous microaneurysms, and intra- and subretinal exudates became visible (fig. ). Endophotocoagulation was performed on the microaneurysms and the presumably avascular retina near the abnormal vessels. At the end of vitrectomy, 0.5 mg of bevacizumab was injected intravitreally.\nPostoperatively, the posterior retina was reattached; however, the dilated retinal vessels and peripheral subretinal exudates had not improved even after 3 months.\nA reoperation with similar techniques to the first surgery was performed (fig. ).\nThree months after the reoperation, a reduction in SRF and exudates was observed. Thereafter, the condition of the eye remained unchanged during the 11 months of follow-up. |
An 85-year-old woman with no significant past medical history, including colon cancer but urethral caruncle two years ago presented at our office because of painless gross hematuria.\nPhysical examination showed no remarkable findings. Laboratory abnormalities were no pyuria but microscopic hematuria and mild anemia.\nInitial ultrasonography examination (US) revealed a mass, 15 mm in diameter, on the right bladder wall. Subsequent cystoscopic examination detected two papillary tumors in the bladder. This confirmed that the bigger one was same size as that on US on the right upper wall with a peduncle. The second was 9 mm with some micro satellite tumors on the left wall. Both of them were typical papillary tumors morphologically (Figure A, B).\nAn enhanced computed tomographic (CT) scan of the bladder showed two masses. Larger one measuring 16 mm was in the right wall and the other was 9 mm mass in the left bladder wall, with enhancement. Moreover, no other masses or no enlarged lymph nodes were seen except for the bladder.\nOn magnetic resonance imaging (MRI), T2-weighted images revealed a solid, low intensity mass measuring 15 mm and the mass could be limited to the right bladder wall without muscle invasion. No urachal remnant was confirmed in a sagittal section. For the 9 mm mass, MRI revealed that it was limited to the left bladder wall and was also without muscle invasion.\nAt this point, we could diagnose multiple non-muscle invasive bladder cancer. Cold punch biopsy was performed at cystoscopic examination. We performed a biopsy only in the right side tumor. The histology confirmed it to be a villous adenoma. According to this result, a colonoscopy examination was then performed and no neoplastic lesion was found. TUR was performed after preoperative examinations. Each tumor was resected and diagnosed, respectively.\nHistopathology confirmed that the resected tumor on the right wall was a villous adenoma, and the left one was urothelial carcinoma (T1, high grade). Histologically, the former consisted of tall columnar epithelium which formed a villous pattern with vessels and stroma consisting of hypo connective tissues, few nuclear atypia, and few mitotic figures. The urothelial tumor consisted predominantly of papillary growth which formed the structure of the gland (Figure a, b). Immunostaining for cytokeratin (CK) 7, CK20 and Ki-67 confirmed that in villous adenoma, for CK20 the staining was positive, Ki-67 was less than 30%, while CK7 was negative. In distinct contrast, there was very strong positive staining for both cytokeratins moreover, the staining for Ki-67 was quite strong at approximately 70% in urothelial carcinoma.\nThese findings supported a diagnosis of villous adenoma and urothelial carcinoma arising in the bladder. On first follow up on the cystoscopic examination, which was held 3 months later, small papillary tumors were found in the trigone. Based on this finding, TUR was performed for the recurring lesion. The recurring tumor was diagnosed as urothelial carcinoma pathologically. She received adjuvant intravesical immunotherapy with BCG. After BCG therapy, she has been followed by cystoscopic examination for every three months. At the last follow-up, 24 months after surgery, no local recurrences were detected. |
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. |
A 56-year-old lady with diabetes of 6 years reported to us with poor vision OD of 3 months duration. Diabetes was under control; anterior segment findings were normal, with a vision of light perception OD due to vitreous hemorrhage and 6/9 OS due to clinically significant macular edema. Additionally, localized areas of flat retinal neovascularization were seen along the temporal arcades OS. Since she was unwilling for the offered pars plana vitrectomy OD due to financial constrains, we went ahead treating the left eye with scatter laser photocoagulation for nasal half of retina and macular focal photocoagulation with 532 nm Nd-YAG laser (model 1149-675 Carl Zeiss Meditec AG, Jena, Germany). The laser was delivered through Mainster wide field contact lens with a spot size of 200 microns. Power and duration were adjusted to achieve a grey–white burn (200 mW and 200 mS, respectively). The pan retinal photocoagulation remained incomplete in temporal half of retina because of her failure to report back to us.\nAfter 8 months of lost follow up the vision in the lasered eye had dropped to 6/60. Anterior segment findings were within normal limits. There was no evidence of iris or angle neovascularization. On fundus examination apart from the narrowed arterioles and white appearing venules, the macula was found obscured with a large neovascular frond and pre-retinal hemorrhage which appeared to be fed by a solitary and tortuous new vessel, apparently originating from one of the photocoagulation scars nearly 3DD nasal to the optic disc margin []. It traversed the optic disc and finally dissolved into the neovascular frond. In order to detect the origin and nature of the vessel, a rapid sequence fluorescein angiography was performed. The new vessel filled early in the choroidal phase of the angiogram, before the dye appeared in the retinal arteries indicative of its choroidal origin []. A gross delay of arterio-venous transit (3 min) prompted us to look for other systemic associations. Duplex Doppler study revealed total occlusion of left distal common carotid artery and left internal carotid artery by echogenic thrombus deposited on calcified plaques. |
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 |
A 4-year-old boy, born in Zhejiang Province of China, was admitted to Yuying Children's Hospital affiliated to Wenzhou Medical University in June 2014 with complaints of productive cough accompanied with high fever for 5 days. He was the first-born child to unrelated healthy parents, born at 38 weeks of gestation after an unremarkable pregnancy. His birth weight was 3.5 kg, and meconium was passed on the first day of life. The patient had no history of meconium ileus or diabetes mellitus and lacked family history of CF. Tracing back his medical history, the patient was formula feeding but failure to thrive with a weight of 6.8 kg at the age of 8 months and had intermittent diarrhea. For further evaluation of the condition of growth and development, the patient was taken to a local hospital at the age of 8 months, and received complete blood count and liver function tests. And the results indicated liver involvement with slightly elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) with values of 78 and 82 U/L, respectively. The patient suffered from recurrently and slightly elevated ALT levels ranging from 70 to 92 U/L and AST levels ranging from 80 to 90 U/L. In addition, the common etiologies that easily lead to increased levels of ALT and AST were also excluded, such as cytomegalovirus and hepatitis B virus infection. Initially, these symptoms were not paid enough attention by the physicians or parents because the elevated levels of ALT and AST can recover to normal levels automatically without treatment or through the injection of magnesium isoglycyrrhizinate before four years of age.\nPhysical examination for the patient at the age of 4 years showed a weigh of 16.5 kg with a height of 104 cm. The patient had a BMI of 15.3, which was in the 50th percentile for his age. The physical examination also revealed tachypnea and a barrel-shaped chest. The liver was palpable ~2 cm below the right costal margin, and the spleen was palpable about 1 cm below the left costal margin. Clubbed fingers were absent. Laboratory examination indicated increased ALT and AST values of 93 and 92 U/L, respectively, whereas other markers such as γ-glutamyl transferase (GGT), bilirubin, bile acid, fasting blood glucose, albumin, and globulin were within normal limits. Other laboratory investigations including of complete blood count, serum electrolytes, urine, arterial blood gas, amylase, and lipase were normal. The sputum and bronchoalveolar lavage fluid cultures tested positive for Pseudomonas aeruginosa. The Sudan III dye test of fecal matter indicated fat droplet positivity. Pulmonary function tests failed to be performed because of the difficulty at this young age for the child. Additionally, the lack of laboratory facilities caused impracticability of the sweat chloride test. Utilizing computed tomography (CT), we identified severe bilateral paranasal sinusitis () and diffuse fatty infiltration of the liver () in the patient. In addition, the chest CT scan verified the presence of bilateral bronchiectasis and marked peribronchial thickening, especially in the middle and lower lobes (). Extensive sticky and purulent secretion were observed in the lungs by bronchoscopy (). Based on the aforementioned pathological findings, the patient was primarily diagnosed with CF.\nGenetic testing of the patient revealed a homozygous nonsense mutation from a C-to-T substitution (c.1657C > T) in the CFTR gene, which was inherited from both his father and mother (). This single-nucleotide variant changed an arginine at position 553 into a premature termination codon (p.R553X). Notably, CF screening using amniotic fluid of the mother during her second pregnancy also indicated the fetus (sibling) to be a p.R553X carrier.\nOther than hypertonic saline nebulization, high-frequency chest wall oscillation, expectorant administration, pancreatic enzyme replacement therapy, and supplementation with vitamins A, D, E, and K, the child was prescribed intravenous ceftriaxone to address the P. aeruginosa. Respiratory symptoms gradually improved after 7 days of treatment, and he was discharged on the 15th day after admission. Ursodeoxycholic acid was prescribed after confirmation of genetic diagnosis, but taken irregularly by the patient. Therefore, the medicine failed to bring about the desired effect. Remarkably, the patient was later re-hospitalized two times because of pulmonary infections and liver involvement. Liver function test showed that the levels of both ALT and AST ranged from 90 to 120 U/L. Further examination of abdominal CT and ultrasound have suggested the progression of hepatic cirrhosis. The final hospital admission in August 2016 was due to complaint of a stomachache for 3 days.\nAbdominal CT showed a wave-like margin of the liver and many areas of multifocal hypoattenuation in the liver, which indicated the occurrence of hepatic cirrhosis on the basis of diffuse hepatic steatosis (). Simultaneously, the patient presented with pancreatic atrophy and splenomegaly (). In addition, both chest CT scan and bronchoscopy showed the characteristics of bilateral bronchiectasis, marked peribronchial thickening, and extensive sticky and purulent secretion, similar to that observed in 2014 (). The abnormal prothrombin time (PT) and activated partial thromboplastin time were 20.2 s (normal control: 13 s) and 52.6 s (normal control: 36 s), respectively. The international normalized ratio (INR) was 1.85, which confirmed the diagnosis of liver failure. |
A 55-year-old female reported to the Outpatient Department with a chief complaint of a swelling on the right lateral border of the tongue, which she noticed 15 days before. The swelling was of primary incidence and sudden in onset. There was no history of biting the tongue. Furthermore, the swelling was neither associated with pain nor showed any bleeding tendency. There was no difficulty in eating, speaking or swallowing. The history included hypertension for which she was on medication since 2 years. Regional lymph nodes were not positive.\nIntraoral examination revealed the presence of a soft tissue growth, measuring 2 cm in greatest dimension with multilobular appearance []. A provisional diagnosis of irritational fibroma was given. The lesion was completely excised and submitted for pathological evaluation.\nHistopathology of the surgical sample revealed a partially encapsulated lesion with lobular configuration of cribriform nests separated by fibrous septa []. Solid mass of tumor cells was a feature at places. The cribriform pattern and solid areas of tumor cells were in variable proportions. Intermingled tubular pattern was noticed. The glands were found to be fused back to back, and focal papillary and pseudopapillary projections were observed []. The glands of the lesional tissue showed cuboidal cells. The cytoplasm was eosinophilic with focal vacuolation. The nuclei were found to be oval, with granular chromatin. In addition, the overlap of the nuclei was noticed []. Cytologic atypia was mild, and mitotic activity was minimal.\nThe background was filled with mucoid matrix []. Invasive growth pattern with infiltration of muscle was seen at places, but lymphovascular invasion was not evident. The tumor was covered by intact squamous epithelium devoid of dysplasia and ulceration.\nConsidering all the above features and in correlation with the reported literature, a diagnosis of CAMSG was made.\nImmunohistochemical analysis was not performed as the patient could not afford for additional investigative procedures.\nMargins of the excised lesion were resected to obtain clearance and microscopic examination of the same revealed to be clear and free of lesional tissue.\nThe patient is on follow-up. A follow-up of 10 months has shown neither recurrence of the tumor nor metastasis to the regional lymph nodes. |
A 74-year-old man was referred to our hospital for abdominal pain and fever. He had hypertension. He underwent surgery for rectal cancer 7 years ago and again for liver metastasis 2 years ago. He had a recurrence of liver metastasis and peritoneal dissemination a year ago and received chemotherapy (XELOX + bevacizumab). His blood tests showed an elevated white blood cell count of 15,300/mm3. A contrast-enhanced computed tomography (CT) of the abdomen showed fluid collection like an abscess surrounding the gallbladder and hepatic flexure colon (Fig. ). The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery.\nOn laparotomy, the abscess was located outside of the hepatic flexure colon and necrosis was found on the gallbladder after mobilization of the ascending colon. The neck of the gallbladder and near the hepatoduodenal ligament was too severely inflamed to dissect. The hepatic flexure colon was part of the abscess wall, and resection was needed. For diagnosis of peritonitis caused by cholecystic perforation, a subtotal cholecystectomy and right hemicolectomy was performed. The gallbladder was removed at the neck, and the mucosa of the gallbladder neck was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterizing the mucosa. An abdominal drainage tube was placed into the gallbladder bed. The total operative time was 318 min, and the estimated blood loss was 1369 ml.\nOn postoperative day (POD) 6, bile was detected from the abdominal drainage tube. Contrast examination of the drainage tube enabled visualization of the neck of the gallbladder, and bile leakage from the gallbladder stump was revealed (Fig. ). On POD 29, bile leakage was still a problem and an endoscopic nasobiliary drainage (ENBD) tube was inserted. Imaging from the ENBD tube revealed the leakage was from the gallbladder stump (Fig. ). After insertion of the ENBD tube, the volume from the abdominal drainage tube decreased and became less biliary, but a white transparent liquid was continuously obtained 100 ml or more per day. On POD 57, imaging from the ENBD tube enabled visualization of the remnant gallbladder and it revealed that the gallbladder stump and common bile duct were connected. The liquid seemed to be secreted from the mucosa of the remnant gallbladder. We planned to use argon plasma coagulation (APC) to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. The patient was given a full explanation of the procedure, and written informed consent was obtained. All procedures used in this case report were approved by the ethical committee of our hospital.\nAPC cauterization was performed three times on PODs 64, 71, and 82 (Figs. and ). It was a video-assisted procedure using a CHF-U cholangioscope (Olympus Co., Tokyo, Japan), and the diameter of the scope was 5.2 mm. APC was performed with high frequency generator (VIO 300D), an automatically regulated argon source (APC2), and flexible APC probes (all manufactured by ERBE Elektromedizin, Tuebingen, Germany). We used argon gas at a flow rate of 1.5–2 L/min and a high-frequency arc output of 50–60 W. Cholangioscopy showed that the membrane of the remnant gallbladder was widely recognized, and entrance to the cholecystic duct was found in the back. Because the safety of APC cauterization of the gallbladder mucosa had not previously been reported, we initially tried to cauterize the membrane not entirely but randomly at several points. Upon the second cauterization, we found sclerosis in the region that was previously cauterized. There were no complications, and the second region was cauterized all over. A very small region of the membrane was cauterized on POD 82. The abdominal drainage volume decreased over time after removal of the ENBD tube on POD 87 and the abdominal drainage tube on POD 90. He was discharged on POD 95, and 7 months after the surgery, a follow-up CT scan showed the remnant gallbladder was atrophic (Fig. ). |
Our case was a 70-days old male child that has presented with respiratory distress and cyanosis following breastfeeding. Physical examination was normal except the tachypnea, subcostal retraction.\nThe infant's arterial oxygen saturation was 92% at room air. The patient has admitted with initial diagnosis of pneumonia and subsequently an antibiotic therapy has initiated. Initial laboratory investigations were normal ().\nA chest radiography has shown an opacity in the lower part of the left lung. A computerized tomography (CT) of the thorax has revealed a well-defined heterogeneously enhancing mass measuring 45 mm × 40 mm in the lower lobe of the left lung ( and ). There was no pleural effusion. Differential diagnoses has proposed by radiological service has included pulmonary sequestration and congenital adenomatoid malformation.\nThe exploration has revealed a mass measuring 50 mm × 40 mm × 20 mm, involving the lower lobe of the left lung, having a solid appearance. The mass has resected via the left lower lobectomy. There was no spread to the chest wall. After installing chest tube, infant has supported through mechanical ventilation during the post-operative period and has discharged from Pediatric Intensive Care Unit after 4 days with no further problems with respiratory distress.\nMacroscopic examination has consisted of a lung lob measuring 50 × 40 × 20 mm. Cross-section shown a gray-white well circumscribed soft to firm mass with irregular brown border. Histological examination of tissue sections has revealed proliferation of neoplastic cells in lung tissue ().\nThere was atypical proliferation of spindled to fusiform cells have arranged in interlacing long fascicules. The neoplastic cells has shown little pleomorphism, scanty cytoplasm with indistinct cell borders and have separated by interwoven collagen fibers and have arranged in a parallel fashion. Occasioned mitotic were were present (1-2 HPF). The tumor has contained areas of hemorrhage and necrosis.\nThere was prominent lymphoid infiltration throughout the neoplasm. Resected margin and pleural surface were free. The resected tissues have also subjected to immunohistochemistry. The tumor cells were positive for Vimentin but non-reactive for cytokeratin, S-100 protein, a smooth muscle actin, and desmin. The pathological evaluation has revealed the diagnosis of primary pulmonary Fibrosarcoma.\nMetastatic workups including radionuclide bone scan and skull CT examinations have taken after initial surgery. Increased skeletal has up taken of the skull bones have detected by (Tc)-99m-labeled methylene diphosphonate (MDP) (). Skull CT examinations have revealed bone lesions without brain parenchymal disease (). There was a residual tumor measuring 5 × 7 mm dimensions on subsequent chest CT scan after surgery.\nPost-operation adjuvant chemotherapy has planned to treat residual disease and distant bone metastasis. Chemotherapy regimen has included (VA: vincristine 0.025 mg/kg day 1; Actinomycin D 7.5 µg/kg days 1-5). He has received 12 cycles of VA regimen supported with granulocyte colony-stimulating factor (G-CSF). The infant has routinely assessed for liver, renal, cardiac and pulmonary functions through physical examination and laboratory investigations during the chemotherapy treatment.\nAfter completing 12 cycles of VA regimen, there was no any sign of residual tumor on CT of the thorax. During the follow-up, skeletal Tc-99m MDP uptake was normal after completing the chemotherapy treatment.\nFDG-active metastatic lesion was normal on FDG-PET imaging after 12 cycles of VA regimen. He has grown up as a 21-months old boy without any sign of recurrence by radiological and physical examinations and has been off therapy since 18 months. During this time, infant has enjoyed normal growth and development. |
A 2-year-old asymptomatic boy was referred to our clinic because of a continuous murmur that was more evident at the left upper sternal border. No other pathological finding was detected in his physical and chest X-ray examinations. During echocardiographic examination, a small shunt from the proximal descending aorta to the main pulmonary artery was observed and diagnosed as patent ductus arteriosus (PDA). We noted an abnormal, continuous, high-velocity flow into the RA, which was dilated, with a gradient of 75 mm Hg. The left and right ventricles were slightly dilated without any functional loss. An extra-cardiac structure was found to be open to the RA on the posterior lateral side of the inferior vena cave (). Computed tomography (CT) angiography confirmed a tortuous, large, and very long fistula (). No connection was observed between this fistula and the liver or the portal system on both CT and abdominal ultrasonography. This ruled out the possibility of hepatic arteriovenous fistula and hepatoportal fistula. Right and left heart catheterization was performed, which revealed a Qp/Qs ratio of 1.8: 1. Descending aorta angiography confirmed the diagnosis of a very small PDA and unusual tortuous fistula between the descending abdominal aorta and the RA (). A catheter was advanced to the fistula orifice directly from the abdominal aorta. The fistula was selectively engaged using a 5-Fr right Judkins catheter. A hydrophilic guidewire was then passed through the proximal fistula into the narrowing proximal portion of the fistula. This area measured approximately 5 mm. A 7-mm Amplatzer vascular plug IV device was loaded into the catheter, and the distal skirt of the device was placed on the narrow and curved part, 5-6 mm away from the proximal fistula. After device replacement, significant residual flow was observed, and thereafter, a second 8-mm Amplatzer vascular plug IV device was advanced close the residual leak (). A non-selective contrast agent was injected into the abdominal aorta, which revealed occlusion of the fistulous tract with the Amplatzer vascular plug IV device in stable position at the proximal mouth of the fistula (). PDA could not be closed as it could not pass through the catheter. No procedure-related complication occurred. The patient was discharged from the hospital on the second day with acetylsalicylic acid (5 mg/kg/day), and he remained well during the 6 months of follow-up. |
A 37-year-old man presented to the clinic with the chief complaint of intermittent neck pain, with no associated history of recent or past major trauma.\nHe also complained of spontaneous posterior head and occipital pain and stiffness during certain neck movements.\nHis current resting baseline pain level was 3/10 on a Numeric Rating Pain Scale (NPRS) (0, no pain;10, maximal pain) and his worst pain in past 24 h was reported to be 6/10 [].\nHe was concerned because of one recent drop attack episodes after a header during a soccer match with subsequent facial numbness reported during prolonged postures after that incident.\nThe patient had not previously visited a medical physician or physiotherapist for these symptoms; however, he did admit controlling symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and pain killers.\nFrom this episode he described a new spontaneous headache episode and limited neck range of motion (ROM) into right rotation. Additionally, he complained of dizziness during neck extension movements. He denied any night pain and reported no upper limb symptoms. However he described two previous episodes in which he had difficulties in lifting or pulling heavy weights. He wasn’t able to exactly define when the NP symptoms originally started. No other neurological symptoms were reported.\nReview of the past medical history, including a review of symptoms, was performed. The patient did not have any significant past or current medical problems but was noted to not be concerned about the symptoms; however, he was seeking treatment for his occipital headaches that reportedly were getting more frequent and more intense.\nThe physical examination started with visual analysis of posture, followed by active ROM testing of the cervical spine. Assessment revealed decreased active cervical ROM in all six planes, especially during left side bending and right rotation, with a dizzy feeling and facial numbness during sustained neck extension. During active cervical extension and right rotation, the patient also complained of occipital pain. No additional provocative or over-pressure testing were performed.\nCranial nerve testing (CNs II-V, VII-VIII, X-XII) were recorded as normal. There was no nystagmus, facial asymmetry, deviation of the tongue, or slurring of words.\nDue to the absence of CN’ findings and the presence of dizziness and facial numbness during sustained extension, it was reasonable to pursue additional physical examination procedures in order to clear the cervical spine.\nA more comprehensive set of neurological tests was performed. Upper extremity reflexes were found to be bilaterally present and symmetrical. No deficits were noted upon light touch sensory testing in the dermatomes of the upper extremities. However motor strength of the upper extremity muscles, assessed with manual muscle testing, revealed a 4/5 grade bilaterally on the C5 (shoulder abduction) innervated muscle group []. Ankle clonus was not present and Hoffman’s reflex [] was negative. Rhomberg’s test did not reveal any loss of balance [, ].\nDue to the presence of dizziness, facial numbness, focal muscle weakness in one myotome, and a recent drop attack episode, it was thought that his signs were more suggestive of a serious medical pathology, rather than a benign musculoskeletal condition.\nHowever the examination continued with the assessment of the craniocervical structures. A modified Sharp-Purser test [] was performed with the patient seated and the head brought into extension. The palm of one hand is placed on the patient’s forehead while the spinous process of the axis is held by the opposite hand. No discernable movement or reduction was noted but the positioning itself appeared to reduce the severity of the dizziness and facial numbness.\nSeveral components of this patient’s history and physical examination were consistent with a condition for which physical therapy intervention would not have been indicated until more definitive cervical spine diagnostic imaging had been completed. More specifically, the physical therapist was primarily concerned about the possibility of a serious pathology that would preclude the use of manual therapy and/or exercise to craniovertebral region.\nA decision to refer the patient to a neurosurgeon was made at this time. Magnetic resonance imaging (MRI) was deemed necessary prior to initiating any additional examination or treatment procedures.\nA cranial-cervical spine MRI revealed a “basilar impression” in the sagittal T2-weighted image and demonstrated a slight dorsal increase of the odontoid dens with a cranio-dorsal sagittal shift of approximately 6 mm with associated footprint of the anterior surface of the bulbospinal tract (yellow arrow in Figs. and ). However, no areas of altered signal intensity of the medulla were identified. A reduction in amplitude of the foramen magnum was also noted, in which the cerebellar tonsils were wedged. Posterior somatic osteophytes, especially at C3-C4 were evident. A moderate disc protrusion at C3-C4 and at C4-C5 and C5-C6, without spinal cord compression, were also visualized [] (Fig. ). A coronal T2-weighted image demonstrated a cranial-cervical malformation with a subtotal fusion of the atlas with the occipital bone and a hypertrophic right articular process of the dens of the axis (yellow arrow in Figs. and ) resulting in an asymmetrical position of the facet joints (Fig. ). A partial somatic fusion at C5-C6 was also visualized [].\nThe neurosurgeon decided to not evaluate the dynamic stability [] at the time. |
A 71-year-old African-American male presented at an outside hospital with acute renal failure and bilateral hydronephrosis and was found to have bladder adenocarcinoma with invasion of the muscularis propria. His past medical history was significant for nephrolithiasis, prostate adenocarcinoma treated with external beam radiation and bilateral simple orchiectomy 20 years previously, and transurethral bladder resection with bilateral ureteral stent placement at an outside hospital. The patient was a poor historian, and no medical records could be obtained documenting either the histology of his bladder and prostate tumors or the known extent of his disease or the diagnostic and therapeutic procedures undertaken at the outside hospital. He was referred to our institution for evaluation for possible cystoprostatectomy with colonic conduit. A preoperative colonoscopy showed a tubular adenoma but was otherwise negative, and his serum prostate-specific antigen (PSA) level was less than 0.01 ng/mL.\nThe patient was scheduled for surgery, but this was canceled after he underwent CT of the abdomen and pelvis, which revealed pulmonary nodules measuring up to 0.6 cm in diameter in the right upper lobe, left upper lobe, and lingula that were suspicious for metastases. In addition, the CT revealed retroperitoneal adenopathy of the left paraortic and aortocaval lymph nodes measuring up to 1.9 cm in diameter; bilateral hydronephrosis and hydroureter; and diffuse bladder wall thickening with perivesical soft tissue stranding, indicative of invasion by a bladder tumor (). Multiple filling defects were present in the bladder lumen, which were also interpreted as secondary to invasive carcinoma. Positron emission tomography (PET) with an 18F-fluorodeoxyglucose (FDG) tracer showed no abnormal metabolic activity in either the pulmonary or the retroperitoneal masses; however, FDG avidity was observed in a left cervical lymph node and in a 1 cm nodule within the abdominal wall musculature of the left flank (). The primary tumor, at the base of the bladder, measured 11.7 cm in greatest dimension; it also showed hypermetabolic activity and appeared to invade into the prostate.\nUltrasound-guided fine needle aspiration was attempted on the cervical lymph node, but insufficient tissue was obtained, so CT-guided core biopsy was performed on the abdominal wall mass. Imprints of the biopsy specimen showed crowded clusters of tumor cells with high nuclear/cytoplasmic ratios and prominent, small nucleoli (). Histologic sections of the biopsy showed malignant glands lined by intestinal type columnar cells and occasional goblet cells, with necrotic debris in the lumina, infiltrating through skeletal muscle (). The glands were surrounded by desmoplastic stroma and acute and chronic inflammatory cells. Immunohistochemistry (IHC) revealed that the malignant glands were positive for CK7, β-catenin (membranous/cytoplasmic staining pattern), caudal-type homeobox transcription factor 2 (CDX2), and α-methylacyl coenzyme A racemase (AMACR) (Figures –) and negative for CK20, p63, PSA, and prostate-specific acid phosphatase (PSAP). These findings were interpreted as being consistent with metastatic adenocarcinoma; given that the patient had a concurrent vesical tumor, his bladder adenocarcinoma was considered the primary site. Colonic adenocarcinoma with local extension to the bladder was deemed a less likely diagnosis, since there was no evidence of a primary colonic tumor; however, prostate adenocarcinoma with local extension was a consideration given the patient's past medical history. Neither of these possibilities could be excluded based solely on histology and IHC.\nIn lieu of surgery, the patient was scheduled for 8 cycles of gemcitabine/cisplatin. After completing 4 cycles, he experienced renal failure and was admitted to an outside hospital in Vicksburg, MS, where he underwent exchange of his ureteral stents and antibiotic therapy for purulent cystitis; chemotherapy was withheld while this treatment was taking place. Although repeat CT and PET scans initially showed that his disease was stable, a CT performed 3 months after his last cycle of chemotherapy showed bilateral hydroureteronephrosis, heterogeneous enhancement of the left kidney with perinephric stranding and fascial thickening, and circumferential thickening of the wall of the left ureter with periureteral fat stranding. A soft tissue mass was identified in the hilum of the left kidney, suggesting a renal hilar neoplasm with superimposed pyelonephritis and ureteritis, and the patient was admitted and given intravenous antibiotics. Urine culture from an earlier clinic visit grew coagulase-negative Staphylococcus; however, inpatient cultures were negative. Urology was consulted, and based on his symptoms it was determined that he most likely did not have pyelonephritis, as he lacked the characteristic clinical triad of flank pain, leukocytosis, and fever. He was discharged home in stable condition.\nEleven days later, the patient presented to an outside hospital with urosepsis, renal failure, and hypotension and was found by CT to have right-sided hydronephrosis and a hemorrhagic left renal mass, in keeping with previous imaging findings at our institution. A nephrostomy tube was placed in the right kidney. Cystoscopy was performed, and tissue was obtained from the bladder mass that was interpreted as moderately differentiated, partially necrotic adenocarcinoma. The tumor was positive for cytoplasmic β-catenin; nuclear staining could not be assessed. CDX2 and villin immunostains were also positive; thrombomodulin was positive in tumor vessels but not within the tumor cells themselves. These findings were consistent with the staining pattern we observed in the metastatic tumor tissue. During the course of the patient's hospital stay, his renal function and hypotension continued to worsen, leading to cardiopulmonary arrest. Despite the resuscitative efforts, he ultimately expired eight days following admission. |
The patient is a 72-year-old male with a history of ACC of the right nasal lacrimal duct treated with orbital exenteration followed by adjuvant radiotherapy of 54 Gy in 27 fractions followed by a stereotactic radiosurgery boost to the right supraorbital dura of 13 Gy 16 years prior to this presentation. Five years after his initial surgery, he had recurrence of the ACC to a right neck level II lymph node, and he subsequently underwent radical resection with adjuvant radiotherapy. His oncologic history is also significant for B cell lymphoma and prostate cancer, which were treated with chemotherapy and radiation, respectively and he was maintained on prophylactic warfarin because of a mechanical heart valve.\nThe patient presented to the ED with uncontrollable bleeding from his right orbit. An estimate of blood loss based on a comparison of the patient’s current hemoglobin to his baseline was three units. Warfarin was reversed, and the patient began receiving a transfusion of packed red blood cells. On examination, the orbital defect exposed a small area of dura and the right nasal cavity. A CT scan was obtained that showed no intracranial bleeding (not shown). Temporary hemostasis was obtained in the ED with a plug of bone wax (Figure ). He was emergently transferred to the hybrid operating room (OR) suite.\nIntervention\nThe patient was intubated and general anesthesia was induced upon arrival. Somatosensory evoked potentials (SSEP) and electroencephalography (EEG) were monitored. Transfemoral digital subtraction angiography (DSA) of the right internal carotid artery (ICA) demonstrated a 3 mm bleb on the medial surface of the cavernous right ICA representing a pseudoaneurysm (Figure ). A second 5 Fr diagnostic catheter was placed in the left ICA via a left transfemoral approach. A 5000-unit bolus of IV heparin was administered, and activated clotting time (ACT) values were kept greater than 250 s for planned BOT and coil embolization. A 7 mm x 10 mm balloon (Transform, Stryker Neurovascular, Inc., CA, USA) was advanced into the horizontal petrous portion of the right ICA (Figure ). A BOT was performed with additional hypotensive challenge (20% below normal mean arterial pressure for 10 minutes) during which SSEP and EEG remained unchanged. Excellent cross filling across the anterior communicating artery was noted (Figure ).\nThe bone wax was removed from the orbit and angiography of the right ICA was performed, which demonstrated active extravasation from the pseudoaneurysm (Figure ). The site was packed again, and the decision was made to sacrifice the right ICA with coils (Target coils, Stryker Neurovascular, Inc., CA, USA) (Figure ). SSEP and EEG remained stable and postoperative angiography demonstrated excellent collateral filling of the right anterior circulation.\nPostoperatively, the patient was extubated in the ICU and had no further bleeding. He developed no neurological deficits and resumed anticoagulation. At one month and one year postoperatively, he had no further arterial bleeding. No evidence of recurrence of ACC was found by positron emission tomography; however, about nine months after intervention, he developed cerebrospinal fluid (CSF) leakage from the periorbital dura and underwent surgical repair. Over a year after treatment, the patient entered hospice care while undergoing treatment for recurrent extracranial lymphoma and expired. |
A 14-year-old boy presented to the emergency department (ED) after sustaining a twisting injury to his right ankle while playing basketball. Clinical evaluation showed significant swelling and deformity around the ankle. There were no neurovascular deficits. He was unable to bear weight. Radiographs showed a displaced distal tibia SH type II physeal fracture and a transverse fracture of the fibula with valgus angulation ().\nAn initial attempt at closed reduction performed in the ED under conscious sedation was unsuccessful; the fracture could not be moved from its displaced position after sustained traction and manipulation (). The patient was taken to the operating room, and a second attempt at closed reduction was performed with the patient under general anesthesia and muscle relaxation. Again, the fracture could not be moved from its displaced position. Tendon interposition was suspected and open reduction of the fracture was performed by making an incision on the anteromedial aspect of the distal tibia centered over the metaphyseal spike. The fracture site was exposed, and the posterior tibial tendon was found interposed within the physeal fracture site. The tendon was bowstringing around the metaphyseal fragment from the proximal-posterior to distal-anterior direction between the metaphysis and epiphysis (). Traction on the distal fragment increased the tension and worsened the bowstringing of the tendon. Hence, the traction was released and the interposed tendon was retracted out from the fracture site. This allowed the fracture to be reduced without difficulty. The tendon had mild fraying but did not show any laceration or tear (). The fracture reduction was confirmed on fluoroscopic evaluation, and two 4 mm partially threaded cannulated screws were used for fracture compression and fixation across the large Thurston-Holland metaphyseal fragment ().\nPostoperatively, the leg was immobilized in a boot and nonweight bearing with crutches was used for 4 weeks, followed by weaning of the boot and gradual transition to full weight bearing. The patient was released to full activities at 4 months. Eighteen months postinjury, he had no pain or deformity, had full ankle range of motion, and had no limitations with sports. The radiographs showed complete healing of the fracture with no deformity and closing physis (). |
We describe a 67-year-old man who was referred from the oncology department due to iris changes which were noted while he was being worked up for metastatic melanoma with unknown source. The patient’s last eye exam had almost been 10 years earlier, and there was no documentation of iris abnormality. The patient himself did not notice if anything was wrong with the eye. His past medical history was also significant for skin basal cell carcinoma. His past social history revealed alcohol and cocaine use. The infection work-up including syphilis was negative. On exam, vision was 20/60 in the right eye and 20/50 in the left eye. Loose iris strands were noted on both eyes, predominantly the left eye. Bilateral cataracts were noticed with narrowing of the angles. Intraocular pressures were normal. On gonioscopic exam, the angle was obscured by iris strands in one quadrant, the rest of the angle seemed narrow. This was confirmed by anterior segment OCT (Zeiss Meditech) (Figure 1 ). The patient was offered to have cataract surgery in his worse seeing eye first. However, he missed multiple appointments, and when he presented one year later, his vision was reduced to bare light perception in the right eye and 20/150 in the left eye, with IOP measuring 45 mm Hg in the right eye and 12 mm Hg in the left eye. The angle was completely closed in the right eye with a large mature cataract. This time, further iris splitting was noted in addition to visible iris vessels on the right (Figure 2 ). Advanced nuclear sclerosis and posterior subcapsular cataract were noted on the left eye as well. This time, the patient agreed to cataract surgery on the left eye only. Axial length was shorter than normal, 22.41 mm and 22.49 mm, right and left eye, respectively. The patient underwent successful cataract surgery on the left eye. Vision improved to 20/20 within one month of surgery. The iris strands obtained during the cataract surgery were sent for a pathologic exam. No atypia, inflammation, or reactive changes were found in the specimen. |
A 65-year-old man (height 155 cm, weight 47 kg) was diagnosed with rectal cancer and was scheduled to undergo open colectomy. He had a medical history of limited-disease small cell lung cancer with tracheal stenosis; a tracheal stent procedure had been performed 8 years ago (Fig. ). During the preoperative assessment, a computed tomography (CT) scan revealed that a part of the tracheal stent placed between the main bronchus and the main right bronchus had penetrated the esophagus (Fig. ). Endoscopic examination of the upper digestive tract revealed the part of the tracheal stent in the esophagus (Fig. ). The patient did not experience recurrence of lung cancer or show symptoms of narrowing of the respiratory tract.\nWe needed to plan the anesthetic management of this patient, especially the intraoperative respiratory management. We planned general-epidural anesthesia via spontaneous breathing because we were concerned that an increase in the airway pressure due to positive pressure ventilation may cause mediastinal emphysema.\nAn epidural catheter was placed into the epidural space between L3 and L4 and 10 ml of 0.75% ropivacaine was administered to induce analgesia under level Th6. After preoxygenation with 100% oxygen, general anesthesia was induced rapidly using 0.025 mg of fentanyl and 60 mg of propofol, but without the use of a muscle relaxant, which resulted in the loss of consciousness. Spontaneous breathing was maintained and anesthesia was deepened using 4% sevoflurane via laryngeal mask airway (LMA) insertion (ProSeal type, #4) without manual bag mask ventilation. Anesthesia was maintained using 2% sevoflurane and intermittent administration of 0.375% ropivacaine through the epidural catheter.\nAn open colectomy was performed in the lithotomy position. The head-down position does not allow for the maintenance of adequate ventilation; therefore, a pad along the lower part of the back to straighten the lower abdomen above the pelvis was used for support during the operation. We did not insert a gastric tube because a penetrating wire was present in the esophagus. During the operation, enough spontaneous breathing was maintained as respiratory frequency was about 16 times and tidal volume was about 250 ml. The operation was completed safely, and the LMA was removed at the end of the procedure without any complication.\nIn this case, we were hesitant to place a tracheal tube through the fractured tracheal stent. Moreover, endotracheal intubation posed a risk of distal movement of the stent and difficulty with extubation owing to interaction between the material of the stent and the endotracheal tube. Furthermore, controlled positive pressure ventilation may have caused air leakage into mediastinal space through the penetrated part of stent. Hung et al. reported the administrations of general anesthesia in a patient with tracheal stent and suggested that the LMA can help maintain a patent airway without harming the trachea or the stent, thus enabling safe induction of general anesthesia []. Davis et al. suggested the use of a supraglottic airway device such as the standard LMA or Proseal™ LMA is the safest option when there is no risk of aspiration as it obviates the need for tracheal intubation [].\nThe patient’s airway remains patent after placement of LMA, and the tracheal stent remains untouched, thus reducing tracheal trauma. LMA also helps maintain the patient’s spontaneous respiration. The LMA provides good anesthetic maintenance and airway patency in patients with tracheal stents undergoing operation under general anesthesia.\nThe complications of airway stenting occurring immediately or a long time after stent deployment include migration, airway obstruction, retention of secretions with airway obstruction, cough, infection, sputum retention, granulation of tissue at the proximal or distal end of the stent, metal fatigue, corruption, or respiratory infections []. Stent fracture is an uncommon complication, but metal stent fracture had been reported []. Zakaluzny et al. discussed that stent breakage requires urgent removal of the stent to minimize the risk of damage to the upper airway, stent collapse, or subsequent distal fragmentation of the metallic pieces that could cause inflammatory lung disease []. In our case, we retained the tracheal stent because it was composed of metal. Although a metal stent can be relatively safely detained even for advanced stenosis, withdrawal after long-term detention is difficult because of the stent lumen infiltration. Compared with silicon stents, the prolonged use of metal stents is observed less often because their removal is more difficult. Lunn et al. reported serious complications such as airway obstruction, tracheal rapture, and death during metal stent removal [, ]. It is important to carefully consider the risk of removal of metal stent and the necessity.\nThe patient has been followed up for 2 years with no respiratory complication. |
A 70-year-old male presented to the emergency department with complaints of sudden onset of severe pain in his left hip while getting up from bed. He was unable to bear weight on his affected lower limb since the episode. The patient had undergone left-sided cemented bipolar hemiarthroplasty for subcapital neck femur fracture 3 weeks ago (). On examination, there was well-healed surgical scar over posterolateral aspect of hip showing no sign of infection. His left lower limb was shortened, adducted, and internal rotated with diffuse severe tenderness over anterior and posterior aspect of his left hip joint without any neurovascular deficit. Pelvis and hip radiographs were ordered in suspicion of dislocation of prosthetic joint. The radiographs reveal posterior dislocation of non-modular bipolar prosthesis (). The patient was taken for urgent closed reduction under general anesthesia. During closed reduction with Allis maneuver under image intensifier, sudden clunk was felt and limb length and alignment improved, though not to the full. Image intensifier images revealed separation of outer head of the bipolar prosthesis from inner head stem assembly. The inner head slipped and got reduced in acetabulum while the separated outer head of prosthesis was floating outside the acetabulum (). The procedure abandoned and the patient and his attendants were counseled for revision surgery in the form of hemiarthroplasty or total hip joint replacement in elective setting.\nThe hip joint was approached from posterolateral approach utilizing the previous surgical scar. The short external rotators and capsule were found to be torn. The prosthesis (INOR Inc., Mumbai, India) outer headliner assembly, which was floating posterior to acetabulum, retrieved and examined. There was no sign of erosion of polyethylene liner or damage to locking mechanism at outer head (). The inner head found to be intact but the stem found to be loose as there was debonding of cement at bone-cement interface. The anteversion of stem found to be around 10° though there was no fracture around acetabulum or proximal femur.\nWe noticed that there were focal cartilage loss and inferior osteophyte in acetabulum; hence, a decision of total hip joint arthroplasty was done. The bipolar stem was removed and total hip arthroplasty was done with cemented acetabular ZCA cup (Zimmer Inc., Warsaw IN, USA) and cemented femoral components with CPT stem (Zimmer Inc., Warsaw IN, USA).We used extended offset femoral stem to restore adequate tension in hip joint abductors and increased femoral anteversion to 15°and kept acetabular cup anteversion around 20°making combined anteversion angle around 35°. We repaired joint capsule and short external rotators meticulously for the prevention of recurrent dislocation. Post-operative radiographs were satisfactory ().\nThe patient was mobilized full weight-bearing on the 2ndpost-operative day and advised to use hip abduction brace at rest for 8 weeks post-surgery. The patient was followed up at 6 weeks, 3 months, at 6 months and 1 year post-surgery and had no complication in meantime. |
An 89-year-old Caucasian woman presented to the emergency department with a one day history of acute onset abdominal pain in the upper right quadrant, with nausea and malaise. On presentation her vital signs were within the normal range and she had no fever. Her medical history included an abdominal rectopexy, retropubic bladder suspension surgery and an abdominal hysterectomy, all performed more than two decades ago. Physical examination showed an abdomen with a scar after median laparotomy with a palpable tender mass in the upper right quadrant with positive Murphy's sign and rebound tenderness. Laboratory blood tests revealed a leukocytosis of 22.7 × 109/L, C-reactive protein of 48 mg/L and normal kidney and liver function tests. Abdominal ultrasonography and computed tomography (CT) scan showed a clearly enlarged gallbladder with a thickened wall of 7 mm (Figure ), with fluid supra- and sub-hepatically (Figure ). Free air within the gallbladder wall was not seen. She was admitted to our hospital with the diagnosis of acute cholecystitis.\nPercutaneous drainage of the gallbladder was considered because of her age and comorbidity, but because of her rapid clinical deterioration we decided to perform a laparoscopic cholecystectomy instead. Laparoscopy was performed and revealed a strongly hydropic and fully necrotic gallbladder, with necrosis extending into the cystic duct (Figure ). The gallbladder was not embedded in the liver, but was hanging from the cystic duct and artery. Further exploration showed a two-fold torsion of the gallbladder around the cystic duct (Figure ). A cholecystectomy was performed. (See Additional file for further imaging of peroperative findings). As the critical level of safety was obtained, with both the cystic and hepatic duct clearly visible, leaving a drain was not considered mandatory. Pathologic examination revealed the gangrenous aspect of the entire gallbladder, extending into the cystic duct. No gallbladder stones were found in the specimen. Postoperatively the patient recovered well and she was discharged from the hospital on the fifth postoperative day. |
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. ). |
The patient is a 25years old male marble layer who presented to the eye clinic of the University of Benin Teaching Hospital on the 4th of April 2006 with a history of trauma and poor vision in the right eye of two weeks duration. He was using a machine to cut marble when a piece flew into his right eye resulting in severe pains, tearing and loss of vision. He used some traditional medication without relief.\nHe is not a known diabetic or hypertensive. There was no previous history of trauma to the eye or any other ocular disorder. He has no known drug allergy. He does not smoke but drinks alcohol occasionally.\nHis visual acuity was light perception in the right eye and 6/5 in the left eye. In the right eye, the conjunctiva was injected, there was a sealed corneal laceration of about 2.5mm representing the entry point of the foreign body at about the 2 o'clock position, the anterior chamber was shallow and there was some lens matter inferiorly. The pupil was mid-dilated, irregular, with posterior synechiae at about the 2 o'clock position. The lens was opaque. The fundus could not be visualized. The left eye was normal. The intraocular pressure, measured with the pulsair non-contact tonometer was 10mmHg in the right eye and 16mmHg in the left eye. An impression of sealed corneal laceration, traumatic cataract and retained intraocular foreign body in the right eye was made. Ocular ultrasound scan showed echogenic debris within the vitreous humour in the right eye suggestive of a vitreous hemorrhage and an acoustic shadow suggestive of a foreign body in the posterior aspect of the right eye (). He was placed on topical steroids to suppress inflammatory reaction and topical cycloplegics to rest the eye.\nHe was subsequently booked for right extracapsular cataract extraction with a posterior chamber intraocular lens implant under local aneasthesia with the aid of an operating microscope. During the surgical procedure, the cornea rapidly became cloudy after anterior capsulotomy with loss of the surface epithelium of the cornea. The lens matter had a brownish colour and the cornea had a brownish tinge. Despite irrigation of the cortical lens matter with balanced salt solution, the posterior chamber intraocular lens could not be inserted because of poor visibility. The incision was sutured. He was given subconjunctival injections of dexamethasone, depomethyl prednisolone acetate and gentamicin, and chloramphenicol ointment applied before the eye was padded.\nIn the first postoperative day, the visual acuity in the right eye was light perception and the corneal haze had cleared a bit. Slit lamp examination showed a defect in the posterior capsule through which the vitreous haemorrhage could be visualised |
The patient is a 83-year-old man with an history of noninvasive urothelial carcinoma 6 years prior to presentation previously treated with TURBT and an induction course of intravesical of BCG therapy. He presented to the spinal cord injury unit after a cauda equina syndrome developed following lumbar spine surgery. Due to his previous UC history, the standard surveillance of urothelial carcinoma was used to investigate for recurrence. A cytology was obtained and showed atypical cells in groups. The initial office flexible cystoscopy demonstrated a noninvasive appearing UC covering approximately 50% of his pendulous urethra with frondular lesions. The prostatic and membranous urethra were spared. The patient was taken to the operating room for cystourethroscopy under anesthesia, biopsies and upper urinary tract evaluation. The upper urinary tracts were negative for lesions on retrograde pyelogram and bladder and urethral biopsies were obtained with similar pathology as seen on office cystoscopy. On pathology, the biopsies showed low-grade superficial urothelial carcinoma (pTa) with a small focus of high-grade carcinoma []. Surgical options were then discussed and the patient wanted a bladder sparing minimally invasive surgery. Therefore, the patient was taken back to the operating room for a second look TURBT and a staged fulguration of urothelial carcinoma with the holmium laser [Figures and ]. Using holmium:YAG laser vaporization through a 21-Fr cystoscope, the lesions in the pendulous urethra were ablated using a 600 μm fiber with settings of 8 Hz and 1.0 Joules (8 Watts). Only one half of the urethra was treated for fear of urethral stricture. A total time of 20 minutes was taken for the procedure with minimal discomfort postoperatively. Mitomycin C was instilled (40 mg in 20 cc of sterile water) for 1 hour immediately after the procedure. This was done due to his history of UC in the bladder as well as cells from the ablation may have been introduced into the bladder with the irrigation fluid. A 22-F Silastic Foley catheter was placed and continued for 4 days after surgery. We subsequently performed the second stage of the procedure which included treatment of the other half of the lesions after one month once an office cystoscopy revealed there was no urethral stricture formation. After the second therapy he elected for BCG therapy and he has now been under surveillance for 18 months without cystoscopic evidence of a urethral recurrence and no formation of urethral stricture []. |
A 76-year-old woman presented with pain and locking of the right knee. She had attempted to sit on a chair fitted with casters and it had slid away behind her, resulting in her almost falling. She had suddenly extended her knee to avoid falling, at which point it locked and she became unable to move it. On initial examination, the right knee was locked at an angle of 80° and could not be moved voluntarily. Local findings comprised displacement of the right patella to below the knee. There were no signs of trauma such as skin abrasions or subcutaneous hemorrhage. Plain lateral radiography of the right knee showed that an osteophyte on the superior pole of the patella had become impacted in the femoral trochlea and the patella was displaced inferiorly (). There was no rotational abnormality of the patella. MRI clearly showed that the osteophyte on the superior pole of the patella was impacted in the femoral trochlea (). The insertion of the femoral quadriceps tendon was not detached, and there was no rupture of the tendon. The patient suffered from osteoporosis, with a low bone mineral density of 0.583 g/cm2 (T score −2.5 SD) prior to the injury. After injection of 0.5% xylocaine 20 mL into the right knee joint, the superior pole of the patella was pressed downward while the knee was gently extended. The right patella was reduced by this procedure, and locking of the right knee was released. Patellar reduction was confirmed on plain lateral radiography (). Insall-Salvati ratio was 0.9. There was no finding of patella baja. The osteophyte on the superior pole of the patella was completely fractured, and the choice was made to use conservative treatment as it was believed that recurrent dislocation was unlikely. The right knee was immobilized in the extended position with a plaster slab for 3 weeks after reduction. Range of motion training was started from week 4, and full weight-bearing walking was permitted from week 5. Range of motion at 21 months after injury was 0° extension and 130° flexion, and there has been no recurrence of inferior dislocation of the patella. The patient has followed an uneventful course and is ambulatory. |
A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.\nHer history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.\nEndemic Zika was identified in Haiti per the CDC early in the epidemic []. When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy []. She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.\nThe patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.\nThe baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment. |
A 60-year-old male with apical variant hypertrophic cardiomyopathy and history of dual-chamber implantable cardioverter defibrillator 18 months before, nonsustained ventricular tachycardia and primary prevention of sudden cardiac death was admitted with New York Heart Association class III dyspnea on exertion that was refractory to medical therapy. He underwent an apical myectomy procedure along with left and right atrial radiofrequency maze procedures [] for treatment of recurrent atrial fibrillation.\nPrior to surgery, his dual chamber Medtronic Secura D224DRG was interrogated, and the device and lead function were found to be functioning normally.\nThe patient underwent successful cardiac surgery. A device interrogation was performed on postoperative day no. 1 while the patient was in atrial fibrillation/flutter, and atrial lead sensing was observed to be normal. For control of the atrial fibrillation, amiodarone 400 mg P.O. twice daily was initiated and metoprolol increased from 50 mg twice daily to 75 mg twice daily.\nTwo days following the surgery, the rhythm converted to sinus, and continuous telemetry revealed the following (). The first and ninth beats are paced atrial beats with adequate capture. The pacing spike to the onset of p wave is prolonged (approximately 80 msec) suggesting conduction delay from the pacing site to atrial depolarization. Although a pacing spike is seen prior to the second p wave, due to the pacing site to atrium conduction delay, a native p wave emerges before the paced captured p wave could occur. The fourth beat shows atrial undersensing with an atrial pacing spike after a native p wave. Atrial undersensing is also observed on the 6th, 10th, 12th, and 14th beats. Also note that ventricular safety pacing occurring on beats 4 and 6. 12 lead ECG is shown in .\nA subsequent device interrogation was performed. Native p waves were sensed late, such that atrial sensing occurred 120 ms after the p wave occurred. p wave amplitude was 3.1 mV (). Interestingly, sensing of an atrial premature complex (APC) was different from sinus sensing in that there appeared to be less conduction delay, likely representing an origin with a closer location or more direct conduction pathway to the pacing lead.\nThreshold testing was also performed and found to be normal. A portable chest radiograph was obtained and accounting for differences in technique showed no evidence of atrial lead macrodislodgement compared with preoperative location in the area of the right atrial appendage.\nBecause pacing requirements were minimal and ventricular pacing, sensing, and defibrillator thresholds adequate, the device mode was set to VVI at 40 bpm to allow for back-up pacing if needed. |
A 29-year-old woman had a chief complaint of chronic abdominal pain for one year and she experienced continuous weight loss of 5 kg over 2 mo prior to her admission.\nThe patient had chronic abdominal pain for 1 year and she experienced continuous weight loss of 5 kg over 2 mo prior to her admission.\nThe patient had undergone ovarian cystectomy, appendectomy, and subtotal hysterectomy for uncontrollable hemorrhage according to her past medical history.\nNo special family history was provided except that her mother was diagnosed with squamous cell carcinoma of the vulvar epithelium and the disease was cured according to her description.\nUpon physical examination, a round mass approximately 7 cm in diameter could be palpated in the right upper abdomen and the mass was smooth, pushable, hard, and indistinguishable from adjacent tissue. Other detailed basic information is displayed in Table .\nLaboratory data demonstrated normal liver function and routine blood test results (Table ). The tumor marker results showed that the level of alpha-fetoprotein was 9850 ng/mL and that of carcinoma embryonic antigen was 0.55 ng/mL.\nAbdominal computed tomography (CT) and magnetic resonance imaging examinations suggested a mass of unknown pathological nature located in segment VIII and it was between the first and second hila and the margin of the lower segment of the right liver lobe (Figure ). The anterior wall of the gastric antrum was unevenly thickened. Positron emission tomography/CT (whole body) examination showed two main points: (1) The anterior wall of the gastric antrum was unevenly thickened, and fluorodeoxyglucose uptake was increased, which was consistent with the manifestations of gastric cancer; and (2) A mass shadow was located at the first and second hepatic hila and the lower right lobe of the liver. As increased fluorodeoxyglucose uptake is a sign of malignancy, whether the mass was liver metastasis or primary liver cancer remained to be identified. Electrocardiograph, chest digital radiography, and CT of the lower abdomen and pelvis showed no obvious abnormalities. |
A 37-year-old male with no significant medical history was brought in by his father with complaints of worsening mental status and functional decline for a couple of months. According to the father, his son had been behaving strangely, and was socially inept, indifferent to his surrounding, lacked attention, did not participate in conversation and was unsteady. On examination, the patient appeared alert, awake and oriented but disheveled and lack of attention. Motor, sensory and cranial nerves were grossly intact except for slight weakness of left arm and leg. With inertia of the left hand on nose to finger test, he had unsteady gait with decreased postural control. He reported to have been smoking about 3 g of marijuana since the age of 12 every day and also had a history of cigarette smoking.\nHis vitals including initial lab values were all normal. A urine drug screen was positive for cannabinoids. Computed tomography (CT) scan of head showed mild parenchymal volume loss and prior chronic ischemic changes in the periventricular region. Subsequently, magnetic resonance imaging MRI of head was done () that revealed multiple foci of abnormal signal intensity in the right cerebral hemisphere and a small focus in the left parietal region. There was absence of blood flow in the region of the internal carotid artery (ICA) bilaterally. The possibility of occlusion and/or dissection of ICA were considered and CT angiogram of the head and neck was recommended for further evaluation.\nCT scan angiogram of head and neck (, ) showed complete occlusion of ICA bilaterally. The patient was transferred to stroke unit and was started with dual antiplatelets aspirin and Plavix. Although overall status remained the same, his mental lucidity gradually started to improve. Extensive workup was done to find the cause of the ICA obstruction. He had normal lipid profile, hypercoagulability workup and vasculitis panel. Screening for human immunodeficiency virus (HIV), heavy metals, Wilsons and hematochromosis showed negative results and no atrial fibrillation was detected on telemetry. He further underwent transesophageal echocardiography (TEE) which revealed no cardiac clots.\nHe was diagnosed to have acute and chronic ischemic stroke due to gradually progressing thrombotic occlusion of ICA bilaterally secondary to atherogenesis. After 8 days of hospitalization, with joint decision of neurology and vascular he was started on anticoagulation with heparin drip as a bridge to coumadin. After he attained the international normalized ratio (INR) of 2 he was discharged to inpatient rehabilitation unit. |
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. |
In a motor vehicle accident, a 42-year-old man sustained several injuries: a Gustilo type IIIC open fracture of the right tibia; an intertrochanteric fracture of the right femur; an uncomplicated left tibial and fibular fracture; and a calcaneal skin defect on his left side (Figs. , , , ). He had an ischemic limb due to an arterial injury at the ankle on the right side.\nThe patient was taken immediately to the operating room and anaesthetised. All devitalized bony and soft tissues were excised on the side of the open tibial fracture. The tibial bone defect was nearly 25 cm after debridement, and the remaining two ends of the tibia were stabilized with a unilateral fixator. Two Schanz pins were placed in the proximal part of the tibia, and one each was placed in the distal tibial end and in the talus. The tibial nerve was compressed but intact at the ankle. At the same level, the posterior tibial artery was also compressed and thrombosis detected in a 1-cm segment. The thrombotic segment was excised and end-to-end primary arterial re-anastomosis was performed to revascularize the distal lower extremity. It was decided to manage the bone defect by transferring the ipsilateral fibula which was entirely intact but for a simple fracture at the level of the ankle joint.\nThe fibula was exposed and then osteotomized proximally just distal to the neck. The length of the fibula transferred was nearly 30 cm. To facilitate transfer of the fibula, a careful dissection was performed. The attached soft tissue and peroneal arterial supply were protected. After preparation of the remaining tibial ends, the vascularized fibula was transferred medially and placed between the two ends of tibia. During that transfer, placement of the unilateral fixator was adjusted to obtain gross overall alignment (Fig. ). The soft tissue defect was covered using remaining undamaged skin with additional skin grafting for uncovered areas. There was no postoperative infection.\nThe other injuries were treated as follows: proximal femoral nailing for the intertrochanteric fracture; intramedullary nailing for the left tibial fracture; and placement of a propeller flap for the calcaneal skin defect. These were performed at 2 weeks once it was declared the right side had no evidence of infection. At the end of the third week, a valgus deformity of the transferred segment of fibula was corrected by realigning the distal Schanz pins under fluoroscopy.\nAt review at 5 months, during which the intervening follow-up period was without complication, the state of bone union was evaluated and the patient was encouraged to engage in partial weight bearing with crutches. At 8 months, the patient was able to walk with a single crutch and without crutches at 14 months. At the 2-year follow-up examination, hypertrophy of the fibula was apparent (Fig. a, b). Complete union was achieved, and the patient did not experience refracture, infection, or permanent pain. Sensation in the sole of his affected foot had recovered and he did not require additional pain medication. There was a limb length discrepancy of 2.5 cm. At the end of the treatment that did not produce an obvious limp. Although an insole was prescribed, it was not used by the patient for most of the day. |
The patient is a 49-year-old male; and his chief complaint is gait disturbance with a past medical history of duodenal ulcer.\nHistory of the Present Illness. The patient experienced right abdominal pain and was diagnosed as having a duodenal ulcer by a physician 4 years before. During further examination and treatment, a 4 cm mass was found in the right kidney on abdominal CT. The mass was diagnosed as a right renal cancer at the urology department of our hospital and was treated with nephrectomy. The histopathological diagnosis was clear cell carcinoma. Upon examination of the whole body, metastases were noted in the right lung and Th11 vertebra, and radiotherapy was initiated for these metastatic lesions. Treatment with a molecular target drug, Sorafenib, was initiated one month later, but both pulmonary and spinal lesions remained progressive. Thus, the drug was switched to another molecular target drug, Sunitinib, 2 months later. The progression of the metastatic lesions was prevented, but spinal deformity progressed slowly, and numbness had appeared in the bilateral lower limbs 1.5 years before. The patient gradually became unable to walk about one year before, and was referred to our department.\nStatus upon Admission. In the spine, kyphosis was noted with a vertex at Th11. The patellar and Achilles tendon reflexes were enhanced bilaterally. Hypesthesia was noted in the region innervated by Th12 and below, and weakness of the iliopsoas and lower muscles was noted on manual muscle testing (MMT). No bladder or rectal disturbances were noted.\nImaging Findings. On plain X-ray radiography, crushed Th11 and anterior dislocation of Th10 were noted. On MRI, severe compression of the spinal cord was noted at Th11 (). A metastatic lesion was noted in the right apical pulmonary region on chest CT, but no metastasis was noted in any other organ on abdominal CT or bone scintigraphy.\nThe time-course changes in spinal MRI from the first examination at the urology department to the first examination at our department are shown in . Since the deformation progressed slowly, severe kyphosis was noted on the first examination at our department, but the progression of paralysis was relatively slow. The metastatic lesion was present only in a single vertebra, but palliative surgery for posterior decompression and fixation was planned because lung metastasis was already present.\nSurgical Findings. Th11 laminectomy was performed, the bone metastatic region was resected concomitantly, as much as possible, and posterior fixation of Th8-L3 was applied (). Regarding the bone quality, the hardness of the vertebral arch had increased, suggesting that the molecular target drugs were effective. The bone metastatic region was present in the Th11 transverse process over the lateral side of the vertebral arch, and this region was examined thoroughly. In the dural tube, the yellow ligament and membranous scar tissue were adhered to the dura. These were dissected as much as possible. When resection was advanced to the root of the Th11 vertebral arch, potential was improved on electrospinographic monitoring.\nPathological Findings. In the excised specimen, the bone tissue was partially accompanied by fibrosis, and no tumor cells were present ().\nCourse. Kyphosis was corrected by the first surgery. Since a defect was evident in the anterior column, no tumor cells were observed on pathological examination, and the pulmonary lesion did not progress; total en bloc spondylectomy was performed 2 weeks after the first surgery. Total en bloc spondylectomy of Th11 was performed by left thoracotomy due to the presence of a crushed Th11 bone fragment on the left side, followed by anterior fixation of Th10–12 with a cage containing autologous bone (). On pathological examination of the excised vertebra, bone tissue was accompanied by necrosis and degeneration, and there was no sign of the metastatic renal cell carcinoma. As of one year after surgery, the condition has improved to cane gait. Since no progression of the right metastatic lung tumor has been noted on CT, endoscopic excision of the malignant pulmonary tumor is planned. |
The second patient is a 69-year-old female who presented to the emergency room with complaints of obstipation and abdominal pain. She reported a 2-month history of intermittent sudden onset abdominal pain accompanied by abrupt bowel movement and nausea. At the time of presentation, she reported constipation for 5 days; she had tried fiber and suppositories without relief. Her past medical history included hypertension and irritable bowel syndrome. She had no prior abdominal surgeries or colonoscopies. Upon evaluation, she was afebrile and hemodynamically stable. Her abdomen was softly distended with localized left lower quadrant tenderness and no peritoneal signs. Her rectal exam was unremarkable. She had a mild leukocytosis of 12.9 thou/cmm. Abdominopelvic CT with intravenous contrast was obtained and revealed inflammatory stranding consistent with acute diverticulitis with a lamellated intraluminal mass in the sigmoid colon in the region of inflammation as well as pneumobilia (); these findings led to the diagnosis of a gallstone impaction with resulting large bowel obstruction.\nThe patient was admitted, started on intravenous antibiotics and provided fluid resuscitation. Shortly after admission, she began passing flatus and the decision was made to observe her with serial abdominal exams in hopes that treating the acute diverticular inflammation would permit passage of the stone; however, by hospital Day 3, the stone remained partially obstructing and the patient required surgical intervention. Upon induction of anesthesia, flexible sigmoidoscopy was performed for diagnostic confirmation and possible removal of the gallstone. The stone was encountered at 40 cm but could not be retrieved or fragmented, so a laparotomy was performed. Her sigmoid colon was noted to be very redundant and tortuous, and the gallstone was palpable at the junction between the descending and sigmoid colon. There was a large degree of surrounding inflammation, consistent with the findings on CT. Due to the inability to pre-operatively prep the colon secondary to her bowel obstruction and the degree of inflammation that was present, a partial colectomy and an end colostomy was performed. The gallbladder was left in situ. The patient tolerated the procedure without difficulty.\nHer post-operative course was without complication; she quickly gained ostomy function and tolerated a diet without difficulty. The pathologic evaluation of the colon specimen was consistent with diverticulitis and focal ulceration with a 36-mm gallstone present. Approximately 3 months after her index case, the patient underwent colonoscopy via her stoma in preparation for reversal of her colostomy. An area was noted in the transverse colon that was thought to represent the site of healed cholecystocolonic fistula. |
A 73-year-old man (patient no. 7 in ) underwent left TKA at another hospital 4 years ago and synovectomy due to infection 9 months after the surgery. Afterwards. the patient had no problems. But he visited our hospital because of repeated pain and swelling that had been persistent despite eight times of joint aspiration at the other local hospital 4 months ago. There was no specific bleeding tendency on the serologic test and he had no history of anticoagulant medication use. There was no loosening or malalignment of the prosthesis on simple radiographs. We diagnosed the patient as having refractory hemarthrosis because he did not respond to conservative treatments with eight times of repetitive joint aspiration.\nInterventional angiography was performed, and the vascular blush pattern was observed in the inferior lateral genicular artery, which was confirmed as a bleeding site, so selective embolization was performed (). However, selective embolization to the inferior lateral genicular artery failed due to the overlap between the entry of the selecting branch and the femoral component. So, we diagnosed it as refractory hemarthrosis and planned an arthroscopic procedure to identify and treat the bleeding sites.\nThe arthroscopic procedure was performed. Even though the pigmented hypertrophic synovium covered all areas of the joint, it was not an active bleeding site. Based on preoperative angiographic findings, we checked the posterolateral corner between the lateral aspect of the tibial component and the capsule in front of the popliteus tendon using the posteromedial viewing portal, and the suspicious bleeding site of the inferior lateral genicular artery was found. Despite the use of a tourniquet, compared with darkly pigmented synovium, there was a fresh distinctive bleeding point. Electrocauterization was performed using Arthrocare (Smith & Nephew, ArthroCare, Austin, TX, USA) on the inferior lateral genicular artery. After this procedure, active bleeding stopped (). The patient gradually showed progressive improvement of symptoms, and hemarthrosis no longer occurred until 23 months after the last follow-up. |
A 74-year-old, white male of Greek origin, was admitted in our hospital in December 2008 in order to be treated for a large mass located in the head of the pancreas. The patient had been originally subjected to a routine blood check up, which revealed mildly elevated transaminase levels. He was then referred for an abdominal U/S and eventually for a CT scan on an outpatient basis. Both revealed a large, well circumscribed mass of 6.8 cm in diameter, which seemed to be in direct contact with the head of the pancreas and the inferior vena cava (Figure ). A subsequent MRI of the abdomen showed the mass to measure about 7.3 cm, to have irregular borders and to be located posterolaterally to the pancreatic head. The inferior vena cava was located directly behind the mass, and seemed to be slightly displaced by the tumor. The portal vein was located directly above the mass. Both these vessels did not appear to be directly invaded by the mass.\nEndoscopic ultrasound scan was performed which allowed FNA of the mass. The cytology revealed cells morphologically and immunogistologically indicative of a neuroendocrine pancreatic neoplasm. Subsequently, the patient was referred to our hospital for further surgical and possible antiproliferative therapy.\nOn physical examination the patient was found to manifest periodic choreo - athetosic movements that had appeared in the 3 months that preceded the diagnosis of his pancreatic tumor, to together with polyarthralgia of his limbs’ large joints. The rest of his neurological clinical examination as well as an MRI of the brain were normal. Serum amylase, bilirubin and transaminase levels and all serum tumor markers were within normal range.\nThe patient underwent surgical resection of the tumor by means of a modified Whipple’s procedure and Roux-n-Y reconstruction of the gastrointestinal tract (Figure ). His recovery was uneventful and he was discharged from the hospital 10 days after the operation.\nPathological examination of the surgical specimen revealed a large pancreatic tumor, located in the head of the pancreas, measuring 12 × 9 × 6 cm. Microscopical examination showed a malignant neoplasm with morphological features of a mixed acinar-endocrine pancreatic tumor. The tumor was multilobular, well circumscribed and fully encapsulated. Numerous neoplastic emboli were present in the vascular and lymphatic channels of the adjacent pancreatic as well as peripancreatic fatty tissue and in the vessels of the outer muscular layer of the duodenum, which was resected en bloc with the tumor. Moreover, 9 out of 10 resected lymph nodes harboured metastases of the neoplasm. Immumohistochemistry revealed (Figures ,) intense positivity for chromogranin (25%), mild to intense positivity for synaptophysin (20%), negativity for NSE, C56, CK7, positivity for α1-antitrypsin (80%), expression of Ki-67 in 80% and no expression of p53.\nThe patient remains well 3 months after his operation, with no evidence of recurrence. He also has a complete remission of his neurological symptoms. |
A 68-year-old man presented for evaluation of a new asymptomatic bump on his left arm. His previous skin examination had been six months earlier and the lesion had not been present. He previously had three basal cell carcinomas (on the left temple, left side of his upper lip, and left mid back excised 32 years, four years and two years earlier, respectively) and one squamous cell carcinoma (on his right upper back that was excised seven years ago). He also had actinic keratoses that were treated with liquid nitrogen cryotherapy.\nHis past medical history was significant for severe acne vulgaris as an adolescent, hypercholesterolemia, hypertension, and prostate cancer that was diagnosed one year ago. He is currently with no evidence of malignant disease after treatment which included a robotic-assisted laparoscopic prostatectomy (with negative margins for tumor) and a bilateral pelvic lymph node dissection (with none of eight nodes positive for cancer). His current oral daily medications included amlodipine 10 mg and simvastatin 20 mg.\nCutaneous examination showed a six by six millimeter flesh-colored nodule on the extensor aspect of his left arm near the elbow (Figure ). A shave biopsy of the superficial portion of the nodule was performed. The site was treated topically with mupirocin two percent ointment, three times daily, until it had healed.\nMicroscopic examination of the hematoxylin and eosin-stained tissue specimen showed strands and nodular aggregates of atypical basaloid tumor cells in the dermis reaching the deep margin of biopsy; the overlying epidermis was thin with effacement of the rete ridges and sparse overlying orthokeratosis (Figure ). Deposition of amorphous material filled the dermal stroma between the tumor aggregates (Figure ); the amount of amyloid present was abundant (+++). The lateral aspect of the specimen showed solar elastosis in the upper dermis above the tumor and below the epidermis (Figure ).\nCorrelation of the clinical presentation and pathological findings established the diagnosis of a nodular basal cell carcinoma with extensive amyloid deposition and adjacent solar elastosis. The residual tumor was excised and a side-to-side layered closure was used to resolve the surgical wound. The surgical site was healed without recurrence at a follow-up examination nine months later. |
A 36-year-old female presented with a nonhealing, painful ulcer in the right buccal mucosa of 2 months duration. There was an associated facial swelling over the angle of the mandible on the right side and low back ache for 1 month. She gave a history of chewing arecanut. There was no history suggestive of ankyloglossia or trismus. Local examination revealed an ulceroproliferative growth measuring 4 cm × 2 cm with raised shelf- like inferior margin and submucosal induration involving the right buccal mucosa and right molar trigone, extending into the upper and lower gingivobuccal sulcus. No cervical lymph nodes were palpable. Per abdomen examination showed a firm mass 3 cm below the left costal margin and hepatomegaly. Computed tomography (CT) scan of the head and neck showed an ill-defined heterogeneously enhancing growth involving the right retromolar trigone, buccal space, masticator space along with the erosions of the ramus of mandible and right lateral pterygoid plate and focal thinning of the posterolateral wall of the right maxillary sinus []. Enlarged right Level Ib and II nodes were noted. In view of suspicion of malignancy, a lesional biopsy was done. Histopathology revealed hyperplastic stratified squamous epithelium adjoining an infiltrating tumor composed of sheets of polygonal malignant cells with abundant clear cytoplasm, mild anisonucleosis, round to oval vesicular nuclei and few cells showing prominent nucleoli []. Differential diagnosis of a clear cell carcinoma, either metastatic or primary tumor of minor salivary gland with myoepithelial differentiation was rendered. On immunohistochemistry, the tumor cells were negative for S-100. Following this, an extensive systemic evaluation was done. Plain and contrast magnetic resonance imaging study of cervical and dorsal spine showed altered signal intensity lesions in almost all the vertebral bodies and multiple posterior elements of visualized vertebrae showing enhancement on contrast injection suggesting skeletal metastasis. Contrast-enhanced CT of the abdomen revealed multiple enhancing hyperintense lesions in the liver suggestive of metastasis. A large hyperintense cystic lesion with internal hemorrhage and peripheral heterogenous enhancing solid components replacing the upper pole of the left kidney was seen conclusive of RCC []. Renal carcinoma immunostains, including PAX8, CD10 and vimentin, were performed, all of them were positive []. On correlating the clinical, radiological and histopathology findings, a final diagnosis of metastatic RCC was rendered. The patient was referred for palliative radiotherapy. |
An 11-year-old girl was referred to our hospital in August 2010 with a lesion in the right cheek area which was progressively enlarging. The patient complained that her nose and mouth corner were crooked and that her face was swelling. In clinical examination, the patient had a slight asymmetry in the right midface as a result of buccal and palatal cortical expansion from the right maxillary canine to the molar region, resulting in depression of the nasal alar and mouth corner (Fig. ).\nA panoramic radiograph showed an increased bone density on the right maxilla and zygoma and obliteration of the right maxillary sinus. Computed tomography (CT) revealed a 4.5 × 4 × 4.5 cm, expansile ground-glass opacity lesion involving the right maxillary sinus, right maxillary alveolar process, zygoma, and hard palate. Bone scan revealed an irregularly shaped hot uptake in the right maxilla, and no abnormally increased uptake was observed at any other sites (Fig. ). The physical examination did not show any other lesions, and the patient had no history of pain, trauma, loosening of teeth, or trismus. Based on the typical radiologic findings, the patient was diagnosed with FD, and no additional biopsy was performed. The patient had regular follow-up every 6 months to monitor the lesion’s progress. At the 1-year follow-up, the development of tooth germ within the lesion was normal, and slight expansion of the lesion to the bucco-lingual side was observed. Because we thought the patient was still growing and increasing in height, we decided to conduct an ongoing progress observation.\nAbout 3 years later in December 2012, there were no significant changes of the FD lesion, but the distance from the mouth corner to the inner canthus was about 2 cm longer on the right side than on the left. Periodic observation was continued, and in August 2017, corrective surgery was planned because the maturation of the lesion was confirmed to be complete and there were no changes in the size of the lesion. At that time, the distance from the mouth corner to the inner canthus was 2.5 cm longer on the right side than on the left, and the distance from the occlusal plane to the outer canthus was 5 cm longer on the right side than on the left. Bone contouring surgery, the primary treatment for facial asymmetry and fibrotic bone lesions, was planned (Fig. ).\nThe patient wanted to improve asymmetrical facial appearance through the surgery. Therefore, we aimed not only to remove the FD lesion, but also to make the patient’s facial as symmetrical as possible. For this, direct visualization and surgical approach to the infraorbital rim and lateral area of zygoma were required, but the surgical approach through buccogingival incision had limited access to these areas. On the other hand, the midfacial degloving approach was expected to help reestablishing symmetric facial contour by allowing direct comparison of the lesion with the normal side. Moreover, this approach provides esthetically acceptable outcomes, leaving no scars and no functional disability. Therefore, we decided to perform the operation through the midfacial degloving approach.\nWith the patient under orotracheal anesthesia, the lesion was removed by the midfacial degloving surgical procedure. Local anesthesia with 2% lidocaine with epinephrine (1:100,000) was infiltrated into the maxillary vestibular mucosa and into the nose. The procedure is performed with a maxillary vestibular incision and three intranasal incisions to expose the entire midface skeleton that include (1) bilateral intercartilaginous, (2) complete transfixion, and (3) bilateral piriform aperture incisions (Fig. ).\nA buccogingival incision was made in the maxillary vestibule approximately 5 mm superior to the mucogingival junction and extended from the second molar to the contralateral second molar. Periosteal elevators were used to elevate the tissues in the subperiosteal plane fist over the anterior maxilla and then extending widely to encompass posterior tissues behind the zygomaticomaxillary buttress. The infraorbital neurovascular bundle was identified superiorly and dissected. Subperiosteal dissection along the piriform aperture stripped the attachments of the nasal labial muscularture to allow its complete release from the midface skeleton. The mucoperiosteal flap was elevated up to the piriform aperture.\nThe intercartilaginous incision divided the junction between the upper and lower lateral cartilages (Fig. b). An incision was made along the inferior border of the upper lateral cartilage, beginning at the lateral end and extending medially curved into the membranous septum anterior to meet transfixion incision (Fig. a). Laterally, the incision was sufficient that it extended to the piriform aperture. The lower lateral cartilage was eventually displaced superiorly during the degloving procedure, whereas the upper lateral cartilage remained attached to the midface skeleton. The transfixion incision was used to separate the membrane septum/columella from the cartilaginous septum. An incision was made along the caudal border of the septal cartilage from the medial end of the intercartilaginous incision toward the anterior spine (Fig. a). The intranasal incision was made by a full-thickness incision down through the periosteum of the piriform margin and the nasal floor.\nDissection through the intercarilaginous incision allowed access to the nasal dorsum and bones (Fig. b). Sharp subperichondrial dissection with a scalpel or a blunt dissection with scissors freed the soft tissues above the upper lateral cartilage as in a standard open rhinoplasty. The dissection should be within the subperichondrium plane to prevent injury to the overlying musculature and blood vessels of the nose. Elevation extended laterally to the nasomaxillary sutures and superiorly to the glabella. Retraction of the freed soft tissues allowed sharp incision to be made with a scalpel or with sharp periosteal elevators through the periosteum at the inferior edge of the nasal bones. Elevation of the soft tissue laterally to the piriform aperture was also performed so that the maxillary vestibular dissection was easily connected to this pocket.\nAfter the connection of the nasal and oral incisions, the midface was degloved. The midface skin was separated from the maxilla and the nasal pyramid. The upper lip and the intact nasal columella, nasal tip, and alar cartilages were then retracted by two Penrose drains introduced through the nostrils over the nose to the level of the inferior orbital rim. This approach provided visualization of the medial maxillary wall, pterygoid junction, nasofrontal suture, infraorbital rim, and laterally to the temporal process of the zygoma (Fig. d). Under direct visualization, the overgrowing bone lesion was then excised using osteotomes and saws. The right maxilla was drilled further at the orbital rim and laterally till zygomatic complex. The contour of the midface was reestablished using burr to give a cosmetically normal looking midfacial skeletal contour while protecting the infraorbital nerve (Fig. ). For the removed lesion, a biopsy was performed for the accurate diagnosis and histologically confirmed as FD. The soft tissues were then carefully redraped and the nasal tip brought back into position. The intranasal incisions were closed using 4-0 resorbable sutures (vicryl), and the transfixion sutures were precisely performed to determine the final position of the nasal tip and prevent vestibular stenosis. The cinch suture of alar base was used to prevent postoperative alar base widening. The intraoral incisions were closed using a 3-0 black silk. Nasal packing into the maxillary dead space with Vaseline gauze was done for 3 days in order to minimize the postoperative bleedings.\nThe patient’s postoperative course was generally uneventful. There was moderate nasal crusting for 3–4 days. Mild swelling with periorbital ecchymosis disappeared after 2 weeks, and transient paresthesia around the infraorbital nerve spontaneously resolved after 3 month. No postoperative complications such as epistaxis, vestibular stenosis, or esthetic problems of the nose were seen. Clinical and radiographic examinations obtained 4 months after surgery showed the anatomical structures were in a stable state without recurrence of FD (Fig. ). The esthetic result was satisfactory for the patient, and occlusal state was also well maintained (Fig. ). Therefore, no additional orthodontic treatment or orthognathic surgery was performed. |
A 65-year-old woman presented with abdominal pain and hypophagia for 2 weeks. She had a medical history of alcoholic pancreatitis. A computed tomography (CT) scan of her abdomen and pelvis revealed thickening of the transverse colon wall. Colonoscopy showed an ulcerated tumor in the transverse colon, and histological analysis indicated moderately differentiated adenocarcinoma. Serum carcinoembryonic antigen (CEA) levels were normal, and no sites of distant metastasis were reported on preoperative examination. She underwent a laparoscopic extended right hemicolectomy using the non-touch isolation technique. Histopathological examination of the specimen revealed a moderately differentiated adenocarcinoma invading the subserosal layer with low venous invasion (v1) and no lymphatic invasion (ly0). The surgical margins were negative. A total of 92 lymph nodes were removed, of which none showed metastases. The tumor was diagnosed as stage IIA (T3, N0, M0) according to the International Union Against Cancer tumor, node, and metastasis (TNM) classification (7th edition) []. The patient had an uneventful recovery and was on regular follow-up every 3 months without adjuvant chemotherapy.\nFifteen months after her colectomy, a CT scan demonstrated a tumor in the antero-lateral rectal wall that was 20 mm in diameter, and a right ovarian tumor that was 25 mm in diameter (Fig. ). The ovarian tumor was a cystic mass with a solid component on magnetic resonance imaging (Fig. ). Colonoscopy revealed a superficial elevated lesion in the middle rectum that was shown by histological examination to be moderately differentiated adenocarcinoma (Fig. ). Serum CEA levels were normal. These findings were indicative of rectal cancer with ovarian metastasis, or double primary cancer of the rectum and ovary. A diagnostic and therapeutic laparoscopy detected no disseminated peritoneal metastases or liver metastases. Intraoperative cytological examination of the peritoneal lavage was negative for carcinoma. An operative rapid pathological diagnosis of the resected right ovarian tumor indicated metastasis of the colorectal cancer. Thus, we performed laparoscopic low anterior resection preserving the left colic artery with partial resection of the vagina, and bilateral adnexectomy.\nThe resected rectal tumor measured 20 × 18 mm (Fig. ). Histological examination demonstrated a moderately differentiated adenocarcinoma that had invaded the vagina and formed a metastasis in one of 32 lymph nodes. High venous invasion (v3) and low lymphatic invasion (ly1) were observed. The adenocarcinoma was mainly present in the submucosa and muscularis propria with a small range of invasion to the vagina (Fig. ), while the carcinoma-involved region of the mucosal layer had mucosal colonization representing the spread of metastatic tumor cells along the basement membrane of preexisting crypts and/or villi (Fig. ) []. There was no adenomatous precursor at the edge of the tumor, and surgical margins were negative. The right ovarian tumor was moderately differentiated adenocarcinoma that was positive for cytokeratin (CK) 20 and negative for CK7 immunohistochemical staining, indicating metastasis of colorectal cancer. The rectal and ovarian tumors shared high similarities with transverse colon cancer in architectural and cytological atypia (Fig. ). Both adenocarcinomas of the transverse colon and rectum were negative for p53 immunohistochemical staining and RAS wild type in genetic assessment (Fig. ). These findings support a diagnosis of rectal and ovarian metastases from primary transverse colon cancer.\nThe patient recovered well after surgery, and adjuvant chemotherapy was decided after a multidisciplinary meeting. She was treated with eight cycles of oxaliplatin and capecitabine, and neither relapse nor metastasis has been observed 18 months after surgery.\nThe incidence of colorectal metastasis from primary colorectal cancer is rare, and distinguishing primary from metastatic colorectal cancer can be challenging. To our knowledge, only three reports in English and six in Japanese have described suspected cases of colorectal metastasis of colorectal cancer [–]. We reviewed a total of eight patients, including seven out of the abovementioned nine patients with detailed clinical information as well as our own (Table ). The patients were three males and five females, with a median age of 66.5 years (range 52–88 years). Ascending colon cancer was the most common primary tumor (n = 3), followed by tumors of the sigmoid (n = 2), transverse colon (n = 2), and cecum (n = 1). Metastatic colorectal lesions were located in the rectum in all cases. In terms of other metastatic sites, seven patients had other metastases (lung, liver, spleen, abdominal wall, axilla, and ovary) and one had no other metastases.\nA previous study of 278,208 malignancies in a nationwide Japanese pathologic autopsy database from 1990 to 2003 identified 18,252 case with metastatic colorectal cancer. Of these, 1302 (7.1%) were from primary colorectal cancer []. The database does not include information about the suspected metastatic pathway (hematogenous, lymphogenous, direct invasion, or dissemination), but most metastatic tumors in the database are attributed to direct invasion or disseminated metastasis, reflecting late-stage disease. However, the number of reported clinical cases might not represent the actual incidence of colorectal metastasis from colorectal cancer. One possible reason for the rarity of reported colorectal metastasis cases is that most cases occur as part of systemic advanced disease, for which surgical resection will not be performed []. The other reason is that diagnosing metastasis is difficult [, ]. Although gastrointestinal metastatic carcinoma usually represents a submucosal tumor, differential diagnosis (as primary disease or metastasis) becomes difficult if the tumor invades the mucosal layer. Estrella et al. argued that metastatic carcinomas involving the mucosal surface frequently mimic second primaries, so histologic features cannot reliably distinguish metastatic from primary carcinoma []. Additionally, primary colorectal cancers resembling submucosal tumors have been reported in previous studies [, ]. This explains why colorectal metastases may be misdiagnosed and treated as primaries.\nDistinguishing primary from metastatic colorectal cancer can be challenging, but a comprehensive evaluation of histological features, clinical history, and tumor distribution enables making the correct diagnosis and implementing the optimal treatments []. In this case, we suspected a metachronous metastasis for the following reasons. First, histological findings demonstrated that the adenocarcinoma was mainly present in the submucosa and muscularis propria with mucosal colonization, which is a supportive finding for metastatic carcinoma, as this indicates a low possibility of primary rectal cancer and implantation of the transverse colon cancer. Second, the rectal and ovarian tumors were very similar to the transverse colon cancer in terms of architectural and cytological atypia, further suggesting metastasis of primary transverse colon cancer. Third, there was no adenomatous precursor at the tumor edge, indicating metastatic cancer. Fourth, both adenocarcinomas of the transverse colon and rectum were negative for p53 in immunohistochemical staining and RAS wild type in genetic assessment, indicating metastatic rectal cancer from primary transverse colon cancer.\nIn reviewed cases, the exact mechanism of colorectal metastasis from primary colorectal cancer has not been fully elucidated; thus, the possibility of hematogenous or lymphogenous spread remains. We suspected hematogenous or lymphogenous metastatic pathways to the rectum from the primary transverse colon cancer because the carcinoma was mainly located in submucosa and muscularis propria; however, there was no additional evidence than tumor localization. In this case, the rectal tumor penetrated into a small range of the subserosal layer with invasion to the vagina; additionally, there was a metastatic ovarian carcinoma. Peritoneal metastatic invasion primarily toward the deep layer of the rectal wall cannot be ruled out. The metastatic colorectal lesions were located in the rectum in all reviewed cases, and this suggests that peritoneal spread to Douglas’s pouch or the rectovesical pouch is a possible pathway for colorectal metastasis from primary colorectal cancer.\nConsidering that the majority of reported cases had multiple metastases, the existence of other metastatic lesions might be a risk factor for colorectal metastasis. Therefore, more attention should be paid to colorectal lesions when other metastatic sites have been identified. Colorectal metastases usually represent late-stage disease and have poor prognoses; however, prolonged survival after surgery and complementary therapy can be achieved in some patients []. In this case, neither relapse nor metastasis has been observed 18 months after surgery. The follow-up periods varied too widely to evaluate patient prognosis in reviewed cases. Therefore, additional studies are needed to better understand this rare metastasis and to determine the optimal therapeutic strategies. |
A 73-year-old-man with 40 pack years of smoking history and hypertension was on treatment with amlodipine 5 mg per day. He was diagnosed with peripheral vascular disease when a surgical consultation for purplish discoloration of toes was sought 3 months ago [] and warfarin sodium 5.0 mg alternating with 2.5 mg per day was prescribed.\nIn the current admission, he presented with passage of black stools and fresh bleeding per rectum. Blood pressure at admission was 150/90 mmHg. There were no clinical features of dehydration or excessive fluid loss. Warfarin was stopped and an upper gastrointestinal endoscopic examination was performed, which showed a healed duodenal ulcer. Abdominal ultrasound examination revealed an abdominal aortic aneurysm. Renal artery Doppler study was normal. Urine output was adequate on the first two days of admission (about 1800 ml) and urine examination at this time showed trace proteinuria, 8-10 pus cells/hpf. There was no evidence of hematuria or heme granular casts on microscopic examination of urine sediment. On the third admission day, he developed abrupt swelling of both legs and sharp decline in urine output to 600 ml which further dropped to 400 ml on fourth day, with development of azotemia. The relevant laboratory parameters at presentation are depicted in . Broad spectrum antibiotics were administered and hemodialysis was initiated. Pending the results of serological investigations, a clinical suspicion of vasculitis was considered and three doses of injection methyl prednisolone 1 gm intravenous daily for three days were administered starting from fifth admission day, followed by oral prednisolone 60 mg per day from 4th day. Inj. cyclophosphamide 750 mg (i.v.) was given on 8th post admission day. A renal biopsy was meanwhile performed which revealed presence of biconvex needle shaped empty spaces in lumen of an interlobular sized artery, consistent with cholesterol atheroemboli []. Tubular atrophy and interstitial fibrosis involved about 40% of the cortex, and the proximal tubules in the viable areas showed features of acute tubular injury, including loss of brush borders, epithelial simplification luminal granular casts. Direct immunofluorescence examination was negative for immunoglobulins (IgA, IgG, IgM), complements (C3, C1q), and also for kappa and lambda light chains. No refractile crystals were noted in frozen sections of biopsy core submitted for Direct Immunofluoroscence (DIF) studies. A final diagnosis of renal failure secondary to atheroembolic renal disease possibly precipitated by oral anticoagulant therapy was rendered.\nPatient's clinical status gradually improved with progressive increase in urine output and reduction of serum creatinine to 2.3 mg/dl on 21st post admission day []. After review of kidney biopsy report, the oral prednisolone was tapered rapidly in 2 weeks, and cyclophosphamide was withdrawn. Hemodialysis was discontinued and patient was discharged, off dialysis in a clinically stable condition with advice for regular outpatient follow-up. |
A 61-year-old female patient without significant comorbidities presented for a check-up for diffuse abdominal pain. The biological evaluation did not reveal any pathological changes, but ultrasonography identified the presence of a right renal mass. Contrast-enhanced abdominal CT was performed and confirmed the diagnosis of a bulky right renal tumor. Chest CT did not reveal any pulmonary metastasis, thus allowing the final staging as cT3aN0M0 (Figure ). On the preoperative imaging evaluation, there was no evidence of the invasion of the vena cava, which was medially dislocated, but significant collateral circulation was present. Due to the characteristic appearance of the tumor at imaging scans, pre-operative biopsy was not performed. The patient signed the informed consent prior to publication of this case.\nFollowing the preparation for standard transperitoneal right radical nephrectomy, the surgical intervention was performed in general anesthesia with orotracheal intubation by pararectal prolonged right subcostal approach. One of the main issues during the surgery was the difficult dissection of the renal pedicle, due to the significant collateral vessels and tumoral invasion. Due to this fact, the surgical strategy was modified. First, circumferential dissection of the tumor was performed. The dissection continued towards the renal hilum, where it was observed that the tumor encompassed the renal vessels and a significant segment of the IVC. Therefore, the next step was to isolate the IVC using vessel loops. During the medial dissection of the tumor, the injury of the infra-renal vena cava occurred. In order to perform hemostasis, rapid excision of the remaining tumor and further isolation of IVC was performed. A Satinsky clamp was placed on the lateral wall of the IVC and a suture was performed using Prolene 4/0. Declamping of the IVC was followed by repeating hemorrhage, thus the decision was taken to completely suture the infrarenal IVC in a transverse manner. The blood loss was 2.500 mL and transfusion was required. Postoperatively, the patient presented edema of the inferior limbs, which resolved by conservative approach in five days. Also, a transient kidney dysfunction was present for the first 72 hours.\nThe macroscopic analysis of the tumor specimen identified the presence of a tumor-adherent tubular vascular formation, which raised the suspicion of the vascular origin for the first time (Figure ). Grossly, the surgical specimen measured 16.5/11/6 cm and was a block composed of kidney with perirenal fat, adrenal gland and fragment of vena cava. The tumor was located at the upper pole of the kidney, infiltrating the capsule and vena cava wall; it was well circumscribed and measured 9×9×6 cm. Renal vessels and ureter were free of tumor. The cut surface was grey-white, firm, with foci of hemorrhage and necrosis.\nFor positive and differential diagnosis, tumor fragments were collected, fixed in 10% neutral buffered formalin and sent to the Laboratory of Pathology, where they were included in paraffin, then sectioned at the microtome and stained with Hematoxylin–Eosin (HE). Some histological preparations were immunohistochemically stained using anti-alpha smooth muscle (anti-α-SMA) (monoclonal mouse anti-human smooth muscle actin, clone 1A4, 1:100 dilution, Dako), and anti-cluster of differentiation 34 (anti-CD34) (monoclonal mouse anti-human CD34 Class II, clone QBEnd 10, 1:50 dilution, Dako) antibodies.\nMicroscopically, the tumor consisted of spindle cells with eosinophilic cytoplasm arranged in sheets and whorled, intersecting fascicles (Figure ). There was pronounced nuclear pleomorphism and a mitotic rate of 16 mitoses/10 high-power fields (HPFs) (field diameter was 0.5 mm), also with atypical mitosis (Figure ). In some areas of the tumor, small areas of necrosis and inflammatory infiltrate have been identified (Figure ). The tumor cells were strongly positive for α-SMA (Figure , D and E). CD34, by revealing the endothelium, showed an intense vascularization of the tumor, the vessels being formed mainly of arterioles, capillaries and venules, some of the capillaries being identified as vessels of angiogenesis (Figure ).\nMacroscopic and microscopic aspects allow us to support the hypothesis that the origin of the tumor was the smooth muscles in the wall of the IVC.\nDuring the four years of follow-up, no recurrent lesions were identified on the imaging, the patient being considered disease-free. Significant collateral venous circulation was described because of the suturing of the IVC (Figure ). |
A 33-year-old male patient (weight 56 kg; height 174 cm) presented complaining of faintness and shivering on the left side of the body that had been occurring for 2 months, associated with unsteadiness toward the left and diplopia that worsened when looking to the right.\nMagnetic resonance imaging showed a 12 × 13 × 9 mm extra-axial tumor lesion on the left middle cerebellar peduncle that accompanied a 24 × 35 × 21 mm cystic lesion under the tumor lesion ().\nThe preoperative diagnosis was hemangioblastoma. The patient had no abnormal findings with regard to salivary glands on the preoperative computed tomography scan. A right retrosigmoid suboccipital craniotomy was planned to remove the tumor. Operative position was right lateral-semiprone position with chin down ().\nNo anesthetic premedication was administrated. Anesthesia was induced with remifentanil with O2, air, and sevoflurane. Muscle relaxation was achieved with rocuronium bromide, and the patient was intubated uneventfully with a 8 mm internal diameter reinforced tube. To facilitate the surgical approach, the patient was placed in the extreme left lateral position and his sides were supported and pressure points secured.\nThe surgery proceeded uneventfully and all hemodynamic parameters as well as fluid input/output were maintained in the intraoperative period. At the end of the surgery, when the patient was found to be conscious and responding to commands, he was extubated in the operation theater. Total operation time was 4 hours and 23 minutes. Total anesthesia time was 6 hours and 8 minutes. Total infusion volume was 2,250 mL. Blood loss was 195 mL. Urine volume was 510 mL. Neurological assessment was satisfactory. However, a slight degree of right submandibular swelling was noticed after the extubation. An ultrasonic examination was performed by a dental surgeon who happened to be there at that time and pointed out the swelling of the right submandibular gland. As his vital signs were found to be within normal limits, he was permitted to leave the operation theater under close observation.\nA computed tomography 1 hour after operation revealed swelling of the right submandibular gland and the associated edematous tissue. The submandibular gland was approximately 32 × 30 × 37 mm in size, consistency being firm, and the margins were well demarcated. No evidence of sialolithiasis was discovered ().\n7 hrs after operation, the swelling worsened and the patient started complaining of mild respiratory distress, although peripheral oxygen saturation (SpO2) was 100% and his vital signs were normal (). A fiberscopy examination revealed apparent swelling of the right posterior part of the tongue. Computed tomography was performed again and revealed swelling of the right submandibular gland and also massive edematous change around the submandibular gland, extending to the right parotid region. Glandular swelling was found to be displacing the larynx (). The patient was shifted to the intensive care unit and intubated soon after showing features of respiratory distress and in consideration of impending airway obstruction was put under mechanical ventilation for 5 days after the operation.\nThe swelling did not appreciably reduce during the first 48 hrs. Duration of intubation was based on clinical evaluation of soft tissue swelling, assessment of airway patency, and ultrasonographic examination.\nThe glandular swelling had almost disappeared on the fifth postoperative day, and he was extubated without any residual complications. After extubation, the patient did not require any further pulmonary care. The laboratory data showed the white blood cell count rose to 11,300/μL and CRP also rose slightly to 0.86 mg/dL on the operation day and then decreased rapidly after operation. Serum amylase rose slightly to 186 IU/L on the day of the operation and decreased rapidly to within normal range while the submandibular gland was swollen. No other laboratory parameters that indicated comorbid disorder were associated with the submandibular swelling. SS-A and SS-B antibodies, antinuclear antibody, rheumatoid factor, LDH, IL-6, and IgG 4 were also within normal range. The result of bacterial cultivation from the floor of the oral cavity showed a small amount of Pseudomonas aeruginosa; however it seemed to have no relationship with the submandibular gland swelling because no purulent discharge or inflammation signs were observed around the sublingual caruncle. Third-generation cephalosporin antibiotics were given from the beginning of the operation to the fifth postoperative day. Betamethasone (4 mg/day) and glyceol (400 mg/day) were also given to reduce brain edema from the operation day to the fifth postoperative day. The pathological diagnosis of the brain tumor was hemangioblastoma. |
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